I: Identifying Data.
Ashley K. is a 23-year old white woman who was confessed to Warner Transitional Solutions on 11/21/12.
II: Chief Grievance.
” I am a little distressed and upset right now. IDTC in Lafayette could refrain from doing anything for me”.
Evaluation info was offered by patient. Interview was performed in a personal space along with psychiatrist, and lead clinician. Other sources utilized for this examination consisted of files from her previous two placements.
IV: Factor for Consultation.
Client was described Warner Transitional Providers by Indiana Developmental Training Center of Lafayette.
She ended up being a candidate for Warner’s program due to her development through treatment, enhanced habits, and having the ability to function at a greater level than many patients at her previous positioning. Patient was discharged from state medical facility and moved to facility. Patient will probably remain at Warner until she can be transitioned into a group home. The treatment group thinks that Warner’s program can improve her overall functioning.
The group likewise thinks that she can gain from a more group orientated, and less restrictive environment.
V: History of Present Illness.
The details obtained in the evaluation, and previous records leads me to presume the client has actually had an extremely complex history. Documents obtained paint Ashley as being understood for manipulation, and making up stories. During the interview she was frequently vibrant and graphic when she began to explain information. Likewise, as she informed her story redirection was typically required to remain focused on the question talked about. She tends to desire to address concerns with questions, and appeared to choose elaborating on certain subjects, instead of progress and complete the interview.
Ashley was upcoming with details mentioning” I usually mess up by hurting myself when I talk, or speak with my household”. She then rolled up her shirt and showed me a bunch of shallow cuts on her ideal arm. Patient seems to be a great story teller, but a bad historian. Throughout the evaluation process the treatment group was rather confused regarding if a few of the historical details offered were originated from Ashley herself, previous documents, or household 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.
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
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Comprehensive Mental Health Assessment. (2017, Jan 18). Retrieved from https://studymoose.com/comprehensive-mental-health-assessment-essay