SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example

SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example

Patient Name: Shelby Colsatrella, Gender: Female, Age: 26 years, Ethnicity: Asia American

Subjective

CC: ‘I am alright, but there have been changes in my life.’

HPI: SC is a 26-year-old unmarried woman second-generation Asian American who presents to the clinic for psychiatric consultation because of a drinking problem after losing her job. The patient considers herself to be okay, but she feels she needs assistance to resolve some changes in her life that have pushed her in seeking solace in alcohol. This was her first psychiatric interview a few months ago.  SC reports that her drinking has increased since she now has more time to herself. She identifies that she started struggling with worthlessness after losing her job and is set to lose her house soon. Other significant stressors in her life are her inability to pay the bills and her drinking problem worsening. She believes the situation at this point in time is getting worse and that she is indifferent now. She reports that if something happened to her dying, nothing of value would have to be taken care of. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Other depressive symptoms include a sense of guilt for having drunk her goals, her job and soon the house. She admits keeping a bottle of alcohol by the bedside so that she can take a few shots in the morning to feel good and forget her sorrows.  She denies a known history of psychiatric or mental disorders. She denies the use of illegal substances and any suicide attempt. Be that as it may, she reports having a suicide plan to end it all as the current situation does not have an alternative. She, however, reports she is not comfortable sharing her plan as the psychotherapist (myself) would want to stop her plan to kill herself. Before life reached the current levels of misery, she wished her life was different. She would like a happy life, she would like not to drink, to a good a life, but it is now pointless as there is nothing she can do to pick up the ruined pieces of her life. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Allergies: No known drug allergies

Current medications: none

Health maintenance

            Exercises: none

            Sleep: inadequate despite being in bed.

            Diet: varied

            Sexual activity: heterosexual, no history of STIs

            Immunizations: up to date as reported by the patient

Social history: Had a full-time job as a supermarket accountant before she was fired. Struggling financially, living alone and drinking a lot. She takes no illegal substances. Parents and siblings live in town.(SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Surgical history: adenoids were removed in her childhood.

Family History:

Mother is 54 years old. Manic depressive disorder treated with Prozac.

Father: 58 years old:  alcohol abuse disorder treated through psychotherapy and motivational interviewing

Brother: 23 years old, no chronic or past medical or psychiatric issues

Sister: Died of breast cancer at age 28.

Objective

Review of Systems (ROS)

Constitutional- Reports no fevers, weight gain or loss

Skin- Normal skin tone, no jaundice, no rashes                            

Head-Negative for headaches, head injuries, no dizziness

Eyes- No changes in vision, no eye pain, and no double vision

Ears- No earache, no hearing changes

Nose- No nasal discharge, no congestion

Mouth /Throat- No mouth sores, no dry mouth, no hoarseness, no dysphagia

Neck –Negative for pain or swelling

Respiratory-Negative for wheezing, coughing, orthopnea or dyspnea

Cardiovascular-No chest pain, no palpitations, no edema (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

GI-No melena or hematochezia, no constipation, vomiting, nausea or diarrhea

GU- No dyspareunia, no dysuria, or hematuria

Endocrine-No history of hypothyroidism, no history of heat or cold intolerance. No polyuria or polydipsia

Mental Status Exam (MSE)

Appearance- Patient, is appropriately dressed for the appointment, is well-groomed and appeared her stated age. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Mood- She states feeling depressed most of the time; the mood is persistently depressed and gets worse in the morning

Affect-Basically depressed and is mood-congruent. She does not smile

Speech- Has appropriate tone and volume but is slowed. Uses gestures also. Speech is fluent, well ordered, coherent, and is logical. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Thought content: Demonstrates no compulsions or obsessions. She has no persecutory delusions or hallucinations.

Cognitive function

Orientation-Alert and oriented to person, place, and time

Attention- Responded to all prompts as posed

Memory- was able to repeat bat, doll, and beer can and recall all three 5 minutes later.

Language- Was able to identify displayed objects by names like the handkerchief and face mask

Abstraction- Correctly gave the literal and figurative meaning of two proverbs –Rome was not built in a day, and all that glitters is not gold. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Knowledge- was able to name five coastal states

Judgement- stated she would take a dropped bag to a lost and found center. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Insight- she talked about current political issues in the US and the global pandemic that is COVID-19.

Physical Exam

Vitals- T: 36.7   degrees Celsius R: 15. BP: 124/86 P: 14, Ht 5’ 10”, Wt.: 75kg, BMI: 24.4

HEENT: A normal head without physical trauma, oral mucosa dry and with no lesions

Cardiovascular No gallops, murmurs, RRR and S1S2

Lungs: No crackles and is clear to auscultation

Skin: No rashes, cyanosis or lesions (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Assessment:

            Major depressive disorder is recurrent but with no psychotic features

Alcohol use disorder (Kranzler & Soyka, 2018)

Insomnia (Sateia et al, 2017)

Risk Assessment: suicide/violence

            History of risk factors- Has a history of depressive episodes

            Current risk factors- feels hopeless and no reason to live

                                    -Feels trapped and cannot bear to lose her home

                                    -Increased use of alcohol

-feels isolated

-has sleep problems

-considers her death a viable alternative

Protective factors- She has good family support that she feels would miss her if she died and they would regret things they would have done differently. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Suicide risk –Based on the above risk factors, the risk of suicide is considered high. She has a suicide plan that she feels uncomfortable sharing with her provider, persistent but passive wish to be dead is present (WHO, 2016) (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Violence risk- Based on the above risk factors for violence, the risk of violence is considered low.

Plan:

In patient hospitalization is recommended for between 5 -10 days

Initiate Depakote ER 1500 mg PO qpm for mood stabilization (emc, nd) (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Initiate Ambien CR 12.5 mg PO at bedtime for insomnia (Kranzler & Soyka, 2018)

Acamprosate 333 mg 1 tablet taken two times daily to treat and manage AUD (Carpenter et al., 2018).

Part 2 of 2

Summary That Highlights the Warning Signs of Suicidality in the Patient

All healthcare providers like psychiatrists and mental health practitioners must understand that suicide is not a mental disorder but a severe consequence of treatable mental disorders like bipolar disorder, borderline personality disorder, post-traumatic stress disorder, substance use disorder. The provider has a responsibility and is obligated to be on the lookout for suicidal ideation or homicidal thoughts that indicate the patient plans to execute a plan of either killing herself or others. Some people may experience suicidal thoughts at least once in their lives, but others are unfortunate to have such thoughts regularly or sometimes even daily. While acknowledging the expected prevalence of suicidal thoughts, most of those who experience them do so during moments of increased stress of reliving a traumatic experience. The patient must get immediate suicide risk assistance to help, support, and get the necessary treatment to cope with these immediate yet pathological needs. As such, this section outlines a summary of the warning signs that Patient SC exhibited that were suggestive of suicidal ideation. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

`           The first sign that suggested that SC was considering ending her life was her talk about feeling hopeless and having to reason to live. During the psychiatric interview, she reported that she was indifferent to what was happening to her. She even wonders why it matters. The second sign was that she admits to increasing her alcohol intake and even keeps a bottle of alcohol next to her bed since she finds it difficult to get out of the bed without taking a shot to blunt the pain of what she is going through. Next, she has gone through significant life crises over the past few months, like losing her job. She is in serious financial problems as she cannot meet her bills, and even fears losing her house is a foregone conclusion now. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Additionally, even the choose use disorder has become worse and in her depressed state feels there is nothing that she or any other person may do to bring her life back on track. The limited scope of the summary means not all the suicide signs were captured here. Others include severe sadness, having a suicide plan and even has sleep problems. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Why I chose the treatment plan I choose in the SOAP Note

Like any other practitioner, it is my primary duty as a healthcare provider to prevent the patient’s suicidal ideations and ensure they are not acted out. Subsequently, psychiatric hospitalization is recommended since, in my considered assessment, the patient’s condition necessitates 24-hour monitoring due to the stated risk of harm to self or severe deterioration of the level of functioning. Therefore, during the session, I discussed with SC regarding the prescribed medications for her within the context of risks, benefits, alternatives, side effects and pregnancy indications if indications to that effect existed. To stabilize her mood, the patient was started on Depakote ER 1500 mg to be administered orally. Similarly, Ambien CR 12,5 at bedtime was prescribed to help control her lack of sleep, while Acamprosate was added to treat alcohol use disorder. The patient has no known history of adverse drug reactions, while the following up clinic was set at 2weeks from her discharge. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

References

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International journal of bipolar disorders, 8(1), 1-13. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Carpenter, J. E., LaPrad, D., Dayo, Y., DeGrote, S., & Williamson, K. (2018). An Overview of Pharmacotherapy Options for Alcohol Use Disorder. Federal Practitioner, 35(10), 48. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

EMC (n.d) Depakote 250 mg tablets URL: https://www.medicines.org.uk/emc/product/6102/smpc#gref Accessed September 14, 2021) (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Kranzler, H. R., & Soyka, M. (2018). Diagnosis and pharmacotherapy of alcohol use disorder: a review. Jama, 320(8), 815-824. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307-349. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)

World Health Organization. (2016). Practice manual for establishing and maintaining surveillance systems for suicide attempts and self-harm. (SOAP NOTE for a Suicide Assessment of a Client with Initially Subtle Warnings of Suicide-Shelby Colatrella Case Study Comprehensive Nursing Essay Example)