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PSYCHOSOCIAL ASSESSMENT Documentation

Mama G is a 75-year-old woman living with relatives in Bacolod. She suffered a stroke two years ago that led to dementia from her history of smoking. She is now bedridden and unable to move half her body. A psychosocial assessment found she has poor hygiene, limited mobility, disorientation, and poor memory and judgment. However, she has a positive mood and loving relationships with her family, who provide her constant care for all her needs.

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Angelo Arabejo
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632 views

PSYCHOSOCIAL ASSESSMENT Documentation

Mama G is a 75-year-old woman living with relatives in Bacolod. She suffered a stroke two years ago that led to dementia from her history of smoking. She is now bedridden and unable to move half her body. A psychosocial assessment found she has poor hygiene, limited mobility, disorientation, and poor memory and judgment. However, she has a positive mood and loving relationships with her family, who provide her constant care for all her needs.

Uploaded by

Angelo Arabejo
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PSYCHOSOCIAL ASSESSMENT

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Patient's History
Patient Mama G is a 75 year old female who is living with my relatives in
Bacolod. Mama G suffered from a stroke which led her from having dementia due to her
smoking habits. She is currently bedridden and couldn’t move half her body. She is also
recovering and receiving therapy after being hospitalized 2 years ago.

General Assessment and Motor Behavior


Her overall appearance seem to look sickly. She has scraggy hair, Her limbs are
really thin, and her teeth are starting to fall off. Her hygiene is well maintained by the
helpers at home and she usually wears a duster since it is easy for her to wear.
For the psychomotor behavior, the client couldn’t move half of her body due to
the stroke she experienced and she mostly uses her left hand to pick up light stuff.

Mood and Affect


My client’s mood was usually positive and didn’t show any grumpiness during our
interaction. On our first day, she seemed lethargic and was eager to take her afternoon
nap.
Thought Process and Content
My client usually has a hard time trying to think about factual information. She
verbalized about having a headache if trying to talk about that kind of stuff. She likes to
think simply and doesn’t engage in any difficult questions during the interaction.

Sensorium and Intellectual Processes


My client shows disorientation when talking about the date of the day since she
spends her time mostly in bed. She seems to remember where she lives and retained
few memories about the life going around her. Her memories revolve around the only in
one day and sometimes forgets it the next day.
Judgment and Insight
Her judgement skills are poor and she mostly relies on our relatives in Bacolod
but she seems to give a simple opinion from time to time.
Self-concept
My client doesn’t linger much in the self-concept because of her condition and all
she thinks about is her needs of feeding her, someone to talk to, bathing, and changing
her diaper.

Abnormal Sensory Experiences and Misperceptions


My client is really forgetful and she seems to retain a few memories or
sometimes the day she has gone through but as much as she can she tries to
remember the things that are going on in her life.

Roles and Relationship


Our relatives take good care of her since she has been a good grandmother to
us. She has established a loving relationship with her family despite her condition.

Physiologic and Self-care Considerations


My Client is really needy with herself and she asks a lot when it's time to eat,
sleep, or bathe her. Her needs are provided all the time and she only asks for the
simple needs and nothing more. She lives by her comfort in bed since she stays home a
lot.

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