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Mother is concerned that daughter is not eating enough, restricting food intake for 8 months because she feels fat, feels she needs to lose ten pounds, feels that her thighs and stomach are to large, reporting 35 lb weight loss over last 8 months

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Introduction

University of Texas at Arlington School of Nursing N303 Psychiatric Management Case Study Student Name:___Elishia Williams ___________ Clinical Advisor:_Dr. Snow_____________ Topic:_Case Study 1 Lauren 19 yr. old white female Date:____06-07-05______ Subjective Data Provided: Subjective Needed: in italics Mother is concerned that daughter is not eating enough, restricting food intake for 8 months because she feels fat, feels she needs to lose ten pounds, feels that her thighs and stomach are to large, reporting 35 lb weight loss over last 8 months, denies any eating problems, began menarche at age 16 periods normally regular, stop three months ago, exercises daily 20 min. to 2 hours, experiences low energy, chronic constipation and lightheadedness, favorite TV show is "America's Next Top Model" and reports "feeling down in the dumps" for about nine months, college student, good grades, finding it difficult to concentrate, admits to feeling worthless and having no friends, moved to new city middle of senior year, has difficulty falling asleep awakens in middle of night often, mother reports that she is often irritable and cries often. ...read more.

Middle

or mental abuse, are you able to groom and cook for your self, what did you do for fun in the past week, did she have friends before the move, is she able to contact those friends now, what did she do socially before the move, any criminal or legal problems, any boyfriends, how do you feel about your current living situation, any spiritual beliefs, who do you feel like you can talk to, any changes in your hair, skin, or nails, any headaches, or vision changes, any chest pain, palpitations, SOB, any joint pain or weakness. Objective Data Provided: Objective Needed: In Italics 5'8", 105lbs, Temp, BP looking for hypotension, Pulse looking for bradycardia, RR, mental status exam- appearance, attitude toward examiner, mood, affect speech, thought process, thought content, orientation, judgment, insight, strengths and assets, Assessment of cardiac, respiratory, GI/GU looking for bloating, abdominal pain due to constipation, HEENT looking at teeth to observe for erosion of enamel indicative of frequent vomiting, MUSK, Lymph looking for dependent edema, Neuro, Skin/Hair/Nails looking for lanugo, administer the inventory of depressive symptomatology. ...read more.

Conclusion

until eating patterns have normalized measured by eating 75% of three meals per day plus two snacks, achieve 85%-90% of ideal body weight, menstruation, demonstrate improved self-acceptance, long term treatment to prevent relapse. Individual cognitive behavior therapy focusing to include problem solving to think through interrelational problems and food problems, meal planning, and coping skills. Family therapy to figure out the family dynamics, and provide counseling. Comforting family by telling them that 25% of patients fully recover and another half are improved and function well. Labs/screenings: BUN, electrolytes, CBC, Thyroid function, UA, if malnourished perform an EKG, calcium, phosphorous, LFT, blood chemistry Medications: Stool softeners - docusate calcium 240mg capsule for constipation prevention, Remeron (mirtazapine) 15mg at hs for one week Teaching plan: Educating family that patients will resist hospitalization and plea for their families to remove them from the hospital. Body image correct BMI, nutritional counseling for appropriate diet and exercise. Counseling plan: individual therapy, family therapy, nutritional counseling (see treatment plan) Follow up: Continual monitoring of weight and progress. Continued outpatient therapy and family therapy. ...read more.

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