Comprehensive Mental Health Assessment
Derek W. Booth
Indiana University Purdue University Indianapolis
I: Identifying Data. Ashley K. is a 23-year old white female who was admitted to Warner Transitional Services on 11/21/12.
II: Chief Complaint.
“ I am a little anxious and upset right now. IDTC in Lafayette could not do anything for me”.
Assessment information was provided by patient. Interview was conducted in a private room along with psychiatrist, and lead clinician. Other sources used for this evaluation included documents from her previous two placements.
IV: Reason for Consultation.
Client was referred to Warner Transitional Services by Indiana Developmental Training Center of Lafayette. She became a candidate for Warner’s program due to her progression through treatment, improved behaviors, and being able to function at a higher level than most patients at her previous placement. Patient was discharged from state hospital and transferred to facility. Patient will most likely remain at Warner until she can be transitioned into a group home. The treatment team believes that Warner’s program can improve her overall functioning. The team also believes that she can benefit from a more group orientated, and less restrictive environment.
V: History of Present Illness.
The information obtained in the assessment, and previous records leads me to assume the patient has had a very complex history. Documents obtained paint Ashley as being known for manipulation, and making up stories. During the interview she was often vivid and graphic when she began to describe details. Also, as she told her story redirection was often needed to stay focused on the question discussed. She tends to want to answer questions with questions, and seemed to prefer elaborating on certain topics, rather than progress and complete the interview. Ashley was forthcoming with information stating “ I usually mess up by hurting myself when I talk, or hear from my family”. She then rolled up her shirt and showed me a bunch of superficial cuts on her right arm. Patient seems to be a good story teller, but a poor historian. During the assessment process the treatment team was somewhat confused as to if some of the historical details provided were derived from Ashley herself, previous documents, or family members.
VI: Psychiatric History. Ashley has historical diagnoses of PTSD and major depression, made at the age of seven. St. Joseph County DCS became involved with her in 1999 due to substantiated physical abuse by her father. The very next year she was seen in the emergency room for a 25 pound weight loss sustained in one month. At this time Ashley reported sexual abuse by her father. The patient’s father previously had been investigated for molesting a neighbor’s child. As a result, the patient and her siblings were removed from the home, and made wards of the state. At some point they were returned to the home then Ashley’s sisters made allegations that she had been “humping” them. In 2004 Ashley was once again declared a Child In Need Of Services. Since then, patient behavior has been difficult to manage. She has a documented history of defiance, property destruction, aggression, and self-harm. As a result, Ashley has had multiple psychiatric hospitalizations in various locations throughout the state of Indiana.
VII: Medical History.
Patient has no known drug allergies, no surgical history, and achieved developmental milestones on time. Patient currently suffers from hypertension, GERD, and obesity. She is prescribed Toprol XL 25mg for HTN, and Zantac 150mg for GERD management. Upon admission she was given a TB skin test, ordered a CBC with diff, CMP, and TSH. All results were unremarkable. Patient is scheduled to have vision testing, and her wisdom teeth removed bilaterally sometime in December 2012.
VIII: Social History and Premorbid Personality.
As mentioned above the patient experienced significant trauma, and was removed from the home at very early age. Most of her social interactions have been in an institutional setting. Previous records indicate she has a history of poor relationships with peers and staff at various placements. She is described as unable to tolerate having other peers receive attention from staff. When questioned, Ashley admitted that she would physically intrude, make up stories, and fake illnesses so people would pay attention to her. She also admits to belittling, and taking advantage of lower functioning peers while in various placements. A review of education documents show that she has received special education services for many years for a learning disability, and emotional handicap. Ashley stated she graduated from special education classes while at Madison State Hospital, but was often escorted back to unit for being aggressive, and using profanity. Also, while at IDTC-Lafayette she completed the Wechsler Adult Intelligence Scale III. This yielded a full scale IQ of 69; verbal, 77; and performance,63. The patient has no children, has never been employed, and she verbalized a sexual preference of both men and women. When I asked her about any substance abuse she began to tell stories about eating a half of pound of marijuana, and “sniffing” crack-cocaine daily. She also stated that she drinks “a lot”, but she was unable to describe the type of alcohol, or quantify the amount.
IX: Family History
The patient has two younger sisters, and their whereabouts are unknown at this time. Ashley’s biological parents are reported to have a history of “significant substance abuse”. Her father has a history of legal issues including charges of molestation, and drug trafficking. Her mother reportedly is a babysitter. In 2010 Ashley’s judge ordered that the family no longer have contact due to constantly attempting to sabotage treatment, telling her not to comply, and making her promises that never materialized. During the interview the patient looked down at the ground as she spoke slowly about her family, and it seemed to be uncomfortable for her. She stated that she has not spoken with, or seen anyone in her family since 2009.
X: Mental Status Exam The patient is overweight with light brown hair that was pulled back in a pony tail. She had a bright affect, and was rather intrusive socially. She had no tics or abnormal movements, and made good eye contact. Ashley denied any current suicidal/homicidal ideation, but endorsed psychosis. She stated that she hears, and has visions of a staff from her previous placement during the day and night, but has not seen her as of today. She identified her mood as depressed and agitated due to a new placement. Patient cognitive functioning seemed to be impaired. She was orientated to the month, but thinks it is still 2011. She stated the current president was George Bush, refused to count from five backwards, and did not seem to know the difference between a tomato and apple. She did not appear to give much effort in answering cognitive questions, and told me she has a bad memory. Also, the patient’s insight and judgment appear to be poor at the time of assessment.
X1: Dynamic Formation
Ashley has suffered from a lot of trauma due to very early physical, emotional, and sexual abuse. Also, she basically became an adult behind institution walls. Over the last several years she has been in various residential programs, and has struggled with this process. Ashley’s past and present all indicate that she will need psychiatric services for a very long time, possibly the remainder of her life. Hopefully, Warner Transitional Services can and improve her overall functioning, so that she can move on to an independent living program.
XII Assets and Strengths/ Holistic Nursing Assessment.
Ashley is a healthy young adult with the capacity to change. If somehow over time she can learn to use the services provided to her advantage, she could very well possibly return to the community one day.
XIII: Multiaxial Psychiatric Diagnoses.
Axis I: Mood Disorder Not Otherwise Specified (296.90) . Rule out PTSD . Intermittent Explosive Disorder (312.34)
Axis II: Mild Mental Retardation (317) Axis III: Hypertension, GERD, and Obesity.
Axis IV: Placement issues and no family contact per court.
Axis V: GAF was 35 upon admission.
XIV: Nursing Diagnoses.
I: Risk for Violence Self –Directed Or Other-Directed. Diagnosis is related to history of self –harm, aggressive behaviors, cognitive impairment, and emotional problems ( Varcarolis, 2011). Although she has only been at Warner for a week, staff reported that she has attempted to destroy furniture on the unit. Staff also reported that she punched herself in the stomach yesterday while in the cafeteria.
II: Ineffective Coping. Diagnosis is related to historically deficient family/peer support system, and poor impulse control (Varcarolis, 2011). Staff on the unit reports that she becomes negative with any re-direction, especially completing morning ADL’s.
III: Chronic Low Self-Esteem. This diagnosis is related to her perceived lack of belonging and a history of disturbed relationships with family, peers, and staff in previous placements (Varcarolis, 2011). During her initial psychiatric evaluation she seemed depressed, and did not verbalize anything positive about herself.
XV: Treatment Plan.
I: Give routine psychotropic and PRN medications as ordered by DR. Osman. The patient is currently prescribed Lexapro, Lamictal, and Trazodone daily. Vistaril and Haldol were ordered as needed for agitation/anxiety.
II: Inform nurses on duty to complete Suicide Assessment Tool daily until patient is able to process off suicide precautions. Physician/APN on-call is to be notified within 30 minutes if patient is placed in a therapeutic physical hold.
III: Educate staff about patients Transition Behavioral Support Plan. Encourage staff to use pro-active, encouraging, and preventative strategies while working with patients. Emergency medication and physical restraint are used only if patient become a danger to self/others.
IV: Encourage patient to participate in all associated milieu groups while in treatment. Patient can improve her overall independent, social, and coping skills with consistent positive reinforcement.
V: Continue with current antihypertensive and GERD medications as ordered by medical physician. Refer patient to physician for issues/problems related to diagnoses of hypertension and GERD. Refer patient to dietitian for weight, and dietary management.
References. Varcarolis, E. (2011 - 4th). Manual of Psychiatric Nursing Care Plans. New York: Elsevier/ 9781437717822 American Psychiatric Association DSM-TR (Text Revision) (2000). Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: American Psychiatric Association
References: Varcarolis, E. (2011 - 4th). Manual of Psychiatric Nursing Care Plans. New York: Elsevier/ 9781437717822 American Psychiatric Association DSM-TR (Text Revision) (2000). Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.: American Psychiatric Association