Help with case study...

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Hello

I have to complete a case study on my mental health patient. The case study must include all medications (with reason, action, etc), Theories including biological, genetic, biochemical and psychological and how they relate to my client, reason for all diagnostic labs/tests, treatments/therapies my client should receive, ericksons developmental stages, advantage of the hospital milieu, discharge care planning and a nursing care plan!

I am SOOOOOOOOO overwhelmed, i have no idea where to begin!

Some info. on my client

She is diagnosed with Axis I bipolar, depressed she has no axis 2 or 3. She has autistic thinking, no delusions or hallucinations have been noted but she definitely isn't thinking clearly. She has MAJOR flight of ideas and cannot focus on any one topic. She is distressed about her husband filing for divorce and came to the hospital after threatening to take 100 tylenol pm. The doctor has put her Paxil 25mg and Lamictal 25 mg and Benadryl 50mg for sleeping. She has some somatic thoughts such as "she has pain in her blood, she can feel her blood stiffening" Her affect is restricted yet often times inappropriate, her speech is normal/clear. She is cooperative, tearful and has severe anxiety. Due to her lack of concentration i was unable to get her to contract for safety she states that she knows she wont try to kill herself while in the hospital but feels she could psychologically hurt herself by "eating too much and stuff like that" All labs were normal except she has slightly RBC, low hematocrit and high monocyte count.

Let me know if you need more info. Am really just hoping someone could point me in the right direction of where to begin!!!

Oh possible Nursing Dx i have so far are:

1. Sleep pattern disturbance

2. sensory perceptual alterations (overload)

3. impaired social interaction

4. chronic low self esteem

5. altered family processes

6. altered thought processes

7. believe i need risk for self directed violence as well

Thanks so much!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i would start out by making pages for each of the sections of this case study that you have to complete:

  1. the medications
  2. all diagnostic labs/tests, treatments/therapies your client should receive
  3. where your patient falls on erikson's developmental stage and a description of that stage of development
  4. what the hospital milieu is and how it will work in with your patient's treatment
  5. the care plan
  6. the discharge plan

here are links to examples of case studies done by nursing students that you can look at to get an idea of how to go about doing this:

as for the care plan, you follow the steps of the nursing process with the most important step being to perform the assessment of your patient. you cannot begin to choose any nursing diagnoses until you make a list of your patient's symptoms.

(from page 4 of
nursing diagnosis handbook: a guide to planning care
, 7th edition, by betty j. ackley and gail b. ladwig)

"when the assessment is complete, identify common patterns/symptoms of response to actual or potential health problems and select an appropriate nursing diagnosis label using critical thinking skills.

  • highlight or underline the relevant symptoms.

  • make a short list of the symptoms.

  • cluster similar symptoms.

  • analyze/interpret the symptoms.

  • select a nursing diagnosis label that fits with the appropriate related factors and defining characteristics.

the process of identifying significant symptoms, clustering or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reasoning (critical thinking) skills that "must be learned in the process of becoming a nurse.

following these steps in this order and do not deviate from them. the steps of the nursing process are:

  1. assessment (collect data from medical record and by doing a physical assessment of the patient)
  2. nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
  3. planning (write measurable goals/outcomes and nursing interventions)
  4. implementation (initiate the care plan)
  5. evaluation (determine if goals/outcomes have been met)

then when you have something more substantial than a potential list of nursing diagnoses along with related factors and defining characteristics we can talk about whether they are appropriate for your patient or not.

you will also find information determining nursing diagnoses and goals on these two threads:

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