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Aliza Ali Muhammad

Demographic Data
Age/Sex: 41 year old female
Cultural/Spiritual: Lacks insight, poor
relationship with mom, feels lonely and
helpless
Current Health Habits (ETOH, tobacco,
etc.): Alcohol (Whisky)
Personal/social History: (marital status,
occupation, living conditions) Unmarried
with one child. Child lives with grandma.
Used to gamble, went to Detox, History of
noncompliant with treatment, abused
benzodiazepine, Xanax and Valium. 2
previous hospitalizations for Psych Illness,
Depression and Alcoholism.

Signs and Symptoms


Objective:
Loss of interest
Irritability & frustration
Loss of interest in activities
Lack of energy
Agitation & Restlessness
Subjective:
Feelings of sadness, emptiness or unhappiness
Frequent thoughts of death
Thoughts of suicide
Insomnia

Family History: Type 2 Diabetes and


Addiction.

Mental Health Medication(s):


Xanax (alprazolam) anti-anxiety 4mg tid
Valium (diazepam) anti-anxiety 2mg bid
Ambien (zolpidem) sedative 5mg qd
Paxil (paroxetine) anti-depressant 10mg qd
Abilify (aripiprazole) anti-psychotic10mg qd
Ativan (lorazepam) anti-anxiety 2mg tid
Abnormal Lab/Diagnostic Studies:
High Eosinophil count: Normal: 30-350
Low Sodium: Normal: 135-145 (mEq/L)
Low Albumin, Normal: 3.5 to 5.5 g/dL
High LDL: Normal: 62 - 130 mg/dl

Admitting Diagnosis
Major Depression w/ Selfmutilation

#1. Nursing Diagnosis: Self Harm related to depressed


mood AEB reported ideation and attempted suicide

Outcomes: Client will verbalize 3 stressors


that preceded suicidal ideation by today at
3pm.

Interventions:
Nurse will watch for and remove any harmful objects that would
trigger the patient to harm herself.
Nurse will develop a therapeutic relationship with the client.
Nurse will ask client to enter into a no suicide contract.
Nurse will observe, record, and report any changes in mood or
behavior that may signify increasing suicide risk and document
results of regular surveillance checks.
Nurse will encourage the client to group therapy for continued
assistance.

Primary Problem
Attempted Suicide

#3. Nursing Diagnosis: Risk for powerlessness r/t alcohol abuse

#2. Nursing Diagnosis:


Alteration in mood-Depressed r/t low self-worth AEB
Hopelessness and Helplessness.
I am overwhelmed and all alone

Outcomes: Patient will verbalize 3 life factors that are uncontrollable

Interventions:
Nurse will observe for factors contributing to powerlessness.
Nurse will encourage patient to share her beliefs and thoughts.
Nurse will help patient achieve her specific health goals.
Nurse will encourage the client in goal directed activities that
promote a sense of accomplishment.
Nurse will give realistic and sincere praise for accomplishment.

Outcomes: Patient will identify 3 positive characteristics she has


after participating in group therapy by 3pm today.

Interventions:
Nurse will monitor and document potential for suicide
Nurse will facilitate access to resources to support spiritual wellbeing
Nurse will reminisce with the client about her life
Nurse will encourage visits from Child and Mother to foster
hopefulness.

Aliza Ali Muhammad

Evaluation of Outcomes:
Outcome #1: Met
1. Patient verbalized that she wanted to kill
herself because she is tired of her addiction
2. Patient shared that she thinks her son will be
better off without her.
3. Patient talked about her relationship with
her mother that her mother is tired of her.
Outcome #2: Partially met
1. Patient said that she misses her son and
wants to get better so she can be with him
again.
2. Patient discussed that she thinks she has
better control on herself as compared to
before she came.
Outcome #3: Partially met
1. Patient discussed that sometimes when she
is really happy she wants to go have a drink
and cant seem to stop.
2. Patient discussed that she sometimes want
to quit all medications because she doesnt
feel like herself.

References:
Ackley, B. Ladwig G. (2012). Nursing Diagnostic
Handbook; An Evidence-Based Guide to Planning
Care (Ninth ed., p665, 740, 811). St. Louis Missouri;
Mosby Elsevier.

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