NURS 223L - Interpersonal Process Analysis 2.

Student: NAME HERE Date: 05/19/20 Clinical Instructor: Name (initials only): JA Unit: SECURE PSYCH UNIT Current Legal Status (Vol., 5150, 5250, 30-day, T-Con, LPS-Conservatorship): Patient has siblings 2 sisters and a brother, including her Father and Mother that are her support system. And mother as the responsible party. Multiaxial Diagnostic System: Axis I (Clinical Disorder): Depression, Anxiety and PTSD. Axis II (Personality Disorder / Mental Retardation): Personality disorder (PTSD) Axis III (General Medical Conditions): none Axis IV (Psychosocial and Environmental Problems): Patient was out going, was on the cheerleading squad before her boyfriend broke up with her. Axis V (Global Assessment of Functioning Scale): Patient some danger of hurting herself/committing suicide. 1. Description of the patient: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization? Number of days in the hospital? Mental Status, etc. Client is 17 years old single Caucasian female with history of depression, Anxiety and PTSD. Patient living with parents who are her support system, with two other sisters and a brother. Patient mother is responsible party. Patient was admitted to Millwood Hospital, due to her suicide attempt today 05/19/20. On the admission process, when asked the reason for her admission, Patient states “I don’t want to live anymore. My boyfriend broke up with me” but the family indicated that patient broke up with the boy friend and her prom is in two weeks, so that is making her sad and depressed. Patient is alert and oriented x 2. Patient has been cooperative with care, has a poor judgment, ambulates independently, she has a low tone and blunted speech, when asked about her suicidal ideation, patient admits that she has suicidal ideation. Pt is so sad and depressed, her of the perception that her life is over because her boyfriend broke up with her before one of the biggest events in her life. although she denies having visual or auditory hallucination, and denies having delusion. 2. Description of environmental setting where interaction took place. Explain the reasons for a supportive or non-supportive environment. (e.g. noise, distractions, light, temperature, etc.) The Discussion with patient took place in patients’ room, and it lasted for 50 minutes, as patient was so sad and has a lot to say about her boyfriend. When I entered the room, patient was in with the family, I respectfully asked her if she would be willing to answer a few questions and to discuss about her admission process. The client affirmed to it and I went ahead and began my interview process. The environment was quite conducive for the conversation, as the room was quiet, dark as the window curtains were closed with the cold air. The client was very cooperative and answered all the question, she confirmed having suicidal ideation. So after the interview, Patient was put on 1:1 care as the charge nurse went ahead to call the Provider to get the order.