Family Members and Family

Psychosocial Process Recording

Theories thrive in situations where facts are scarce or sparse in human endeavors. Medicine is a field in which such truths are evident. According to Gorman (1990), radical biologists hold the view that all psychiatric complications are caused by brain abnormalities. On the other hand, dogmatic psychologists claim that medical treatment only covers up psychiatric symptoms. They state that psychological treatment gets to the root of the problem (cited in Waldo, 2013).

This case analysis scenario has applied the Bio-psychosocial Model analysis of psychiatry. The approach was made popular by George L. Engelis. The biological element of the bio-psychosocial model seeks to understand how illnesses are due to the functioning of an individual's body. The psychological aspect investigates potential psychologically related causes for illness including lack of self-control, negative thoughts and emotional turmoil. The social element investigates how social factors including how socio economic dynamics, technology, poverty, culture and religion influence one's health (cited in Waldo, 2013).

This case refers to Betty Cole (not real name). I have chosen this client for process recording and subsequent case report because I was in company of the duty nurse when she was taken in for treatment. She sought voluntary counseling from when she started improving. Her medication controlled her and she is in remission from her health issue at the moment. She is currently an outpatient client who keeps all her appointments and follow-up meetings for check up in the facility.

GENERAL DATA

• Information reliability: 98% - clinical health record

• Informant: close family member (sister)

• Clinical interview: psychiatrist notes and admission notes from nurse

DEMOGRAPHIC DATA:

Full name: Betty M. Cole (not real name)

Age: 47 y/o

Sex: female

DOB: 30th ay 1964

Place of Birth: Baguio City

Address: 68, Marcedo, la Trinidad Benguet

Civil status: not separated legally

Religion: Catholic

Nationality: Phillipino

Occupation: Vendor

Educational Level: Graduate -- Commerce and Finance

Admission Date: 3rd of April 2013

Admission time: 6:30 PM

Admission Physician: Dr. West

History of Illness:

The patient was taken in the mental health institution (RRCC) in 1999. She was diagnosed with Bipolar and psychosis. She was, later, treated and discharged. The patient had been using home medication consistently for a long time. She was attended to consistently in follow up sessions; which lasted for three months only. The patient was admitted on 25th March 1999 and discharged on 7th June 1999. She had improved when she was discharged. She was given Chlorpromazine 100mg Bid, one tab of Paroxetine 20mg, 20mg Biperiden HCL 1/2 tab bid and O.D. She was put on four follow up sessions. The last one she effectively attended was on 5th of April 1999. She did not attend further follow ups.

She manifested symptoms in a sporadic manner but was not entertained further because she helped out at the trading centre. People around her at the trading post tolerated her because they knew she was unwell.

History of the Present illness:

The client did not attend to her daily work schedule in the first week of September. She was seen yelling at any passer-by and often splashed water at strangers. She neglected her grooming routine and ignored house chores. She even took other people's items without their consent. This behavior persisted for months.

She was taken to the authorities in the second week of November for the offence of stealing t-shirts, pants and bags. She was imprisoned at BCJM for the theft. Later, the patient was brought to RRCC for readmission and further attention and care management.

The patient exhibits strange behavior including smiling inappropriately. She also experiences auditory hallucinations and is frequently deluded. She remembered having taken a pair of pants and a shirt but she believed that these items were given to her by someone. She thought that the attendants at the mall were communicating to her in symbols. She also showed signs of committing suicide verbally to the attending nurses and other personnel. The patient is being attended to as a Schizoaffective Disorder case.

EVALUATION SUMMARY AND RECOMMENDATIONS:

She is estimated to be functioning in the 79 IQ levels; which is below average. She shows some amount of emotional responsibility and has low energy levels. Mrs. Cole may show signs of aggressiveness, hostility, and vainness to the extent of acting beside the normal expected behavior. She shows dependency, muddiness and impulsiveness. The completion test responses clearly showed her problems with her family and children. It is recommended, from the findings, that the client should be put back on a consistent and sustained therapy and counseling in order to assist her to process her feelings since her mind is still filled with her problems. She needs to develop or learn functional ways of coping with her stresses.

It seems there is need for family therapy for the client and her family including her husband. Such therapy will help to thresh out the negative emotions between the family members and the predicament of the client. Mrs. Cole will also see that she still has her family by her side.

INTERVENTIONS:

Biological Problems:

The biological problems experienced by Betty Cole were picked out. Some interventions in nursing depend on the psychiatrist's medical interventions. Standard precautionary and strict interventions in nursing must be conducted in the course of her psychopharmacologic therapy. There should also be independent nursing care as the situation demands. In Cole's case, neglecting her grooming routines and personal hygiene are common problems. Such a need should be fulfilled by the nurse in case it arises. Self-care activities are highly encouraged but staying with the patient is mandatory.

Psychological Problems:

Cole's problems have been found to be deeply rooted in her mental and psychological constructs. When one is weak in their psychological constructs, they are likely to be affected by mental illnesses. The stressors that Cole has undergone in frequency and intensity have made her miss out on her chance to grow psychologically and achieve a reasonable level of well being. She thinks that self-harm is the only escape route from her problems. She declared her wish to die before affiliated student nurses in one of the re-motivational sessions. She processed the incident and further quipped that she had no reason to live. The nurses had to start the Suicide, Homicide and Escape precautionary measures. People manifest different reasons for suicide, however, in Cole's case, she blamed herself for all her problems though she was the root cause. Suicidal patients often divert their drives to other people. Therefore, Suicidal precautions had to be taken. There was also need for escape precautions in Cole's case because most such patients relapse into such acts until they succeed. She may seek to commit suicide in a place no one is present to stop her.

Social Problems:

Cole was also noted to experience social interaction disturbance; judging from her refusal to participate in the ward activities. She isolated herself; one week after she was admitted; and confined herself to her bed most of the time. Patients who were stable extended a friendly hand to her. We encouraged her to be in the company of another patient in one of our exercise sessions. Cole and the patient are friends and currently lead the exercise sessions. This is only one of the many possible interventions a nurse should institute. Such reflex and skill is just as important as the wellbeing of the patient. She showed many improvements thereafter and met xxxx.

One of the problems that were identified was linked to disturbance in the family. It was discovered later that the family was running out of financial resources to foot her medical bills and related costs. The theft case with the SM mall took a tall on family members too. The intervention that was applied was a behavioral observation of her progress. These were shared with her sister who burst into tears of joy when she heard the developments and progress that Cole had made. She shared the information with Cole's daughter too. The sister was grateful for our efforts. Family members visited twice a week thereafter.