Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
NURS 223L - Interpersonal Process Analysis 2.
Student: NAME HERE Date: 05/19/20
Clinical Instructor:
Name (initials only): JA Unit: SECURE PSYCH UNIT
Current Legal Status (Vol., 5150, 5250, 30-day, T-Con, LPS-Conservatorship): Patient has siblings 2 sisters and a brother, including her Father and
Mother that are her support system. And mother as the responsible party.
Multiaxial Diagnostic System: Axis I (Clinical Disorder): Depression, Anxiety and PTSD.
Axis II (Personality Disorder / Mental Retardation): Personality disorder (PTSD)
Axis III (General Medical Conditions): none
Axis IV (Psychosocial and Environmental Problems): Patient was out going, was on the cheerleading squad before her boyfriend broke up with her.
Axis V (Global Assessment of Functioning Scale): Patient some danger of hurting herself/committing suicide.
1. Description of the patient: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization? Number of days in the hospital? Mental
Status, etc.
Client is 17 years old single Caucasian female with history of depression, Anxiety and PTSD. Patient living with parents who are her support system,
with two other sisters and a brother. Patient mother is responsible party. Patient was admitted to Millwood Hospital, due to her suicide attempt
today 05/19/20. On the admission process, when asked the reason for her admission, Patient states “I don’t want to live anymore. My boyfriend
broke up with me” but the family indicated that patient broke up with the boy friend and her prom is in two weeks, so that is making her sad and
Page 1 of 7
, Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
depressed. Patient is alert and oriented x 2. Patient has been cooperative with care, has a poor judgment, ambulates independently, she has a low
Page 2 of 7
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
NURS 223L - Interpersonal Process Analysis 2.
Student: NAME HERE Date: 05/19/20
Clinical Instructor:
Name (initials only): JA Unit: SECURE PSYCH UNIT
Current Legal Status (Vol., 5150, 5250, 30-day, T-Con, LPS-Conservatorship): Patient has siblings 2 sisters and a brother, including her Father and
Mother that are her support system. And mother as the responsible party.
Multiaxial Diagnostic System: Axis I (Clinical Disorder): Depression, Anxiety and PTSD.
Axis II (Personality Disorder / Mental Retardation): Personality disorder (PTSD)
Axis III (General Medical Conditions): none
Axis IV (Psychosocial and Environmental Problems): Patient was out going, was on the cheerleading squad before her boyfriend broke up with her.
Axis V (Global Assessment of Functioning Scale): Patient some danger of hurting herself/committing suicide.
1. Description of the patient: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization? Number of days in the hospital? Mental
Status, etc.
Client is 17 years old single Caucasian female with history of depression, Anxiety and PTSD. Patient living with parents who are her support system,
with two other sisters and a brother. Patient mother is responsible party. Patient was admitted to Millwood Hospital, due to her suicide attempt
today 05/19/20. On the admission process, when asked the reason for her admission, Patient states “I don’t want to live anymore. My boyfriend
broke up with me” but the family indicated that patient broke up with the boy friend and her prom is in two weeks, so that is making her sad and
Page 1 of 7
, Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
depressed. Patient is alert and oriented x 2. Patient has been cooperative with care, has a poor judgment, ambulates independently, she has a low
Page 2 of 7
