10.11 Learning Activity: Case Study
Case Study
Nurse Handoff Report
Situation
Tara Mitchell was admitted to the hospital last night for observation after she was found outside the back door of a local bar, where she works as a waitress, burning her arm with a cigarette. She has a history of nonsuicidal self-injurious behavior beginning in adolescence, including cutting, burning herself, and pulling out her hair.
Eight months ago, Tara was admitted to the hospital following a suicide attempt in which she stepped in front of a car after completing her shift at another local bar. She states that thinking about suicide helps her relax and allows her to “escape” from the distracting thoughts she experiences throughout the day.
Background
Tara was diagnosed with borderline personality disorder following her most recent hospitalization. She has not been participating consistently in therapy.
Her medical records indicate that Tara’s father served in the military and was frequently physically abusive during her childhood, particularly when using alcohol or other substances. He was diagnosed with post-traumatic stress disorder after returning from military service in Somalia. Tara’s mother worked two jobs and was frequently absent from the home.
Tara has two siblings, a brother and a sister, but neither lives in the area. She reports that she has not had contact with them for “several years.”
Tara left college with one year remaining in a graphic design degree program. During the past three years, she has changed jobs frequently, primarily working as a bartender or waitress in local restaurants and bars.
Assessment
Since admission, Tara has been quiet and withdrawn in her room. She reports experiencing the “worst pain ever” related to eight circular burn marks on her left forearm arranged in the shape of the number 8.
Tara does not make eye contact when communicating. Instead, she looks toward the doorway or over the other person’s shoulder. Her hair is down, her makeup is smeared beneath her eyes, and she is wearing hospital scrubs.
During the admission assessment, Tara states that she burned her arm because she was “upset at the bartender because they did not make her drink order first.” She adds, “They hate me. I don’t know why I keep coming back to that job. They are the most incompetent people in the world!”
Tara occasionally “zones out” during conversations, including in the middle of a sentence. She states, “I don’t even know who Tara is. I feel like I’m watching what she does from outside of my body.”
Tara explains that she has a long history of frequently changing her hobbies, employment, fashion preferences, and relationships based on her current social circle.
At times, Tara describes her friends, family members, and romantic partner as “the best thing that ever happened to me.” During these periods, she frequently buys them gifts and sends them caring messages. At other times, she abruptly changes her opinion of these individuals, states, “I can’t stand them,” and lashes out verbally, physically, or through social media.
Following these actions, Tara experiences remorse, immediate regret, and an intense fear that the other person will leave her.
Tara also reports a history of engaging in sexual activity with multiple partners, including people she did not know. She states that she concealed these encounters from her current partner.
When asked why she burned herself with the cigarette, Tara explains that she was angry because she had to work while her current boyfriend, Josh, attended a bachelor party for his best friend, Ben. She states, “I was sure that Josh was going to hook up with someone else at the party.”
Reflective Questions
- What cues do you recognize as relevant when providing client-centered care for Tara?
- What is your hypothesis regarding Tara’s priority nursing problem or problems?
- What are your first steps when providing nursing care for Tara?
