section name header

Table 10-9

Physical and Intellectual

  1. Presence of physical illness or disability.
  2. Appearance and energy level.
  3. Current and potential levels of intellectual functioning.
  4. How client sees personal world, translates events around self; client’s perceptual abilities.
  5. Cause-and-effect reasoning, ability to focus.

Socioeconomic Factors

  1. Economic factors—level of income, adequacy of subsistence; how this affects lifestyle, sense of adequacy, self-worth.
  2. Employment and attitudes about it.
  3. Racial, cultural, and ethnic identification; sense of identity and belonging.
  4. Religious identification and link to significant value systems, norms, and practices.

Personal Values and Goals

  1. Presence or absence of congruence between values and their expression in action; meaning of values to individual.
  2. Congruence between individual’s values and goals and the immediate systems with which client interacts.
  3. Congruence between individual’s values and assessor’s values; meaning of this for intervention process.

Adaptive Functioning and Response to Present Involvement

  1. Manner in which individual presents self to others—grooming, appearance, posture.
  2. Emotional tone and change or constancy of levels.
  3. Style of communication—verbal and nonverbal; ability to express appropriate emotion, follow train of thought; factors of dissonance, confusion, uncertainty.
  4. Symptoms or symptomatic behavior.
  5. Quality of relationship individual seeks to establish—direction, purposes, and uses of such relationships for individual.
  6. Perception of self.
  7. Social roles that are assumed or ascribed; competence in fulfilling these roles.
  8. Relational behavior:
    1. Capacity for intimacy.
    2. Dependence-independence balance.
    3. Power and control conflicts.
    4. Exploitiveness.
    5. Openness.

Developmental Factors

  1. Role performance equated with life stage.
  2. How developmental experiences have been interpreted and used.
  3. How individual has dealt with past conflicts, tasks, and problems.
  4. Uniqueness of present problem in life experience.

Adapted from Wilson, HS, and Kneisl, CR: Psychiatric Nursing, ed. 2. Addison-Wesley, Menlo Park, CA. (out of print)