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Need ADPIE nursing note on this case study • You are a nurse at a Community Mental Health Center. You are interviewing a new client, David Whitehorn, who has voluntarily come for help. • David says, “No matter how hard I try, my life is just not working out.” DW David tells you that he has alienated his coworkers, his girlfriend has just about “given up” on him, and that his personal life is “a mess.” He also comments that discussing his personal problems is difficult for him. David avoids eye contact, and speaks in a soft, gentle, halting voice. Your interview proceeds smoothly, although David is reluctant to share a lot of information. DW You are able to obtain a brief psychosocial history, and discover that David is a Lakota Indian.DW You are able to obtain a brief psychosocial history, and discover that David is a Lakota Indian. DW • You are also able to obtain a brief history of David’s presenting problems. • You learn that David has “funny thoughts and habits” that make him feel uncomfortable and anxious. Psychosocial History: 39 years old and unmarried David an american lakota indian lives alone. has been dating a 25 years old women for one year. relationship is serious but couple is experiencing conflict. employed as computer programmer for past eight years. grew up on indian reservation. raised by grandparents , who he has not visited in the recent year. Presenting problem: David admits, with some embarrassment, to having “funny habits” that are distressing to both him and the people around him. he says that he feels anxious about the way he sometimes thinks and acts. DW Before making any judgments about David and his problems, more data must be collected. You continue your interview with David, advising him that you would like to spend thirty minutes talking with him. DW David denies taking any medications or drugs, including alcohol. He says, “I’ve seen too much of that.” When asked what he has “seen,” David does not respond. You ask David what he means by “My life is a mess.” He responds, “Nothing has turned out the way it was supposed to.” When asked what he wanted to turn out differently, David just shakes his head. David maintains an unreadable facial expression, is vague about most things he says, and continues to avoid eye contact. You know that you need more information about David’s “habits” to help him. DW The fact that David feels uncomfortable and anxious about his “habits” and behaviors indicates that they do not fit with his self-concept. Feelings or behaviors that cause discomfort to a person are said to be ego dystonic or ego alien. Feelings or behaviors that are a good fit with a person’s self-concept are ego syntonic or ego compatible.DW The fact that David feels uncomfortable and anxious about his “habits” and behaviors indicates that they do not fit with his self-concept. Feelings or behaviors that cause discomfort to a person are said to be ego dystonic or ego alien. Feelings or behaviors that are a good fit with a person’s self-concept are ego syntonic or ego compatible. DW David gradually settles into your session with him, and talks about being a Lakota Indian. David tells you that he grew up on a Reservation, where his grandparents raised him. While growing up, he loved the Reservation and learned to hunt, fish, sing, and dance in the Lakota tradition. As he got older, David noticed that many of the adults were unemployed and got into trouble because of drinking. Despite these observations, David, whose Indian name is Strong Bear, wanted to stay on the Reservation and work. DW By the time David graduated from high school, however, he realized that to be successful, he would need to leave the Reservation and go to college. Since the computer industry was growing, David chose to become a programmer. Following graduation from college, David made a conscious decision not to return to the Reservation, in spite of his pride in being a Lakota. Eventually, David goes on and tells you about his “habits.” He says he repeatedly counts things, such as the number of papers on his desk, the number of steps from his car into his office, and the number of shirts in his closet. David also tells you that he has periodic, repetitive thoughts of danger and disaster, and that counting temporarily makes him feel better. DW Obsessive-compulsive symptoms characterize both obsessive-compulsive personality disorder and obsessive- compulsive disorder. With obsessive-compulsive personality disorder, a person has enduring obsessive-compulsive character traits, such as inflexible thinking, perfectionism, over- conscientiousness, preoccupation with rules, and hoarding. DW When obsessive-compulsive symptoms are not enduring features of a person’s personality, the person is said to have obsessive-compulsive disorder. Symptoms require treatment when they are time-consuming, cause distress, or interfere with everyday functioning. David elaborates on his thoughts and habits. He says they occur more often over the weekend, although they do occur on other days of the week as well. He is not able to identify any triggering situations. The danger and disaster that David worries about enter his thoughts as “This is not right. You’d better watch out or you’ll be in trouble.” As soon as David begins to count something, he feels better. DW Suicide assessment is a routine part of all mental health assessments. Your session with David includes a suicide assessment. When asked if he has had thoughts or feelings of harming himself, or life not being worth living, David responds, “No. I have many things I love and would not hurt myself. I just want my “habits” to go away.” There is a high comorbidity of obsessive-compulsive disorders with depressive disorders. After Caucasians, Native Americans are at highest risk for suicide.DW Suicide assessment is a routine part of all mental health assessments. Your session with David includes a suicide assessment. When asked if he has had thoughts or feelings of harming himself, or life not being worth living, David responds, “No. I have many things I love and would not hurt myself. I just want my “habits” to go away.” There is a high comorbidity of obsessive-compulsive disorders with depressive disorders. After Caucasians, Native Americans are at highest risk for suicide. DW Before David leaves, you contract with him for eight weekly sessions. He agrees to come back next week, and to call if he needs help in the meantime. Before David leaves, he agrees to keep a log of each time he has a repetitive thought or needs to count. He will list the date, time, and situation in which the thought or behavior occurs, the degree of stress (on a scale of 0-100) he feels before and after the thought or behavior, and any other stressful worries that occur at the same time. David comments, “That’s a lot to do. But, if it will help, I’ll do it. I really want to get over this.” DW Your goal for your next meeting with David is to continue with a situational assessment. You will gather more data about David’s behaviors and specific situations that elicit his obsessions and compulsions. You will try to identify more clearly the “ritual” David uses to decrease his anxiety. You will also try to identify the situations or thoughts he is trying to avoid. Before your next session with David, you read about the Lakota Indians and their culture. You discover that Lakota Indians respect the earth and nature, and put little value on material goods. Silence and deference are used as signs of respect. Individual problems are taken seriously and felt to have an effect on the entire tribe. The Lakota Indians tend to socialize primarily with their tribesman. DW • You also formulate a list of nursing diagnoses that apply to David, and develop a tentative treatment plan. DW David returns for his next meeting eager to talk. He says he learned a lot through keeping a log. David confides that his recurrent thoughts are much more specific than he thought. He has images of his tribe and the Reservation being destroyed by floods and high winds. He pictures everyone being swept away. His counting takes place when these images occur. David also tells you that these images occur near and on the weekend, when he spends the most time with his girlfriend, Eileen. In fact, the disastrous images and counting started when David first began thinking about marrying Eileen, about six months ago. DW When mildly anxious, a person tends to ask questions, seek information, and accurately relate one piece of information to another. Ability to focus on tasks at hand and concentrate with little change in skin tone, skin temperature, or breathing, characterizes mild anxiety. Mild anxiety is considered helpful to learning and problem-solving. Attention, concentration, and the ability to process information are heightened. DW The severely anxious person has great difficulty learning, trouble communicating clearly, and difficulty understanding what is happening in the present. Sympathetic nervous system stimulation characterizes severe anxiety. Focus on the past and on scattered detail, rapid breathing high in the chest, and inability to concentrate are symptoms of severe anxiety. Other signs and symptoms of severe anxiety include an increased heart rate and temperature, headache, nausea, and light-headedness. DW Focus on details, difficulty speaking and breathing, and cool, pale, diaphoretic skin characterize panic. Other signs and symptoms of panic include inability to learn, illusions, hallucinations, blocking of thoughts, and an impending feeling of doom. Physical activity may be purposeless and increased, or the person may be motionless. You comment to David that he appears anxious. He confirms this when you ask him, but adds “I can deal with it.” DW As you wonder what David’s trigger might be, he becomes immobile and looks as if he is watching something you can’t see. This behavior lasts for just a minute, after which David shakes his head, grimaces, and apologizes for the “lapse.” Almost immediately, David becomes tense again. He then carefully and methodically begins to count the papers on your desk, beginning at the left and moving to the right. DW Within about ten minutes, David completes his ritual. He tells you that he had one of his images, followed by the counting habit. When asked how he is feeling, David says, “Better.” His nonverbal behavior confirms that he is less tense than he was before he started counting. David goes on to say, “It was talking about Eileen and getting married that made me feel tense … I was alright until then.” As your session with David continues, it becomes clear that he feels guilt about leaving his people on the Reservation and having a non- Indian girlfriend. DW As your session with David finishes, you encourage him to continue keeping a log, and to think about the relationship between his images and counting. David’s log reveals that his compulsions take more than an hour each day and cause him great distress. After your session with David, you meet with your supervisor and plan strategies that might be useful for David. It is determined that cognitive behavioral therapy (CBT) would be useful with David. You are certified to use this treatment modality DW In your next meeting with David, as part of response prevention, you teach David about delaying tactics designed to postpone the onset his compulsive actions. You also encourage him to decrease the amount of time spent on his compulsions. You also suggest to David that he distract himself with a favorite activity when he feels tense. Alternately, progressive relaxation can be used to reduce anxiety and tension or delay the onset of obsessive thoughts or compulsive acts. DW It is agreed that David will see you for one more session. Although his images and counting have not completely stopped, he feels he has enough control over them to “try his life without your help.” patient review image David believes his problems will soon stop entirely, as he plans to continue using the techniques he has learned. And, while he still feels some tension, the breathing and relaxation techniques he has learned help to alleviate his tense feelings rather quickly. patient review image David has talked to some Indian friends and family members on the telephone, and plans to visit his Reservation in the next few months. Since work keeps him busy, he has decided not to get involved in local Indian activities for now. At the end of your last session, David gives you a book on Indian art and thanks you for all he has learned from you. You too, have learned a lot from David. • You are a nurse at a Community Mental Health Center. You are interviewing a new client, David Whitehorn, who has voluntarily come for help. • David says, “No matter how hard I try, my life is just not working out.” DW David tells you that he has alienated his coworkers, his girlfriend has just about “given up” on him, and that his personal life is “a mess.” He also comments that discussing his personal problems is difficult for him. David avoids eye contact, and speaks in a soft, gentle, halting voice. Your interview proceeds smoothly, although David is reluctant to share a lot of information. DW You are able to obtain a brief psychosocial history, and discover that David is a Lakota Indian.DW You are able to obtain a brief psychosocial history, and discover that David is a Lakota Indian. DW • You are also able to obtain a brief history of David’s presenting problems. • You learn that David has “funny thoughts and habits” that make him feel uncomfortable and anxious. DW Before making any judgments about David and his problems, more data must be collected. You continue your interview with David, advising him that you would like to spend thirty minutes talking with him. DW David denies taking any medications or drugs, including alcohol. He says, “I’ve seen too much of that.” When asked what he has “seen,” David does not respond. You ask David what he means by “My life is a mess.” He responds, “Nothing has turned out the way it was supposed to.” When asked what he wanted to turn out differently, David just shakes his head. David maintains an unreadable facial expression, is vague about most things he says, and continues to avoid eye contact. You know that you need more information about David’s “habits” to help him. DW The fact that David feels uncomfortable and anxious about his “habits” and behaviors indicates that they do not fit with his self-concept. Feelings or behaviors that cause discomfort to a person are said to be ego dystonic or ego alien. Feelings or behaviors that are a good fit with a person’s self-concept are ego syntonic or ego compatible.DW The fact that David feels uncomfortable and anxious about his “habits” and behaviors indicates that they do not fit with his self-concept. Feelings or behaviors that cause discomfort to a person are said to be ego dystonic or ego alien. Feelings or behaviors that are a good fit with a person’s self-concept are ego syntonic or ego compatible. DW David gradually settles into your session with him, and talks about being a Lakota Indian. David tells you that he grew up on a Reservation, where his grandparents raised him. While growing up, he loved the Reservation and learned to hunt, fish, sing, and dance in the Lakota tradition. As he got older, David noticed that many of the adults were unemployed and got into trouble because of drinking. Despite these observations, David, whose Indian name is Strong Bear, wanted to stay on the Reservation and work. DW By the time David graduated from high school, however, he realized that to be successful, he would need to leave the Reservation and go to college. Since the computer industry was growing, David chose to become a programmer. Following graduation from college, David made a conscious decision not to return to the Reservation, in spite of his pride in being a Lakota. Eventually, David goes on and tells you about his “habits.” He says he repeatedly counts things, such as the number of papers on his desk, the number of steps from his car into his office, and the number of shirts in his closet. David also tells you that he has periodic, repetitive thoughts of danger and disaster, and that counting temporarily makes him feel better. DW Obsessive-compulsive symptoms characterize both obsessive-compulsive personality disorder and obsessive- compulsive disorder. With obsessive-compulsive personality disorder, a person has enduring obsessive-compulsive character traits, such as inflexible thinking, perfectionism, over- conscientiousness, preoccupation with rules, and hoarding. DW When obsessive-compulsive symptoms are not enduring features of a person’s personality, the person is said to have obsessive-compulsive disorder. Symptoms require treatment when they are time-consuming, cause distress, or interfere with everyday functioning. David elaborates on his thoughts and habits. He says they occur more often over the weekend, although they do occur on other days of the week as well. He is not able to identify any triggering situations. The danger and disaster that David worries about enter his thoughts as “This is not right. You’d better watch out or you’ll be in trouble.” As soon as David begins to count something, he feels better. DW Suicide assessment is a routine part of all mental health assessments. Your session with David includes a suicide assessment. When asked if he has had thoughts or feelings of harming himself, or life not being worth living, David responds, “No. I have many things I love and would not hurt myself. I just want my “habits” to go away.” There is a high comorbidity of obsessive-compulsive disorders with depressive disorders. After Caucasians, Native Americans are at highest risk for suicide.DW Suicide assessment is a routine part of all mental health assessments. Your session with David includes a suicide assessment. When asked if he has had thoughts or feelings of harming himself, or life not being worth living, David responds, “No. I have many things I love and would not hurt myself. I just want my “habits” to go away.” There is a high comorbidity of obsessive-compulsive disorders with depressive disorders. After Caucasians, Native Americans are at highest risk for suicide. DW Before David leaves, you contract with him for eight weekly sessions. He agrees to come back next week, and to call if he needs help in the meantime. Before David leaves, he agrees to keep a log of each time he has a repetitive thought or needs to count. He will list the date, time, and situation in which the thought or behavior occurs, the degree of stress (on a scale of 0-100) he feels before and after the thought or behavior, and any other stressful worries that occur at the same time. David comments, “That’s a lot to do. But, if it will help, I’ll do it. I really want to get over this.” DW Your goal for your next meeting with David is to continue with a situational assessment. You will gather more data about David’s behaviors and specific situations that elicit his obsessions and compulsions. You will try to identify more clearly the “ritual” David uses to decrease his anxiety. You will also try to identify the situations or thoughts he is trying to avoid. Before your next session with David, you read about the Lakota Indians and their culture. You discover that Lakota Indians respect the earth and nature, and put little value on material goods. Silence and deference are used as signs of respect. Individual problems are taken seriously and felt to have an effect on the entire tribe. The Lakota Indians tend to socialize primarily with their tribesman. DW • You also formulate a list of nursing diagnoses that apply to David, and develop a tentative treatment plan. DW David returns for his next meeting eager to talk. He says he learned a lot through keeping a log. David confides that his recurrent thoughts are much more specific than he thought. He has images of his tribe and the Reservation being destroyed by floods and high winds. He pictures everyone being swept away. His counting takes place when these images occur. David also tells you that these images occur near and on the weekend, when he spends the most time with his girlfriend, Eileen. In fact, the disastrous images and counting started when David first began thinking about marrying Eileen, about six months ago. DW When mildly anxious, a person tends to ask questions, seek information, and accurately relate one piece of information to another. Ability to focus on tasks at hand and concentrate with little change in skin tone, skin temperature, or breathing, characterizes mild anxiety. Mild anxiety is considered helpful to learning and problem-solving. Attention, concentration, and the ability to process information are heightened. DW The severely anxious person has great difficulty learning, trouble communicating clearly, and difficulty understanding what is happening in the present. Sympathetic nervous system stimulation characterizes severe anxiety. Focus on the past and on scattered detail, rapid breathing high in the chest, and inability to concentrate are symptoms of severe anxiety. Other signs and symptoms of severe anxiety include an increased heart rate and temperature, headache, nausea, and light-headedness. DW Focus on details, difficulty speaking and breathing, and cool, pale, diaphoretic skin characterize panic. Other signs and symptoms of panic include inability to learn, illusions, hallucinations, blocking of thoughts, and an impending feeling of doom. Physical activity may be purposeless and increased, or the person may be motionless. You comment to David that he appears anxious. He confirms this when you ask him, but adds “I can deal with it.” DW As you wonder what David’s trigger might be, he becomes immobile and looks as if he is watching something you can’t see. This behavior lasts for just a minute, after which David shakes his head, grimaces, and apologizes for the “lapse.” Almost immediately, David becomes tense again. He then carefully and methodically begins to count the papers on your desk, beginning at the left and moving to the right. DW Within about ten minutes, David completes his ritual. He tells you that he had one of his images, followed by the counting habit. When asked how he is feeling, David says, “Better.” His nonverbal behavior confirms that he is less tense than he was before he started counting. David goes on to say, “It was talking about Eileen and getting married that made me feel tense … I was alright until then.” As your session with David continues, it becomes clear that he feels guilt about leaving his people on the Reservation and having a non- Indian girlfriend. DW As your session with David finishes, you encourage him to continue keeping a log, and to think about the relationship between his images and counting. David’s log reveals that his compulsions take more than an hour each day and cause him great distress. After your session with David, you meet with your supervisor and plan strategies that might be useful for David. It is determined that cognitive behavioral therapy (CBT) would be useful with David. You are certified to use this treatment modality DW In your next meeting with David, as part of response prevention, you teach David about delaying tactics designed to postpone the onset his compulsive actions. You also encourage him to decrease the amount of time spent on his compulsions. You also suggest to David that he distract himself with a favorite activity when he feels tense. Alternately, progressive relaxation can be used to reduce anxiety and tension or delay the onset of obsessive thoughts or compulsive acts. DW It is agreed that David will see you for one more session. Although his images and counting have not completely stopped, he feels he has enough control over them to “try his life without your help.” patient review image David believes his problems will soon stop entirely, as he plans to continue using the techniques he has learned. And, while he still feels some tension, the breathing and relaxation techniques he has learned help to alleviate his tense feelings rather quickly. patient review image David has talked to some Indian friends and family members on the telephone, and plans to visit his Reservation in the next few months. Since work keeps him busy, he has decided not to get involved in local Indian activities for now. At the end of your last session, David gives you a book on Indian art and thanks you for all he has learned from you. You too, have learned a lot from David.

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