"I don't have any money," the client says. I don't have a bank account or a credit card." Client had recently relocated from Oxon Hill, MD to be with her biological mother in Las Vegas, NV. Client was recently approved for Medicaid and the Supplemental Nutrition Assistance Program (SNAP) benefits upon becoming a resident of NV.
Source and Reliability of Informant: The client gave the information.
Past Use of Health Care System and Health Seeking Behaviors:
Client reports minor primary care services and frequent usage of outpatient psychiatric services.
Present Health or History of Present Illness:
The patient endorsed having a self-injury/cutting disorder stating “I started cutting, again, on my thighs. It’s been 2 years on and off. I just want to stop this habit.” Client has hx of major depression (MDD), substance abuse, self-injury, and suicide attempt x1.
Past Health History
General Health:
Client states, “my body seems to be healthy, but my mind is not so great. I have so much negative energy built up, it’s gonna mess me up health wise.”
Allergies:
Latex, shrimp, dairy products, haloperidol & penicillin
Reaction:
Latex: mild reaction , rash
Shrimp: moderate reaction, rash
Dairy products: moderate reaction, irritable bowel
Haldol : severe reaction, dystonia
Penicillin : moderate reaction, nausea & vomiting
Current Medications:
Sertraline Hydrocholoride (Zoloft) 50mg PO QAM
Trazodone ER 150mg PO QHS
Multivitamin Supplement PO Q day
Loratadine (Claritin) 10mg PO Q day PRN
Ibuprophren (Motrin) 800mg Q 8 hrs PO PRN
Last Exam Date:
12/10/2015
Immunizations:
Pt unaware of immunization status stating, “I have no clue about that stuff. I do know that I got a tetanus shot before though.”
Childhood Illnesses:
Conjunctivitis, influenza & strep throat
Serious or Chronic Illnesses:
MDD, Self-harm, substance abuse
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:
The injuries the client encountered in the past are: bilateral wrist lacerations due to suicide attempt (2013) and multiple bilateral thigh abrasions due to self-injury (2014-present).
Past Hospitalizations:
Suicide attempt in 2013. Client states, “I had cut both my wrists with a razor blade.”
Past Operations:
Sutures for bilateral wrist lacerations (2013).
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Mother
Allergies: Allergic to Penicillin (mother)
Arthritis: mother
Asthma: N/A
Blood Disorders: Polycythemia (mother)
Breast Cancer: N/A
Cancer (Other): N/A
Cerebral Vascular Accident (Stroke): N/A
Diabetes: Father & sister
Heart Disease: N/A
High Blood Pressure: Father
Immunological Disorders: Psoriasis (mother)
Kidney Disease: N/A
Mental Illness: Bipolar disorder (father)
Neurological Disorder: N/A
Obesity: N/A
Seizure Disorder: N/A
Tuberculosis: N/A
Obstetric History (if applicable)
Gravida: N/A
Term: N/A
Preterm: N/A
Ab/incomplete: N/A
Course of Pregnancy: N/A
Well Young Adult Behavioral Health History Screening
Socio-Demographic Content and Questions:
What organizations or activities are you involved in?
Client states, “I just moved here. I’m not really involved much with anything. My mom encourages me to go to church on Sunday’s. I go sometimes. I have no work and I am looking for a job. I like to play basketball at the park.”
How would you describe your community?
Client states, “my society is Sin City, Vegas. I’m surrounded by gamblers, drinkers, druggies, smokers… You name, we have it all.”
Hobbies, skills, interests, recreational activities?
Client states, “I play basketball. I’d like to take some classes at the community school, but I am not sure of what I want to study.”
Military service: Yes_______ No______x ____
If yes, overseas assignment? Yes________ No_________
Close friends or family members who have died within past 2 years?
The client says, “my closest neighbor, Sheryl, died from Lupus with other complications a year ½ ago.”
Number of relatives or close friends in this area?
Client states, “I am with two relative, my younger sister and mother with no close friends in this area.”
Marital status: Single______x ___ Married________Divorced_________Separated_________ In serious relationship____N/A Length of time_____N/A____
Environmental Content and Questions:
Do you live alone? Yes________ No _____x _____
When did you last move? Client states, “half a year ago.”
Describe your living situation? Client states, “I live in my mother’s house. My younger sister lives with us too.”
Number of years of education completed? The client says, “I finished high school in 2008. I took some college courses at Prince Georges Community College in MD but stopped because I wasn’t sure what I want to be.”
Occupation?
If employed, how long? Client states, “I’m not employed at the moment.”
Are you satisfied with this work situation? Client states, “I’m unhappy because I can’t find work”
Do you consider your work dangerous or risky? N/A
Is your work stressful? N/A
Over the past 2 years have you felt depressed or hopeless?
Client says, “I have experienced depression on and off for over for approximately seven years. Hopeless? I don’t know… Maybe I am.”
Biophysical Content and Questions
Have you smoked cigarettes? Yes____x___ No________
How much?
Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day____x__
Are you smoking now? Yes___x____ No________ Length of time smoking? __”I have been smoking for ten years”____________
Have you ever smoked illicit drugs? Yes____x______ No_________
If yes, for how long? _____”2 years”______ Do you smoke these now? Yes _x_______ No __________
Do you ingest illicit drugs of any kind? Yes_____ No___x____
If so, what drugs do you use and what is the route of ingestion?___ _____
How long have you used these drugs _________________
Review of Systems
(Include both past and current health problems. Comment on all present issues.)
General Health State
Current weight= 78kg (171 lb 15.37 oz), Height= 180cm (5 ft 10.87in), BMI= 24.07 kg/m2
Pt endorses weight gain stating, “I gained 7 lbs since I moved here to Vegas. I think it’s because I’ve been eating all my mom’s cooking.” Client endorses fatigue, malaise and weakness stating, “I feel tired all the time these days. Perhaps because I’m in the house all day and not doing much with my life.” Pt chills or night sweats.
Skin: Client does not admit having lesion or rashes, moisture or excessive dryness, skin disease, excessive bruising, change in mole, pruritis and pigment or color change.
Health Promotion: The client avoids exposure to sun stating, “It will not for me to get darker than I am today. I use sunblock especially if I go swimming.” Client uses Vaseline lotion to moisturize skin when needed.
Hair: The recent change hair texture or loss of hair was denied by the client. Client’s hair is thick and coarse.
Health Promotion: Client states, “I use whatever is in the shower for my hair. I think the shampoo I use is Pantene. “
Nails: Client denies any nail changes in color, shape or brittleness. Nail beds are pink and round shaped.
Health Promotion: Client states, “I cut my nails when they get long. I don’t do manicures.”
Head: Client denies any head injury, dizziness, syncope or vertigo. Client endorses occasional headaches and self-medicates with ibuprofen (Motrin) for headache relief.
Health Promotion: Client states “I take Motrin whenever I get headaches.”
Eyes: Client denies glaucoma, eye pain, discharge, contracts, decreased acuity, difficulty or change in vision, blind sports, or blurring. There are no cases of eye drainage or eye deformity, sclera clear, moist and intact.
Health Promotion: Client wears prescription eyeglasses and contact. His last vision exam was in 4/2016.
Ears: Client denies vertigo, tinnitus, discharge, earaches, discharge or infections. There is absence of ear drainage or ear deformity in the client.
Health Promotion: Client denies any environmental noise exposure, hearing aid use or hearing loss. The client uses woolen swabs to remove dirt from his ears on daily basis after taking bathe.
Nose and Sinuses: Client denies sinus pain, change in sense of smell, discharge and its characteristics, nasal obstruction or severe and frequent colds. Client does endorse nosebleed at any occasion and regular allergies.
Health Promotion: Client states, “I just use tissues for nosebleeds and sneezing. I take Claritin for my allergies.”
Mouth and Throat: Client denies toothache, lesions in throat, tongue or mouth, sore throat, mouth pain or bleeding gums. Client denies alteration in taste, hoarseness, tonsillectomy or dysphagia. The tongue of the client appears pink and intact. His mucous membranes (or oral mucus) appear pink, moist and intact.
Health Promotion: Client brushes his teeth three times in a day. His last dental examination was in12/2014.
Neck Client denies goiter, swelling or lumps, pain, tender or enlarged lymph nodes, or limitation of motion. The range of motion in the neck of the client is normal.
Neurologic System: Client denies CVA, memory disorder, paresthesia, history of seizure disorder, coordination disorder, motor function disorder or syncopal episodes. Client endorses mood changes, depression and history of psychological health illness stating, “I have a depression history. I’ve tried to commit suicide once. I’m a cutter too.”
Health Promotion:
Client reports not having activities that stimulate thinking. Client endorses difficulty concentrating at times. Affect/behavior of client is flat & withdrawn.
Endocrine System: Client denies intolerance to high or low temperature, history of thyroid disease or history of resistance to insulin or diabetes.
Health Promotion: Client states, “I should eat healthier, but I don’t.”
Breast and Axilla: Client denies history of nipple discharge in the axillia or nipple region, swelling and rush, lump pain, or tenderness.
Health Promotion: The client refusing undergoing any breast examination and reports his inability to perform such task. Client uses Degree anti- perspirant.
Respiratory System: Client denies history of pollution or toxin exposure, smoking, lung disease, shortness of breathe, wheezing, sputum, chest pain with breathing, hemoptysis and cough (productive or nonproductive).
Client has apparent breath sounds on all fields, respiration are regular in rate and rhythm, no cough, chest movement is symmetrical, no secretion, and respiration rates are unlabored.
Health Promotion: Client denies having any chest x-ray performed. Client refuses any form of smoking cessation.
Cardiac System: He denies history of angina, sharp chest pain, MI, arteriosclerosis, or cardiac disease. Client’s capillary refill is less than 3 seconds, nail beds pink, and no edema, and no clubbing, peripheral pulses are 2+, tolerates activity and regular rate/rhythm.
Health Promotion: Client denies ever having a cardiac examination.
Peripheral Vascular System: Client denies ulcers, varicose veins, coldness, swelling of ankles/legs, numbness, discoloration of feet/hands, thrombophlebitis, tingling, or intermittent claudication.
Health Promotion: Client endorses that he avoids leg crossing and standing/sitting for extended period of time.
Hematologic System: Client says he has not experience radiation or toxic agents, exposure, lymph nodes swelling, excessive bruising, and any reaction or blood transfusion. Client endorses self cutting by self-cutting.
Health Promotion: Client endorses utilization of standard precautions when exposed to body/bood fluids of others stating, “other people’s blood/body fluids gross me out. I stay away from it.”
Gastrointestinal System: Client denies change in stool (color or consistency), dysphagia, vomiting, history of abdominal disease, heartburn, hemorrhoids or rectal bleeding ,indigestion, constipation, pyroais, diarrhea, gastric ulcers, nausea, or pain (with eating or other). Client endorses increased appetite having gained weight. His bowel movement frequency is once a day. Client is lactose intolerant stating, “I get stomachs, gas and diarrhea if I eat anything that’s dairy.”
Health Promotion: Client endorses eating nutrient rich meals at home when his mother cooks. Client rarely experiences heartburn, but uses Tums antacids for relief should it occur.
Musculoskeletal System: Client denies history of weakness, stiffness, cramps, limitation of motion, arthritis, pain, deformity, swelling, or joint pain. Client does not have amputations, no deformities, contractures, or swelling and his range of motion is normal.
Health Promotion: Client does not use any mobility aids/devices. Client exercises by playing basketball once a day.
Urinary System: Client denies recent change in urgency and frequency, narrowed stream, oluria, polyuria, incontinence, straining or hesitancy, nocturia, urine color; urinary disease in the past; groin, low back, or pain in flank.
Health Promotion: For preventing urinary tract infections, client states, “I like to drink cranberry juice.”
Male Genital System: Client denies hernia, lumps, lesions/sores, lumps or testicular/penis pain.
Health Promotion (performs testicular self-exam):
Client confesses he has never carried out testicular self-exam and reports his inability to perform such task stating, “I am not even aware of what I’m feeling for or supposed to be looking.”
Female Genital System): N/A
Health Promotion: N/A
Sexual Health: Client refuses any relationship involving intercourse or other sexual activity. Client is currently practicing abstinence. Client denies history of STD.
Health Promotion: Client practices safe-sex stating, “I’ve used condoms whenever I had sex. I am used to practicing safe sex and I have e been in a relationship for one year.”
Nursing Diagnoses:
Based on this health history and health screening, identify three nursing diagnoses that would be applicable for this client as well as your rationale for your selection of each nursing diagnosis.
Ineffective coping linked to the inadequate level of confidence in the ability to cope is the “actual” diagnosis for this client. Ineffective coping is the capability to form a valid appraisal, poor choice of practice responses, stressor, and inability to use available resources. JDJ presents lack of goal-directed behavior/ resolution of the problem by continuing to self-injure through cutting his skin as a form of tension release. This particular form of coping impedes adaptive behavior and is a destructive behavior toward self. JDJ endorsed using illicit drugs of cannabis on a daily basis. JDJ has a decreased social support structure especially when he moved from MD to NV 6 months ago. JDJ lacks employment, financial independence and has inadequate resources available.
The wellness nursing diagnosis for this client is “readiness for coping enhancement.” JDJ has been self-cutting since 2014. JDJ understands that this form of coping is not healthy behavior and has recently expressed his desire to change. JDJ is open and receptive to learn positive, effective coping strategies and therapeutic techniques such as guided imagery and relaxation. JDJ has endorsed his readiness to focus on strengths rather than weaknesses.
The “risk for” nursing diagnosis for this patient is “danger for suicide related to feelings of hopelessness secondary to MDD.” JDJ was unable to provide identification of any protective factors. JDJ risk factors for suicide include MDD, financial difficulty, flat affect, hopelessness, lack of employment and recent interpersonal loss.
Wellness plan for the young adult
Nursing Interventions and Rationales
Assist the client to set a goals which can be easily achieved and identify personal knowledge and skills. Make the client participate in decision making since it will make them move toward independence (Connelly et al, 1993).
Advice the client to get involved in schedule activities and planning. The client should also be encouraged to make choices. The client self-esteem and feeling of control will be boosted via participation.
As required refer for counseling. Organize for the referral and help the client in working to develop problem copping and problem solving skill (Feeley, Gottlieb, 1998).
Client Teaching
The client should be taught relaxation.The client’s sense of control is promoted through problem solving skills. Relaxation enhances coping and minimizes stress (Fontaine, 1994).
Teach imagery process as it will evoke mental effect of desired effect
By the use of process imagery, an individual is able to see an old challenge in a different way, freeing the challenge from the original memory and making new connection (Stephens, 1993).
Develop the relevant educational techniques that look into individualized coping strategies by working closely with the client. Partnership between the staff and the client in the production of client information will boost the understanding of the client and empower the family and the client participates in the treatment (Willock et Grogan, 1998).
Make client aware of the recourses available in the community such as counselors, ministers, and therapists. The development of the coping skills and problem-solving skills is boosted by the use of resource helps (Feeley & Gottlieb, 1998).
References
Connelly, A., Keele, B., Kleinbeck, S. (1993). A place to be yourself from the client’s perspective. Journal of Nursing Scholarship. 25: 4, 297-303.
Feely, M. & Gottlieb, R. (1988). Incorporating a wellness perspective for nursing diagnosis. North American Nursing Diagnosis Association. Philadelphia: J. B. Lippincott.
Fontaine, A. (1994). Stress and coping. Family & Community Health, 29:28s-34s.
Stephens, S. (1993). Self-help interventions. Journal of Consulting and Clinical Psychology, 61, 790-803.
Willock, P., & Grogan, T. (1998). Family support and coping: Some determinants and adaptive correlates. British Journal of Social Psychology, 34, 107-124.
