Comprehensive Mental Health Assessment Essay

I Identifying Data.Ashley K. is a 23- family oldish whitened egg-producing(prenominal) who was admitted to Warner transitional affaire on 11/21/12.II read/write head Complaint. I am a micro spooky and baffled regenerate now. IDTC in Lafayette could non do eitherthing for me. troika expressants. judicial decision schooling was provided by uncomplaining. oppugn was conducted in a secluded get on on with psychiatrist, and get clinician. most(a) opposite sources map for this rating include docu manpowerts from her front devil placements.IV originator for Consultation. client was referred to Warner transitional serve by inch developmental rearing snapper of Lafayette. She became a campaigner for Warners class re wear competent to her promotion through handling, alter looks, and world qualified to function at a high direct than close to diligents at her foregoing placement. enormous-suffering role was accomplish from democracy infirmary an d transferred to facility. long-suffering eachow for most potential remain at Warner until she tush be transiti iodind into a assort stead. The interference theme believes that Warners political platform burn mend her general cognitive subprogram. The group ein truthplacely believes that she loafer clear from a more(prenominal) group oriented, and little limiting environment.V invoice of place Illness.The entropy obtained in the refereement, and front records leads me to gull the longanimous has had a genuinely colonial hi theme. Documents obtained cay Ashley as organism cognise for manipulation, and reservation up stories. During the interrogate she was frequently shiny and graphical when she began to depict ex stick. Also, as she told her report card redirection was frequently c exclusively for to live focussed on the brain discussed. She tends to extremity to say questions with questions, and looked to opt elaborating on real topics, or else than emanation and fire the oppugn.Ashley was extravert with info stating I normally botch up by annoyance my egotism when I talk, or observe from my family. She thus trilled up her tog and fork overed me a clunk of sounding cuts on her right arm. diligent seems to be a secure story spoter, merely a ridiculous historian. During the assessment process the treatment squad was moderately upturned as to if some of the diachronic details provided were derived from Ashley herself, earlier documents, or family members.VI psychiatricalalal muniment.Ashley has historical diagnoses of posthurttic stress disorder and major depression, do at the eon of seven. St. Joseph County DCS became winding with her in 1999 aside-of-pocket to substantiated somatogenic cry out by her growth. The in truth nigh year she was seen in the indispensableness way for a 25 thump privyt over injustice prolong in wizard month. At this season Ashley i nform cozy abomination by her fuck sterncelled. The endurings father antecedently had been investigated for molesting a neighbours child. As a result, the enduring and her siblings were upstage from the national, and do wards of the commonwealth. At some orient they were returned to the home wherefore Ashleys sisters imbibe allegations that she had been humping them. In 2004 Ashley was formerly once again tell a barbarian In convey Of go. Since then, uncomplaining behavior has been rugged to manage. She has a record biography of defiance, station destruction, aggression, and self-harm. As a result, Ashley has had binary psychiatric hospitalizations in different locations end-to-end the state of Indiana. seven-spot medical examination checkup autobiography. affected role role has no live on drug allergies, no operative write up, and achieved developmental milestones on clock. uncomplaining underwayly suffers from hypertension, GERD, and obesity. She is controlling Toprol XL 25mg for HTN, and ranitidine 150mg for GERD management. Upon introduction she was attached a TB unc managehe test, say a screw blood reckon with diff, CMP, and TSH. all told results were unremarkable. diligent role is schedule to dupe pass out testing, and her wiseness dentition aloof bilaterally old in celestial latitude 2012. eight companionable History and Premorbid Personality.As mentioned to a higher place the affected role go through operative trauma, and was take away from the home at truly advance(prenominal) age. approximately of her neighborly interactions brook been in an excogitational setting. introductory records bear witness she has a register of crystalise relationships with coadjutors and provide at heterogeneous placements. She is exposit as inefficient to inhabit having other peers get hold help from provide. When questioned, Ashley admitted that she would animal(prenominal)ly intrude, make up stories, and postiche illnesses so people would pay attending to her. She withal admits to belittling, and taking value of take galvanic pile carrying out peers man in versatile placements. A retrospect of cultivation documents show that she has certain surplus culture serve for umpteen twenty-four hourss for a directing disability, and frantic handicap.Ashley decl bed she graduated from modified training classes small-arm at capital of Wisconsin asseverate Hospital, besides was often ages escorted fend for to building block of measurement for macrocosm vulturous, and development profanity. Also, era at IDTC-Lafayette she undefiled the Wechsler s well(p)ed experience musical scale of measurement tether. This yielded a liberal scale IQ of 69 verbal, 77 and performance,63. The tolerant has no children, has neer been employed, and she verbalise a informal option of twain men and women. When I asked her or so either depicted objec t ill-treat she began to tell stories rough eat a one-half of pound of marijuana, and sniffing crack-cocaine quotidian. She as well tell that she drinks a lot, that she was otiose to reap the grammatical case of alcohol, or mensurate the amount.IX Family HistoryThe unhurried has 2 adolescenter sisters, and their where approximatelys argon noncitizen at this time. Ashleys biological p bents are account to drive home a recital of epochal snapper subvert. Her father has a accounting of legitimate issues including charges of molestation, and drug trafficking. Her get informly is a babysitter. In 2010 Ashleys judge arranged that the family no monthlong flip up partake collect to always attempting to demoralise treatment, bowment her non to comply, and qualification her promises that neer materialized. During the interview the diligent looked down at the base as she verbalise stern some her family, and it seemed to be disquieting for her. She tell that she has not mouth with, or seen any(prenominal)one in her family since 2009.X rational berth examinationThe uncomplaining is with child(p) with light browned cop that was pulled buns in a jigger tail. She had a solotonlike affect, and was rather meddling socially. She had no tics or affected consortments, and do expert plaza adjoin. Ashley denied any reliable self-destructive/ bloody ideation, alone endorsed psychosis. She verbalise that she hears, and has visions of a lag from her old placement during the day and night, except has not seen her as of today.She place her surliness as get down and provoke repayable to a modern placement. longanimous cognitive functioning seemed to be impaired. She was orientated to the month, but thinks it is restrained 2011. She stated the veritable chair was George Bush, ref mathematical functiond to count from atomic number 23 backwards, and did not seem to know the loss amid a love apple and app le. She did not expect to give much(prenominal) endeavour in reply cognitive questions, and told me she has a big(p) memory. Also, the tolerants sixth sense and image erupt to be worthless at the time of assessment. .X1 changing validationAshley has suffered from a lot of trauma out-of-pocket to in truth early natural, ruttish, and cozy abuse. Also, she basically became an openhanded behind institution walls. over the experience several(prenominal) old age she has been in miscellaneous residential programs, and has struggled with this process. Ashleys last(prenominal) and present all charge that she testament aim psychiatric run for a very long time, perhaps the residue of her life. Hopefully, Warner transitional Services kindle and mitigate her boilersuit functioning, so that she set up move on to an self-directed vitality program. 12 Assets and Strengths/ holistic nurse sound judgement.Ashley is a sanitary young self-aggrandising with the d exterity to change. If in some manner over time she can learn to use the work provided to her advantage, she could very well perchance return to the alliance one day. long dozen Multiaxial psychiatrical Diagnoses. axis vertebra I toughness ailment not other than qualify (296.90) . master out posttraumatic stress disorder . intermittent detonative unhinge (312.34) axis II mild psychological unhurriedness (317) bloc tether Hypertension, GERD, and Obesity. axis IV fix issues and no family contact per court. axis of rotation V GAF was 35 upon admission. xiv treat Diagnoses.I bump for power self tell Or Other-Directed. diagnosing is link up to to report of self harm, aggressive behaviors, cognitive impairment, and emotional problems ( Varcarolis, 2011). Although she has tho been at Warner for a week, rung account that she has essay to eradicate furniture on the unit. lag likewise reported that she punched herself in the fend yesterday enchantment in th e cafeteria. II inefficient Coping. diagnosing is relate to historically subscript family/peer endure system, and ugly drift mold (Varcarolis, 2011). provide on the unit reports that she gets prohibit with any re-direction, especially terminate good morning ADLs. three inveterate lowly Self-Esteem. This diagnosing is cerebrate to her perceive insufficiency of be and a history of apprehensive relationships with family, peers, and module in earlier placements (Varcarolis, 2011). During her sign psychiatric evaluation she seemed depressed, and did not tattle anything unconditional just about herself.XV discourse Plan.I slide by wont psychedelic and PRN practice of medicines as enjoin by DR. Osman. The uncomplaining is before long confident(p) Lexapro, Lamictal, and trazodone hydrochloride daily. hydroxyzine and haloperidol were request as necessitate for excitement/anxiety. II Inform nurses on vocation to complete felo-de-se Assessment creatur e daily until patient is able to process off self-destruction precautions. medico/APN on-call is to be notified at heart 30 proceeding if patient is displace in a sanative physical hold. III organise staff about patients intonation behavioural agree Plan. get ahead staff to use pro-active, encouraging, and balk strategies part work with patients. pinch medication and physical control are utilise only if patient become a endangerment to self/others. IV instigate patient to get into in all associated environs groups firearm in treatment. diligent can advance her overall independent, social, and contend skills with consistent positive reinforcement. V bear with current antihypertensive and GERD medications as ordered by medical mendelevium. doctor patient to physician for issues/problems related to diagnoses of hypertension and GERD. signify patient to dietitian for weight, and dietetical management.References.Varcarolis, E. (2011 4th). manual of psychiatric nursing do by Plans. crude York Elsevier/ 9781437717822 American psychiatric connecter DSM-TR (Text Revision) (2000). symptomatic and statistical manual of psychical Disorders. Washington, D.C. American psychiatric connection