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Psycho Social Spiritual Assessment

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| Psycho-Social-Spiritual Assessment | NURS320 – Holistic Nursing | 2/26/2013 |

Psycho-Social-Spiritual Assessment Psychosocial development occurs throughout one’s lifetime and may change if there are certain factors such as stress, trauma, illness, or drastic life changes. Being able to recognize maladaptive and adaptive behaviors in someone, especially a client or patient, is important when I am the one responsible for the care they will receive. Educating myself on the different topics and questions that will be used during the interview portion of assessing a patient are critical for the nursing profession. The client, SR, maintains a busy schedule daily, and reflects on traumatic past events which are affecting her wellness and state of mind. SR has had complaints of severe headaches and moderate chest pains several times a week. SR stated during the interview that she does not like to take over the counter medications for pain relief, but rather tries to sleep to relieve the pain she feels. She has previously taken herbal stress supplements to relieve chest pain. SR noted many other symptoms contributing to her state of being: fatigue, difficulty sleeping, dizziness, shortness of breath, frequent urination, abnormal menstruation, and concentration problems. Looking deeper into her family history, there are no reports of neither of her parents or any of her grandparents being treated for severe headaches or migraines, but her one sibling made reports. There are several noted medical conditions in her family such as: diabetes, high blood pressure, heart disease, high cholesterol, cancer, glaucoma, and arthritis. When questioning SR, she was quite hesitant in answering many of the questions concerning her physical health. I also examined her body language and observed she shifted her position often and felt uncomfortable making eye contact. As I transitioned into questions regarding her spiritual lifestyle she immediately had begun to perk up, make eye contact, and spoke louder as well as gave thorough answers without hesitation. The way she lit up talking about her faith assured me that she was stable in her spirituality and relationship with God. My major concern dealt with her physical state of well-being. Through multiple factors, such as her eating intake and patterns, difficulty sleeping, her symptoms of pain, her daily schedule, and previous events in her life, have aided me to reach the conclusion of the following psychosocial issues present in her life: self-esteem, trust, guilt, and sense of loss. Recently ending a three year relationship, SR has developed low self-esteem and a lack of trust towards male figures. Issues of trust arose when SR discovered the lies that her significant other had hidden during the length of the relationship. SR was reluctant to share those details but confirmed that she no longer trusted males who were interested in developing a relationship beyond friendship. She is afraid of another male lying about the same topic which then progresses into low self-esteem about herself as a person in whole. She began exercising and joined an intramural soccer team to keep herself fit and her mind not focused on the former relationship. I asked if she had changed her diet to accommodate her new exercising schedule. She claimed to have no change in her eating patterns because of her dislike of most fruits and vegetables. She claims to eat only two meals a day at odd times, skipping breakfast, and drinks about two bottles worth of water. These facts play a part in the cause of her frequent headaches, and the chest pains may be brought on by the loss of trust stimulating stress and anxiety. Before SR’s relationship, her family suffered from the loss of a loved one that caused a great deal of guilt. Her older sibling’s fiancé had taken his own life. During this part of the interview SR became emotional but held back from crying in front of me. To me, this linked back to self-esteem as a sign of not wanting to seem weak in front of others. She continued to tell me about her sister’s fiancé and how they were unaware of any signs that would lead them to suspect thoughts of suicide from him. SR explained that she was close her sister and him which triggered the sense of guilt to which she should have been suspicious that something was wrong. I asked her how frequently she thinks about him and his suicide. She responded: “There isn’t a day that goes by where I don’t think about him. He was an important person in my family’s life. I sometimes have nightmares about it since we were the ones who found him. It replays in my mind constantly. My sister hasn’t been the same since and in a way I’ve lost her because of it” (S.R. personal communication, February 21, 2013).
She has difficulty sleeping from these nightmares and since she recognizing this, she has made her days end early by going to bed no later than 9:00 p.m. to make up for each time she wakes up during the night. In order to do so, SR will pack her day full with classes, school work, work, bible readings, prayer, and different tasks beginning at 7:00 a.m. From the loss of a loved one from suicide, a sense of loss of a sibling, and the guilt from it all results in SR piling on stress in order to try to block it out. Since she lets the stress build up, it elevates to chronic chest pains. By seeking other methods of relief, she may be able to dramatically decrease the number of headaches and chest pains she suffers from. To begin the healing process, SR will be referred to professional counseling in order to dig deeper into her past history to gain better insight on the issues consuming her thoughts and everyday life. I believe that through talking to a counselor or therapist, SR will gain the trust of that person and be able to clear out the thoughts and memories which are holding her back from living life wholly. The traumatic events from the suicide which have impacted her family greatly will be further analyzed. SR may be suffering from depression since such events can trigger this type of chemical imbalance of neurotransmitters in the brain (Anxiety & Depression, 2013). After speaking with a professional, SR may take the next step of trying other approaches to healing her body and mind. Participating in activities that are relaxing to the body and mind can bring a person back to a state of being whole and well. One therapy that relaxes the body and aids in reducing stress that I find suitable for SR is Reiki. Reiki will help to reduce SR’s fatigue, stress, and pain (Reiki, 2013). The gentle vibrations that begin at the head and move through the body should leave SR feeling refreshed, calm, and tension free. Feelings such as those should result in SR feeling confident about regaining a healthy body and mind. My main target for the practice of Reiki is to provide deeper and better quality sleep for SR. By improving her quality of sleep she may reduce the number of times during the night in which she wakes up from a nightmare. Through a good night sleep she will reduce the fatigue she experiences throughout her day. Generally, it is recommended to about four sessions per series (How Does Reiki Work, 2013). SR will begin with this treatment and then should begin to incorporate other types of therapies that will we related to Reiki. An additional method of treatment, Healing Touch, also works to relax one’s body and mind like Reiki. Healing Touch involves gentle touches that penetrate through the body’s field of energy to promote healing of the mind, body, and spirit (Healing & Touch, 2013). Through this method, SR may experience deep relaxation to refocus her mind. SR has been known to have high blood pressure and through multiple sessions of Healing Touch, she may lower her blood pressure, causing less stress on the heart. Healing Touch involves one on one healing, but if SR senses she is ready to move onto another form of treatment, she may explore practices which involve a group atmosphere. A therapy which would be most suitable, yoga is excellent in promoting wholeness of body, mind, and spirit for SR. Yoga is known for greatly reducing stress and other areas of the body in which stress has affected. SR will learn techniques on breathing that will provide muscle tension relief. SR’s longing to be relieved of chest pains will be met through this practice. She had mentioned during the interview that lately she has been struggling in class because she is having difficulty concentrating on the lecture. “Psychological benefits of practice include relaxation, greater equanimity, better concentration, and improved mood” (Yoga, 2013). I believe through practicing yoga, she will be able to focus better in class, and even at work. Not only will she benefit in those areas, but she will gain strength and flexibility (Yoga, 2013). Yoga will also enhance her spiritual life which has been a stronghold in her life. With the array of benefits from the different methods of therapy, a final plan of action to deal with the maladaptive behaviors in SR’s life is to improve her diet. She claims to dislike many fruits and vegetables but has not tasted them to prove these beliefs. Maintaining a healthy diet will supply SR’s body with the nutrients it needs to sustain wellness, fight and prevent diseases, and improve overall health (Diet & Nutrition, 2013). SR only eats about two meals a day at different times each day and only consumes about two 16oz water bottles each day. For breakfast, if she does not skip, she will eat a high calorie granola bar. Usually at night, she stated she will eat a small package of fruit snack gummies before going to bed. This type of diet will not be able to sustain a healthy lifestyle. By seeking help from a registered dietitian (R.D.), SR can be guided in planning a healthy diet as well as an eating schedule, which will in benefit her whole health. Spirituality in life can significantly have an impact if strong in faith and practiced daily. SR begins each day by reading scripture and uses the remainder of the time before leaving for class to meditate on the reading through prayer. SR expressed more feelings of joy when talking about her faith and smiled more frequently. It demonstrated to me that she is very comfortable with where she is now in her relationship with God. She admitted that “even though there have been some really horrible things to happen in my life, I know that God has a plan set out for me and these are only the narrows pathways I have to push through” (S.R. personal communication, February 21, 2013). She has grown up being taught about the Bible by her parents and through teachers at the private Christian school she attended. Being at college has made it difficult for her to attend a church regularly because she hasn’t found a church in the area where she feels content. This has been the only factor which inhibiting her from learning more. To compensate for the inability to hear a pastor’s sermon, she will listen to podcast from other churches when she makes time available during the day. If she were to take more time and to attend some other churches, or even try attending services again at previously tried churches for a better feel, she may fill in that empty space. Connecting with others who share similar spiritual beliefs could cause a positive change in SR’s spiritual growth. They could be encouraging to her, giving her an extra boost of hope. Much of the maladaptive behavior that has been consuming SR’s life may be easily resolved if she is to take action through seeking professional help within the methods of therapy suggested. Stress and chest pains were SR’s main concern pertaining to her health, but taking the time to engage in conversation during the interview had unwrapped to deeper matters. Recognizing the psychosocial issues in my client has encouraged me to continue to look deeper into my own maladaptive behaviors to better my life. Many people are most likely to hide their maladaptive behaviors and through thorough questioning and thinking on a more critical level, we are able to unravel those hidden behaviors. Taking the time to interview someone, asking personal and intimate questions was truly insightful for future situations as I prepare for my career in nursing. Since I know the client I interviewed, I myself did not feel uncomfortable asking the majority of the questions, but when I could feel that she was uneasy answering most of them; it made me feel uncomfortable. Identifying her behavioral patterns has made me more aware of the person she is, as well as how to comfort her during times where she is expressing her maladaptive behaviors. Gaining knowledge about her beliefs in spirituality and her relationship with God provided a great deal of awareness in understanding what motivates her through her struggles. Each interaction with a patient or client will strengthen my own comfort as well as provide reassurance to them that my concern is to provide the best quality care for them possible.

1. Example Intake and Assessment Forms. (2007). Baltimore: Bravewell Clinical Network. Retrieved from
2. Dossey, B. M., & Keegan, L. (2013). Holistic nursing: A handbook for practice. (6 ed., pp. 168-169). Burlington, MA: Jones & Bartlett Learning.
3. Regents of the University of Minnesota and the Life Science Foundation (2013). Anxiety & Depression. Retrieved from:
4. Regents of the University of Minnesota and the Life Science Foundation (2013). Diet & Nutrition. Retrieved from:
5. Regents of the University of Minnesota and the Life Science Foundation (2013). Healing Touch. Retrieved from :
6. Regents of the University of Minnesota and the Life Science Foundation (2013). How does Reiki work? Retrieved from: practices/reiki/how-does-reiki-work
7. Regents of the University of Minnesota and the Life Science Foundation (2013). Reiki. Retrieved from:
8. Regents of the University of Minnesota and the Life Science Foundation (2013). Yoga. Retrieved from:

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