Revised Fall 2009
NORTH IDAHO COLLEGE
Associate Degree Nursing Program
Nursing Interventions III
PSYCHIATRIC CASE STUDY
_____________ Date of Clinical _____________ UNIT_____________
Patient: Sam (not his real name)
A. Demographic Data
Male X Female
Age __38__ Height __6’1‖ Weight _250 Ethnicity _ Caucasian ____ Religion: _not known_____________________
Occupation: Grocery Stocking Clerk
Code Status: __full____________Date of Admission: __8/26/08_______________________________ List Clinical Diagnoses according to DSM-IV Classification. List all five axes: Axis I:___ 295.30 Schizophrenia:_Paranoid Type_____________________________________ Axis II:___none________________________________________________________________ Axis III:___HTN_______________________________________________________________ Axis IV:___Occupational; Social_________________________________________________ Axis V:___10: danger of hurting others; highest level the last year: 71____________________ Allergies (Medications, Food, Latex), List: __N/A___________________________________________ Diet:____regular______________________________________________________________________ List the therapeutic program prescribed for the patient:
IPU on admission; C0; IPU program as tolerated; medication per order Self-care Ability/Activity Level: (0 – independent; 1 – needs assistance) ___0_____________________ Specify:_______________________________________________________________________ Describe pattern of vital signs and implications for care/monitoring: ___VS bid x 3 days then daily: 164/96 on admission; P: 80 reg; T: 99; R: 18. (unable to take VS on admission due to agitation. Day 1: 154/88; all others WNL; Day 2: 148/88. ntipsychotic meds could increase effect of HTN meds; some risk for prolonged QTc interval arythmias_____________________________________________________________________
List Current Privilege Level: ___________________________________________________________________________ List Current Observation Level: __CO; H________________________________________________________________ List any restrictions: __________________________________________________________________________________
B. Describe concurrent, pertinent Axis III diagnoses.
History of HTN since age 32; placed on hydrochlorothiazide 25 mg. PO daily at that time. Pt intermittently reliable with taking medication.
C. Describe history of past psychiatric illness. Focus on behaviors in addition to other relevant considerations.
Sam had first psychotic episode during junior year in college. Up to this point, he did well academically and socially. First admission to Gritman Medical Center after both roommate and several instructors brought him to attention of counseling department. He demonstrated paranoid delusions and hallucination on admission. He believed that the housekeeping personnel on his dormitory floor were watching him and out to harm him because he was an imposter. Two instructors reported agitated behavior in class which included talking to himself. He was never able to return to college, moving back in with his mother and younger sister in Coeur d Alene. He held numerous jobs over the next ten years, but has not kept them due to in instability of his mental illness. He was initially placed on Haldol, and had some relief of positive symptoms although he was not reliable in remaining on medication and his symptoms would return. sam was able to remain in the community with the assistance of his community mental health center assertive treatment team and the support of his family. On several occasions he was fired after becoming agitated at work around the theme of co-workers saying ―bad things‖ about him. At age 30 his mother died, precipitating another psychotic reaction and hospitalization. After stabilization, he ―went on the road‖ to see the world and ―find himself‖. He was...