Client Assessment
Jean is an 87-year-old widow with a complex history of a debilitating stroke that resulted
in left-side paralysis and a diagnosis of PTSD due to a break-in at her home and being sexually
assaulted. Due to the stroke, the client now has impacted capabilities regarding movement,
eating, and other activities of daily living (ADLs). The level of care that this client needed
regarding her stroke has left her financially compromised and is underinsured medically. Post-
discharge care for this client is currently undetermined as her children have not stated if they
would be staying with the client in her home post-discharge and despite her home being secured
by family, the client no longer feels safe at home due to the break-in and assault and her new
lack of mobility. Despite her condition, the client remains a devout Catholic and finds comfort in
her faith. She is organized and humorous, citing this being the result of her career as an
elementary school educator. The client has a history of participating in the local community and
has a reliable social circle.
The client is a vulnerable member of society due to her age, mobility status, financial
state, and her history of PTSD. The client needs to have her needs addressed with evidence-
based practices (EBPs). Focusing on the patient’s diagnosis of PTSD, examples of EBPs that we
can implement regarding the client’s care are open communication with the client, understanding
the lasting effects of sexual trauma, and utilizing her support networks, personality type, and
beliefs to optimize her outcome.
The American Psychological Association names one of the primary long-term effects of
sexual trauma as the loss of autonomy, something that is reflected in the client’s case with her
, lack of trust to be in her home (Pappas, 2022). To maintain the client’s autonomy, open
communication between the care team and the client is crucial. Explaining procedures that are
being performed, particularly ones of an intimate nature, and obtaining explicit consent to
perform these procedures as well as ensuring the client is aware of the nature of her care plan and
can communicate her concerns and thoughts regarding it is one example of implementing this
EBP in her care that can help the client trust her care team.
Expert in psychology and faith Kenneth I. Pargament, PhD states that “Competent care
rests on basic knowledge about religious and spiritual diversity, understanding of how religion
and spirituality are interwoven into adaptive and maladaptive human behavior, and skills in
assessing and addressing religious and spiritual issues that arise in treatment.” When asked about
the relationship between mental health treatment and religion (Pargament, 2013). Because our
client identifies as devoutly Catholic, understanding the beliefs the client holds due to her faith
can also aid in the client trusting her care team. Things that the care team can learn to be
conscious of her beliefs regarding dietary restrictions, thoughts on medical interventions
(resuscitation, blood transfers, etc.), levels of modesty the patient holds, and other critical
elements of her faith.
Inpatient Care Plan
After talking with the client, I have concluded that many complexities in her case must be
addressed for her to achieve a successful outcome. These complexities include her past trauma
from a home invasion/sexual assault, financial burdens, and inability to complete ADLs. To
increase successful patient outcomes, her care team must uphold patient dignity, work with
Jean is an 87-year-old widow with a complex history of a debilitating stroke that resulted
in left-side paralysis and a diagnosis of PTSD due to a break-in at her home and being sexually
assaulted. Due to the stroke, the client now has impacted capabilities regarding movement,
eating, and other activities of daily living (ADLs). The level of care that this client needed
regarding her stroke has left her financially compromised and is underinsured medically. Post-
discharge care for this client is currently undetermined as her children have not stated if they
would be staying with the client in her home post-discharge and despite her home being secured
by family, the client no longer feels safe at home due to the break-in and assault and her new
lack of mobility. Despite her condition, the client remains a devout Catholic and finds comfort in
her faith. She is organized and humorous, citing this being the result of her career as an
elementary school educator. The client has a history of participating in the local community and
has a reliable social circle.
The client is a vulnerable member of society due to her age, mobility status, financial
state, and her history of PTSD. The client needs to have her needs addressed with evidence-
based practices (EBPs). Focusing on the patient’s diagnosis of PTSD, examples of EBPs that we
can implement regarding the client’s care are open communication with the client, understanding
the lasting effects of sexual trauma, and utilizing her support networks, personality type, and
beliefs to optimize her outcome.
The American Psychological Association names one of the primary long-term effects of
sexual trauma as the loss of autonomy, something that is reflected in the client’s case with her
, lack of trust to be in her home (Pappas, 2022). To maintain the client’s autonomy, open
communication between the care team and the client is crucial. Explaining procedures that are
being performed, particularly ones of an intimate nature, and obtaining explicit consent to
perform these procedures as well as ensuring the client is aware of the nature of her care plan and
can communicate her concerns and thoughts regarding it is one example of implementing this
EBP in her care that can help the client trust her care team.
Expert in psychology and faith Kenneth I. Pargament, PhD states that “Competent care
rests on basic knowledge about religious and spiritual diversity, understanding of how religion
and spirituality are interwoven into adaptive and maladaptive human behavior, and skills in
assessing and addressing religious and spiritual issues that arise in treatment.” When asked about
the relationship between mental health treatment and religion (Pargament, 2013). Because our
client identifies as devoutly Catholic, understanding the beliefs the client holds due to her faith
can also aid in the client trusting her care team. Things that the care team can learn to be
conscious of her beliefs regarding dietary restrictions, thoughts on medical interventions
(resuscitation, blood transfers, etc.), levels of modesty the patient holds, and other critical
elements of her faith.
Inpatient Care Plan
After talking with the client, I have concluded that many complexities in her case must be
addressed for her to achieve a successful outcome. These complexities include her past trauma
from a home invasion/sexual assault, financial burdens, and inability to complete ADLs. To
increase successful patient outcomes, her care team must uphold patient dignity, work with
