Psychiatric Nursing Case History Example

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Pyschiatric Nursing Case History with Diagnosis, HPI, ad Diagnostics

1. Identifying Statement 59 year old, married white female who was brought to the Emergency Department by the police by herself because of public intoxication with suicidal ideations. Chief complaint was “I was depressed and wanted to kill myself”.

2.Admitting diagnosis (DSM IV-TR classification):

Axis I : Bipolar Disorder
Axis II : None noted
Axis III : Kidney disease, Liver cirrhosis
Axis IV : No friends/outside support
Axis V ( GAF) : 30
3. Discuss theories of etiology for Axis I and Axis II diagnosis: Bipolar Disorder (in Psychosis): The etiology for Bipolar disorder is based on the stress-diathesis model. This model shows the relationship between biological risks (genetic predisposition)and environmental stressors. It is postulated that those who are biologically at risk may develop the psychosis secondary to a stressor. Bipolar Disorder is often seen with people who have mood disorders, schizophrenia, delirium, dementia, or substance abuse. They may experience hallucinations, delusions, or disorganized speech or behavior. Substance abuse and a family history of the disorder are both risk factors. Bipolar Disorder (in Depression): The etiology for Bipolar disorder related to depression revolves around incomplete synthesis and increased metabolism of neurotransmitters. Environmental stressors and behavior that is learned can affect these neurotransmitters and an influence on depression.

4. Type of admission:

____ Voluntary __X_ Involuntary (describe): Brought by law enforcement

5. Teaching/learning data: (Relevant communication/ teaching data: Patient needs to be given education involving smoking cessation and alcohol abuse. Patient also needs to be given medication education so that adherence may be attainable.

6. HPI: (History of Present Illness: What behaviors/ symptoms led to this hospitalization, what symptoms are still being experienced? How do these symptoms compare with those found in the literature?)

My patient was found publically intoxicated while walking on the sidewalk near her home. The police said she stated that she was “depressed” and wanted to end her life. From the paperwork, they stated that they found what appeared to be a suicide note in her pocket. Upon talking with the patient, she told me that she was walking down the street intoxicated and does not discount the policeman’s story, but she does not believe she was actually suicidal. She denied having a note with her and does not believe she would “write such a thing”.

Some of the symptoms seen in her story correlate with what I have seen in literature for Bipolar Disorder related to depression. The patient will have a depressed mood for the majority of the day with instances of anhedonia. She states that she has sleep disturbances (insomnia) and is often restless. Patient stated that she has had suicidal ideations that recur somewhat frequently but she does not know if they are “real” or not. All of these above symptoms relate directly to the symptoms often seen with bipolar disorder.

7. Mental Status Exam (General, Orientation, Memory, Insight/Judgement, Thought processes [formal, content, perceptual]; description should be concise)

Appearance: 59 year old white female admitted on 10/5 with an average height and weight with good body hygiene. Patient had no visible tattoos, scars, or other markers. She could ambulate on her own and move all extremities. Behavior: Patient was calm and cooperative. She displayed good eye contact throughout questioning and did not show abnormal extra movements or nervous fidgeting. Speech: Speech volume was appropriate but patient was hyper verbal and appeared pressured. No disturbances in speech such as slurring were noted. Responses were irrelevant. Facial symmetry present while speaking. Mood: Patient described herself...
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