Name of Client
docx
keyboard_arrow_up
School
Bridge Business College *
*We aren’t endorsed by this school
Course
BSBINM501
Subject
Health Science
Date
Nov 24, 2024
Type
docx
Pages
4
Uploaded by DeanOtterMaster1190
Name of Client: Jacinta Jackson
Date of Birth: 28/10/1996
Client’s Address: Insurance Info: Biopsychosocial assessment
Referral Source:
Jacinta was referred to our hospital by her friend Janet who was a client about a year ago after she got her first born. Janet treatment was successful and that is the main reason she referred her friend Jacinta to our clinic. History Presenting Problem: The case scenario presents Jacinta Jackson, an African American woman aged 26 years. Mrs. Jackson is married and works as a customer representative in a local bank. Currently, Jacinta is nursing her 2 months baby which is her first born. Since the birth of her child, Jacinta has been experiencing mood swings, anxiety, sadness, irritability, feeling of being overwhelmed, crying a lot, reduced appetite and concentration and insomnia or trouble sleeping. Jacinta claims she is experiencing “baby blues” however, she discloses to her friend Janet that she was not ready to have a baby and that she wanted to build a career first. Jacinta’s husband travels a lot from one city to another due to the nature of his job and rarely has time to help her with the baby. Also, Jacinta does not have anyone else to help her with different chores and taking care of her baby. Her mother and sisters live and works in a different city and cannot leave their jobs to come and help with the baby. Jacinta’s friend Janet advised her to seek therapeutic help or intervention from a psychologist.
Source of data: client’s interview and observations methods were used to gather the information
about her presenting problem. The client was very cooperative in answering the interview questions. Client's History and Current Functioning
Family history: Jacinta is the third and last born of a family of three sisters and no brother. Her father and mother lives in different cities die to their jobs and do not have any known substance use problem. Her sisters also do not have any substance use issues. Her mother has a history of prepartum depression especially with her first and last born. Educational background: client holds a bachelor’s degree in business commerce and a diploma
in business communication.
Employment status and history: client current works as a customer representative in a bank. Religious or spiritual beliefs and practices:
client identifies with the Christianity faith and goes to church every Sunday except for the period since she had the baby. Current and past medical background: clients deny any history of a disease or illness except for the occasional flu and cold.
Mental health history:
client denies any history of mental illnesses, neglect or abuse History of substance abuse: client denies any history of substance use problems
Present legal concerns or past issues: clients deny any current or past legal issues.
Assessment and Recommendations
Client's appearance: the client appeared tired, stressful, anxious and sad. She did not appear properly groomed as her hair was not kempt and her clothes were not properly ironed.
Differential Diagnoses:
Postpartum Depression
: screening of postpartum depression will involve the use of Edinburgh Postnatal Depression Scale (EPDS) which will critically assess the client’s moods and thoughts. The client will also be required to undergo a blood test to rule out if physical conditions such as hyperthyroidism or hypothyroidism may be the cause of the depression. Depression (major depressive disorder): the client will be passed through a psychiatric evaluation tests and answer questions about their thought’s feelings and behavior patterns. The DSM-5 diagnostic criteria for depression will also be administered to the client. Recommendations: the client is most likely suffering from postpartum depression. Thus, short- and long-term treatments plan for postpartum depression should be implemented to the client.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
Treatment Plan
ASSESSED NEED:
Client will: will be able to develops coping Skills to manage difficult situations through Psychotherapy
GOAL:
client will learn to cope with their feelings, solve issues or problems, learn to set realistic goals and learn to respond to difficult situation is positive ways.
Objective #1
: client will: learn and use 2 new coping skills to assist them when dealing with difficult situations in their lives. Action #1:
Therapist will: assist client with learning how to cope up with their feelings especially during difficult times.
Action#2:
Therapist will: teach the client how to solve problems presented in their life Action #3:
Therapist will: teach the client to set realistic goals/objectives and how
to positively respond to difficult situation