LORDSON GEM P.

IBON
BSN III-B (Florence Nightingale)
NCM 117b

PSYCHOSOCIAL ASSESSMENT

A. History

1. Age: 42 years old.

2. Developmental Stage: Generativity vs. Stagnation

Havighurst’s Development Theory

Robert Havighurst theorizes that learning is essential to life and that people continue to
learn throughout life. A developmental task is a task which arises at or about a certain period in
the life of an individual, successful achievement of which leads to an individual’s happiness and
to success with later tasks, while failure leads to unhappiness in the individual, disapproval by
society, and difficulty with later tasks.

My client belongs to the stage of Middle age (30-60years old). The tasks included in this
Achieving adult civic and social responsibility, Establishing and maintaining an economic
standard of living , Assisting teenage children to become responsible and happy adults ,
Developing adult leisure-time activities , Relating oneself to one’s spouse as a person ,
Accepting and adjusting to the physiologic changes or middle age , and Adjusting to aging
parents.

Developmental Fully Partially Not Achieved Justification

Task Achieved Achieved
Achieving adult / According to the patient,
civic and social he actively participates
responsibility during election and voting
of leaders. He attends in
there fiestas. He also
attends in “clean and
green” which happens
quarterly in their barangay.
Establishing and / The patient has currently
maintaining an no occupation due to his
economic illness but as he verbalized
LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

standard of “kayat ko ti agsarak ti

living. trabaho tapno biagek met
kuma toy pamilyak nu han
lang kuma gappo kadetoy
mapaspasamak kanyak
kayat ko ti agsarak tun
malaingan nak kaasin Apo
Dios.”
Assisting / According to the patient,
teenage children he taught his nephews and
to become nieces to become
responsible and responsible like doing
happy adults  household chores, doing
their school
responsibilities, and giving
these children proper
guidance and freedom to
explore on their own.
Developing / According to the patient,
adult leisure- he usually watches
time activities  television, listen to radio
and chit-chat with his
friends.
Relating oneself / The patient has no better
to one’s spouse half but he adapted the
as a person  responsibilities as uncle of
his nephews and nieces.
Accepting and / According to the patient,
adjusting to the he knows that the
physiologic physiological change of
changes or middle age (such as
middle age  wrinkling of skin, hair loss,
and decrease physical
strength) is one of the
 LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

stages of life and every one

of us will experience it. He
verbalized “Natural lang
met nga lumakay da tao
ket haan tay met maigawid
ti panaglakay wenno
panagbaket ti maysa a
tao.”
Adjusting to / According to the client, his
aging parents family (the patient,
nephews and nieces) are all
still depending to his
parents. They are still
being supported by the
income of his father from
farming who is already 61
years old and considered
on his retirable age. They
are still depending their
basic needs to his father.

ANALYSIS: Based on the table above as supported by his verbalizations and statements, the
client achieved 4 tasks, 1 task is partially achieved and 2 tasks which is not achieved. According
to the theory, the client still has tasks which are partially and not achieved because with his age,
he is in the stage of Middle age wherein he still has up to the age of 60 years old to achieved the
tasks.

3. Client’s History
 LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

Christian Grey is 42 years old from Brgy. Barcelona, Solsona, Ilocos Norte. The client

stated that when he was still a child, his parents taught him good manners and right conduct and

how to respect people. During his childhood development, he received adequate love and care

from his parents and when he wants something; his parents work hard to buy all the stuff he

wants. During his school age, the client stated that he studied elementary at Barcelona-Aguitap

Elementary. He stated that he doesn't want to go to school because he was too lazy to write but

his parents encouraged him to go to school because in that way he could achieve whatever

dreams he has in mind. He spent his 4 years of secondary education at Solsona National High

School. He had friends way back and they usually play on the street and go to other barangays

through biking. He claimed that he was a trouble maker when he was a teenager. He was once

involved in a fight against other teenagers because of basketball and he claimed that he really

wanted to fight because he believed that he was stronger than other people. Also, his friends

taught him how to smoke and drink liquor. He can consume 1-2 Red Horse Beer and a pack of

Marlboro in a day. Because of such situations, his parents usually scold him or whip him to make

him a good person. He continued studying college at Data Center College of Laoag and took up

Bachelor of Teacher Education but he failed his 1 st attempt of taking the Professional Teacher’s

Examination.

According to the client, he was never admitted to hospital because of his condition,

nevertheless he’s grateful because he still in moderate mode of thinking.

The client has a good social network since he has his family to support him no matter

what happens. Even though he has an illness, they still treat him as a part of the family.

Watching television, sleeping, and walking are his primary sources of relaxation.

4. Cultural and Spiritual Beliefs

 LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

Upon asking the different questions to the client, he answered simultaneously. On the

other hand, he is a citizen; he keeps the society fair and peaceful. He has the role and

responsibility to follow the laws such as crime prevention, and obey the rules of society.

Moreover, client is Catholic in the society. He goes to church and attend Mass every Sunday. He

prays and sings hymns in the church. Sometimes, he used to perform during mass, through this

role; he can spread joy to others. His perception on having eye contact is being serious and

genuine when creating a conversation. Besides, he is experiencing such conditions, he always

pray to God that he will guide him to any endeavors that he may face every day in his life,

because no matter what happens, God is always there for me, he added.

5. Beliefs and practices about mental health illness

Client has a lot of roles and responsibilities in different aspects in society. He was very

pleased and willing to serve people and he will do as much as he can to improve the society so

that everyone is living under a peaceful world. Although he cannot change the world, he will try

his best to make the world a better place and its people more joyful. This instinct of him helps

him to manage emotional problems. According to the client, there’s no such thing that could

handle someone’s emotional state. He mentioned that if we trust God’s process, then everything

will be fine. “Just give to Him everything and he will pour you the best practice that could help

you to grow and glow,” he added.

B. General Assessment and Motor Behavior

Mr. Christian Grey was wearing a T-shirt, shorts and a slipper when seen at the area. His

manner of dressing is appropriate to his age, sex and the current situation. He appears clean and

well-groomed. It also appears that he looks younger than his chronological age. During the

conversation, he appears sad and slouchy. His head is lowered and shoulders are shrugged down.
LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

He does not maintain a good eye contact yet still answers questions. Most of the time, he looks at

a different direction and just glanced at me once in a while. He also stare blankly when asked

questions. He also walks slowly when observed.

During the course of the interview, he is still cooperative but talks slow and soft. His

answers are barely audible thus requiring repeating his answers for clarification when not clear.

There is also poverty of speech because he does elaborate statements that much. There are also

instances that the patient is seen smiling for unknown reason then goes back to his emotionless

face.

The patient seems well yet lethargic. He does not show activeness in the things he do. As

observed, he does not initiate interactions or any communications with other people. He

responded all my questions as he elaborates everything. He also talks in moderate manner. He

stays in his room most of the time or sits in a corner when observed. He is underactive because

he doesn’t engage in activities done by the other people. He was also observed that he has

mannerisms like moving his lips just like smiling.

C. Mood and Affect

I conducted an activity which is a puzzle game and he was asked if what does he felt after

the game and he said it was fun yet he does not look happy. He was not smiling or does not show

any signs of happiness. He just sat in a chair like he did not engage himself to an activity. He has

a flat affect. This is his affect most of the entire course of interview.

The patient claimed that his brothers and sisters humiliated and laughed at him when he

did not passed his board exams and that he has hatred towards them since they belittled him. As

he utters such statements, he did not show any signs of anger in his face or in his actions. He did

not express his feelings towards the situations. His claims are not appropriate to his emotional
LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

reactions. On the latter sessions of interview, he again claimed that he is already fine with her

sisters yet he doesn’t look fine in the outside. There is a sign of anger on his face especially on

his eyes.

D. Thought Content, Process and Experience

Content
The client claimed that he often dreamt about ghost every other night, according to him

“Agtagtagainep nak ti ar-araya, tallo nga babai suda nga napuraw ti rupa da ken nangisit ti

bibig da, kasarsarita dak, ay-aywen dak pay ken kigkigtuten isu nga makariing nak nukwa.”

Sometimes, he also dreamed of an old girl and two children. Often, he claimed that he dreamt

that he was in a forest alone. In this forest there was full of light and he said he cannot get out of

the light. He said he was “napandagan” by a big tree. After that, he saw a river and he took a

bath in there. That’s the time that he woke up already.

He also shared another dream of him when he was 16 years old, he says “ ada crush ko,

natagtagainep ko suna nga kikisen nak ken love nak, ay-ayaban nak nga mapan kam kano

mangan saluyut. Napudaw suna, natayag, nasileng ken attidug buok na. Para kanyak perfect

isuna.” He also claimed that it’s the reason that he is into building a family or lacking of interest

to girls because he already have a girlfriend in his dreams. In addition, he said he has feelings

that someone wants to kill him when he has bad dreams.

Mr. Christian Grey has a fear of dark places because he thought that there were lizards

and gecko. He is done not explained further why.

When he was a young, he also verbalized “ adda nakitak nga pakkang nga agkatkatawa

maymaysa jay siruk ti kayu jay ditoy ayanm.” This is his response when we asked if he have ever

seen ghosts in his life.

LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

When the patient was asked about his own idea of himself, he said he is contented and

happy because he has a lot of changes since he stayed in his room for a long time. He even

claimed that he is healthy and felt like he is stronger than before. He also claimed that if he has

anything to do for himself, he verbalized, “agpagwapo nak tapno mapansin nak met ti tao.”

During at night, he claimed that he heard a voice but he cannot determined if it’s a boy or

a girl and also he cannot understand what the voice is saying. This happened just recently.

Self-harm
According to him, he has no thoughts of hurting other person. He just ignores those

people who bully him because of his condition. “Adda met pela nabatbati nga respeto’k ti tao

ading, ta gamin haan met a tungpal biag daytoy mapaspasamak kanyak, addan to latta aldaw a

agtalna da,” he added.

E. Sensorium and Intellectual Processes

1. Orientation
The client was oriented to person, place, and situation but not on time. On the

assessment, he was able to recall names of his family who cared him and those that are involved

in his life. He can tell where he is staying at the moment and the reason why he was experiencing

being like this. He has difficulty recalling the present date and time and that he require seeing the

calendar and the clock to check the time.

2. Confusion

The client was not confused on his surroundings or figure things out.

3. Memory
LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

The client was able to recall past experiences in his life, he was able to remember the

unrelated words (immediate) he was able to recall events in his past like his childhood moments

and college experiences (recent) and he was also able to remember the name of his student-nurse

during their first interaction (recent).

4. Ability to concentrate

He was able to recall the 5-letter word (world) that was presented on him and able to

repeat the 5-letter word on forward and backward manner. At the first attempt of the Serial 7 test,

the client was able to reached until 93 while in the second attempt of the Serial 7 Test, he

reached and able to answer until 48. The client performed well the instructions I asked him to do.

5. Abstract thinking and intellectual abilities

The client is an abstract thinker; he explains series of proverbs in well understood

statements like “A stitch in time saves nine”. He answered “Dapat nu ada ubraem, dapat

tulungam ta bagim ta ni Apo to ti mangubra ti daduman para metla ti masakbayam.” For the

next, “People who live in glass houses should not throw stones” he said, “Dim ububraen ti

sabali ta haan mo kayat a maubran to metlang kenka.”

.F. Sensory-Perceptual Alterations

During at night, he claimed that he heard a voice but he cannot determined if it’s a boy or

a girl and also he cannot understand what the voice is saying. This happened just recently.

G. Judgment and Insights

LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

The patient has also a good judgment because he was asked a situation then he was able

to make a good and sound judgment on the situation given. His given decisions were appropriate

and acceptable. The client has a good judgment, perceptual and visual functioning.

H. Self-Concept
He describes himself as being very resourceful and ambitious at the same time. He finds

solutions, get creative and solve problems without needing the help of others, if he can. He

knows when to ask for help and he doesn’t stay quiet if he does need assistance. But when it is

possible to handle something without occupying the time of others, he do it and he consider his

self as very good at it. He has mixed emotions during the course of interview. He’s slim, curly

and tanned skin color.

I. Roles and Relationships

Current Roles

According to him, nurturing and supporting role are affective role and that includes

providing comfort, warmth, and reassurance for family members and to the society. He sees

his self as what mentioned. Despite of his condition, he was able to do these roles in such a

small manner. “Presensyak ti kailangan, ading, dakkel a tulong kanyadan nu ana man ti

mabalin ko itulong,” he added.

Satisfaction with Roles

Mr. Grey was satisfied of his role because he does these roles unconditionally and

purposefully.

Success at Roles
LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

The client feels satisfaction and he feels like winner when he fulfilled his duty to

his family despite of his condition. He always believes that everything happens for a reason.

“In-time adingko, I will make them so proud”, he mentioned. As much as he can, he will do

his role properly and that makes him happy every time he made good deeds.

Significant Relationships

He was focused to his relationship with his family. It’s the most important thing

that he could focus in to. According to him, having in a relationship is not his top priority.

Making his family happy and contented is something he could hold on.

Support System

A healthy support system includes someone who can call your bluff when needed,

offer honest feedback without you getting angry, and help you stay or get back on track.

He was surrounded with people who share their goals, values and ambitions. A

mastermind group for instance. This group understands his journey because they too are

on his own journey. They help him lift him up and keep him moving in the right

direction. So, in addition he has his family as his support system, which he can be his

confidante and everything that a family could for the betterment of their family member.

“We were not put on this earth to live alone or to operate in isolation. We were created

to live in community and to help and support one another. And just like you help and

support other people in your life, you also have to allow others to return the favor. Give

others the opportunity to help and support you”, he added.

LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

J. Physiologic and Self-Care Conditions

Eating Habits

He eats three times a day (breakfast, lunch and dinner). He usually eats his

breakfast between 7-7:30 am, lunch between 11:30-12pm and dinner between 6:30-7pm.

He consumes 1 cup of rice in each of every meal. His meal usually consists of 1 cup of

rice, 1 small bowl of vegetable and a small portion or slices of fish or meat. He is fond of

eating salty foods such as dried fish, adobo and junk foods. He seldom eats fruits. He has

no allergy to any foods and he does not consume any kind of snacks all throughout the

day.

Sleep Patterns

He usually sleeps at 10:00PM to 11:00PM and awakes around 4AM. He uses

electric fan, one blanket and one pillows and lights off. He takes a nap in the afternoon,

lasts for 30minutes and he doesn’t experience disturbance in sleeping.

Health problems

According to the client, he was asked if he is experiencing major chronic health

problem, he answered yes and elaborated what was this problem is. He mildly depressed

because of what’s happening to the environment. “Ag 1 year to detoy pandemic’n, di pay

malmalpas,” he uttered. He was absolutely clueless about the government’s action for

these problems in environment. The student nurse asked the client if there was prescribed

medicines he’s taking in, he answered “None, ading”. He believes that a person can feel

depression in any way and on the other hand he knew and controls his feelings towards

these problems. During his college days, he was a drinker with alcohols and he

mentioned that he stopped from drinking. And no drugs over-the-counter he’s taking in.
LORDSON GEM P. IBON
BSN III-B (Florence Nightingale)
NCM 117b

Compliance with prescribed medications

Client is not complying any prescribed medications right now unless if it is

prescribed. “Diak kayat ken mabutengak agtumar-tumar nu haan nga ireseta ti doctor,

ading”, he mentioned.

Ability to perform ADL

Mr. Grey bathes himself completely in every single part of the body such as the

back, genital area. And according to him, he gets clothes from closets and drawers and

puts on clothes and outer garments complete with fasteners. He doesn’t need help in tying

shoes. He easily goes to toilet, gets on and off, arranges clothes, cleans genital area

without help. He moves in and out of bed or chair unassisted. He exercises complete self-

control over urination and defecation. And lastly he gets food from plate into mouth

without help. Preparation of food may be done by him.