Ashley was forth-coming with details stating ” I usually mess up by injuring myself when I talk, or hear from my personal family”. She then thrown up her shirt and showed us a bunch of succinct, pithy cuts onto her right equip. Patient seems to be a good story teller, but a poor historian. During the assessment process the therapy team was somewhat mixed up as to in the event some of the historical details presented were based on Ashley herself, previous papers, or family. Ashley stated she managed to graduate from unique education classes while at Madison State Medical center, but was generally escorted back in unit internet marketing aggressive, and using profanity.
Also, while at the IDTC-Lafayette the lady completed the Wechsler Mature Intelligence Level III. This kind of yielded a complete scale IQ of 69; verbal, 77; and performance, 63. The patient has zero children, is never employed, and she verbalized a sex preference of both men and women. When I asked her about any kind of substance abuse your woman began to inform stories about eating a half of pound of marijuana, and “sniffing” crack-cocaine daily.
She also explained that the girl drinks “a lot”, but she was unable to identify the type of liquor, or evaluate the amount. She identified her mood as depressed and agitated as a result of a new placement. Patient cognitive functioning appeared to be impaired.
Your woman was orientated to the month, but believes it is nonetheless 2011. The girl stated the existing president was George Bush, refused to count coming from five in reverse, and did not seem to understand the difference among a tomato and apple. She did not appear to give much efforts in answering cognitive inquiries, and explained she has a poor memory. Also, the patient’s insight and judgment seem to be poor during the time of assessment..
Inspire staff to use pro-active, motivating, and preventative strategies whilst working with people. Emergency medication and physical restraint are being used only if affected person become a danger to self/others. IV: Encourage patient to participate in almost all associated milieu groups although in treatment. Patient can easily improve her overall independent, social, and coping abilities with consistent positive reinforcement. V: Continue with current antihypertensive and GERD prescription drugs as bought by medical physician.
Refer patient to physician pertaining to issues/problems linked to diagnoses of hypertension and GERD. Direct patient to dietitian intended for weight, and dietary management.