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Psychiatric Nursing Assessment Essay

2204 words - 9 pages

{text:bookmark-start} Psychiatric Nursing Assessment {text:bookmark-end} Identifying Data Client T. S. is a single 55 year-old-female. She is Caucasian. She is not employed. T. S. was referred from Roanoke Memorial Hospital emergency room by Dr. Thomas Bolton with a temporary detention order, which resulted in an involuntary commitment. She had active hallucinations, paranoia, delusions, and noncompliance with medications, she missed her appointment with Dr. Mussleman at Blue Ridge Behavioral Health. Chief Complaint Her chief complaint as she stated, “I hear voices of children in my head and they never stop.” Previous Psychiatric History T. S. has had fourteen hospitalizations ...view middle of the document...

The CSB worker checked on her and found that she was totally unable to care for herself. She had decompensated. She was not taking her medications and she was not eating properly. She was having auditory and visual hallucinations, her thoughts were very disorganized. She denied having any suicidal or homicidal ideations or intent. She was readmitted to Catawba on April 21, 2008. She has no history of ECT or similar treatment. Family History T. S. is estranged from her family. Her chart states that she had a son that was put up for adoption at birth. She does have a payee but does not always cooperate with the payee, because she is paranoid that the payee is stealing her money. Personal History T. S. was born and raised in The Roanoke Valley. She attended school through the ninth grade. She is unemployed. She tells me that she was adopted, but there is no mention of this in her chart, only that she is estranged from her family, and that she had a son that was put up for adoption at birth. She has a significant history of alcohol, marijuana, cocaine and tobacco abuse. She states that is has been fifteen years since she last used any alcohol or illegal drugs. I believe that T. S. is in Erikson’s Stage of Trust versus Mistrust, because she does not view the world as safe and reliable. The formation of trust is essential, mistrust the negative outcome of this stage, will impair the person’s development throughout his or her life. Once she is discharged she will live in the community in her own apartment. T. S. stated she did not have any friends. Upon observation, I believe T. S. to be a loaner with poor social skills. She does not trust anyone. Medical History T. S. gives a history of being in reasonably good health. She does have a diagnosis of diabetes, depression, asthma, gerd, and diverticulosis. She has an allergy to Penicillin, Cephalosporin’s, Haldol, Phenothiazine, which type of reaction is unknown. Previous surgery she had a bilateral tubal ligation per her last admission documentation. She has a history of positive PPD. She has a body mass index of twenty-six. Mental Status of Client Relationship to Nurse/Staff/Peers General Appearance and Grooming T. S.’s clothes were appropriate for the season, and she was always neat and well groomed. She would wear crocks without socks most of the time. Her hair is cut very short to her head. She has upper dentures and her own lower teeth that are in good condition. Her nails are short and clean. She always appears to be freshly bathed, as I have not noticed any body odor. C.) Motor Behavior T. S.’s motor movements are smooth, but slow. She displays no wringing of hands, tics, twitches, or tremors. There is no hyperactivity and her movements seem purposeful. D.) Posture T. S. walks tall and straight with no slouching. When she sits, however, it is relaxed and somewhat sprawled out and hangs her legs and feet over the arm of the chair. If she is...

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