NURS 511: Psychiatric Mental Health Nursing for the Clinical Nurse Leader Professor Zelda Falck

Clinical Case Study 2: Sandra Littlefield Amanda Brown University of Maryland Baltimore NURS 511: Psychiatric Mental Health Nursing for the Clinical Nurse Leader Professor Zelda Falck 3/25/20 ` 2 Clinical Case Study 2: Sandra Littlefield CASE TWO Description of the patient: Pt. S.L. is a 36-year-old Caucasian female. Pt. has been complaining of back pain and was admitted for unrelieved back pain and further examination. History of present illness: Pt S.L. has been diagnosed with borderline personality disorder. Currently, the pt. was arrested and is an inmate at the Blooming County Jail for the past week on prostitution charges. She has a history of sexual abuse, attempted suicide, alcohol abuse, and back pain with frequent emergency room visits. Pt states medication (acetaminophen and ibuprofen) is not enough to help endure her pain – she rates pain 9 out of 10 on the pain scale. Pt. is convinced that stronger medication is the only solution to her pain and is dismissive and uninterested in learning relaxation techniques. She is angry, accusatory, and is feeling very lonely. She seems to be projecting her frustrations onto the staff as a defense mechanism. Pt. states being in jail is very lonely, and she is not sure if she can handle being alone like this. Pt. S.L has stated that she no longer reads romance novels, walks, or listens to music—which she enjoyed doing in the past to help her cope and be happy. Pt. S.L. is not coping well with her personality disorder or her current situation in jail. Mental status exam Appearance: Appropriately dressed; pt is wearing orange jail jumpsuit. Hair is neatly styled in a ponytail. Pt has large, colorful tattoos on both forearms. Piercings on nose and bridge of nose removed. Consciousness/Orientation: Pt. was alert and oriented X4. She was able to state her name, DOB, date, location, and current situation. Based on her answers and awareness, she seems to be a reliable historian. Speech: Pt. demonstrated appropriate speech rate and sometimes with the proper volume; she tended to get loud when she did not get her way. RN found no articulation issues during the examination. Pt showed no presence of mutism or flight of ideas. Pt. did show circumstantiality speech by uttering out - “You think you are better than me because I’m in jail. Well, you are not!” ` 3 - “Everyone is against me. You, the other nurses, the provider—you all hate me. The only one who likes me is that cute guard.” - “Just because you are in love with the guards, you prance around like you own this place and you do not!” RN responded with therapeutic techniques and continued to set boundaries. Motor Activity: Upon inspection, pt. had no involuntary facial, oral, upper/lower extremities, or torso movements. All observational movements were coordinated and purposeful. No tics, tremors were noted. Attitude toward examiner: Pt. was very short-tempered and aggressive towards RN during the examination. Pt. stated, “I am in so much pain. You are a nurse. Don’t you know how to tell when someone is hurting?” RN responded with therapeutic technique saying, “Ms. Littlefield, you need to lower your voice now. I am here to help you.” Pt. was not forthcoming with information or advice given to her about relaxation techniques. Mood: Pt. was very frustrated, with mood fluctuations during the examination. When RN asked pt. was she experiencing any pain, pt. stated “I’m done with you and your worthless medicine”. Affect: Pt. did show some overreactions during the examination when she did not get her way. For the most part, pt. showed full affect – she is able to express herself. Perceptual: Pt. had no presence of perceptual disturbances. Pt. states she is not crazy – she has no issues with hallucinations (auditory or visual). Thought content: Pt is worried, shows frustrations and hopelessness/helplessness. - Pt stated: o “Being in jail is terrible. I don’t know if I can go through this alone”. o “There’s no reason for me to be here anymore. No one cares about me at all”. Thought process: Liner and goal-directed, but pt. consistently comes back to her issue of pain. Pt cont. would use various splitting thought processes throughout the examination. ` 4 RN asked her, “how would you describe your mood?” Pt. responded, “no one has even looked at my back today. I know it’s worse than it was, no matter what those tests said,” she responded with frustration. RN responded with the therapeutic technique of suggesting collaboration and formulating a plan of action by saying, “let’s sit together and discuss a way you can handle your frustration appropriately”. Concentration and attention: Pt. was assessed for concentration and attention using the Serial Sevens and abstract thinking test. Pt was able to complete both tests effectively and found similarities between multiple objects — but would still return to expressing back pain feelings. Memory: Pt. remote memory and immediate memory were intact; pt. was able to remember different phases whenever RN requested. Pt was able to tell RN what she did for her last birthday. Information and intellect: Pt. was able to show intelligence and recent remote memory. Pt. demonstrated that she understood what was going on and what was currently happening in her situation. Pt. was able to follow all directions given and respond appropriately when asked. Insight: Pt demonstrated partial insight. Pt. does not seem willing to be more involved in her care or learn other relaxation techniques. - RN asked about other pain management strategies used in the past – pt. responded, “No. let’s stick to the meds”. - Pt also stated how nobody looked at her back today, and she knows it was worse than what those tests said. Judgment: Pt. demonstrated poor judgment during the examination. RN asked, “do you have any thoughts or wishes to harm anybody else?” Pt responded, “If they don’t help me with my pain, I might,” she replied simply.