Bio-Psycho-Social-Cultural-Spiritual Assessment - Essay Sample

Introduction

Health Insurance Portability and Accountability Act (HIPAA) requires that before any evaluation, the resident ought to be fully aware of the levels of confidentiality. As such, the interviewee was informed of the level of confidentiality before the start of the exercise and chose to voluntarily participate. This report is based upon the information that was provided by the interviewee and his physician, Dr. Ortiz who were considered suitable for the exercise.

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Bio-Psycho-Social Database

Consumer Identification

Consumer or resident is a 76-year-old, widower, Vietnamese, male born in Hanoi, Vietnam on June 16, 1943. Dr. Ortiz, the consumer's Primary Care Physician (PCP), referred him to Longleaf Hospital for temporary rehabilitation and talk therapy services. This was after a brief stay at the Our Lady of The Lake Regional Medical Center.

Behavioral Mental Health History

Major Complaint

It came to our attention that the resident had been calling throughout the night due to anxiety linked to fears, trauma, and pain experienced as a teenager. He mentioned that he is depressed as a result of chronic pain and the inability to take care of himself. The resident also has a history of falls which resulted in lower back injury and surgery. In addition, the resident has of late exhibited aggressive behaviors towards family members and caregivers.

History of Current Symptoms/Stressors

Presenting Problem/Reason for Coming to Longleaf Hospital

Prior to being admitted to Longleaf Hospital on January 10, 2019, the resident had been living with his nephew in Leesville, Louisiana. Currently, Medicare insurance offers in-home health care services such as home health care aides who are available to provide at least twenty-five hours of in-home services a week. The in-home services include feeding, bathing, dressing, and toileting. Resident's nephew, who assists in taking care of him throughout the week, supplements the Medicare services. Due to the resident's history of falls, it was established by the Primary Care Physician that the resident is at risk of injuries and falls due to poor safety awareness.

The resident also mentioned that he has a tendency of attempting self-transfers when anxious, restless or impulsive. The resident also seems to be unaware of why he is staying at the Longleaf Hospital as he is seen frequently disoriented. The resident mentioned that he experienced quite a number of traumas growing up and these causes him a lot of pain.

Likewise, he stated that he suffers from anxiety and depression due to the inability to do things for himself and is not happy staying at the Longleaf even though it is just temporary. This has in return led the resident to develop aggressive behaviors such as name calling, cursing and yelling to both his nephew, Longleaf Hospital staff and in-home caregivers. According to Dr. Ortiz, resident exhibits symptoms and behaviors similar to the following DSM-5 diagnosis: Adjustment disorder with Anxiety and Depression.

Similarly, the resident was diagnosed with age-related osteoporosis and he has currently prescribed two medications: An analgesic for chronic lower back pains and mild -psychotropic antidepressant prescribed for the symptoms related to anxiety and depression. The medication has so far shown positive results as the resident has indicated that he has not been bothered over the past one month of his stay at Longleaf Hospital.

Current symptoms include Impulsivity, anxiety, adjustment disorder, chronic back pain, aggression, confusion, disorientation, and mild depression (Cummings & Galambos, 2016).

Current stressors include Temporary change in living environment from his home to Longleaf Hospital in-home living facility, loss of independence and trauma related to his youthful years.

Psychosocial History: Ethnic/Cultural Factors and Preferences

Social History

The resident lives in Leesville, Louisiana, where he has lived in the same home for the past 17 years alone since the demise of his wife, however, he now stays with his nephew, who provides the support needed. The resident was married before but lost his wife in a tragic road accident. He did not have any children. He is close to his younger brother and nephew both of whom reside in Leesville, Louisiana. The resident is a Bachelor of Arts degree holder from Can Tho University. He moved to the United States upon graduation in search of better employment opportunities. He worked at Jefferson and Sons as an art administrator until he retired at the age of 65-years-old. He enjoys fishing when he has a chance. The resident also stated that he is of a lower-middle class and his income is fixed survives on whatever he receives from his savings, Social security benefits and money from his younger brother.

Educational Background: The resident is a Bachelor of Arts degree holder from Can Tho University. He stated that he loved poetry and graduated top of his class.

Relationship Status: Widower

Trauma and Abuse History: The resident mentioned that he suffered various forms of trauma growing up. However, he fails to give specific details of the trauma he experienced.

Legal History: The resident stated that he has never been arrested before and therefore did not have any legal history.

Medical/Psychiatric History

Current physical pain assessment: The resident states that on a scale of 0-10, where 0=no pain and 10=incredible pain, his pain is at a 7.

Family Medical History: Resident states that there is no known familial medical history.

Personal Medical history: As a result of previous falls, the resident has chronic back pain and L1, L2, and T12 compression fractures. He underwent vertebroplasty on September 3, 2017, to correct a new L1 fracture. Also, the resident has been diagnosed with osteoporosis. According to Dr. Ortiz, anxiety may also contribute to his overall pain.

Alcohol and drug use: Resident stated that he has been sober for the past 10 years.

Medications: Resident currently takes Xanax (.30 mg) a mild-psychotropic antidepressant to help manage the symptoms linked to anxiety and depression, and Naproxen (650 mg) an analgesic to help ease the chronic lower back pain.

Current Factors

Spirituality: Resident stated that he is spiritual and that his faith in God is what keeps him going.

Financial Status: Resident was assessed and it was agreed that there is no current need for additional referrals.

Overall Safety Risk-Assessment

The resident was assessed for risk factors, warning signs and protective factors using a Mood Interview Assessment (MIA). After observing the resident's overall disposition the resident assuredly denied plans of suicidal ideation and homicidal ideation. The resident did not present as harm to themselves or others during this assessment. Protective factors include familial support, hope towards the future, the resident's desire to return to his own home, and his religious beliefs. Risk factors include anxiety, depression, chronic pain, and limited social support. The resident does not have access to weapons in his home and is not a current risk to his safety or the safety of others.

Mental Status Examination

The resident was attentive and aware of his environment. His body language was relaxed as he lay in bed. The resident did not seem, by all accounts, to be in perceptible torment in spite of his self-report.

Resident's overall mood was "ok" and he appeared to be stable throughout the assessment. The resident stated that he has not been bothered over the last month by poor sleeping, sleeping too much, having a poor appetite, or thoughts that he would be better off dead. He stated that he has been experiencing pain in his lower back and that he has felt anxious and fearful as a result of trauma experienced as a teenager.

Resident's thought process was realistic, goal-oriented, simple, attainable, and clear. Resident's cognition and memory appeared to be intact and he could recall past and present information with ease. His overall demeanor did not appear to be confused or anxious. Formal intellectual capacity appeared to be in the average range for Resident's age, and his insight, judgment, and impulse control appeared to be intact.

DSM-V Diagnostic Impressions

Resident shows symptoms and behaviors similar to adjustment disorder, anxiety, and depression. Based on the etiology of the resident's symptoms, the most appropriate diagnosis at this time is Adjustment Disorder with Anxiety and Depression (Pollard, 2018).

Principal Diagnosis: Adjustment Disorder with Anxiety and Depression.

Comorbid Conditions: The resident reports symptoms that meet criteria for Anxiety Disorder and Depression.

Resident's Socio-Cultural-Spiritual Context and Areas of Identified Need

Cultural Context

The resident stated that he is Catholic and is interested in attending Mass when it is held at Longleaf Hospital. When he is unable to attend, volunteers will provide visits to his room to offer communion and blessings. The resident stated that he will attend activities of his choice offered by Longleaf Hospital such as Catholic Mass, musical entertainment, and other programs that promote his religious beliefs. The resident stated that choosing his own clothing, taking care of his personal belongings, being provided snacks in-between meals, and having his family involved in discussions regarding his care are very important to him. The resident will accept visits from his brother and nephew, activity staff, and volunteers.

Potential community supports to sustain the client in his community: Resident states that he feels connected to his brother and nephew and perceives himself as having a strong social support network. Furthermore, he feels connected to members of his church, St. Michael Church, and hopes to continue attending regular Mass when he returns home.

Client’s Concerns, Needs, and Expectations

The resident has stated that he has feelings of 'sadness' regarding the loss of his ability to drive and do daily tasks for himself. He feels hopeful that with the continued assistance of his home health care aides, that he can continue to live independently and avoid living in a long-term facility such as Hospice Compassus. Resident states that he is concerned for the pain in his lower back and the anxiety he feels even with medication. He stated that he would be willing to try talk therapy with the Longleaf hospital therapist, Dr. Ross.

Assessment of Resident’s Strengths and Readiness: Resources, Options, Possibilities, Exceptions, and Solutions (Ropes)

In working with the resident, he is not only resilient and resourceful but he has a hopeful outlook on life and shows readiness to set goals to work towards. While the resident has episodes of anxiety and depression, he is more often than not happy and easy to talk with. He communicates well and is able to clearly visualize what he wants most, which is to return home and maintain his independence for as long as possible. The resident realizes that while it is not ideal to need help with his daily tasks, he is grateful that he is not in a long-term living facility and that he can live his life how he pleases. Despite some medical setbacks, the resident is grateful that he is still in good health, which allows him to live mostly alone. He is happy to rely on his brother and nephew in the case of an emergency, and he stated that he hopes to return to his "normal" routine as soon as possible.

Recommendations/Treatment Plan

Intervention Modality: Strengths-based Approach/Cognitive Behavioral Therapy/Motivational Interviewing/Crisis Prevention Intervention

Long-term Goals:

Resident's chronic pain will be manageable.

The resident will experience a decrease in anxiety...