History of Present Problem:
Karen West is a 26-year-old single female who was admitted to the mental health unit this morning (0200) for a possible
overdose of pills following a fight with Steve, her boyfriend of six months. Steve shared that Karen flew into a rage when
he suggested that she “slow down” on her drinking at a party last night. She stormed out after throwing a drink at him.
When he arrived home an hour later Karen was breathing, but unresponsive with an open bottle of unknown pills on the
floor. Steve called 911, and she brought to the emergency department (ED).
In the ED, Karen began to awaken and stated that she remembers getting angry at her boyfriend at the party and
thinks she may have thrown a drink in his face. When she gets that angry, “Everything goes black.” She feels
embarrassed at what she did but is more upset that her boyfriend turned out to be “like everybody else. People always let
you down. He will probably leave me now, won’t he?” She remembers she couldn’t calm down after she got home and
just kept taking more and more pills hoping that would help. She states, “I wasn’t trying to kill myself.” There is a recent
superficial cut on her left thigh that is 4 cm in length. She admits that her life is getting out of control again and agreed to
admit herself voluntarily to a behavioral health unit, so she doesn’t “do something crazy.”
Personal/Social History:
Karen describes herself as someone who never feels content. She can feel deliriously happy at one point and then sad or
angry ten minutes later. She tries to put on a happy face for others, but almost always feels anxious. Even when things
are going well, she states that she feels like she is a fraud. She admits that sometimes the only way to feel better is to
cut herself. She revealed “old” razor blade cuts (scarring) to her inner thighs. She frequently drinks and uses marijuana
to calm down.
She was hospitalized once in her freshman year of college for depression and “cutting.” She saw a therapist for a few
weeks and started on an antidepressant, but the therapist was “awful,” and the medication made her gain weight, so she
quit both.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
• Possible overdose pf pills following a • This indicates that the patient is a danger to self
fight with her boyfriend
• flew into a rage when her boyfriend • Patient seems to have irrational thinking when under the influence
suggested that she “slow down” on of alcohol and can be a danger to others as well when doing so
drinking at a party last night, storming
out and throwing a drink at him. When
she gets that angry, “Everything goes
black.”
• was breathing, but unresponsive with an
open bottle of unknown pills on the floor. • Even though the patient states that she “wasn’t trying to kill
Boyfriend called 911 and she brought to herself,” her actions indicate that she is a danger to herself, and
the ED safety precautions should be put in place
• remembers she couldn’t calm down after
she got home and just kept taking more
and more pills hoping that would help.
She states, “I wasn’t trying to kill
myself.” There is a recent superficial cut
on her left thigh that is 4 cm in length
• admits that her life is getting out of • Voluntary admission to mental health unit. Patient is willing to get
control again and agreed to admit herself the help she needs
voluntarily to a behavioral health unit, so
she doesn’t “do something crazy.”
1
, RELEVANT Data from Social History: Clinical Significance:
• describes herself as someone who never • Drastic fluctuation of emotions, inability to feel happy, anxious,
feels content. She can feel deliriously and feeling like a fraud are all S/S of personality disorder
happy at one point and then sad or angry
ten minutes later
• frequently drinks and uses marijuana to • Abuses alcohol and marijuana to feel better
calm down.
• She was hospitalized once in her • Reveals history of self-harm and depression as well as
freshman year of college for depression noncompliance to treatment, which are contributing factors to her
and “cutting.” She saw a therapist for a current condition
few weeks and started on an
antidepressant, but the therapist was
“awful,” and the medication made her
gain weight, so she quit both.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 99.0 F/37.2 C (oral) Provoking/Palliative: Provoked by movement of leg
P: 86 (regular) Quality: Dull
R: 20 (regular) Region/Radiation: Left inner thigh
BP: 130/82 Severity: 2/10
O2 sat: 98% room air Timing: Continuous
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
T: 99.0 F • Although temp is not a fever, it is elevated and may be due to attempted drug overdose
BP: 130/82 and heavy alcohol use.
Pain 2/10 continuous • BP elevated and may be due to attempted drug overdose and heavy alcohol use.
• Left inner thigh pain may be due to inflicted self-harm
Mental Status Examination:
APPEARANCE: Disheveled with no body odor; appears younger than stated age.
MOTOR BEHAVIOR: Fidgeting in chair; wringing hands
SPEECH: Clear with normal rate and rhythm
MOOD/AFFECT: Reports feeling sad and remorseful for her behavior. Flat affect. Reports feeling anxiety
level of 8 out of 10.
THOUGHT PROCESS: Linear, logical
THOUGHT CONTENT: Currently reality-based thinking. No evidence of delusional thinking when assessed.
Some evidence of cognitive distortions
PERCEPTION: Denies hallucinations
INSIGHT/JUDGMENT: Insight fair – knows she needs some help now. Judgment: Fair to poor: Tends to think
about using maladaptive coping skills
COGNITION: Alert and orientated x4. Reports some memory issues around the events of previous night
Short term memory intact when tested. Long-term memory grossly intact – able to give an
accurate history
INTERACTIONS: Reports “people always let you down” so she doesn’t trust people
SUICIDAL/HOMICIDAL: Admits she could have died “by accident” from taking so many pills. Reports she thinks
2
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