Running head: CLINICAL CASE STUDY

Clinical Case Study

Astrid Nicolau-Raducu
October 4, 2014
NU 416

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Clinical Case Study

Background History:
(1) The Patient
The focus of this case study is a 54-year-old single white female suffering from a mental
illness. She voluntarily admitted herself on the acute Level III unit at the beginning of
September. She is a veteran of the United States Army and was transferred from a neighboring
state for treatment at the closest Veterans Affairs Hospital. Her legal status is clear of any
pending trials or convictions.
(2) Chief Complaint
The patients chief complaint at admission was suicidal and homicidal ideations
following a three-day drug binge. At time of admission patient stated that she experienced
auditory hallucinations telling her she needs to seek help, because if she does not she will kill
herself by overdosing, serving as the main driving factors that led her to seek help.
(3) History of Present Illness
A week before admission to unit he had lost everything on a three-day drug binge. She
got evicted from her place of residence, sold her car, and lost her job during those three days. She
had nothing left when she had the stated auditory hallucinations and checked into a shelter,
where she was advised to seek admission to psychiatric unit for help and treatment for her drug
use. During the time she was waiting to get admitted for treatment, which took about four to five
days. Because of the days spent waiting and the time since she had last used any type of
substance/drug, she underwent withdrawal at the shelter before being admitted to unit. The
patient stated that those, however many days and nights, were the longest and hardest hours of
her life; they were worse then any previous attempts to quit.

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(4) Psychiatric History

The patient has a psychiatric history and diagnosis of Post-Traumatic Stress Disorder
(PTSD), Depressive Disorder, Anxiety Disorder, as well as a history of Polysubstance
Dependence.
(5) Alcohol and Substance Abuse History
The patient has a long history of both severe alcohol and substance abuse. According to
patient she has been drinking alcohol for as long as I can remember, probably over 25 to 30
years. Also according to patient her substances of choice methamphetamine, cocaine, and some
occasional marijuana. She states that she is a cigarette smoker as well as a coffee drinker. She
started smoking cigarettes when she was 18 years old and she started drinking coffee after her
first child was born.
(5) Medical History
According to both the patient and her medical records she has no significant medical
history other then giving birth to three children and frequent urinary tract infections.
(7) Family and Developmental History
The patient stated that none of the members in her immediate family were ever officially
diagnosed with any type of mental illness. However during our conversation, she stated that the
triggering event to her mental instability was the fact her brother had been sexually abusing
her from the age of 6 until she was 15 years old. According to her, the fact that her parents never
believed her and accused her of lying when she told them about what was happening, was more
hurtful then the sexual abuse itself. Also based on information provided by the patient her father
unusually drank about half of bottle to hard alcohol almost every night. Patient appears to have

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poor coping skills that are possibly augmenting to the alcohol and substance abuse. Also, based
on the account of her social history she has a poor support system.
(8) Social History
The patient has had relationships on and off in the last few months but none that have
lasted. She has been divorced for 15 years from her former husband, the father of all her
children, and has not been in contact with since the children turned 18 years of age. The children
are now all grown and presently living in three different states. She has not talked to the oldest
two in over two years and if she did try and reach out to them, they wanted nothing to do with
her and refused to talk or even answer her phone calls. The youngest son, on the other hand, was
in contact with her during the time when he was abusing substances as well. According to the
patient for the past year however, he has been drug free and doing well but has been very distant
and does not talk to her as often as he used too before he became clean. Besides her immediate
family from whom she is estranged from, the one other person she mentioned that she could turn
to for support is one of the social workers at the shelter she was at before getting admitted to the
psychiatric unit for treatment.
(9) Occupational and Educational History
The patient is an Army veteran. She joined the armed forces as soon as she became 18
years old and she was eligible to enlist. She got out 14 years later due to disability following
sexual abuse by her superior throughout her active duty. She had to go through a very long
process in order to obtain her well-deserved military benefits, including health benefits.
According to her, her coverage as a veteran started with the current admission to the psychiatric
unit. She has a high school level education and from observing her throughout the day she would
chose reading over watching the television. She is up to date with all the current news and is able

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to objectively discuss various topics. Prior to her admission to the unit she worked as a certified
nurses aid in a nursing home. However at the moment she is unemployed due to losing her job as
a result of her recent three-day drug binge.
Pattern of Relating:
(1) General Appearance and Behavior
The patient is a short skinny middle-aged woman who appears much older then
biological age. She appears to be minimally groomed but not disheveled, and dressed
appropriately given the circumstances (Keltner, Schwecke, and Bostrom, 2007). Her teeth show
significant decay and her hair is short and neat. Her posture seems relaxed yet she is restless and
has to get up and readjust her position often. Her attitude during interactions is friendly, making
frequent eye contact.
(2) Emotions and Speech
This patient did not display normal expression of emotions. Her responses were
restricted, even blunted, when she talked about her current situation or about the abuse she
experienced earlier in life (Keltner, Schwecke, and Bostrom, 2007). She stated that she is
anxious about the future but he is almost certain that she will not relapse once she receives the
treatment she needs. Her speech was fast and mumbled at times but understandable.
(3) Cognition and Perception
The patient was alert and oriented to person, place, time, and event; both short term and
long term memory is intact (Keltner, Schwecke, and Bostrom, 2007). She was attentive of the
questions I was asking, followed by thought through responses especially if the topic was
sensitive in nature. Ideas and information communicated by the patient was linked and goaldirected and transitions from one thought to the next were logical. There was slight skipping

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around of topics but majority of the time it thought process was clear (Keltner, Schwecke, and
Bostrom, 2007).
(4) Impulse Control
Impulsivity is what led to her seeking and admission to a psychiatric facility for
treatment. Doing things without thinking about the effects those choices or actions could have in
the long run (Keltner, Schwecke, and Bostrom, 2007). She did display poor impulse control
during conversation through actions of getting up and looking out the window in the middle of a
conversation.
(5) Knowledge, Insight, and Judgment
The patient acknowledges that there is a problem and that change needs to be made in
order for her to become a positive member of society. She says that her drug use is irrational and
that it needs to stop, which gives evidence of insight about her problem (Keltner, Schwecke, and
Bostrom, 2007). Her judgment is intact at present since she chose to seek help for her condition,
however prior to her admission her judgment was severely impaired because she made poor
choices that altered her whole life.
Treatment Plan:
(1) Multiaxial DSM-IV Diagnosis
Based on the patients chart her Multiaxial DSM-IV diagnosis is as follows: Axis I Major
Depressive disorder (296.2) and Acute stress disorder (308.3); Axis II Polysubstance abuse
disorder (304.80): Severe alcohol and cocaine dependence; Axis III Chronic urinary tract
infection; Axis IV Financial difficulties and family discord; Axis V GAF = 45 (on admission
to psychiatric unit) (American Psychiatric Association, 2000).

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(2) Interventions, Relapse Prevention, Symptom Management

Evaluate for presence of self-destructive and/or suicidal/homicidal behaviors. Identify
and discuss degree of dysfunctional coping (e.g., denial, rationalization), including use/abuse of
chemical substances. Refer to occupational therapy and vocational rehabilitation. Determine
understanding of current situation and previous/other methods of coping with lifes problems.
Sleep pattern disturbance by observation and reports from patient and/or significant others.
Identify possible/actual triggers for relapse. Explore support in peer group. Encourage sharing
about drug hunger, situations that increase the desire to indulge, and ways that substance has
influenced life. Assists in planning for long-range changes necessary for maintaining
sobriety/drug-free status. Patient may have street knowledge of the drug but be ignorant of
medical facts. Discuss variety of helpful organizations and programs that are available for
assistance/referral such as Alcoholics Anonymous, Dual Recovery Anonymous, and Narcotics
Anonymous. Discuss potential for reemergence of withdrawal symptoms in stimulant abuse as
early as 3 months or as late as 912 months after discontinuing use. Even though intoxication
may have passed, patient may manifest denial, drug hunger, and periods of flare-up, wherein
there is a delayed recurrence of withdrawal symptoms.
(3) Medications
Medications are prescribed according to the symptoms that are presenting in the
individual patient. Medications are used to decrease anxiety, lift mood, aid in management of
behavior, and ensure rest until patient regains control of own self. They are also helpful in
suppressing intrusive thoughts and explosive anger. Patient is currently on the selective seratonin
reuptake inhibitor (SSRI) Celexa 20 milligrams before bed to help with her anxiety before bed

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and improve her sleep; anti-anxiety capsule Hydroxyzine 50 milligrams as needed every six
hours (Valerand and Sanoski, 2013).
(4) Active Problems
At present she has one active problem in her chart and that is lack of housing.
(5) Patients View
According to the patient the care and treatment she has been receiving since her
admittance to the unit has helped alleviate some of her problems. Among there problems is
decreased energy, sleeplessness, agitation, and anxiety. The two medications she has been
prescribed have helped her sleep at night, which means she is less anxious, has more energy, and
is not as agitated like a can of soda ready to explode.
Progress of Care:
(1) Patient View
According to the patient although some of her minor complaints and/or problems have
been ameliorated she is a little distraught with the speed at which her transfer to a substance
abuse program is moving. She had been on the unit for almost four weeks now and they have not
told her anything about a possible date when she will go to a facility that will provide her with
the help she really needs.
(2) Healthcare Team View
The health care team states that they have been unable to find an opening at a facility
where she could get treatment for substance abuse. They do believe that her being there even for
such a long period of with has been beneficial for her withdrawal from the substance abuse. They
are also saying that in order for the treatment at the other facility to go well, her mood and

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anxiety level need to be stabilized thus implementation of effective avoidance and coping
mechanisms could be easier to implement.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: Author.
Keltner N.L., Schwecke L.H., and Bostrom C.E. (2007) Psychiatric Nursing (6th ed.). St. Louis
MO: Mosby.
Valerand, A. H., & Sanoski, C. A. (2013). Daviss drug guide for nurses (13th ed.). Philadelphia,
PA: FA Davis Company.