Case History and Protocol Development

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Case History and Protocol Development Jill Ryan Molloy College NUR 593 Dr. Nona Holmes October 28, 2013 Case History and Protocol Development Assessment In Psychiatric-Mental Health Nursing: Scope and Standards of Practice (2007) the advanced practice nurse’s role in the assessment of the client is comprehensive. Diagnostic testing is ordered and evaluated to assess for medical and psychiatric comorbidities. A thorough evaluation of past psychiatric and medical history is obtained as is an accounting of family interaction and social, occupational, spiritual functioning and multigenerational psychiatric history. K is a 41-year-old separated, white, Catholic female who is an unemployed nurse’s aide. She has her GED and lives with her two children and boyfriend. She was referred to the outpatient clinic by her in-patient psychiatrist for continued psychiatric evaluation and treatment. K states that: “ no matter what medications they put me on I end up in the hospital twice a year. My highs are my lows. I fly so fast that I end up paranoid and out of it.” As per K; she was sexually abused by an uncle at age 15. She states that her older sister was also sexually abused during that same period of time. K states that she repressed the memories of her sexual abuse for many years and only recently recovered them. Her first admission to a psychiatric hospital occurred at age 15 and she states that she has had multiple admissions thereafter including a sixth month stay at Sagamore Children’s Psychiatric Hospital. She states that her most recent psychiatric admission was at Southside Hospital where she was admitted with a diagnosis of psychosis. On discharge, she states that she was given a diagnosis of schizoaffective disorder and prescriptions for Zyprexa (olanzapine), Haldol (haloperidol) and Seroquel XR (quetiapine). Although K filled these

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