UNFOLDING Clinical Reasoning Case Study
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:
26 year old female emotionally unstable
fight with boyfriend
RELEVANT Data from Social History: Clinical Significance:
Feels sad and happy from moment to moment. emotionally unstable, and is suicidal
Smokes marijuana, drinks alcohol, and cuts
herself
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
,
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:
26 year old female emotionally unstable
fight with boyfriend
RELEVANT Data from Social History: Clinical Significance:
Feels sad and happy from moment to moment. emotionally unstable, and is suicidal
Smokes marijuana, drinks alcohol, and cuts
herself
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
,
