Download METROPOLITAN COMMUNITY COLLEGE – Mental Health Nursing II NURS2310

METROPOLITAN COMMUNITY COLLEGE
NURS2310 – Mental Health Nursing II
Case Study #2
Client Initials: _K. A.
Axis 1)
Axis 2)
Axis 3)
Axis 4)
Axis 5)
Age:
28
Gender:
F
Primary Physician:
Smith
Generalized Anxiety Disorder (GAD)
Borderline personality disorder
Deferred
Recent break-up with fiancé, mother has custody of 3-year-old son
48
Vital Signs—
On Admission:
Day 2:
Day 3:
Day 4:
98.1; 88; 24; 138/86
97.9; 90; 24; 128/78
98.3; 86; 22; 122/82
98.5; 92; 24; 136/90
Lab Values (only applicable or abnormal labs are listed)—
hCG
BAC
Glucose, fasting
pH
PCO2
Potassium, serum
TSH
T4
negative
0
142 mg/dl
7.65
28 mmHg
3.4 mEq/L
6.8 U/mL
4.2 ug/dl
Medications—
Combivent 90mcg/18mcg 2 puffs INH TID
Effexor XR 75mg PO QD
MVI 1 tab PO QD
Synthroid 0.125mg PO QD
Tylenol 1-2 tabs Q 4 h PRN for low back pain (not to exceed 4g in 24 hours)
Xanax 0.5mg PO Q 4-6 h PRN for agitation/anxiety
Day Shift Nursing Notes (from Admission to the Present…)
Day 1—
Nursing Notes; Admission Narrative
Day 2—
Nursing Notes; 1:1 with Client
Client admitted to the general adult psychiatric
unit under a voluntary admission for suicidal
ideation with a plan to cut her wrists with a
razor blade. Client reports feeling depressed
due to a failed relationship with her fiancé,
whom she states she had met approximately
two weeks prior to becoming engaged. Client
says her fiancé “broke up with me on the
phone the day before our 6-month
anniversary”, which she reports was two days
ago. Client rates her current suicidal ideation at
a 4 on a scale of 0-5 with 5 being most severe.
Client is able to contract for safety while
hospitalized only. Client admits to previous
self-harming behaviors such as burning her
legs with a lit cigarette as recently as six
months ago. Client states sometimes inflicting
pain on herself physically is the “only thing that
makes life bearable”, but denies current
thoughts to self harm. Client was initiated on Q
15-minute rounds and safety precautions for
suicidal ideation.
A) Client complains of feeling anxious about
being in the hospital. She is restless, pacing,
and unable to sit through groups without
leaving to pace the hallway. Client states she is
waiting for a phone call from her fiancé asking
for a reconciliation, and says she doesn’t know
what she’ll do if that doesn’t happen. Client
admits to having other stressors, such as
possibly losing her job as a hostess at a local
restaurant due to her hospitalization, as well as
trying to regain custody of her son who lives
with her mother due to the client’s inconsistent
(and at times inappropriate) living
arrangements. Client appears to minimize
these issues in comparison to her troubled
relationship with her fiancé. Client rates her SI
at a 2, depression 3, anxiety 5, anger 3, and
homicidal ideation 0 on a scale of 0-5 with 5
beings most severe. I) Client was given PRN
Xanax for her anxiety and encouraged to
journal her feelings. Client maintained on
safety precautions via 15-minute visual checks.
R) Client able to verbally contract for safety,
and remains cooperative and compliant with
her treatment regimen this shift.
Day 3—
Nursing Notes; 1:1 with Client
Day 4—
Nursing Notes; Safety Intervention
A) Client’s affect much brighter today, and she
reports seeing her fiancé last evening during
visiting hours on the unit. Client states her
fiancé wants to resume their relationship, and
she is requesting to be discharged home as a
result. Client denies SI, HI, or depression this
shift. Client admits to feeling anxious because
she wants to leave the hospital so she can see
her fiancé. Client rates her anxiety at a 5 on a
0-5 scale, and is unable to verbalize
appropriate coping skills she can use to
decrease her emotional distress. I) Client given
PRN Xanax for anxiety. Discussed with client
measures she can take to deal with her
feelings, such as deep-breathing techniques,
imagery, and journaling. Client encouraged to
work on her safety plan so that it will be an
effective tool in assisting her in maintaining her
safety at home. R) Client states she will use
the deep-breathing techniques she learned in
patient education group as a healthy coping
skill at home, and she verbalizes
understanding of the importance of completing
her safety plan prior to discharge. Client
reports a decrease in her anxiety level to 2/5
after taking her prescribed PRN anxiolytic.
A) Client approached the nurse’s station after
breakfast demanding to leave immediately.
Client’s speech is loud and pressured, and her
pacing in the hallway has increased. Client
refuses her PRN medication, and states none
of her coping skills are helping. Client is
threatening staff that she will call the police to
report her “mistreatment and false
imprisonment in this crazy place” if she is not
released right away. I) Attempted to discuss
with client the benefits of being in the hospital
in terms of a safe environment for learning to
adapt to her day-to-day stressors, but client
remains uncooperative with treatment and
disruptive to the unit milieu. Physician called
for orders to change client’s status from
voluntary admission to involuntary
hospitalization under a physician’s hold. R)
Client yelled obscenities at staff and ran to her
room, slamming her door, after being told she
would not be allowed to leave the facility until
her physician has determined that she can stay
safe outside of the hospital. Client remains on
safety precautions via 15-minute visual rounds,
and will continue to be given the opportunity to
ventilate her feelings in an appropriate manner.