Psychiatric Nursing Case History Example Essay examples

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Pyschiatric Nursing Case History with Diagnosis, HPI, ad Diagnostics

1. Identifying Statement 59 year old, married white female who was brought to the Emergency Department by the police by herself because of public intoxication with suicidal ideations. Chief complaint was “I was depressed and wanted to kill myself”.

2.Admitting diagnosis (DSM IV-TR classification):

Axis I : Bipolar Disorder Axis II : None noted Axis III : Kidney disease, Liver cirrhosis Axis IV : No friends/outside support Axis V ( GAF) : 30
3. Discuss theories of etiology for Axis I and Axis II diagnosis:
Bipolar Disorder (in Psychosis): The etiology for Bipolar disorder is based on the stress-diathesis model. This model
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She says that most of the time it keeps her from getting out of the house to do simple tasks or go out with her husband. From these responses, I believe anhedonia is present. Patient also reports sleep disturbances and feelings of restlessness.

10. Family history: (psychiatric history or substance abuse): No psychiatric history noted within the family. Father has history of ETOH abuse. ]

11. Substances of Abuse: • Tobacco Use: Yes Stage of change: None. 1 pack per day • Alcohol Use: Yes Frequency: Daily Amount: 5-6 drinks per day Age of first use: 16 y/o Last Use: 10/5/11 (date of admission) Stage of change: None. History of physical symptoms of withdrawal (describe): Patient states she has had feelings of lethargy secondary to alcohol use. Patient denies withdrawal presently or in the past.

Legal Problems Secondary to use: Cited for public intoxication on 10/5/11. No previous legal problems.

Physical Problems secondary to alcohol use: -Cirrhosis of the liver. Kidney disease.

Social Problems secondary to alcohol use: -Social isolation. Drinks primarily at home.

Other drug use: Patient denies

12. Abuse History (physical, emotional, sexual): Patient denies