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You are a nursing case manager on the county mental health outreach team. The local Mental Health Center has a treatment and referral contract for behavioral services with local healthcare practitioners.
A Health Insurance Portability and Accountability Act (HIPAA) business agreement has been signed between the parties, which allows for exchange of need-to-know information and appropriate planning and treatment of patients to occur. A nurse midwife affiliated with a local obstetrician’s office calls and reports that Mrs. Iminez (Rosa) has been in for prenatal care over the last several months. At Rosa’s prenatal visit two weeks ago, the midwife noted multiple bruises, and belt marks on her chest, back, and abdomen. Rosa said that she ‘bumped into a door,’ and would not comment any further. At today’s prenatal visit, new bruises and what appear to be cigarette burns were noted. Rosa is to return the following day with her husband for a prescheduled class. Fearing intimate partner violence (IPV), you arrange to be present when Rosa and her husband attend the class, and plan to speak with them.

Research has demonstrated that intimate partner violence occurs in both genders, and across all ethnic/racial groups, age groups, sexual preference groups, and economic, cultural, intellectual groups. It is important that nurses avoid stereotypes and remain open to warning signs and clues to intimate partner violence in all clients. Intimate partner violence typically evolves inter-generationally over time. Both partners in an abusive relationship often have experienced or witnessed physical and emotional violence by people close to them.
Frequently there are warning signs before violence occurs: increased possessiveness and jealousy on the part of the abuser, demeaning comments toward the victim, and efforts to isolate the victim from friends and family.

Abused persons often develop somatic complaints that, helpfully, keep them in contact with health care providers. Frequently, they seek care from a variety of providers, in an effort to prevent the abusive situation from being identified. Abused persons may also have symptoms of stress. These can include difficulty sleeping, recurring nightmares, diminished appetite and poor eating, memory deficits, and even out-of-body experiences. Intimate partner violence often involves a repeated pattern of tension-building, acute battering, and loving reconciliation. This is known as the cycle of violence.
The tension-building phase includes verbal abuse and minor incidents. The acute battering phase includes the outbreak of serious violence. The loving reconciliation (honeymoon) phase is marked by remorse and promises to reform. As the cycle progresses, the first two phases predominate. The following day, prior to your meeting Rosa and her husband, you review Rosa’s medical record, including the family and social history originally provided. 
Both Rosa and her husband are United States citizens whose great-grandparents came to North America from Cuba to establish a better life. Rosa is an elementary school teacher. Miguel owns a department store chain.

 

You are introduced to Rosa and Miguel when they arrive.
You notice that Miguel is very protective of Rosa, insists on staying with her, and often answers for her. Rosa looks to Miguel before she speaks, and keeps her eyes on him or looks at the floor when she speaks. After Rosa and Miguel share information about their health and family, you mention concern about Rosa’s bruises.
Miguel states “Rosa is very clumsy, especially since she became pregnant.”

You ask Miguel to stay and speak with you while Rosa is examined by the midwife.

Miguel becomes angry and initially refuses to speak with you alone, or have Rosa be seen alone without him present.

Miguel finally agrees to talk with you, and allows Rosa to be seen alone.

You know that the abusive person often seeks relief from anxiety and tension by becoming angry, aggressive, and physically harmful to those around him. Not only are anxiety and frustration relieved ….. but the abuser may temporarily feel more powerful and in control through his aggressive acts.

The abusive person generally has a deflated self-concept ….. aggression is a means to dominate the family and help the abuser feel superior, thereby unconsciously overriding his poor self-image. Often, the abusive person was exposed to abuse while growing up.

As you talk with Miguel, he remains superficial and social in his words and affect. Although generally polite and smiling, at times he is condescending, conveying an attitude that he doesn’t have to answer your questions.

Miguel assures you that there is no need for concern. He and Rosa are doing fine. Rosa’s pregnancy is not causing any unusual tension between them.
Miguel is proud that he will be a father and hopes he will have a son. Furthermore, he is a successful businessman with many friends. He knows how to deal with problems ….. his reputation depends on it. And, “NO”, he does not drink. He needs a clear head to maintain his business. And, “NO AGAIN,” he does not use any drugs, nor has he had any head injuries, episodes of depression, or other medical problems.

After sarcastically thanking you for the inquiries into his health, Miguel asks, “Who is the patient here anyway? Me or my wife?”

 

I need a SOAP note on this patient review . 

 

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NUR 2520

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