Student: Joseph Bogle Date: 11/21/16 Clinical Instructor: Lorena Fluentes Client’s Initials: K.K. Unit: Locked Current Legal Status (Vol, 5150, 5250, 30 days, T-Con, LPS-Conservatorship): 5150 Psychiatric Diagnosis: 1. Description of the client: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization? Number of days in the hospital? Mental Status, etc. Client is an 48y/o African American male. He was recently divorced, and has been admitted DTS for psychosis and suicidal ideation. He is oriented x3-4. Displays good insight and sound judgment. Very non-confrontational attitude and behavior. He was admitted after a suicide attempt by his daughter. He has been in this facility for three days after being transferred from the ER after He tried to overdose with pills. When prompted to speak about his family, client became very withdrawn and secretive. When prompted to speak of his experiences, he gladly shares stories. He loves animals especially cats, and to occupy his time he enjoys reading books (the bible) and watching movies. Claims to have no prior history of smoking or substance abuse. 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 meeting took place in the activity room. While the environment was rather loud and unfocused, K.K. stated that
The client is more than the patient I am caring for on the unit. It extends to the family, caregivers, and friends. When working with complex patients, I remind families they are the “expert” on the patient. They feel valued knowing their information and input is
Could the client have any other psychiatric disorder? If so, list and include supporting DSM-IV-TR criteria.
Discuss what is required to disclose patient information to family members, friends, and when ordered by courts or government
A lot of information can of course be collected on an initial consultation notation form and I think the information requested on this form is extremely important to start to establish a picture of each client. The initial consultation notation form should start with basic information such as the client’s full name and whether they have a “known as” or a preferred name, their contact details and whether they have any instructions as to who you can leave a message with, their date of birth, any medical history or medication they are currently taking. It should also ask for details of their GP but ensure the client knows that “their GP would not be able
is currently working on establishing a healthy social support system. Pt. has been attending all AMS TX activities and dosing on a daily basis. Pt. has not yet begun to gain the knowledge of the assistances and organization that are available to him such as peer mentors, recovery coaching, self-help meetings, etc. Pt. doesn't attend any outside groups such as AA/NA meetings. Counselor will continue to encourage Pt. to get out into the community, discuss the activities he can become involved in and talk about the importance of not isolating for his recovery and from positive family members. During this upcoming session, Primary Counselor will assist Pt. to learn and identify ways to get help from supportive others at home, work, and in other settings. Pt. needs to find sponsor(s) and set of emergency numbers of supportive
Presenting for treatment is a 39 year old single, Caucasian female born in Montreal, Canada. The client identifies as heterosexual with no children and no current intimate relationship. The client was recently released from a psychiatric residential treatment in the U.S. and referred for ongoing outpatient treatment by her doctor at the hospital. The client has a history of suicidal ideation, with her last attempt leading to her hospitalization. The client reported that both her parents died in a car accident when she was an infant. The client stated that she has a twin brother whom she did not meet until much later in life. The client reported being raised in a hyper-religious school in Quebec and it was there, the client stated,
the client met with his counselor on 01/29/2017 for his weekly 1x1 session to discuss his recovery program and what progress has been made during his time in the program. the client has been in compliance with the program requirements . the client has been attending his group session and 1x1 session, he also has been attending family group with his mother and girlfriend that are currently supporting his recovery. the client has been attending all of his doctor appointments and taking his medication on a regular basis. the client has been attending outside meeting as well, and is now phased up in the program to go on weekend passes. The client appears to be taking his recovery seriously, he talking about attending an AA meeting close to his
Purpose: The focus of this assignment is identifying patient’s needs and analysis and synthesis of details within the written client record and planning an appropriate discharge plan with necessary patient teaching of the disease process.
Client appears to be depressed. She reported living in the shelter is not easy its very depressing. Client also reported she is currently participating in a psychotherapy individual session at NY Psychotherapy Mental Health every Wednesday.
I am currently working with a 30-year-old male who comes from a lower socioeconomic background. He has a history of incarceration, abuse, and addiction to drugs. He is currently sober, and has been for a few years. He is currently married, has three children, and is currently unemployed. He is living with his wife, children, and two siblings. They live in a 3-bedroom apartment, with his brother and sister. His wife is the only source of income for his family, and he does odd jobs to help pay for things around the house. He is seeking help because he is aware that he is unable to control his anger at times, and needs help with how to deal with it. He also says that he has depression, anxiety, and PTSD from the time that he was incarcerated. He has received services through the clinic before, but has a history of inconsistent attendance. He will come to the clinic for a few weeks and stops coming. With the last therapist, he showed up for two sessions. He is not enrolled in any other programs, but receives government assistance to pay for food, and for health insurance. Initially, I was taken back because he looked so young. My initial reaction when I was first met him was curiosity: what brings him to therapy? In our first session, he shared that is having issues assimilating back to life outside of prison, and was having flashbacks of traumatic moments from when he was incarcerated. After the session, I realized my immediate assumption was wrong. Yes, he is young per his age
Since the closure of the asylum’s doors, the prison compound has become the home to mentally ill offenders. They receive help by getting treated, but others, are abused further inside the prison’s walls. Each year, the number of inmates diagnosed increases, but also the ones who get arrested already mentally ill. The public shies away from them, but they also think they should be treated in a hospital, not in a prison. While there are many cases out there, that have either made a significant difference to their treatment, or just a little nudge to change, the numbers do not drop.
The client's objective in seeking help including any reservations they may have. Is it a long-term problem or a new problem.
The client is a young, White-American, Christian, male. He most likely come from lower middle class (currently unemployed and used to work in a local furniture store). He is a single man, but his sexual orientation, romantic and sexual relationships are not mentioned in the report. Considering his particular cultural elements, he is in advantageous situation in some part such as, ethnicity, sex, religion and age. Thus, he is not likely to feel “extra” oppression due to his metal health and alcohol use problems. However, his comes from low SES and has a mental disability (therefore, he become eligible to Medicare), these probably negatively influence his mental health progression. For example, he is not able to access his former psychiatrist due to his current insurance. When it comes to his spirituality, even though his father is a religious man, the client does not seem to be interested in spiritual issues. However, his father’s strong spirituality would be beneficial for both. Since, the client’s father, as a main social support source, his mental and physical health is also vital for Tom. In fact, his father plays a critical role in Tom’s life.
The most challenging aspect of this clinical situation was that the client always wants to run away from us as soon as he believes he is doing fine and does not need to be with the nurses. It was hard to deal with a client who loves to seek attention, as soon as he gets a hold of the nurse and gets what he wants, he just wanted to run away from the nurse. Working with a client with such behaviours, I would wonder if I, as a nurse was taking too long to provide the care that he receives every day from other nurses. I wanted to make sure that the client’s condition is stable, as Canadian Nurses Association (2008) stated one of the nursing values and ethical responsibilities is that “[n]urses work with people to enable them to attain their highest possible level of health and well-being” (p. 10). It was my responsibility to make sure my client’s
This was evidenced after a recent episode where the male talked about relinquishing all his possessions with the idea that he would travel to Washington, DC and advise the president on Native American rights and the responsibilities of the United States to the indigenous population. It was after a polite rejection letter that the male subject went into an extreme depression with thoughts of self harm that the client decided to come to our offices to seek treatment. The client is also in danger of losing his current job and most importantly has himself noticed that he has been alienated from his friends and close family