Mrs. Kathleen Jones Gender: Female
Age: 41 Ethnicity: Caucasian
Education: Associates Degree Income: Private employment, Private Insurance
Religious/Spirituality: Methodist Family: Husband, Son 22 diagnosis of schizophrenia, Daughter 16 deceased suicide 1 year ago
Diagnosis: Major Depressive Disorder (MDD)
Chief Complaint
“There is no point to my life, I want to end it all.”
History of Present Illness
Client admitted following husband calling an ambulance when Kathleen was found unconscious in the family home. Kathleen has been on the unit for 3 weeks, she has limited interaction with other clients in the milieu. She prefers to sit alone near the window and keeps her body in a hunched position with her eyes downcast.
Kathleen admits to taking several of her sleeping pills in an attempt to commit suicide. Kathleen’s husband has limited contact with her and when he does visit he makes no physical contact and only stays briefly. The client and her husband do not appear to converse when he visits.
Kathleen has stated several times in therapy that she intends to attempt suicide again if given the chance and has recently been discovered cheeking her pills.
Past Psychiatric History
No previous psychiatric treatment or hospitalizations. Prescriptions for escitalopram and zolpidem. Under care of a general physician for medication.
Substance Abuse History
Patient has history of tobacco and alcohol use, denies recreational drug use. Pt. spouse confirms.
Family History
Client’s parents both alive ages 70 (mother) and 86 (father) and have no psychiatric history. Both parents have hypertension and her father has type II diabetes. Client has 1 brother (age 45) with a diagnosis of hyperlipidemia, hypertension and bipolar disorder.
Social History
Client born and raised in the United States. Father in the military and frequently moved during childhood. Client married her husband at age 18 and had 2 children. A son who is 22 with a diagnosis of paranoid schizophrenia and a daughter that would be 17, died 1 year ago at the age of 16 to suicide. She is an accountant and financial advisor. She is insured and on FMLA. No financial concerns. Client is Methodist and questioning her faith in a higher power. Has a prior history of alcohol addiction and frequented Alcoholics Anonymous meetings prior to the death of her daughter when she began drinking again.
Mental Status Exam
Client presenting to the day room in pajamas, states that she is too tired to dress. Has not showered in several days and has a stooped posture. She has orders for psychotherapy and group therapy and states that there is no point in attending because nobody could understand what she is going through. She continually attempts to go back to her room and has begun hiding pills during medication pass, which was discovered upon a room search.
Past Medical History
Wisdom teeth removal 15 years ago
Cesarean section 22 years ago and 17 years ago
Medications
Escitalopram 20 mg PO Daily
Zolpidem 10 mg PO HS
Allergies
Aspirin
PCN
Questions:
1. What information is pertinent to you as the nurse?
2. What do you think the problem is?
3. Prepare a list of goals for the interview
4. Write down a few sentences of how you will introduce yourself to the client
5. Write down a list of questions you will ask the client