4 Psychosocial Factors & Special Situations

Psychosocial and lifestyle factors

Assessment of social, cultural, spiritual aspects, coping and stress tolerance, and overall mental health

Mental health assessment

Evaluation of mental health history, current medications in use, and psychological wellbeing

Alcohol and illegal drug use assessment

Screening for substance use patterns and potential abuse problems

Human violence assessment

Screening for possible abuse, domestic violence, or other safety concerns

Sexual history and orientation

Assessment to establish baseline and identify need for education while respecting privacy

Special interview situations

Adaptations needed for hearing impairment, low level of consciousness, cognitive impairment, mental illness, anxiety, crying, anger, alcohol or drug use, personal questions, and sexual aggression

Hearing impairment accommodation

Speaking clearly, facing patient, using written communication, and ensuring hearing aids are functioning

Cognitive impairment accommodation

Using simple language, short sentences, allowing extra time, and involving family members when appropriate

Interview preparation process

Reading available material, allowing adequate time with patient, remembering communication techniques, reviewing all past and present history including medications, and reviewing chief complaint

Chief complaint

What the patient is presenting for today, which guides the focus of the assessment and examination

Medical diagnosis timing

Comes after healthcare provider performs testing based on chief complaint, distinct from nursing assessment