Case Study S – Situation 28-year old

Case Study S – Situation 28-year old male was brought to the emergency room by his mother after an angry outburst where he threw a lamp in the house. He complained of hearing voices for the past 10 months, and loss of appetite. He also complained that he roamed around town, and even though he returned home, he was sometimes physically abusive to his mother and sister. The patient further added that he felt unsafe and thought that people wanted to harm him. He has not taken any regular medications in the previous 6 months. B – Background His social history revealed that he lived in the city with his mother and sister. He had a girlfriend who stayed at a different suburb of the city. His past medical history included a history of paranoid delusions. There was no family history of mental or physical illness. His mother states that if his violent outbursts continue, she’s afraid she might have to kick him out of the house. The patient explained that he took a leave from work because he was feeling feverish and asked someone to replace him, but he never returned to the workplace. A month after commencing leave, he received his salary for work done but subsequently was not paid by his company. He decided to move from one bank branch to another, trying to make withdrawals. On his third attempt at one branch, he was arrested and put in cells for four days, but he was never given any reason. He said he had also received death threats, one of which was a call from an unfamiliar number. No words were spoken, but he perceived that it was a signal that meant that his life was to be taken. A – Assessment Appearance – Disheveled clothes but appropriate for weather, poor hygiene, beard and mustache, hair unkempt. Apprehensive, emaciated. Speech – Coherent, verbose and pressured, normal volume Motor activity – Restless, pacing Mood – depressed Affect – constricted Cognition – alert without signs of cognitive impairment Thought process – Circumstantial, disorganized Thought content – paranoid, persecutory delusions; auditory hallucinations. Responding to internal stimuli. Memory – intact Insight and Judgment – poor Attitude toward interviewer – suspicious and impatient Vital signs: HR 91, RR 19, BP 130/92, Pulse Ox 99%, Denies pain. R – Recommendations Draw labs: CBC, BMP, Liver enzymes, Thyroid panel, Toxicology screen CASE STUDY QUESTIONS List symptoms List any other assessments you’d like to see or information you’d like to have List possible medical diagnoses Give 2 NANDA nursing interventions with outcomes What else are you concerned about? What type of care would you recommend for this patient? (Inpatient, residential, outpatient, PHP or IOP, etc.?) What discharge planning would you want to see?

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