Psychiatric Nursing Case History Example
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 shows the relationship between biological risks (genetic predisposition)and environmental stressors. It is postulated that those who are biologically at risk may develop the psychosis secondary to a stressor. Bipolar Disorder is often seen with people who have mood disorders, schizophrenia, delirium, dementia, or substance abuse. They may experience hallucinations, delusions, or disorganized speech or behavior. Substance abuse and a family history of the disorder are both risk factors.
Bipolar Disorder (in Depression): The etiology for Bipolar disorder related to depression revolves around incomplete synthesis and increased metabolism of neurotransmitters. Environmental stressors and behavior that is learned can affect these neurotransmitters and an influence on depression.
4. Type of admission:
____ Voluntary __X_ Involuntary (describe): Brought by law enforcement
5. Teaching/learning data: (Relevant communication/ teaching data: Patient needs to be given education involving smoking cessation and alcohol abuse. Patient also needs to be given medication education so that adherence may be attainable.
6. HPI: (History of Present Illness: What behaviors/ symptoms led to this hospitalization, what
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 shows the relationship between biological risks (genetic predisposition)and environmental stressors. It is postulated that those who are biologically at risk may develop the psychosis secondary to a stressor. Bipolar Disorder is often seen with people who have mood disorders, schizophrenia, delirium, dementia, or substance abuse. They may experience hallucinations, delusions, or disorganized speech or behavior. Substance abuse and a family history of the disorder are both risk factors.
Bipolar Disorder (in Depression): The etiology for Bipolar disorder related to depression revolves around incomplete synthesis and increased metabolism of neurotransmitters. Environmental stressors and behavior that is learned can affect these neurotransmitters and an influence on depression.
4. Type of admission:
____ Voluntary __X_ Involuntary (describe): Brought by law enforcement
5. Teaching/learning data: (Relevant communication/ teaching data: Patient needs to be given education involving smoking cessation and alcohol abuse. Patient also needs to be given medication education so that adherence may be attainable.
6. HPI: (History of Present Illness: What behaviors/ symptoms led to this hospitalization, what
Cited: Reference: Oei T. Coping and alcohol use and abuse disorder. Addiction Research & Theory. October 2005;13(5):407-409. Available from: PsycINFO, Ipswich, MA. Accessed October 17, 2011. Reference: Cramer H, Salisbury C, Conrad J, Eldred J, Araya R. Group cognitive behavioural therapy for women with depression: BMC Psychiatry.May 2011;11Available from: PsycINFO, Ipswich, MA. Accessed October 17, 2011