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Taylor Anderson SJCN Psychiatric Hospital
DOB 11/23/08 MRN 20891080
Situation: Taylor, a 16-year-old non-binary individual, has been admitted to the
psychiatric unit with a diagnosis of depression and a suicide attempt
Background: Taylor has been using marijuana and alcohol as a coping mechanism
for the past year. The client’s has history of depressive symptoms multiple suicide
attempts, and a history of sexual abuse from their uncle from the ages of 2-12.
Assessment: Taylor exhibits minimal verbal communication, a flat affect, and is
visibly uncomfortable around male staff. Substance use disorder is also present,
with a one-year history of marijuana and alcohol use .
Recommendation:
1.Admit to the inpatient psychiatric unit
2.Complete vital signs
3.Complete psychosocial assessment
4.Establish a therapeutic relationship and assess for immediate safety concerns.
Labs VITAL Signs
Urine Drug Screen Result
1.Ethanol (ETOH): Positive- Detected
concentration: 120 mg/dL
2.Marijuana (THC): Positive- Detected
concentration: 50 ng/mL
3.Cocaine: Negative
4.PCP: Negative
5.Opioids: Negative
6.Pregnancy test: Negative
Blood Pressure: 124/76
Respiratory Rate: 18
Medication Administration Record
0900 1200 2100
Methylphenidate 60mg Methylphenidate 60mg
Sertraline 50mg Sertraline 50mg
Medication Reconciliation

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tayloranderson12222222222222222222222222222222.pptx

  • 1. Taylor Anderson SJCN Psychiatric Hospital DOB 11/23/08 MRN 20891080 Situation: Taylor, a 16-year-old non-binary individual, has been admitted to the psychiatric unit with a diagnosis of depression and a suicide attempt Background: Taylor has been using marijuana and alcohol as a coping mechanism for the past year. The client’s has history of depressive symptoms multiple suicide attempts, and a history of sexual abuse from their uncle from the ages of 2-12. Assessment: Taylor exhibits minimal verbal communication, a flat affect, and is visibly uncomfortable around male staff. Substance use disorder is also present, with a one-year history of marijuana and alcohol use . Recommendation: 1.Admit to the inpatient psychiatric unit 2.Complete vital signs 3.Complete psychosocial assessment 4.Establish a therapeutic relationship and assess for immediate safety concerns.
  • 2. Labs VITAL Signs Urine Drug Screen Result 1.Ethanol (ETOH): Positive- Detected concentration: 120 mg/dL 2.Marijuana (THC): Positive- Detected concentration: 50 ng/mL 3.Cocaine: Negative 4.PCP: Negative 5.Opioids: Negative 6.Pregnancy test: Negative Blood Pressure: 124/76 Respiratory Rate: 18
  • 3. Medication Administration Record 0900 1200 2100 Methylphenidate 60mg Methylphenidate 60mg Sertraline 50mg Sertraline 50mg