Chapter 20 Psychosocial Nursing of the Physically Ill Client Psychosocial Assessment Interactive process that involves gathering data and evaluating

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1 Chapter 20 Psychosocial Nursing of the Physically Ill Client Psychosocial Assessment Interactive process that involves gathering data and evaluating the past and current level of functioning of the client Relates to following processes of the client: o Emotional o Behavioral o Mental o Environmental o Spiritual Components of the Psychosocial Assessment [corresponds to Box 20-1] Social history assessment includes: o Religion/spirituality o Occupation o Interests o Ability to socialize o Pattern of communication with significant others o Roles client plays within family and community o Ways the family handles conflict, stress; usual coping patterns o What happened last time client was under severe stress o Client s rating of current stress level o Understanding of current illness and need for hospitalization o Major issues raised by current illness o Physical problems related to psychosocial issues o Body image o Self concept, self-esteem, self perception of competence o Goals o Power o Spirituality o Interpersonal relationships Body image assessment o Instruct the client to draw a picture of their appearance o Ask questions to determine client s feelings about body o Ask what client likes about their body o Ask client what they would change about their body, if anything. Self concept/self-esteem assessment o Ask client how they would describe themselves to others o Ask client what their strengths and weaknesses are o Ask client who they would like to be o Ask client who or what has influenced their self expectation o Ask client what are their expectations in life and are they realistic. o Self-esteem can be assessed by asking, Do you like who you are? Assessing client s perception of competence and power o Competence - ask: How do you feel about your ability to do all the things your roles demand? o Power - ask, To what extent do you feel able to control your life?

2 Assessing goals o Ask the client: Where do you see yourself in 1 month? 1 year? 5 years? Assessing spirituality o Is there a spiritual belief system that is important to you? How? o What gives meaning to your life, or makes you want to live? o Does your spiritual system help when you are not feeling well? o Does your spiritual system influence health care decisions in anyway? How? o Do you have any beliefs of a religious or spiritual nature about the cause or treatment of your problems? Assessing interpersonal relationships o Family o School o Work o Community o Level of dependence/independence. Assessment of sexuality o Are you sexually active? o Are you satisfied with your sex life? o Has your desire for sex or interest in sex changed? If so, how? o How has the state of physical health affected you and your spouse or partner? o Is your significant other living? (If yes) Is your relationship satisfying? (If no) How do you cope with the loss of that relationship? Mental Status Exam Part of a psychosocial assessment If the client is in crisis: o RN will perform the initial assessment o Practical or vocational nurses will monitor delegated aspects The mental status examination includes: o Appearance o Behavior (such as catatonic, agitated, compulsive) o Sensation/perception o Affect o Mood o Memory o Orientation, attention, judgment o Abstract thinking o Insight o Statements make sense and are logical or not o Identification of themes if present o Evidence of delusions and/or hallucinations, paranoia Psychologic Responses to Serious Medical Illness Depression o Clinical depression

3 o Types of depression Bipolar affective disorder (manic depression) Postnatal (postpartum) depression Seasonal affective disorder Major depressive disorder o Age-related manifestations [corresponds to Table 20-1] o Treatment [corresponds to Box 20-3] Cognitive therapy Counseling Electroconvulsive therapy Anxiety o Phobias o Panic attacks o Obsessive compulsive disorder o Post-traumatic stress disorder o Mechanisms for coping with anxiety Self-help [corresponds to Box 20-4] Grief and loss Denial Fear of dependency Stress o Fight or flight o Physical changes [corresponds to Figure 20-2] o Emotional changes o Behavioral changes Psychosocial factors in medical illness o Human rights abuses of persons with stigmatizing medically illnesses Dual diagnosis o Two independent disorders occur together o Substance abuse caused the other mental disorder o Person with mental disorder uses substances to self-medicate or feel better o Anesthesia or pain medication must be handled carefully with dual diagnosis o Be objective, not judgmental, with such clients. o Convalescent period following surgery or other serious illness may not be time to start a substance abuse treatment program. o Diagnostic groupings Defense mechanisms [corresponds to Table 20-2] o Effective coping behaviors Reviewing strengths and weaknesses Setting short and long range goals Formulating a plan of action to deal with anxiety producing situations. o.stress can manifest itself in behaviors such as: Anger

4 Agitation Fear Withdrawal Inappropriate behavior ICU psychosis form of delirium, organic and environmental factors Sources of stress include: o Physical illness o Need to adjust to an unfamiliar environment o Sensory deprivation or overload. o Temporary loss of connection to reality Means of reducing incidence o Treatment depends on cause. Usually resolves completely when the client leaves the ICU. Sundowning- tends to occur at dusk Suicide Young and old at special risk Myths [corresponds to Table 20-3] Associated risks for suicide [corresponds to Box 20-5] o Death of relative or friend; broken relationship (divorce, separation) o Loss of health (perceived or real), job, money, status o Overwhelming pain o Alcohol or drug abuse o Depression Changes associated with suicide o Hopelessness, powerlessness, feelings of worthlessness, shame, guilt, self-hatred, expressing a feeling no one cares and fear of losing control, harming self or others. o Looking and or behaving sad, withdrawn, tired, apathetic, anxious, irritable, or prone to angry outbursts. o Declining performance; volunteering for extra duties just to fill up time and keep from being alone o Social isolation; or association with a group that has different moral standards than those of the family. o Changes in sleeping or eating habits. o Self-starvation, dietary mismanagement, disobeying medical instructions (particularly in the elderly). o Previous suicide attempts, mini-attempts., explicit statements of suicidal ideation (suicidal thinking) or feelings o Development of suicidal plan o Acquiring the means to commit suicide o Rehearsal behavior, setting a time for the attempt o Self-inflicted injuries, such as cuts, burns, or head banging o Reckless behavior o Making out a will or giving away favorite possession

5 o Inappropriate goodbyes or hints of suicide e.g. I'm going away on a real long trip, You won't have to worry about me anymore. Nursing Care Alertness to meaning of illness to client [corresponds to Box 20-6 Provide therapeutic relationship[corresponds to Box 20-7]] Provide compassionate, consistent care. Do not take client s reactions personally. Explain all care and procedures before beginning interventions. Ask client about feelings of self-harm. Report any suicidal ideation. Nursing Process Care Plan: Physically Ill Client with Psychosocial Issues Critical Thinking Care Map: Caring for a Client with Myocardial Infarction

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