My spouse and i: Identifying Info.
Ashley K. is a 23-year old white feminine who was accepted to Warner Transitional Providers on 11/21/12.
II: Main Complaint.
” I am just a little anxious and upset right now. IDTC in Lafayette could hardly do anything for me.
3: Informants.
Assessment information was provided by patient. Interview was conducted in a exclusive room along with professional, and lead clinician. Other sources used for this kind of evaluation included documents via her previous two positions.
IV: Reason behind Consultation.
Client was referred to Warner Transitional Companies by Indiana Developmental Training Center of Lafayette.
The lady became a candidate for Warner’s program due to her advancement through treatment, improved behaviors, and having the capacity to function by a higher level than most patients at her previous position. Patient was discharged by state clinic and utilized in facility. Sufferer will most likely continue to be at Warner until your woman can be transitioned into a group home. The procedure team is convinced that Warner’s program may improve her overall working.
The team also feels that she can benefit from a much more group orientated, and less limited environment.
Sixth is v: History of Present Illness.
The information attained in the assessment, and previous information leads me personally to presume the patient has had a very intricate history. Papers obtained fresh paint Ashley to be known for treatment, and making up stories. Through the interview she was generally vivid and graphic when she started to describe details. Also, as she told her story redirection was often needed to concentrate on the problem discussed. The lady tends to desire to answer queries with queries, and seemed to prefer elaborating on selected topics, instead of progress and complete the interview.
Ashley was forthcoming with information saying ” I usually mess up by hurting personally when I discuss, or listen to my family. She then simply rolled up her tee shirt and demonstrated me a few superficial reductions on her right arm. Individual seems to be a good story teller, but an undesirable historian. Throughout the assessment method the treatment team was relatively confused regarding if a number of the historical information provided were derived from Ashley herself, past documents, or family members.
VI: Psychiatric Background.
Ashley has famous diagnoses of PTSD and major depressive disorder, made when justin was seven. St Joseph Region DCS became involved with her in 1999 due to substantiated physical abuse simply by her father. The very next yr she was seen in the emergency room for a 25 pound weight loss endured in one month. At this time Ashley reported sex abuse by her father. The person’s father previously had been looked into for molesting a neighbor’s child. As a result, the patient and her siblings were taken out of the home, to make wards with the state. Eventually they were delivered to the residence then Ashley’s sisters produced allegations that she was “humping these people. In 2005 Ashley was at one time again announced a Child Needing Services. After that, patient patterns has been difficult to manage. This wounderful woman has a written about history of disobedient, property break down, aggression, and self-harm. Consequently, Ashley has had multiple psychiatric hospitalizations in numerous locations throughout the state of Indiana.
VII: Medical History.
Patient has no known drug allergies, zero surgical history, and accomplished developmental breakthrough on time. Affected person currently is experiencing hypertension, GERD, and overweight. She is recommended Toprol XL 25mg intended for HTN, and Zantac 150mg for GERD management. Upon admission the girl was given a TB skin test, ordered a CBC with difference, CMP, and TSH. Most results were unremarkable. Patient is usually scheduled to obtain vision testing, and her wisdom pearly whites removed bilaterally sometime in 12 , 2012.
VIII: Social History and Premorbid Personality.
As stated above the patient experienced significant shock, and was removed from your home at very early age. Almost all of her interpersonal interactions are usually in an institutional setting. Earlier records suggest she has a history of poor relationships with peers and staff for various positions. She is referred to as unable to endure having additional peers obtain attention from staff. The moment questioned, Ashley admitted that she would actually intrude, make-up stories, and fake illnesses and so people might pay attention to her. She also confesses to belittling, and using lower operating peers although in various positions. A review of education documents demonstrate that she gets received unique education providers for many years to get a learning disability, and psychological handicap.
Ashley stated the girl graduated coming from special education classes while at the Madison Express Hospital, unfortunately he often escorted back to product for being hostile, and using profanity. Also, while at IDTC-Lafayette she completed the Wechsler Adult Cleverness Scale 3. This yielded a full range IQ of 69; verbal, 77; and satisfaction, 63. You will have no kids, has never been employed, and the lady verbalized a sexual preference of men and women. When I asked her regarding any drug abuse she began to tell reports about eating a 50 % of pound of marijuana, and “sniffing crack-cocaine daily. She also stated that she beverages “a lot, but the girl was unable to describe the sort of alcohol, or quantify the amount.
IX: Genealogy
The patient has two youthful sisters, and their whereabouts happen to be unknown currently. 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 medicine trafficking. Her mother apparently is a babysitter. In 2010 Ashley’s judge purchased that the family no longer include contact due to constantly trying to sabotage treatment, telling her not to comply, and producing her pledges that under no circumstances materialized. Through the interview the individual looked down at the earth as the girl spoke slowly and gradually about her family, and it seemed to be uncomfortable for her. She mentioned that this wounderful woman has not spoken with, or seen any individual in her family seeing that 2009.
X: Mental Status Exam
The patient is overweight with light dark brown hair that was ripped back in a pony tail. She a new bright impact, and was rather distressing socially. The lady had zero tics or perhaps abnormal actions, and made good eye contact. Ashley denied any current suicidal/homicidal ideation, but endorsed psychosis. She mentioned that the lady hears, and has thoughts of a staff from her previous location during the day and night, although has not viewed her currently.
She discovered her disposition as stressed out and irritated due to a new placement. Patient cognitive operating seemed to be damaged. She was orientated for the month, although thinks it is still 2011. She mentioned the current leader was George Bush, refused to count number from five backwards, and did not seem to know the big difference between a tomato and apple. She did not apparently give much effort in answering intellectual questions, and told me this wounderful woman has a bad memory. Also, the patient’s insight and common sense appear to be poor at the time of evaluation..
X1: Powerful Formation
Ashley has suffered from a whole lot of injury due to extremely early physical, emotional, and sexual maltreatment. Also, she basically became an adult at the rear of institution surfaces. Over the last many years she has been in various home programs, and has had trouble with this procedure. Ashley’s previous and present all reveal that she is going to need psychiatric services to get a very long time, possibly the remainder of her life. Hopefully, Warner Transitional Companies can and improve her overall performing, so that the girl can begin an independent living program.
XII Assets and Strengths/ All natural Nursing Evaluation.
Ashley is a healthy and balanced young adult with the capacity to change. In the event that somehow with time she can learn to utilize services provided to her advantage, she could well possibly come back to the community one day.
XIII: Multiaxial Psychiatric Diagnostic category.
Axis I: Feeling Disorder Not Otherwise Particular (296. 90). Rule out PTSD. Intermittent Mind blowing Disorder (312. 34) Axis II: Gentle Mental Retardation (317) Axis III: Hypertension, GERD, and Obesity. Axis IV: Positioning issues without family contact per court. Axis V: GAF was 35 after admission.
XIV: Nursing Diagnostic category.
My spouse and i: Risk for Assault Self “Directed Or Other-Directed. Diagnosis relates to history of do it yourself “harm, intense behaviors, intellectual impairment, and emotional problems ( Varcarolis, 2011). Although she has only been at Warner to get a week, staff reported that she has attemptedto destroy household furniture on the device. Staff likewise reported that she smacked herself inside the stomach the other day while in the cafe. II: Inadequate Coping. Diagnosis is related to in the past deficient family/peer support system, and poor impulse control (Varcarolis, 2011). Staff within the unit studies that the lady becomes negative with any kind of re-direction, specifically completing early morning ADL’s. 3: Chronic Low Self-Esteem. This diagnosis is related to her recognized lack of that belong and a history of disrupted relationships with family, colleagues, and staff in prior placements (Varcarolis, 2011). During her preliminary psychiatric evaluation she looked like depressed, and did not verbalize anything positive about herself.
XV: Treatment Plan.
I: Give routine psychotropic and PRN prescription drugs as purchased by DR . Osman. The individual is currently approved Lexapro, Lamictal, and Trazodone daily. Vistaril and Haldol were ordered as needed for agitation/anxiety. 2: Inform healthcare professionals on duty to complete Suicide Assessment Instrument daily right up until patient will be able to process away suicide precautions. Physician/APN on-call is to be notified within thirty minutes if sufferer is placed within a therapeutic physical hold. 3: Educate staff about people Transition Behavioral Support Prepare.
Encourage staff to use pro-active, encouraging, and preventative approaches while working with patients. Urgent medication and physical restraining are used as long as patient be a danger to self/others. IV: Encourage individual to take part in all associated milieu groupings while in treatment. Sufferer can boost her general independent, interpersonal, and dealing skills with consistent confident reinforcement. Sixth is v: Continue with current antihypertensive and GERD medications because ordered by medical physician. Refer affected person to medical professional for issues/problems related to diagnostic category of hypertonie and GERD. Refer affected person to dietitian for fat, and dietary management.
Referrals.
Varcarolis, E. (2011 ” 4th). Manual of Psychiatric Nursing Care Ideas. 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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