Mental Health Nursing Case Studies

SOCIAL HISTORY: Patient admits alcohol ingestion nightly and on weekends. Denies tobacco use and illicit drug us. He is married.

Patient lives with her husband of 10 years and 3 children in Denver, Colorado. Patient denies any spousal abuse. She also denies smoking, alcohol, or drug use during her pregnancy. Patient completed middle school, and currently works as a house wife. Patient is of low economic status.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

The deposition of Dr. Joe Gonzales occurred on March 16, 2016. Dr. Gonzalez was retained by Plaintiff as an expert in this case and was requested to prepare a life care plan for Plaintiff’s future medical care needs. Dr. Gonzales has served as a life care planner since 1988, when he received is license to practice medicine. He became a certified life care planner in 2006. He is a medical doctor in San Antonio who is board certified in physical medicine and rehabilitation, pain medicine, and occupational and environmental medicine. Half of his work consists of treating patients and the other half consists of preparing life care plans related to litigation. When he does life care planning work, 85-90% of that work is on behalf of the plaintiffs in the respective litigation. He sees on average 20-50 patients a week in his medical practice. He has not practiced in a hospital in at least 10 years.

The participant is a 49 year old African American male who began using substances at the age of 13. He was diagnosed with severe alcohol, cocaine, and opioid use. The participant has been incarcerated over the past 32 years. He was recently paroled after completing eight years of a sixteen year sentence in the Illinois Department of Corrections for burglary and theft. The participant is on medications to treat HIV/AIDS and has been diagnosed with Major Depressive Disorder. He was referred to Healthcare Alternative Systems residential program through TASC as a condition of his probation.

last 4 months. The client has bipolar disorder has erratic behavior since she has not been on

The patient is a 34 year old black male. The patient reports he is single with 3 daughter ages 3, 11, and 13. The 3 year old live with him. He reports currently live with his mother and brother. The patient reports he has 14 years of education however has not received his degree. The patient reports being on probation for Injury to a child for the next two years. The patient is scheduled to be complete his probation in September 2016. The patient reports Cannabis is primary substances and his last use July 20, 2015. He stated on that day he smoked about 5 joint. The patient also report that he tried Xanax . The patient denies any issues with HI/SI. Patient also reports he is taking his medication as prescribed. The patient appear to be in the pre-contemplation stage of change. The patient next scheduled individual session with the counselor is on Thursday, July 30, 2015 at

Mrs. W is a 35-year-old, married but recently separated for the past two years, African-American woman with 4 children, and works full-time as a Trainer for a large corporation. She had her first child at the age of 15. Her primary language is English and Mrs. W is a Christian who actively goes to church, sings in the choir, and is president of the youth department at her church. As a Trainer, Mrs. W reports an annual income of approximately 40,000 dollars.

A 42-year-old female by the name of Mrs. Janice checked into the emergency department (ED) for low back pain. Mrs. Janice has a history of chronic back pain from an

Xavier then reported, the applicant recovery is up and down and the reason the patient was transferred and admitted to the Norwich location was due to an altercation as the Hartford Dispensary has zero tolerance for physical violence. Since May of of this year, the applicant's UDS results are negative. Last positive result was in April for cocaine, according to the counselor. Please note, during the applicant intake, he was asked about other illicit drugs and only confirmed for use of heroin and THC, not the cocaine. The applicant's current dose at the Hartford Dispensary is 105mgs as he is being detoxed daily. His highest dose was at 145 mgs before his detoxification. The physical altercation was the applicant's first behavioral incident at the clinic. He was also on a 90 Probation for his illicit use and it would have expired in August, but due to the recent incident, he was removed from the clinic, not discharged, but transferred as mentioned before. Counselor Xavier only concern of the applicant is maintaining his

Client was considered to be in semi-compliance with treatment during this reporting period. Client attended two secheduled groups with two absences. UA were negative for all tested substances. Client reported participating in self-help meeting regularly; verification was provided. Treatment attendance needs to be improved in 30 days.

Supervisor Comments: This writer met with Cherron to address some concerns of what is patients on his caseload have reported and their request to be reassigned. Please note, there was a previous conversation with Cherron yesterday about patient #9100 and #2693 as Cherron reports of the two patient non-compliance with keeping appointments referring to counseling sessions. In addition, Cherron shared some concerns about patient #2693 ongoing use of illicit benzos/cocaine and the need to seek a higher level of care. This writer informed Cherron that patient #9100 admits to his non-compliance with his appointment; however, often finds it difficult to reschedule with Cherron due to Cherron lack of response of his request. In addition, the patient felt disrespected of Cherron refusal to meet with him on 3/13/2017.

The patient I have chosen to write about is a seventy year old male who has been married for nearly fifty years. He has two grown up sons, both married with

Social History: The patient widowed and lives in a house with her two daughters. Currently employed as a supervisor at Walmart and has health insurance through her work. Works full time and enjoy her work. She enjoys spending time with her family. She is sexually active. She is currently in an intimate relationship for the past one year after the death of her husband and used condoms occasionally when having sex. Highest level of education is bachelor’s degree