Running head: PSYCHOSOCIAL ASSESSMENT

Psychosocial Assessment Shane Maciel California State University Fullerton Professional Nursing 1 Lab Nursing 305 Lab Lisa Armstrong December 07, 2011

PSYCHOSOCIAL ASSESSMENT Psychosocial Assessment I. Demographics CC is a 37 year old Caucasian female with no religious preference although she reports being baptized as a Christian when she was a little girl. This interview took place on November 20, 2011 at Arrowhead Regional Medical Center. CC has never been married but has three children ages 20, 17, and 15 from several relationships. Her children live with family members

of their fathers, and she reports not having seeing them for years. CC is unemployed and lives in San Bernardino, CA, in a 24ft travel trailer. She reports that approximately a week before her hospitalization she was asked to leave the trailer because the owner has a friend that he is going to let stay there. During this interview CC stated that she has nowhere to go when she is discharged. CC was born and raised in San Bernardino. She left home at 15 years old and never finished high school. She does not know where her father is and she has not spoken to her mother in 15 years. Her mother moved back to Missouri, where she is from, in 1996. CC states that she does not have any family living in California. She is alone and has no source of income or support. CC was admitted to ARMC for Bilateral Hemothorax and multiple fractured ribs on the left side. She is alert and oriented, but requires maximum assistance with activities of daily living. She has bilateral chest tubes to water seal with massive bruising and abrasions to her left side. She reports that she was drinking with her boyfriend. They got into a fight while they were in his truck, and she jumped out of the vehicle while it was moving. Somehow, she got stuck and was run over by the back wheel. She reports that her boyfriend then backed up and ran over her again. He then helped her back into his truck and took her back to her trailer and dropped

PSYCHOSOCIAL ASSESSMENT her off. She spent three days in the trailer unable to breathe or move. A female friend found her and insisted that she go to the hospital. Only after her friend said that she was going to call 911 did CC allow her to take her to the hospital. Apparently, in the Emergency Department the police were notified and were investigating the circumstances of CCs injuries. II. Perception of Health A. CC states that prior to this hospitalization her health was good. She has never been hospitalized except to deliver her babies. She reports that she was diagnosed with

Hepatitis C three years ago, but she has no signs or symptoms, so she is still healthy. She has had no treatment or follow up for Hepatitis C. B. CC describes her body as well built, but a little chubby. She states that she looks older than she is from hard living. 1. She regrets the multiple large homemade tattoos she has on her back, chest, and left thigh. She states that if she could change anything she would get rid of the tattoos. 2. Her favorite part of her body is her blue eyes. She says that she always gets compliments on them. C. When I asked CC to describe what kind of person she was, she did not have a lot of good things to say about herself. She started off by saying she was selfish. She stated that she uses people to get what she wants. She also described herself as weak and lazy. She said she treated her family and kids like shit. She reports that she has never been able to get her life together because she is a drug addict. When I asked her if she had any strengths she said Im good at fucking things up. She became tearful and upset at this point, so I did not pursue this question further.

PSYCHOSOCIAL ASSESSMENT III. Mental Status/Psychological Assessment

A. CCs physical appearance is unremarkable except for the bruising, abrasions, and chest tubes. She was wearing a hospital gown, so it was difficult to assess how she dressed. Her hair had been bleached with four to five inches of brown roots showing. She did not seem concerned with her appearance. Her behavior was erratic. When she was not sleeping she was restless and anxious. She spoke using profanity freely, and frequently required interventions to calm her down. She would escalate to the point that she could not breathe, which made her more restless and anxious. She responded well to me sitting with her during this interview however, certain topics would set her off. 1. CC has full motor ability. a. Her posture was affected by her positional ability to breathe. b. Her gait was difficult to assess. She was on bed rest. 2. As described above, she was not concerned with her grooming or apparel. 3. Her non-verbal behavior was restless with periods of depression or anxiety. 4. CCs sensory ability was unremarkable. All five senses were intact. B. Sensorium 1. CC was alert and oriented. Her decision making was poor. She kept trying to get up by herself to use the bathroom. She disconnected her IV several times and knocked both of her chest tube pleuravacs over. 2. CCs emotional status was significant. a. Her affect and mood was labile. b. When she gets angry she drinks alcohol and uses drugs.

PSYCHOSOCIAL ASSESSMENT c. When she is sad she cries and gets mad.

3. CCs ability to perceive herself realistically appears intact. She openly admits that her life is a mess. 4. Indicators of CCs judgment are her decisions to jump out of a moving car and continuing to attempt to get out of bed with bilateral chest tubes. 5. CC scored 26 on the Mini Mental Status Exam. She was able to give the year, season, and month. She was unable to give the day or date. She knew the state, country, city, and facility she was in. She easily repeated the names of three objects after I named them on the first attempt. CC had difficulty counting backwards from 20 in threes. She only got to 14. On her first attempt, she was able to recall all three names of the objects stated earlier. CC was able to give an adequate explanation of the proverb, dont count your chickens before they hatch. CC easily identified a pencil and a watch, repeated the phrase no ifs, and, or buts, and performed a three stage command. She was unable to

comprehend the command to write close your eyes. She tried to write on paper with her eyes closed. She was able to write a simple sentence and draw

overlapping pentagons. Her level of consciousness along a continuum was alert. C. Mental Dysfunction 1. CC denies delusions, hallucinations, or obsessive compulsive behaviors. 2. CC is open about her drug and alcohol abuse. She claims to smoke a pack of cigarettes a day and usually drinks alcohol daily. She smokes marijuana when it is available, but states that it is not her drug of choice. She also reports using Meth regularly and used to do a lot of heroin intravenously. She believes using

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heroin is how she was infected with Hepatitis C. CC also admits to using cocaine and meth intravenously. She openly admits to being a drug addict and has no desire to quit. 3. Her family history is positive for alcohol and drug abuse. She states that as far back as she can remember her parents and grand-parents drank and used. She grew up in a family that was always loaded. IV. Activities of Daily Living A. CC has no job. She does not have a drivers license or transportation. She states that she does not have a cell phone. Her typical day is spent sleeping during the sunlight hours and partying at night. She explained that much of her time is spent trying to hookup with men that have drugs or alcohol. She has no commitments, or anywhere she needs to be at a scheduled time. She explained that sometimes she does not make it back to her trailer for 3 or 4 days. B. Diet History 1. CC explained that her diet consists of a lot of fast food and canned goods. She likes Jack-in-the-Box tacos and chunky soup. She reports that the refrigerator in her trailer does not work, so she cannot keep perishable foods. She said that the people living in the trailer park share food with her. 2. CC has no food allergies. She does not like many vegetables. 3. When she is on a drug or alcohol binge she has no appetite. 4. She has no scheduled eating times. The atmosphere at meals depends on who she is with. She rarely has money for food herself and depends on others. 5. CC believes she is about 30 pounds overweight.

PSYCHOSOCIAL ASSESSMENT C. Sleep, Relaxation, Exercise

1. CC has no regular sleep pattern. Sometimes, she does not get out of bed for 24 hours. While on Meth she can go 2-3 days without sleep. She reports no difficulty sleeping when she is not using. 2. CC denies any hobbies. Her relaxation consists of sleeping a lot. When I asked her how she relieves tension she said I drink. 3. CCs only form of exercise is walking. She has several people that she knows that live within walking distance, and often walks to their houses when she gets up. She said that she used to like to ride her bicycle and rollerblade when she was young. V. Social History A. As described earlier, has no family in California, She is absent from the lives of her children and has not spoken to her mother for 15 years. Her only sibling, a sister, lives in Texas and wants nothing to do with her. CC explained that Dave, the guy who manages the trailer park and let her live in the trailer, has helped her, but he wants her to leave. Her only close friend is Samantha, the girl who insisted CC go to the hospital. CC feels that at this time Samantha is the most important person in her life and the only person she could go to for help. CC stated that she really does not have any close friends because she uses people and they get tired of her. She is uncomfortable in groups unless she is partying with them and tends to gravitate towards lower companionship. She openly explained that she likes to spend time with men that can provide her with drugs, alcohol, and money.

PSYCHOSOCIAL ASSESSMENT B.

CC explains her trailer as a place to crash. She said that it is an old trailer in a

shabby trailer park where a lot of druggies live. She has no transportation except from others. Several people who live in the trailer park give her rides and share their food with her. C. CC has not been employed for over three years. Her last job was cleaning motel

rooms. She stated that she was fired from every job she has ever had. D. CC has no health insurance. Her only source of money is from the men she meets.

She emphasized that she does not hook for money. She said that she hooks-up with guys and spends several days with them. They usually spend money on her and give her drugs, alcohol, and food. She became tearful when explaining this to me and said that she wished she did not live this way. When I suggested going to rehab, she said that she tried to go to one of those places before, but left after 5 days. She could not stand it in there. E. CC never finished 10th grade. She has no specialized training, or interest in getting her GED. VI. Cultural and Social History A. CC explained that she is from a low-income white American Christian background. She stated that she has not been to church since she was a little girl. B. English is her only language. C. Although she believes in god, she gave up on him a long time ago. D. CC was unable to describe any practices in her culture that help her stay well. E. CC rarely seeks medical help. She was admitted to Arrowhead Regional Medical Center 3 years ago for pneumonia. This is when she was diagnosed with Hepatitis C.

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F. CC had difficulty answering the question regarding who or what else could help her apart from health care professionals. She believes chicken soup helps for a cold. D. She declined needing to speak to a chaplain during this hospitalization. VII. Responses to Health and Illness A. CC has little value on her health. She demonstrates this by her lifestyle choices, the people she associates with, her diet, and lack of consistent medical care. When I asked her what she was doing for three days in her trailer, when it was obvious that she was severely injured, she stated I dont know, I guess I was hoping to die. B. Her reaction to illness is to sleep. C. CCs response to care is hostile. She required restraints in the emergency department. She speaks to the staff with profanity. Her perception of caregivers is that they are like the police. They are authority figures telling her what to do and judging her. She is noncompliant with her plan of care. She refuses to stay in bed; she disconnects her IV, and refuses to us the incentive spirometer as instructed. D. CC does not follow any health maintenance practices. She only goes to the hospital when she is really sick. VIII. Developmental Stage According to Eriksons developmental stages, CCs age puts her in stage 7 called Generativity vs. Self-Absorption or Stagnation. However, she appears to fall closer into Eriksons 6th stage called Intimacy and Solidarity vs. Isolation. Because of her prolonged alcohol and drug abuse she has never established intimate relationships. She isolates and distances herself from others.

PSYCHOSOCIAL ASSESSMENT IX. Psychosocial Health Assets

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Clearly, CCs health deficits far outnumber her health assets. The only real assets she has is her age and her friend Samantha. 1. Adequate age to develop positive health practices. 2. Adequate social support X. Psychosocial Health Deficits A. Ineffective Coping related to inability to manage stressors constructively without drugs/alcohol. B. Impaired Social Interaction related to alcoholic problematic behavior with emotional immaturity, irritability, high anxiety, impulsive behavior, or aggressive responses. C. Disabled Family Coping related to the destructive effects of alcoholic family member on family functioning and each family member. D. Ineffective Self-Health Management related to insufficient knowledge of condition, treatments available, high-risk situations, and community resources. E. Ineffective Breathing Pattern related to bilateral hemothorax with chest tubes and multiple rib fractures. F. Dysfunctional Family Processes related to destructive family response patterns to alcohol/drug abuse. XI. Priority Diagnosis CCs primary issue is her drug and alcohol abuse. It has affected every aspect of her life. Her only coping skill is to use or drink. Her living arrangements, her lack of health practices, her separation from her family and children, and her hospitalization are

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all directly related to her addiction to drugs and alcohol. Here are the interventions suggested to facilitate CCs ability to manage stressors without drugs or alcohol. A. Determine if CC wants to stop drinking and using. In CCs case this would be done through an intervention by healthcare providers. B. Detoxification period. Preferably in a controlled environment with skilled caregivers to monitor CCs progress. Ideally, she would go directly there after discharge from ARMC. C. Long term in-patient rehabilitation. For CCs best chance at success she should be living in a clean and sober facility with a supportive staff. This facility would provide her with group and individual therapy. It would provide education and the ability to practice positive coping skills. She would receive proper rest and nutrition, allowing her body, mind and spirit to heal. Preferably, she should stay there at least a year, acquiring privileges as she progresses in her recovery. D. Involvement with a 12 step program. Permanent long term recovery usually involves sponsorship and implementing the 12 steps into ones life. 12 step groups are also beneficial in developing supportive relationships with other sober alcoholics.