Case Study Template - Marisa Astiz-Martinez PDF

Preview

Summary

Marisa Astiz-Martinez...

Description

Case Study #1 Alyssa Velez NURS 329 SG1: Psychiatric Mental Health Nursing Dr. Ben Canha, Prof. Astiz-Martinez, & Prof. Cecilia Lau March 11, 2021 History of Present Illness: Current Presentation: General Description Mode of Arrival Chief Complaint

Assessment:

Sequence of Events & Active Problem/Symptoms

OnsetProgressionDescriptorsFrequency: Duration: Intensity: Impact Distress: Problems: Function: ManagementPrecipitating Factors: Alleviating Factors: Aggravating Factors: Pattern:

Psychosocial Stressors Past Psychiatric History: Previous Psychiatric Treatment

Family Psychiatric History

Assessment: DiagnosisHospitalizationsOutpatient TreatmentTherapy: Medication: Self-Harm/Suicide AttemptViolence-

Mental Status Exam (MSE): General Observations: Appearance Behavior Speech

Assessment:

Motor Attitude Emotional State: Mood Affect

Assessment:

Thinking & Experience: Thought Process Thought Content

Assessment: Self-Harm/Suicide AttemptViolenceDelusionsParanoia-

Perceptions

Sensorium & Cognition: Level of Consciousness/ Orientation Concentration Memory

Assessment:

Fund of Knowledge Insight Judgment Neurovegetative: Sleep Appetite Energy

Libido Pain

Assessment:

Mini-Mental Status Exam (MMSE)

Assessment:

Diagnoses: Psychiatric Diagnosis 

Medical Diagnosis 

Nursing Diagnosis 

Reflection Questions: 1. What three skills did you learn in this simulation that will help you in your nursing career? Explain your answer.

2. What do you think it would be like for you to communicate with depression and suicidal ideation in the hospital either on a psychiatric or medical unit?...