Acute Care Psychiatric Nursing Clinical Case Study

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Acute Care Psychiatric Nursing Clinical Case Study Assignment

Patient Interview
Chief Complaint
Patient JL states she has a problem internalizing issues and this leads to anger and depression.

History Of Present Illness
JL is a 20-year-old Visual Arts college student who has two older brothers and one older sister, and is the offspring of a Chinese father and white French Canadian mother. Her father has been incarceration several times for fraud and violence, and has been separated from her mother since JL was a little girl. She has a history of broken relationships having left her home in California to be with a man in New York. She now lives with a Romanian boyfriend who is often away from home because he works as a truck driver across the states. She admits that he tries to be at home at least once each week. She states that she does not know why her relationships do not last but all of her past relationships just did not work out. JL states that her boyfriend works for a private Romanian family-owned business and he is very close with the owner’s wife who always has a reason for him to do paper work at her home. When her boyfriend did not come home on the day he promised, she called and found out that he was at his employer’s home. She got angry, called the employer’s wife and was very abusive to her over the phone. They hung up the phone on her and she made several shallow cuts on her left arm. JL states this is not the first time that she has cut herself in anger; she did it several times before. She states that her therapist called to check on her and after she told her that she had cut herself, the therapist notified the police. Several police officers and an ambulance came to her home. The EMS workers persuaded her to go to the emergency room to have the cuts on her arm checked and she agreed to do that. However when she got to the hospital she was held in the emergency room for 24 hours then transferred to the psychiatric unit. She was admitted to the psychiatric unit on March 24, 2009 and has been there for one day. On admission, JL was diagnosed as follows: Axis I Major depressive disorder

Axis IIBorderline personality disorder
Axis IIINone
Axis IVChildhood neglect - paternal
Axis VFear of boyfriend leaving her,

II. Brief Psychiatric History
She was first admitted to a Pyschiatric Unit of a hospital five years ago when she was 15 years old and drank an overdose of sleeping pills because she was angry with her mother. JL states that she had not been hospitalized again until now as her mother would usually intervene. She has been seeing a therapist since then on a regular basis but says that “she hates this present therapist who is not helping her but calling the police on her. She states that this therapist is not helping her and she wants to see someone else.

III. Psychiatric Treatment

JL states she has been taking Lexapro for her depression and has been adhering to the treatment. She states that if she does not have money for her medication, she would as her brother who would always give to her. She is now taking Zoloft in the hospital and has been adhering to that treatment as well. She states that the Zoloft is giving her dry mouth but makes her feel less anxious and angry.

IV. Mental Status Exam

General Appearance
JL was neat, clean and tidily dressed. Her hair was not well groomed. She appeared her age, had a pleasant facial expression, and made eye contact.

Behavior & Psychomotor Activity
JL was relaxed and mild mannered. Her gait was balanced, even and well coordinated. She was wearing a high-heeled boots and walked confidently to the interviewing room.

Attitude Toward Examiner
JL was cooperative, friendly and responsive. She often lead the conversation by asking questions to clarify what she was saying.

Mood
JL did not seem depressed but was hopefully looking...
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