NURS3910 MENTAL HEALTH NURSING

NURSING ASSESSMENT FORM

Student Name: Caitlin Martinez___________________ Date: March 17, 2014_____
Patient data:
Admission Date: Age: 30 Gender: Significant Other/marital status and children:
2/16/14
Female
single, 4 children (2 have been adopted); states
she has a husband Andy Garcia and more
than 10 children. When I asked the patient
where her children were currently she stated,
in a day care I hope.
Employment:
Educational
Pt. Legal Status: Legal
Primary
No employment Level: High
Temporary
history:
Language:
hx; unemployed school-did not
Conservatorship Drug-related English
graduate; states DTS GD
issues; hx of
she graduated
arrests and
from Yale
jail time
Chief complaint: What patient says prompted them to present at the hospital: I was on
someones driveway using their hose. I needed water because I had money and I
needed to wash the blood off of it, you know, the blood and other stuff on it. I murdered
someone.
What is the documented cause for hospitalization? Modesto Police Department was
called because the patient was in peoples yards yelling, threatening, and turning on their
water.
Patients living situation at time of admission: Homeless
DSM IV AXES from chart
I: Chronic Schizophrenia, Psychotic Disorder
NOS, amphetamine dependence
III: None reported

II: Deferred
IV: Poor primary support,
psychosocial breakdown, housing
(homeless), other psych/environment

V:(With rationale) 20- Some danger of hurting

self or others OR occasionally fails to maintain
minimal person hygiene OR gross impairment in
communication. I think that this GAF value is
appropriate because there was gross
impairment in communication due to her flight of
ideas, distractibility, and grandiose delusions.
PATIENT HISTORY
Medical History: N/A-none per chart and patient refused to answer any questions
pertaining to past medical history

Current medical issues of importance to nursing management of patient: (present

all relevant information from review of systems)
No medical history available and the patient is not a reliable historian.
Psychiatric history: Diagnosed in the past with psychotic disorder and poly-substance
abuse; previous admissions to DBHC on: 1/30/14, 11/26/13, 10/24/13, 3/12/13, 1/26/13
Alcohol and Other Drug Abuse: hx of marijuana use, meth dependence, ETOH use,
tobacco use (1 pack/day); urine tox showed negative meth use, but positive THC
Abuse (physical/sexual): physical abuse as a child per chart; patient didnt mention
any abuse; however, I got the feeling that her father may have been abusive when she
told me a story toward the end of the interview about her parents. It was something
along the lines that her dad would get very angry and her mother had to do things
certain ways and had to stay in the house.
FAMILY HISTORY
Mental Health: my mom has agoraphobiaand anxiety my dad is perfecthes in the
marines
Alcohol and Other Drug Abuse: Patient denied any family history of alcohol or drug
abuse.
MENTAL STATUS EXAM
General Appearance:
Dress & Grooming: well groomed, showered,
wearing DBHC blue scrubs

Posture and Gait:

3/17: erect posture, steady gait
3/24: stooped posture, steady gait
Motor behavior: (describe)
3/17: inappropriate direct (fixed) eye contact,
uses hands when talking, pacing and moving
around a lot
3/24: poor to no eye contactstaring off into
distance, no pacing or unusual behavior

Facial Expression:
3/17: wide eyes, no facial expressions,
no emotion
3/17: no facial expressions, no emotion,
appears dazed
Physical Characteristics: Patient is of
short stature, slender, light brown hair,
blue eyes, appears younger than
chronological age, no cosmetics worn,
Attitude toward interview and mood
(observed):
3/17: Patient seemed to be interested
in being interviewedshe wanted to
talk to me and was very responsive to
1:1 time; patient was very energetic
3/24: Patient wanted nothing to do with
me and did not want to talk to me in the
morning, but approached me later to
talk; however, she seemed very anergic

Physiological responses (tremor, nystagmus,

sweating): None noted
Affect and Mood
Appropriateness:
3/17: Inappropriate to situationaffect is bright
and manic-like; affect and mood are congruent
3/24: appropriate to situationpatient seems to
be more in touch with reality; affect is
tense/agitated to calm/flat; mood and affect are
congruent
Stability (patients report of swings, and
interviewers observation of changes):
No mood swings reported. However, on both
days the patient showed changes in mood.

Speech
Volume:
3/17: Patients tone of speech was very loud
3/24: Patients tone was low and very quiet

Thought Content
Theme:
1. Murder-She is preoccupied with the murder
of her sonshe states that he was murdered
but also told me that he committed suicide. She
told me that she committed more than 10
murders.
2. Her identity as Madonnaher fans,
paparazzi, celebrity friends
3. Her husband Andy Garcia
4. Surveillances and investigations
5. The marines and her father
Phobias: No, never

Range:
3/17: Euphoric to expansive
3/24: Irritable to depressed

Describe (e.g., anxious, depressed,

disengaged, etc.):
Patients mood would become very
defensive and agitated during my
interview; she becomes very annoyed
when she is referred to by her given
name and not Madonna
Rate (flow, speed):
3/17: pressured speech, was talking
very fast; had flight of ideasthoughts
were rapid and intense, associated
looseness, tangential,
3/24: speech is very slow, but is
related to the conversation and is
logical, but still disorganized
sometimes
Delusions (persecution, influence,
reference, thought insertion):
1.Grandiose delusions-she believes
that she is Madonna and that she is
friends with Garth Brooks; she talks a
lot about her fans and the paparazzi;
she also believes she is a trained
investigator and a surgeon
2. Paranoid delusions-surveillances,
investigations of DBHC and its nurses
3. Somatic delusions- back pain from a
surgery, car accident, sit ups, etc.
Obsessions: Denies.

Compulsions: I cant tell you that.

De-realization, depersonalization: No
depersonalization per say, but she is
not in touch with her identityshe truly
believes that she is Madonna

Disorders of Perception (give an example of

those that apply)
Hallucinations (type with description):
appropriate ones that I have to hear, like my
husband, Andy Garcia, and my dad states that
they tell her private stuff that I want to keep
personal
Clarity and organization:
3/17: Disorganized thinking related to
delusions, inappropriate responses
3/24: Thinking is more reality-based, but still
somewhat disorganized
Other unusual experiences
Hypnogogic phenomena: Denies.
Dj vu Experiences: No, never, dj vu
is a stereotypical term.
Memory & Cognition
Orientation to self- Patient is not oriented
to selfshe believes that she is Madonna
Garcia and told me that the name on her
ID band (her real name) is not her actual
name, but one that she used one time to
get into the Marines.
Orientation to day & date- Patient was
oriented to the month and the year.
Attention: ability to count digits forward
(provide digits for patient to repeat)

Illusions (described as shadows, or

reported as misinterpretation of
stimuli): That doesnt make any
sense. No.
Tone/inflection:
3/17: Loud,
3/24: Low/quiet

Dreams: Denies.
Nightmares/Night Terrors: No.

Orientation to Place- Patient is oriented to

place. She knew that she was at DBHC;
however, she believed that the reason she
was there was to investigate the place
because the nurses dont know how to do
their jobs and she is a trained investigator.
Serial 3s and serial 7s: (count backward
from 100 by 3 or 7)

10 to 15. I asked her to count the

numbers in between. No I cant do that.

No.

Recent memory: (assess via memory for

how long has been in hospital, memory for
recent meal, home address etc.)

Confabulation: (ask patient if he has seen

the examiner before, assuming he has not
or ask for another detail which gives the
patient the opportunity to fill in the gaps of
memory)

Not sure. I cant talk about that. My dad

would know, he investigates things like

that. Hes in the marines.
Fund of information: (ask general
information such as: how many days in a
week, how many months in a year, what
makes water boil? Name the four seasons
of the year, where does the sun set?)
I asked how many days were in a week
and how many months were in a year.
She stated 7 and 12, respectively.

Yes, Ive been meeting with you

frequently. Before today; states she
doesnt remember when she first met me
Vocabulary: (observe the words used
and/or present several words and ask the
patient to tell you what they mean)
Patient used term coining out and when I
asked her what it meant she told me that
its when you get surgery while youre
pregnant. I looked it up and it actually has
a meaninggraduation from a treatment
program. She also used the term
agoraphobia to describe the fears her
mother had. Her vocabulary was strong
and she seems like she has a lot of
potential and may be very knowledgeable.

Abstraction: ask to tell you what a proverb

means

Similarities: state two objects (orange and

apple) and ask how they are similar or alike

I asked her what the following proverb

meantYou mustnt cry over spilled milk.
She stated, That rehabilitation is
available.

The stemand the bottom of the orange

too where they get picked.

Judgment and Comprehension: provide

examples of common events or situations
and ask pt what he would do in those
situations:

Perception and Coordination: (have patient

write his own name, copy a circle, a cross
(x), a square, a diamond or a row of dots
on a blank sheet of paper.)

I asked the patient what she would do if

she found an envelope on the ground that
was stamped and addressed. She stated,
I would pick it up and read it because I
went to school to investigate these things.
Im trained. I graduated when I was five
years old, you know. There are people that
get born who are not smart..

I asked the patient to write her name down

on a piece of paper. She wrote Madonna.

Suicidal Ideation: Yes

SAT score=1

No (If yes, complete suicide assessment)

Homicidal Ideation:

Yes

No (If yes, complete homicide assessment)

What does this person do when angry, stressed or uptight?

I talk out loud about things.
Patients description of him/herself. What does she like best best/least about
her/himself?
Her description of herself was, Im an amazing, smart daughter of my dad.
What she likes best about herself is, that Im loved by my dad and my husband, Andy
Garcia.
What she likes least about herself is, the emotional torment by my fans. The paparazzi
and everyone always wanting my attention.
Include real or potential strengths of the client.
1. Patient is mostly compliant with medication regimen.
2. Patient voiced that her medications seem to be working and that she is feeling
better-this gives me the sense that she realizes the need for the medication and
this may cause her to be more compliant once she is discharged from DBHC.
3. Patient is creative as seen in her artwork during ART therapy groups.
4. Patient attends groups and participates.
5. Patient has been in contact with her mother and seems to have better support.
Routine Medications (including category, dose, standard dose, target effects,
interactions and side effects) See attached care plan
Pertinent Lab values: See attached care plan
Written Summary (Give summary of relevant findings from above. Discuss congruence
and incongruence between DSM criteria & patient assessment)
DSM-IV-TR Criteria for Substance Dependence
Patient must have at least 3 of the following characteristics:
1. Evidence of tolerance, defined by either a need for increased amounts of the
substance to achieve intoxication or diminished effect with continued use of the
same amount of the substance
2. Evidence of withdrawal symptoms: showing the characteristic withdrawal
symptoms for the substance or the same (or a closely related) substance is taken
to relieve or avoid withdrawal symptoms
3. The substance is often taken in larger amounts or over a longer period than was
intended
4. There is a persistent desire or unsuccessful efforts to cut down or control
substance abuse
5. A great deal of time is spent in activities necessary to obtain the substance, use
the substance, or recover from its effects
6. Important social, occupational, or recreational activities are given up or
reduced because of substance use
7. The substance use is continued despite knowledge of having a persistent

or recurrent physical or psychological problem that is likely to have been

caused or exacerbated by the substance
DSM-IV-TR Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood, lasting 1 week (or any duration if hospitalization is required)
B. During the period of mood disturbance, 3 or more of the following symptoms have
persisted and have been present to a significant degree
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility
6. Increase in goal-directed activity or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for
painful consequences
C. The mood disturbance is sufficiently severe to cause marked impairment in
occupational functioning or in usual social activities or relationships with others, or
to necessitate hospitalization to prevent harm to self or others, or there are
psychotic features
D. The symptoms are not due to the direct physiological effects of a substance or a
general medical condition
DSM IV-TR Criteria for Schizophrenia
1. Two or more of the following, each present for a significant portion of a 1-month
period:
a. Delusions
b. Hallucinations
c. Disorganized speech
d. Grossly disorganized or catatonic
e. Negative symptoms
2. Social/Occupational Dysfunction: One or more major areas of functioning, such
as work, interpersonal relations, or self-care, are markedly below the level
achieved before the onset.
3. Duration: Continuous signs of the disturbance persist for at least 6 months. This
6-month period must include at least 1 month of symptoms that meet criterion 1.
4. Schizoaffective and Mood Disorder: Schizoaffective and Mood Disorder with
psychotic features have been ruled out because (a) no major depressive, manic,
or mixed episodes have occurred currently with the active-phase symptoms; or
(b) if mood episodes have occurred during active-phase symptoms, their total
duration has been brief relative to the duration of the active and residual periods.
5. Substance/General Medical Condition: Disturbance is not due to the direct
physiological effects of a substance or a general medical condition
6. Relationship to Pervasive Developmental Disorder: If there is hx of autistic
disorder or another pervasive developmental disorder, the additional diagnosis of
schizophrenia is made only if prominent delusions or hallucinations are also

present for at least 1 month.

Summary: This patient qualifies for the DSM-IV-TR criteria for all of the above
diagnoses. She has substance dependence as evidenced by the criteria 4, 6, and 7. It
was hard to assess tolerance and increase in the amount used because I dont know her
history. I dont know how much she uses now compared to what she used in the past.
She also meets the criteria for a manic episode because she was hospitalized (DBHC);
has inflated self-esteem/grandiosity, decreased need for sleep, pressured speech, flight
of ideas, and distractibility; she shows impairment in functioning and relationships and
had to be hospitalized to prevent self-harm/harm to others; and the symptoms were not
due to substance use or a medical condition (negative tox screen for meth). Lastly she
meets all of the criterion for schizophrenia.
Three Nursing Diagnoses according to priority (include plan of care for each,
expected outcomes, and attach nursing care plan)
1. Risk for Self-Harm or Other-Directed Harm related to delusional thinking, auditory
hallucinations, hx of threats of violence toward self and others, substance abuse
a. Plan of Care: Maintain low level of stimuli, observe patients behavior
frequently (q15m), maintain a calm attitude toward client, complete SAT,
administer medications
b. Expected Outcomes
i. Within 3 days, client will recognize signs of increasing anxiety and
agitation and report to staff for assistance with intervention.
ii. Client will not harm self or others.
2. Social Isolation related to lack of trust, anxiety, delusional thinking, preoccupation
with thoughts; evidenced by staying in room most of the day
a. Plan of Care: Convey an accepting attitude toward patient, make
brief/frequent visits, show positive regard, attend group sessions with the
patient, be honest, give recognition and positive reinforcement for patients
voluntary interactions with others, encourage group attendance, administer
medications
b. Expected Outcomes
i. Client demonstrates willingness and desire to socialize with others.
ii. Client voluntarily attends group activities.
iii. Client approaches others in appropriate manner for one-to-one
interaction.
3. Risk for Medication Noncompliance
a. Plan of Care: Assess knowledge regarding medication regimen, explain the
importance of taking medication daily, explain what each medication is for,
ask why patient stopped taking medications, monitor responses
b. Expected Outcomes
i. Patient will report compliance with the therapeutic plan.
ii. Patient complies with therapeutic plan, as evidenced by appropriate
pill count, appropriate amount of drug in blood or urine, evidence of
therapeutic effect, maintained appointments, and/or fewer hospital

admissions.
Minimum of two peer reviewed references (evidence for interventions planned,
from last 10 years of literature).
In the article, Encouraging patients to take medication as prescribed, from the Harvard
Mental Health Letter, medication compliance interventions are discussed in order to
improve treatment adherence among patients with schizophrenia. Often times patients
do not verbalize whether they are taking all of their medications. Clinicians tend to
overestimate the percentage of their clients who are not compliant with their medication
regimen. This is why is it important to assess each and every patient. Patient education
about their illness and treatment is extremely important, but may not be enough to
improve adherence to treatment. The article suggests cognitive behavioral therapy to
help explain how medication adherence will reduce the patients symptoms. This,
combined with motivational interviewing can help patients comply to medication
regimens. A technique called, rolling with resistance, finding out why a patient is not
taking their medication, helps health care practitioners understand a patients concerns.
In addition, side effects of medications need to be monitored by health care practitioners
to address concerns as early as possible. The article suggests providing patients with a
daily checklist or a mood chart to bring to their follow-up appointments. Other ways that
may help patients adhere to their medication regimen are using weekly pill boxes, using
signs, or electronic devices to remind patients to take their medications. Overall,
therapeutic relationships are the most important component in medication compliance.
Nurses need to have mutual trust and respect for their patients.
This article supports my interventions for medication noncompliance. Patients are
assessed and educated about their medications and the responses to these
medications are monitored. I have been taught motivational interviewing and it is
a therapeutic communication technique that is extremely beneficial. I think that
patients at DBHC could benefit from cognitive behavioral therapy. I also think that
providing patients with a checklist or a mood chart would be beneficial. These
could be given to the patients at DBHC while they are there and they could
continue using them when they are discharged and asked to bring them to the
follow-up appointments. In addition, therapeutic communication is stressed in the
article and i agree that it is one of the most powerful components of a patients
treatment because without trust and respect, patients will not want to open up to
nurses and doctors, which makes it hard to find out their concerns and struggles
In the article, Managing suicide risk in patients with schizophrenia, the authors discuss
pharmacological approaches to managing suicide risk through the use of antipsychotics
and antidepressants. The article suggests that second generation antipsychotics,
specifically clozapine, are more effective than first generation antipsychotics in reducing
suicide risk. In addition, depressive symptoms in schizophrenics should be treated with
antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs). SSRIs
should be the first-line agents used to treat depression in schizophrenics. The article
also explains that many schizophrenic patients experience the demoralization syndrome

where they become aware of their illness and its consequences, which causes them to
feel hopeless. This can lead to depression and risk of suicide. According to the article,
medication adherence is extremely important for these patients because poor treatment
adherence is associated with suicide risk.
This article completely supports my interventions. My patient is on a second
generation antipsychotic, risperidone, and is on an SSRI, citalopram. These
mediations in combination are recommended for decreasing depression and
suicide risk.
Students response to experience with this patient:
I absolutely loved this case study assignment. I was a little nervous to be on D unit at
first, but after working with this patient I ended up liking mental health so much more.
This patient taught me so much about the spectrum of a disorder. I was fortunate
enough to work with her two weeks in a row and see her progression. I saw the maniclike state that schizophrenics can have and I also saw the depressive states that they
struggle with. This patient really opened my eyes to the severity of chronic mental health
disorders and the complications that arise when patients are noncompliant with their
medication regimen and have dual diagnoses. Although this patient was very
entertaining the first week I worked with her, it was sad to realize that she truly believes
in her delusions and that is her reality when she is in an active phase. The second week
I worked with her I was amazed at how different she was acting. She was on C1 and she
seemed very depressed and withdrawn. I felt like she was happier when she was in her
manic-like state and I didnt like seeing her in this more depressed state, but I knew that
it meant that her medications were working. It made me feel better when she told me
that she feels better. It was still sad though because I felt like she was more in touch with
reality and with her disorder and this was depressing her (like one of the article said
she was probably experiencing the demoralization syndrome). Its amazing what
medications can do and just how important it is for mental health patients to take their
medications regularly. I really feel like I have a better understanding of mental health and
I have come to really enjoy working with these patients.
Student Name: Caitlin Martinez

References
Kasckow, J., Felmet, K., Zisook, S. (2011). Managing suicide risk in patients with
schizophrenia. CNS Drugs, 25 (2). 129-143. Retrieved from
http://web.a.ebscohost.com.proxylib.csueastbay.edu/ehost/detail?sid=f22affc576c8-45fd-98f7-2f52c4c8516e
%40sessionmgr4001&vid=3&hid=4207&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZz
Y29wZT1zaXRl#db=aph&AN=47247736

President and Fellows of Harvard College. (2010). Encouraging patients to take

medication as prescribed. Harvard Mental Health Letter, 26 (7). 4-5. Retrieved
from http://web.b.ebscohost.com.proxylib.csueastbay.edu/ehost/detail?
sid=c490d62e-785a-442b-ae7e-95bbcd523efc
%40sessionmgr115&vid=1&hid=112&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY
29wZT1zaXRl#db=rzh&AN=2010919815