Psychosocial Assessment Paper

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Psychosocial/Assessment The client L.M. is a 58 year-old female, whom identifies herself as Caucasian, and speaks only English. L.M. is divorced and has a son who is married and has two children that live in Parker, AZ. L.M. denies any relationship with mother or father, and denies having any siblings. Per a court ordered admission on October 7, 2015 to the Mountain Health and Wellness, Sub Acute Facility (SAF) located in Yuma, AZ. for a clinical evaluation. L.M. was brought in because she was found in the middle of the street, having delusions such as being raped by the “Hells Angels and the Devil”. She was found by court to be a danger to herself and others. She made threats about hurting herself, “I’m going to fucking blow my head off”, and hurting others, “I took a knife and killed everyone” (Mountain Health and Wellness, 2015). L.M. was noted as, “emotional liability, having …show more content…

doesn’t appear to have any mobility, hearing, or vision impairments or assistive devices. L.M.’s ears and eyes symmetric, nose and throat are midline no deformities or deviations noted. Missing many teeth. Makes funny faces at random times at different staff members. She is allergic to penicillin. Heart, lung, and bowel sounds assessed by nurse stated they were “within normal limits” (Mountain Health and Wellness, 2015). Resident appears unkempt, hair is greasy, clothing stained, and fingernails dirty, toenails yellow, discolored, and thick. Skin is dry with small bruises on arms bilaterally. L.M. has a small scratch on left shin, where L.M. states she has been “shanked” during the evening. Musculoskeletal appears within normal limits in both upper and lower extremities no deficits noted. Appetite seems appropriate, her weight is 140 pounds, height is 55 inches with a normal BMI of 23.3, and abdomen is round, symmetric, and non-tender (Mountain Health and Wellness, 2015). L.M. states she hasn’t had a bowel movement in days and is constipated. She voids without

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