Psychiatric Nursing Case History Example Essay

2523 Words May 23rd, 2012 11 Pages
Pyschiatric Nursing Case History with Diagnosis, HPI, ad Diagnostics


1. Identifying Statement 59 year old, married white female who was brought to the Emergency Department by the police by herself because of public intoxication with suicidal ideations. Chief complaint was “I was depressed and wanted to kill myself”.

2.Admitting diagnosis (DSM IV-TR classification):

Axis I : Bipolar Disorder
Axis II : None noted
Axis III : Kidney disease, Liver cirrhosis
Axis IV : No friends/outside support
Axis V ( GAF) : 30
3. Discuss theories of etiology for Axis I and Axis II diagnosis:
Bipolar Disorder (in Psychosis): The etiology for Bipolar disorder is based on the stress-diathesis model. This model
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Formal Thought Disorders: Thoughts were often irrelevant and unrelated. No occurrences of word salad noted. Answers were given spontaneously and without delay.
Content Thought Disorders: Patient’s content was reality based with no delusions. No obsessions present.
Perceptual Thought Disorder: Patient denied presently having hallucinations or illusions. None noted by observation.
Cognition: Patient was alert and oriented x4 and able to recall the past with ease. Patient’s attention span was appropriate and could communicate effectively when on topic. She had adequate insight about why she was admitted and the background of her disorder.

8. Lethality:
Suicidality: (Past or present suicidal ideation, intent or attempts? Self-mutilation?): Denies feeling suicidal at this time, but prior to admission, patient had threatened to kill herself when law enforcement found her. Patient states this is not the first time she has felt suicidal. Past history of intent in February 2010, but no past history of attempts, or self-mutilation.

Violence: Past or previous attempts to hurt others?: Patient denies ever wanting to hurt others. No history noted.


9. Psychiatric history: ( Onset and course of illness, previous diagnosis, include any previous diagnosis)
Patient states she was diagnosed with Bipolar Disorder in June of 2009. She says that after a period of severe depression that was…