Professional Documents
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DATA:
DSM DIAGNOSIS
Axis I : Major Depression, Bipolar
Axis II: Borderline Personality Disorder/Cluster B, Borderline traits
Axis III: None
Axis IV: Unstable living conditions, Unemployed, Strained
relationships
Axis V: GAF is 40
(Some impairment in reality testing or communication
(speech at times illogical, obscure, or irrelevant) OR major
impairment in several areas such as work or school, family
relations, judgment, thinking or mood.)
301.83
FINANCIAL DATA
Medicare Insurance
Monthly income: $1,120 per
month.
Rent is $350 per month for a room
in a 4 bedroom group home with
three other individuals.
Patient also receives $350 food
stamps monthly.
Patient claims to have adequate
income to meet her needs.
Limitations:
- Self-destructive impulses, self-mutilating behavior, suicidal threats or gestures,
especially when an attachment relationship is disrupted or threatened.
-Lack a stable sense of self: Attitudes, values, goals, and feelings about
themselves are unstable or ever-changing.
-Fear rejection and abandonment, fear being alone, become attached quickly
and intensely.
-Play the role of "victim", often elicit intense emotions in other people who they
manipulate.
-Feel misunderstood, mistreated, or victimized.
-Relationships tend to be unstable, chaotic, and rapidly changing
-Splitting: When upset, trouble perceiving positive and negative qualities in the
same person at the same time. Idealization to devaluation. Love you.. hate you
MEDICATIONS
Antidepressants, anxiolytics, antipsychotics, or mood stabilizers
may be prescribed.
escitalopram oxalate Lexapro 5mg PO daily.
(Anti-depressant SSRI ) (Dose: 10-20mg/day PO)
hydroxyzine Atarax 10mg tab PO Q8h PRN (Mild-moderate anxiety,
offer before Ativan) (Antihistamine)
lorazepam Ativan 0.5mg tab PO Q8hrs PRN (Agitation, moderate to
severe anxiety) If hydroxyzine ineffective after 1 hour
(Benzodiazepine) (Dose: 1-4mg/day PO)
MEDICAL ISSUES/LABS
Urine toxicology screen: Positive for
methamphetamine
CBC w/diff, CMP, BMP lab values WNL except
elevated K+ 5.3 (H) (3.3-5.1mEq/l)
MSE
Appearance: Poor hygiene aeb greasy uncombed hair and disheveled appearance.
Clothes age and environmentally appropriate
Behavior: Cooperative, attentive and friendly. Speech: Articulate, clear and
spontaneous, occasional rapid speech, able to hold a conversation. Agitated motor
activity AEB pacing back and forth from room to nursing station. Distracted with periods
of irritability, anger, and sadness AEB yelling at case worker on the phone when
informed of need to reschedule appointment and crying when talking about changing
case workers. Attention seeking behavior and self- injury AEB self-inflicted pencil
puncture to left hand and giving writer sharpened pencil while smiling.
Affect: Labile affect, incongruent with mood AEB smiling and laughing while talking
about suicidal thoughts and self harm.
Mood: Depressed mood with feelings of hopelessness, helplessness with ambivalent.
Major depression AEB 35 on Burns Depression check list. Very low self-esteem AEB 9 on
Coopersmith self-esteem tool.
Thought process: Linear, easy to follow.
Thought content: Positive suicidal ideation, suicidal threat, gestures, attempts and with
plans to overdose with pills or use neighbors gun if discharged early.TM33=17. High risk
precautions. Positive threat to hurt self. Agreed to contact Nursing staff and writer for
safety.
Cognitive exam: Alert and oriented x3, able to express oneself. Long term and short term
memory intact. Able to recall events.
Insight and judgment: Poor insight and judgement related to negative consequences of
behaviors and the impact that it has on her life, relationships, housing situation, and
mental wellness.
Protect the client and others from harm or injury when client loses control as
a result of impulsive, aggressive behaviors.
Staff members who use appropriate safety methods for clients with
impulsive/threatening or aggressive behaviors are the best source of protection
against harm or injury to the client and others in the milieu. Use methods according
to facility policies/procedures and standards of care.
Scientific Rationale
There is always a chance that clients at risk for suicide will act out
on their thoughts, and studies show that the more detailed the
plan, the greater risk for suicide. (Fortinash, p.96)
The nurses first priority is to provide for the clients safety and
protect the client from self-inflicted life threatening injury or/and
death. (Fortinash, p.96)
Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th Edition. Mosby, 2012, St.Louis
Scientific Rationale
Engage the client in therapeutic groups, including roleplay/ sociodrama, behavioral cognitive therapy,
assertiveness training, and process/focus groups daily.
Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th Edition. Mosby,2012, St.Louis
LT goal: Client will demonstrate confidence in abilities and have a positive selfperception prior to discharge.
Scientific Rationale
Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th Edition. Mosby, 2012, St.Louis
LINK
http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost
/pdfviewer/pdfviewer?vid=4&sid=45567287-d549-4306-b078a633d854a502%40sessionmgr4004&hid=4107
Medication compliance
Actively participate in aggressive treatment therapy: Inpatient/outpatient
Dialectical behavioral therapy (DBT)
Cognitive therapy (CBT)
Individual therapy
Group therapy
NA 12 step program
Increase support systems- Case worker, church, Mother
Stable living situation
Vocational rehabilitation
Volunteer
Clubhouse
REFERENCES
American Psychiatric Association: Diagnostic and statistical manual of
mental disorders. 5th Edition, Arlington, VA. American Psychiatric
Association, 2013
Fortinash, Katherine, Patricia Worret. Psychiatric Mental Health Nursing,
5th Edition. Mosby, 2012. VitalBook file.
Fortinash, Katherine, Patricia Worret. Psychiatric Nursing Care Plans 5th
Edition. Mosby, 2012, St.Louis.