Nurs 223L - Interpersonal Process Analysis 1.

Student: NAME HERE Date: 05/01/20 Clinical Instructor: Name (initials only): VR Unit: secure psych unit Current Legal Status (Vol., 5150, 5250, 30-day, T-Con, LPS-Conservatorship): Family still care for patient. “Grandson and niece that is her support system and Power of Attorney” Multiaxial Diagnostic System: Axis I (Clinical Disorder): ANXIETY, DEMENTIA, DEPRESSION Axis II (Personality Disorder / Mental Retardation): Alter mental statue Axis III (General Medical Conditions): CHF, DVT, Stage IV ovarian cancer. Axis IV (Psychosocial and Environmental Problems): Lack of education, only attended high school. Refused to attend group activities. Axis V (Global Assessment of Functioning Scale): Level 31. Pt possesses some danger of hurting self or others. 1. Description of the patient: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization? Number of days in the hospital? Mental Status, etc. Client is 57 years old Caucasian female, divorced some couple of years ago, but has a grandson and a niece, who is her support and also her power of Attorney. Patient was in the memory care about two years ago. Patients wanders to other patients’ rooms and slap them in the face, go around stealing medication cups. Before her admission to the hospital, she was admitted to the hospice, due her terminal illness, that have metastasized to her brain causing her alter mental statue. Patient was admitted to Millwood hospital for an attempted elopement from her memory care unit. Patient was admitted on the 04/24/20, and has been in the hospital for one week now. She is alert and oriented x 1. Patient has a wander guard on her ankle so she does not attempt to elope. Patient has been uncooperative with care, has a poor judgment, ambulates independently, she has a low tone and soft speech, and thinks that everyone is trying to hold her hostage. When asked the reason for admission, patient was tearful without eye contact states “I don’t know”. Pt is so anxious that she couldn’t sit down during the interaction process, she was just pacing all forth and back the room, but could still answer some questions.