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Background History:
The patient has a psychiatric history and diagnosis of Post-Traumatic Stress Disorder
(PTSD), Depressive Disorder, Anxiety Disorder, as well as a history of Polysubstance
Dependence.
(5) Alcohol and Substance Abuse History
The patient has a long history of both severe alcohol and substance abuse. According to
patient she has been drinking alcohol for as long as I can remember, probably over 25 to 30
years. Also according to patient her substances of choice methamphetamine, cocaine, and some
occasional marijuana. She states that she is a cigarette smoker as well as a coffee drinker. She
started smoking cigarettes when she was 18 years old and she started drinking coffee after her
first child was born.
(5) Medical History
According to both the patient and her medical records she has no significant medical
history other then giving birth to three children and frequent urinary tract infections.
(7) Family and Developmental History
The patient stated that none of the members in her immediate family were ever officially
diagnosed with any type of mental illness. However during our conversation, she stated that the
triggering event to her mental instability was the fact her brother had been sexually abusing
her from the age of 6 until she was 15 years old. According to her, the fact that her parents never
believed her and accused her of lying when she told them about what was happening, was more
hurtful then the sexual abuse itself. Also based on information provided by the patient her father
unusually drank about half of bottle to hard alcohol almost every night. Patient appears to have
poor coping skills that are possibly augmenting to the alcohol and substance abuse. Also, based
on the account of her social history she has a poor support system.
nurses aid in a nursing home. However at the moment she is unemployed due to losing her job as
a result of her recent three-day drug binge.
Pattern of Relating:
(1) General Appearance and Behavior
The patient is a short skinny middle-aged woman who appears much older then biological
age. She appears to be minimally groomed but not disheveled, and dressed appropriately given
the circumstances (Keltner, Schwecke, and Bostrom, 2007). Her teeth show significant decay
and her hair is short and neat. Her posture seems relaxed yet she is restless and has to get up and
readjust her position often. Her attitude during interactions is friendly, making frequent eye
contact.
(2) Emotions and Speech
This patient did not display normal expression of emotions. Her responses were
restricted, even blunted, when she talked about her current situation or about the abuse she
experienced earlier in life (Keltner, Schwecke, and Bostrom, 2007). She stated that she is
anxious about the future but he is almost certain that she will not relapse once she receives the
treatment she needs. Her speech was fast and mumbled at times but understandable.
(3) Cognition and Perception
The patient was alert and oriented to person, place, time, and event; both short term and
long term memory is intact (Keltner, Schwecke, and Bostrom, 2007). She was attentive of the
questions I was asking, followed by thought through responses especially if the topic was
sensitive in nature. Ideas and information communicated by the patient was linked and goaldirected and transitions from one thought to the next were logical. There was slight skipping
around of topics but majority of the time it thought process was clear (Keltner, Schwecke, and
Bostrom, 2007).
(4) Impulse Control
Impulsivity is what led to her seeking and admission to a psychiatric facility for
treatment. Doing things without thinking about the effects those choices or actions could have in
the long run (Keltner, Schwecke, and Bostrom, 2007). She did display poor impulse control
during conversation through actions of getting up and looking out the window in the middle of a
conversation.
(5) Knowledge, Insight, and Judgment
The patient acknowledges that there is a problem and that change needs to be made in
order for her to become a positive member of society. She says that her drug use is irrational and
that it needs to stop, which gives evidence of insight about her problem (Keltner, Schwecke, and
Bostrom, 2007). Her judgment is intact at present since she chose to seek help for her condition,
however prior to her admission her judgment was severely impaired because she made poor
choices that altered her whole life.
Treatment Plan:
(1) Multiaxial DSM-IV Diagnosis
Based on the patients chart her Multiaxial DSM-IV diagnosis is as follows: Axis I Major
Depressive disorder (296.2) and Acute stress disorder (308.3); Axis II Polysubstance abuse
disorder (304.80): Severe alcohol and cocaine dependence; Axis III Chronic urinary tract
infection; Axis IV Financial difficulties and family discord; Axis V GAF = 45 (on admission
to psychiatric unit) (American Psychiatric Association, 2000).
and improve her sleep; anti-anxiety capsule Hydroxyzine 50 milligrams as needed every six
hours (Valerand and Sanoski, 2013).
(4) Active Problems
At present she has one active problem in her chart and that is lack of housing.
(5) Patients View
According to the patient the care and treatment she has been receiving since her
admittance to the unit has helped alleviate some of her problems. Among there problems is
decreased energy, sleeplessness, agitation, and anxiety. The two medications she has been
prescribed have helped her sleep at night, which means she is less anxious, has more energy, and
is not as agitated like a can of soda ready to explode.
Progress of Care:
(1) Patient View
According to the patient although some of her minor complaints and/or problems have
been ameliorated she is a little distraught with the speed at which her transfer to a substance
abuse program is moving. She had been on the unit for almost four weeks now and they have not
told her anything about a possible date when she will go to a facility that will provide her with
the help she really needs.
(2) Healthcare Team View
The health care team states that they have been unable to find an opening at a facility
where she could get treatment for substance abuse. They do believe that her being there even for
such a long period of with has been beneficial for her withdrawal from the substance abuse. They
are also saying that in order for the treatment at the other facility to go well, her mood and
anxiety level need to be stabilized thus implementation of effective avoidance and coping
mechanisms could be easier to implement.
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References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: Author.
Keltner N.L., Schwecke L.H., and Bostrom C.E. (2007) Psychiatric Nursing (6th ed.). St. Louis
MO: Mosby.
Valerand, A. H., & Sanoski, C. A. (2013). Daviss drug guide for nurses (13th ed.). Philadelphia,
PA: FA Davis Company.