2.3 Psychosocial Assessment

Developmental Stages of Adulthood (Erikson)

Erik Erikson's psychosocial stages frame how adults of different ages experience illness and hospitalization. ANCC expects you to match the nursing approach to the developmental task:

Clinical pearl: a middle-aged patient who refuses recommended treatment may be acting from generativity concerns ('Who will run my business / care for my mother?'), not denial — explore the role conflict before labeling noncompliance.

Suicide Risk Assessment

Suicide risk assessment is a nursing responsibility in every setting, including med-surg units (post-diagnosis despair, chronic pain, and new ostomies are classic triggers). Key principles:

• Ask directly: 'Are you thinking of killing yourself?' Direct questioning does not plant the idea or increase risk — this is the most tested concept in this domain. Euphemisms ('You're not thinking of hurting yourself, are you?') invite denial.
• If ideation is present, assess the triad: plan (specific method and time?), means (access to the method?), and intent (how committed?). A specific, lethal, available plan is highest risk.
• Warning signs: prior attempt (strongest single predictor), hopelessness, giving away prized possessions, saying goodbye, sudden unexplained calm or improvement (often means the decision is made — the classic trap), substance use, recent major loss.
• Priority interventions: means restriction (remove firearms, stockpiled medications, sharps, belts, cords from the environment), continuous one-to-one observation, removal of the patient from windows/unmonitored exits, and notification of the provider for psychiatric evaluation.
• 'No-suicide contracts' are not evidence-based and do not substitute for observation.

Abuse and Neglect Screening

Screen privately, without the partner or caregiver present, using a matter-of-fact, nonjudgmental tone.

Elder abuse types: physical, sexual, emotional/psychological, financial exploitation, neglect, and abandonment. Red flags: injuries inconsistent with the stated mechanism, injuries in various stages of healing, delay in seeking care, a caregiver who answers for the patient or refuses to leave, poor hygiene, dehydration, untreated pressure injuries, and sudden financial changes. Nurses are mandatory reporters of suspected elder and dependent-adult abuse in every U.S. state — you report reasonable suspicion, not proof, and you report to Adult Protective Services per state law, not to the family.

Intimate partner violence (IPV): use validated tools such as HITS (Hurt, Insult, Threaten, Scream) or WAST (Woman Abuse Screening Tool). Screen all adult patients routinely, especially at new injuries, pregnancy, and frequent visits. If disclosure occurs, prioritize immediate safety assessment, offer resources (shelter contacts, safety planning), respect the patient's decision about leaving, and document objectively with body maps and the patient's own words. Mandatory reporting of IPV varies by state (often required when injuries involve weapons); elder and child abuse reporting is universal.

Substance Use Screening and Withdrawal

Screening tools:

• AUDIT (Alcohol Use Disorders Identification Test): 10 items covering consumption, dependence, and harm; a score of ≥8 indicates hazardous or harmful use. The 3-item AUDIT-C is the brief consumption screen.
• CAGE: 4 questions — Cut down (felt you should?), Annoyed (by criticism of drinking?), Guilty (about drinking?), Eye-opener (morning drink?). ≥2 positive answers is a positive screen and prompts full assessment. CAGE-AID adapts it for drugs.

Alcohol withdrawal timeline (memorize this — it drives med-surg triage questions):

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) scores 10 items — nausea/vomiting, tremor, sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, and orientation — for a maximum of 67 points. Symptom-triggered therapy with benzodiazepines (chlordiazepoxide, lorazepam, diazepam) uses CIWA-Ar scores to dose: generally <8 mild, 8-15 moderate, ≥15 severe. Lorazepam is preferred in liver disease and older adults (no active metabolites). Thiamine is given before glucose to prevent Wernicke encephalopathy.

Opioid withdrawal (piloerection, lacrimation, rhinorrhea, yawning, diarrhea, mydriasis) is miserable but rarely life-threatening; onset depends on half-life (heroin 8-12 hours, methadone 24-36 hours).

Coping and Support Systems

Assess how the patient has coped with past stressors, current coping strategies (adaptive vs maladaptive — problem-solving and support-seeking vs denial, withdrawal, substance use), spiritual resources, and the actual (not assumed) support network. Ask: 'Who do you turn to when things get hard?' Screen caregivers too — caregiver strain predicts patient readmission. Document specific supports ('lives with spouse; daughter visits daily') rather than 'support system in place.'

Therapeutic Communication in Psychosocial Assessment

Psychosocial data only surface when the patient trusts the interviewer. Use open-ended questions ('How has this illness affected your life at home?'), silence, reflecting ('You say you've lost interest in everything since the diagnosis'), and clarifying rather than probing ('why' questions feel accusatory). Avoid false reassurance ('Everything will be fine'), giving premature advice, and changing the subject from uncomfortable topics — ANCC communication items consistently reward responses that acknowledge the patient's stated feeling before offering information. Confidentiality has limits you should state up front: threats of harm to self or identifiable others and reportable abuse override privacy.