Care plan

Student Name: Charity Oduro

Week: 5

Dates of Care: 11/6/2022

Demographics and Brief History

Patient Initials

S K

Sex

F

Age

39

Room

225

Admitting Date

11/10/22

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Patient presented to St Joseph hospital Joliet, on the 11/6/2022 for psychosis, disorganized delusion, and auditory hallucination. Per the chart patient came into the hospital for evaluation of possible kidnapping by her boyfriend. Patient has anxiety, insomnia, depression decreased concentration and loss of appetite.

Attending physician/Treatment team:

Aquel A. Khan, M.D

Precautions:

Suicide precaution (SP)

Close observation (CO)

Primary Diagnosis:

Paranoid delusion

Co-morbidities:

None

Allergies:

Coded allergy: No known drug allergy

Code Status:

Full code

Isolation: (type and reason)

None

Admission Height:

64.0 inches

Admission Weight:

78.8 kilograms

Arm Band Location (colors & reasons)

White in color on the left arm

Past Medical History: (pertinent & how managed)

Per the chart, the patient became anxious, difficulty sleeping (insomnia), decreased concentration loss of appetite, depressed, auditory hallucination, paranoia, delusion and came to the hospital for evaluation. Patient reported that, in February this year, she was sexually assaulted and kidnapped by a man who have been her boyfriend at a point. who was hopping from a hotel to a hotel. Patient is a high safety risk and unable to care for herself and her two children. Due to her depressed mood and behavior, she abuses cocaine and unable to complete her activities of daily living and needs medication to ease herself. The patient said, she feels sad and guilty when she remembers the incidence and make her do things that she is not aware of, smoking 5 sticks of cigar rete a day. The patient was diagnosed with paranoid delusion and has a history of depression. Patient denies suicidal and homicidal ideation.

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)

The patient was involuntarily admitted to the hospital for evaluation of the raped case. At 9:00 am, the patient was sitting at the dining room watching television and arguing with some of her colleagues on a television program. The patient was talking loudly and telling them about a guy who invited her to his house and later raped her. The patient later said she has no insight about what happened but realize it was a set up by the boyfriend.

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

11/3/22 11/5/22

General Appearance

·
Grooming/Clothing

· The patient was clean and well groomed. The patient clothes were appropriate to the weather. The patient was wearing a white top and a jogging pant with a hospital socks.

·
Hygiene

· The Patient was nicely dressed, hair well kept

·
Posture

· The patient was sitting upright at the dining room watching television with her friends.

·
Gait

patient has a steady gait and need no ambulatory assistant.

·
Obese/average or normal/ underweight

· The patient is within the normal body weight and has a BMI of 21

·
Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

The patient skin is intact, no scars and no tattoos, or physical marks on the body.

Activities of Daily Living

·
Sleep/rest

·
Per the chart patient was having insomnia but stated she can sleep well now for at least 6 hours. Th patient stated, she is not taking any sleeping aid.

·
Diet

·
Patient is on a general / regular diet

·
The patient eats three meals a day and ate 75% of her lunch. Patient denies any changes in diet

·
Exercise/mobility

·
The patient is self-independent and ambulate in the hallway.

·
Elimination

·
The patient has no problems with voiding, stated she urinates frequently throughout the day.

·
Hygiene

·
The patient was clean, neatly dressed and well groomed. The patient stated, she takes showers 3 times a week and has good oral hygiene

GI

Diet: The patient is on a regular/general diet and normally eats 75% of her meals. The patient stated, she has a bowel movement yesterday at 5: 00 pm.

Blood Glucose (time & date): None

Last bowel movement (time & date): 5:00 pm 11/5/2022

Pertinent Labs/Test: None

Assessments:

·
Stool

·
Not able to assess patient stool

·
Bowel sounds

·
Not able to assess bowel sounds

·
Tenderness, distention

·
Not able to assess for tenderness and distention

·
Appetite, nausea, vomiting

·
The patient ate 75%of her lunch, denies nausea and vomiting.

Interventions: Continue current medications, closed observation and checking of vital signs

Respiratory:

Assessments: N/A

·
Lung sounds: N/A

·
Cough, sputum: N/A

·
SOB; N/A

Interventions:

Neurosensory:

Alert & Orientated: The patient is awake, alert, oriented to person, place and circumstances.

Follows commands: The patients follow instructions/directions.

Speech Comprehensible: The patient has a clear speech with normal tone, rate, rhythm and answers all questions appropriately.

Pertinent Labs/Test: None on patient chart

Assessments:

·
LOC

·
Patient was alert and orient *4

·
Pupils

·
PERRLA

·
Glasgow Coma Scale

·
Not applicable on patients’ chart

·
Dizziness

·
The patient denies any dizziness

·
Headaches

·
The patient has headache in the morning

·
Tremors

·
The patient denies any hand tremors

·
Tingling, weakness, paralysis, or numbness

·
The patient denies tingling, weakness, and paralysis or numberless upon questioning

Interventions: Continue to assess patient headache, give prescribed medication, and check vital signs.

Cardiovascular: N/A

Pertinent Labs/Test: None

Assessments

·
Peripheral pulses

·
N/A

·
Heart sounds (murmurs or bruits)

N/A

·
Edema

·
Patient has no facial or edema at the lower extremities.

·
Chest pain, discomfort, palpitations

·
Patient stated, has no discomfort, chest pain and palpitation

Interventions: Continue close observations.

Musculoskeletal:

Activity: Normal motor with no tremors

Casts/Slings: None

Assessments:

·
Strength, weakness

·
The patient has a + 2 strength and denies any muscle weakness

·
ROM

·
N/A

·
Gait (documented under appearance)

The patient has a steady gait and need no ambulatory assistant

·
Pain

·
Patient has no pains (0/10) on the pain rating scale.

·
Fractures, amputations, or transfers

·
None

Interventions: Close monitoring and checking of vital signs.

Renal:

Pertinent Labs/Test: N/A

Assessments:

·
Bruit, thrill, location; N/A

·
Urine-quality

·
Patient stated, she urinates frequently throughout the day.

·
Burning with urination, hematuria

·
Denies no burning /hematuria

·
Incontinent, continent, I & O

·
The patient is continent

·
I&O: N/A

Interventions:

Close observation

Skin:

Braden Score: none

Pertinent Labs/Test: none

Assessments

·
Bruising, wounds, drains

·
The patient has an intact skin with no bruising, wounds, and drains.

·
Turgor

·
N/A

·
Surgical incisions

·
The patient denies any previous surgical incisions

·
Finger & toenails

·
The patient nails were well trimmed with no clubbing.

Interventions:

Close observation of patient

Pain:

Pain score:0/10

Assessments/Interventions:

·
Scale used

·
0- 10 numerical scale

·
Location, duration, intensity, character

·
None

·
Exacerbation, relief

·
None

Interventions:

·
Continue assess pain daily for any changes

Gyn:

Gravida/Para: G2P2

LMP: Not applicable on patient chart but States last month during our interview.

Last Pap: patient States She has never done a pap smear.

Breast exam: None

Pertinent Labs/Test: None

Assessment

·
Bleeding

·
The patient denies any bleeding

·
Discharge

·
The patient denies any discharge

Interventions: Continue monitoring.

Safety: N/A

Bed Rails: None

Bed alarms: None

Fall risk: The patient ambulates independently and has no fall risk. Wear hospital socks to protect her feet.

Assistive Devices: No assistive device for the patients.

Interventions:

·
Close observation.

Advance Directives/Ethical considerations:

AD: Not applicable

POA: Not application

Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)

10 Panel Toxicology/Drug Screen: if available

Blood Alcohol Level/Ethyl Serum Level: if available

Psycho/Social Assessment

·
Level of education

·
The patient stated, she completed two years of college

·
Occupation

·
Works as bar attendants and hairdresser

·
Race/Ethnic Background or Identification

·
White

·
Religion/Spiritual Beliefs

·
Christian

·
Communication needs: (verbal, nonverbal, barriers, languages)

·
The patient has no communication barriers and speak English frequently

·
Special Talents/Interests/Skills

·
Hairdressing/ singing

·
Environment (home and community)

·
The patient stated, she lives with her 2 children, boy and a girl and feels safe at her community.

·
Family Structure/History: The patient was born in Chicago, she attended a two-year college and now working as a bar attendant and do a hairdressing as her part time job. The patient lived with her two children boy and a girl. Her parents live together and sometimes visited them every 2 weeks. The family has a history of Psychiatric problems, depression auditory hallucination, paranoia, and delusion.

Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)

The patient is 39 years old and based on Erikson’s developmental stage, we compare stagnation vs. generativity. Generativity includes the achievement of other developmental process. This increases sharply in midlife when individuals try to focus on other interest beyond their own. In this stage, the patient wants to indulge in society, establish relationship or isolate themselves. Previous stage successfully completed.

Support System:

Two children and mother

Stressors/Stress Management Practices:

The patient stated, she feels stressed of being raped by the boyfriend. The patient stated, she smokes cigarettes 5 sticks a day to relieve stress, learn to be assertive, relaxation, exercising and talk to someone, mother, and children.

Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article.

Discuss the current disease process:

The development of delusional disorder occurs in five primary stages. The first stage is known as Trema. In this stage, an individual develops a delusional mood and expresses a total change in opinion about the world (Garcia et al., 2022). This is followed by searching and finding new meaning for the psychological beliefs or events in the second stage known as apophany. This stage lasts for some period and eventually worsens as the person dives deeper in the world of psychosis. The heightening of psychosis marks the occurrence of the third stage which is called anastrophy. In the fourth stage, consolidation, a person builds a new world or psychological set using the new found meaning. Their thinking or perception about things become bizarre as their interpretation is based on their new meaning of psychological events (Ritunnano & Bortolotti, 2022). Lastly, patients enter the residuum stage which is the eventual autistic state. In paranoid delusions disorder, individuals present with unwarranted pervasive distrust and suspiciousness of other people and their motives.

Discuss the etiology of the patient’s illness:

The exact cause of delusional disorder is not known. However, current research data shows that different genetic, biochemical, neurological, and psychological factors contribute to the development of the disorder (Garcia et al., 2022). With regards to genetic factors, data shows that patterns of familiar inheritance are common for those with exposure to paranoid personality disorder. On the other hand, many biological factors such as substance abuse, neurological conditions as well as medical problems have been associated with development of delusions. Primarily, the development of the disorder is attributed to alterations in the limbic system and basal ganglia in persons with intact cortical functioning. According to Joseph & Siddiqui (2022), psychological factors such as low self-esteem, envy and distrust increases the likelihood of people becoming delusional. When these factors become intolerable, an individual start to seek alternative explanations and therefore form delusions as their solutions.

Also note the complications that may occur with treatments and patient’s overall prognosis:

Delusional disorder is associated with different complications. The first complication is depression (Joseph & Siddiqui, 2022). Individuals with the disorder may suffer depression as they find it hard to cope with delusions. For those with paranoid delusions for example, they might feel helpless and lose hope of finding a solution to their delusions. The second complication disruption of personal life. Individuals with delusions tend to be separated from others especially for those in relationships which makes hard for them to trust their partners. They are distrustful and are less likely to maintain relationships (Joseph & Siddiqui, 2022). The next complication is harm towards self or others. Some patients might become violent due to their delusions and might end up hurting others or themselves in the process.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:

The article seeks to investigate the efficacy and tolerability of aripiprazole in delusional disorders. The study which is a systematic review was conducted using articles retrieved from different research databases. They included PubMed, Cochrane Database of Systematic Reviews, and Scopus databases
using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The researchers found out that many cases of delusional disorders especially the somatic type were treated with aripiprazole. All studies reported patient clinical improvements after the beginning of
the treatment with aripiprazole with an average dose of 11.1 mg/day and an average time of 5.7 weeks to achieve a clinical response. The findings of the study indicate that aripiprazole may be an effective treatment for delusional disorders with good tolerability.

.

References

Garcia, C. A., Martínez, D. G., & Navarro, L. N. (2022). Identification of trema in first episode psychosis: a case report.
European Psychiatry,
65(S1), S789-S790. DOI:

https://doi.org/10.1192/j.eurpsy.2022.2040

Joseph, S. M., & Siddiqui, W. (2022). Delusional disorder. In
StatPearls [Internet]. StatPearls Publishing. Retrieved on 30th November 2022 from
https://www.ncbi.nlm.nih.gov/books/NBK539855/#_article-20332_s3_

Miola, A., Salvati, B., Sambataro, F., & Toffanin, T. (2020). Aripiprazole for the treatment of delusional disorders: A systematic review.
General hospital psychiatry,
66, 34-43.DOI:
https://doi.org/10.1016/j.genhosppsych.2020.06.012

Ritunnano, R., & Bortolotti, L. (2022). Do delusions have and give meaning?.
Phenomenology and the Cognitive Sciences,
21(4), 949-968. DOI:
https://doi.org/10.1007/s11097-021-09764-9

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Acetaminophen

Analgesic/ antipyretics

650mg

P O

Oral

PRN

Q4

Fever and pain

May bloc pain impulses peripherally that occurs in response to inhibition of prostaglandins synthesis and does not possess anti-inflammatory properties.

Anorexia, nausea, vomiting, diaphoresis, chills, epigastric/ abdominal pair hepatic coma, renal damage.

monitor for signs and symptoms of hepatoxicity even with moderate acetaminophen doses, especially in individuals with poor nutrition or who ingested alcohol for a longer period. Monitor for anemia and decreased red, white blood counts.

Haloperidol

Antipsychotics

5 mg

Q 6

PRN

P O

Psychotic symptoms

Depressed cerebral cortex, hypothalamus, limbic system, which control activity and aggression, blocks neurotransmission produces by dopamine at synapse.

Parkinson’s, dystonia, akathisia, tardive dyskinesia, tremor, ataxia, headache, confusion, increased libido, hypoglycemia, blurred vision, diaphoresis, grandma seizure.

Monitor patient mental status.

Monitor for extrapyramidal symptoms, akathisia, dystonia, headache, tardive dyskinesia drowsiness.

Monitor for exacerbation of seizure activity

Observe patient closely for rapid mood shift to depression when haloperidol is used to control mania.

Haloperidol Lactate

Antipsychotics

5 mg

Q 6

PRN

IM

Psychotic symptoms

Parkinson’s, dystonia, akathisia, tardive dyskinesia, tremor, ataxia, headache, confusion, increased libido, hypoglycemia, blurred vision, diaphoresis, grandma seizure.

Monitor patient mental status.

Monitor for extrapyramidal symptoms akathisia, dystonia, headache, tardive dyskinesia drowsiness.

Monitor for exacerbation of seizure activity

Observe patient closely for rapid mood shift to depression when haloperidol is used to control mania.

Monitor for WBC count with differential and liver function in patient with prolong therapy.

Lorazepam

Benzodiazepines

2 mg

PRN

Q 6 H

IM

Anxiety and agitation

Potentiate the actions of GABA, especially in the limbic system and the reticular formation.

Amnesia, dizziness, sedation, disorientation, depression, sleep disturbances, blurred vision, restlessness, nausea, vomiting, depressed hearing, anorexia, and abdominal discomfort.

Have equipment for maintaining patent airways immediately available before sharing iv administration.

Im or iv lorazepam injection of 2-4 mg is usually followed by a depth of drowsiness, sleepiness that permits to responds to simple instruction whether patient appears to be asleep or awake.

Assess CBC and liver function fest periodically for patient on long term therapy

Lorazepam

Benzodiazepines

2 mg

PRN

Q 6 H

PO

Anxiety and Agitation

Potentiate the actions of GABA, especially in the limbic system and the reticular formation

depression, sleep disturbances, blurred vision, restlessness, nausea, vomiting, depressed hearing, anorexia, and abdominal discomfort.

airways immediately available before sharing iv administration.

Im or iv lorazepam injection of 2-4 mg is usually followed by a depth of drowsiness, sleepiness that permits to responds to simple instruction whether patient appears to be asleep or awake.

Assess CBC and liver function fest periodically for patient on long term therapy

Magnesium hydroxide

Saline laxative

30 ml

Daily

PRN

PO

Constipation

Increases osmotic pressure, draws fluids into colon, neutralizes HCL

Muscle weakness, flushing, confusion, sedation, nausea, vomiting, prolonged bleeding time and respiratory depression.

Monitor serum magnesium with signs of hypermagnesemia, such as bradycardia.

Evaluate the patients continued need for drug. Prolonged and frequently use of laxative doses may lead to dependence.

Risperidone

antipsychotic

1 mg

Nightly

P O

Schizophrenia

May be mediated through both dopamine type 2 (D2) and serotonin type (5- HT2) antagonist.

EPS, Pseudo parkinsonism, akathisia, dystonia, tardive dyskinesia, orthostatic hypotension, blurred vision, agitation, nausea, vomiting, anorexia, upper respiration, gynecomastia

Monitor diabetes for loss of glycemic control

Reassess patient periodically and maintain on lower effective drug doses

Monitor closely neurologic status of older adults

Monitor cardiovascular status closely. Assess for environmental hazards.

Monitor liver function and complete blood counts.

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Risk for self-directed or other-directed violence

Paranoid delusion /command hallucination

By agitation, physical aggressive to other and hearing voices.

Physical safety of the client and others are important. Many common items can be uses in self destructive manner.

2

Insomnia

Hallucination

Difficulty falling asleep

3

Anxiety

Related to situational crisis

By visual perception of traumatic event

4

Disturbed sensory perception: auditory /visual

Panic level of anxiety

poor concentration

Patient safety is priority

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objectives

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

· The patient presents with delusions

·

Objectives: The patient was agitated and arguing on a television program with her collogues at the dining room.

The patient was showing signs of aggressiveness by moving from place to place and having trouble concentrating

Subjective: The patient states she sometimes hears the voice of her boyfriend who raped her asking her to come to his house.

The patient tells me states anytime men approaches her, she gets panic attack

The patient will be free from violent thought and will not be a treat to herself and others at the hospital within 24 hours.

There is no evidence of violent behavior to self or others within the 24 hours of hospitalization.

Observe client behavior frequently for every 15 minutes. Do this while caring out routine activities to avoid creating suspicious in the individual.

Close observation is necessary so that intervention can occur if required to ensure client safety.

Remove all dangerous objects from client’s environment such as sharp, belts, smoking materials so that in her agitated, hyperactive state, patient may not use them to harm self or others.

Administer medications as ordered by the physician and monitor medication for effectiveness and adverse side effects.

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objectives

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

The client is able to recognize that hallucinations occur at a times of extreme anxiety.

The patient is able to recognize signs of increasing anxiety and employ techniques to interrupt the response.

Observe clients for signs of hallucination (listening pose, laughing, or talking to self.

Early intervention may prevent aggressive responses to command hallucination

Encourage patient to listening to music or watch television helps distract some clients from attention to voices.

Encourage the patient to do a voice dismissal by telling the voice to go away or leave me alone thereby exerting some conscious control over the behavior

Try to distract the client away from the hallucination to times of increased anxiety. If the client can learn interrupted escalating hallucination will be prevented.

Student Name:

Week:

Dates of Care:

Demographics and Brief History

Patient

Initials

DM

Sex

M

Age

59

Room

202-1

Admitting Date

11/01/2022

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Patient tried to commit suicide.

Attending physician/Treatment team:

Khan Aqeel A. MD

Precautions:

Hypertension

Primary Diagnosis:

Depression with suicide ideation

Co-morbidities:

Hypertension

Allergies:

No know allergies

Code Status:

Full code

Isolation: (type and reason)

No Isolation

Admission Height:

69.2 in

Admission Weight:

100.5 kg

Arm Band Location (colors &

reasons)

On the right arm white color

Past Medical History: (pertinent & how managed)

Mild mental retardation, bipolar disorder, generalized anxiety disorder, alcohol abuse, hypertension, sleep apneas

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome) Patient was put under suicide precaution.

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

General Appearance

Assessment:

Patient appeared clean but his hair was not well combed. His clothes were clean and appeared appropriate to age.

Activities of Daily Living

·
sleep/rest

o Patient said he able to sleep eight hours and more in the night and an hour or more during the day.

·
Diet Patient eats three square meals and some snacks each day.

o

·
Exercise/mobility Patient walks perfectly without any assistive device .

o

·
Elimination o
Patient said he moves his bowls daily without any problem.

·
Hygiene

o
Patient takes his shower daily and brushes his teeth twice daily and changes his clothes daily. He said he does his laundry twice in the week.

GI

Diet:

Blood Glucose (time & date):

Last bowel movement (time & date):

Pertinent Labs/Test:

Assessments/Interventions:

·
Stool

·
Bowel sounds : Patient said he moves his bowels at least once a day without any difficulty

·
Tenderness, distention:

·
Appetite, nausea, vomiting:

·
Interventions:

o
Patient urinates well without any pain or burning during urination

Respiratory:

Assessments/Interventions:

·
Lung sounds

·
Cough, sputum

·
SOB

·
Interventions:

o
Patient has no respiration problems. His breathing sounds are clear, no cough or difficulty breathing.

Neurosensory:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

· Slow

Pertinent Labs/Test:

Assessments/Interventions:

·
LOC

·
Pupils

·
Glascow Coma Scale

·
Dizziness

·
Headaches

·
Tremors

·
Tingling, weakness, paralysis, or numbness

·
Interventions:

o

Cardiovascular:

Pertinent Labs/Test:

Assessments/Interventions:

·
Peripheral pulses

·
Heart sounds (murmurs or bruits):

·
Edema:

·
Chest pain, discomfort, palpitations:

·
Interventions:

o

Musculoskeletal:

Activity:

Casts/Slings:

Assessments/Interventions:

·
Strength, weakness:

·
ROM:

·
Gait: patients’ gait was good and smooth.

·
Pain: Patient said he had no pain and score zero for pain

·
Fractures, amputations, or transfers: Patient had no fractures on him.

·
Interventions:

o

Renal:

Pertinent Labs/Test:

Assessments/Interventions:

·
Bruit, thrill, location:

·
Urine-quality:

·
Burning with urination, hematuria:

·
Incontinent, continent, I & O:

·
Interventions:

o

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:

·
Bruising, wounds, drains:

·
Turgor: 2+

·
Surgical incisions: Patient had no surgical incisions.

·
Finger & toe nails: Finger and toe nails were neatly kept.

·
Interventions:

Pain:

Pain score:

Assessments/Interventions:

·
Scale used: Numerical

·
Location, duration, intensity, character •
Exacerbation, relief •
Interventions:

o

o
Patient has no bruises or surgical incision sites on his skin. He has turgor was 2+.

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test:

Assessment/Interventions:

·
Bleeding:

·
Discharge:

·
Interventions:

o

Safety:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Advance Directives/Ethical considerations:

AD:

POA:

Lab Values

Results

Normal Lab Values

Significance to your patient (if applicable)

WBC

7.1 L

5.2-12.4

RBC

4.27 L

4.7-6.2

HGB

12.4 L

12.0-15.0

HCT

37.9 L

37-50%

MCV

89

95.3

MCH

29.1

27-31

MCHC

32.8

32-36

Platelets

153

151-401

RDW

14.7

12-15%

MPV

N/A

7-9

Glucose

N/A

70-99

BUN

N/A

7-25

Creatinine

1.1

0.6-1.3

Sodium

137

135-145

Potassium

3.6

3.5-5.2

Cloride

9.8

98-107

Calcium

8.9

8.6-10.3

Salicylate

N/A

<30

Pathophysical Discussion: For this section include appropriate references and use APA format

Discuss the current disease process:

Psycho/Social Assessment

·
Level of education

o
High School

·
Occupation

o Unemployed

·
Race/Ethnic Background or Identification

o
Caucasian

·
Religion/Spiritual Beliefs

o
Does not go to church

·
Communication needs: (verbal, nonverbal, barriers, languages)

o

·
Special Talents/Interests/Skills

o
Patient lives to sweep, mob, and dust to keep his environment clean so he has implemented it since he came to the unit to help keep it clean and safe for everyone,

·
Environment (home and community) o

·
Family Structure/History:

· Patient lives in a group home but has a sister who supports him.

Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)

Patient is in the middle age group of Erikson’s stage of Development.

Support System:

Patient lives in a group home and said his sister and group members are his support system and they are always there for him.

Stressors/Stress Management Practices:

Patient said he normally takes a walk and talks to friends in the group home to relief his stress.

Discuss the etiology of the patient’s illness:

Also note the complications that may occur with treatments and patient’s overall prognosis:

Attach a research article pertaining to diagnosis of patient. Write a summary about the article:

.

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Acetaminophen

Pain Medication

650 mg

Oral

Q4

Pain and Fever

-Rash, Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric, diarrhea.

-Monitor for signs and symptoms

-Monitor potential abuse from psychological dependence

Simethicone

15 mg

Oral

PRN Q6

Syspesia

-Severe dizziness, trouble breathing, rash, itching, swelling

Benztropine Mesylate

Anticholinergic

2 mg

IM

PRN Q12

Extra Paramedial Symptoms

-Drowsiness, dizziness, nausea, vomiting, constipation, blurred vision, tachycardia

-Access therapeutic effectiveness

-Monitor for muscle weakness

-Monitor for signs and symptoms

Haloperidol

Psychotherapeutic

5 mg

Oral

Q 6

Psychotic symptoms

-Weakness, insomnia, tachycardia, blurred vison, respiratory depression, diaphoresis

-Monitor for therapeutic effectiveness and exacerbation of seizure activity

Haloperidol lactated

Psychotherapeutic

5 mg

IM

PRN Q6

Psychotic symptoms

-Weakness, insomnia, tachycardia, blurred vison, respiratory depression, diaphoresis

-Monitor for therapeutic effectiveness and exacerbation of seizure activity

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Lorazepam

Anxiolytic

2 mg

IM

Q 6

PRN

Moderate to severe agitation

-Sedation, weakness, nausea, vomiting, anorexia, hypertension or hypotension, confusion, and anterograde amnesia

-Do not drink large volumes of coffee or alcoholic beverages

-Supervise patient who exhibits depression with anxiety

Lorazepam

Anxiolytic

2 mg

Oral PO

Q 6

PRN

Mild agitation

-Sedation, weakness, nausea, vomiting, anorexia, hypertension or hypotension, confusion, and anterograde amnesia

-Do not drink large volumes of coffee or alcoholic beverages

-Supervise patient who exhibits depression with anxiety

Magnesium Hydroxide

Antacid

30 mL

Oral

PRN Daily

Constipation

-Nausea, vomiting, abdominal cramps, hypotension, bradycardia, respiratory depression, weakness, and dehydration, coma

-Moniotr seum magnesium with signs of hypermagnesemia

-Prolong frequent use of laxative

Trazodone

Antidepressant

50mg

Oral PO

PRN Oral

Insomnia

-Light-headedness, dizziness, muscular twitches and aches, diarrhea, hematuria

-Monitor pulse rate

-Observe patient’s level of activity

-Monitor for symptoms of hypotension

Risperidone

Antipsychotic

4 mg

Oral PO

B.I.D.

Interferes with dopamine binding region of the brain

-Weakness, headache, blurred vision, insomnia, cough, urinary retention, hyperglycemia

-Monitor closely neurologic status of older adults

-Be aware of the risk of orthostatic hypotension

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Depression

Hopelessness

Patient’s history of different mental disorders.

This is number 1 due to the patient possibly visiting the hospital multiple times and feeling like there’s no for of treatment available for them.

2

Suicide Ideation

Preoccupied mental status

History if suicide attempts

This is number 2 because the patient has a past history of suicide attempts and could possibly be thinking about committing suicide again.

3

4

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

This is made evident by the patient’s past medical history of general anxiety disorder, bipolar disorder, alcohol abuse, and mild mental retardation.

-To determine degree of impairment

-To assess coping abilities and skills

-To assist client to deal with current situation

-Patient will seek help when experiencing self-destructive impulses.

-Patient will have a behavioral manifestation of absent depression.

-Patient will have satisfaction with social circumstances and achievements of life goals.

-Patient will identify at least two-three people he/she can seek out for support and emotional guidance when he/she is feeling self-destructive before discharge.

-Patient will not inflict any harm to self or others.

-Educate patient about depression

-Provide for patient’s physical needs

-Assume active role in initiating communication

-Patient’s ability to assess current situation accurately.

-Patient’s ability to identify ineffective coping behaviors and consequences.

-Verbalization of awareness of own coping abilities and of feelings congruent with behavior.

-Meet physiological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

This is evident by the patient attempting to commit suicide in the past on numerous occasions.

-To provide for meeting psychological needs

-To promote wellness

-Patient will verbalize understanding of treatment plan

-Patient will refrain from attempting suicide.

-Patient will remain safe while in the hospital, with the aid of nursing intervention and support.

-Patient will stay with a friend or family if the person still has the potential for suicide.

-Patient will identify at least one goal for the future.

-Encourage the client to talk freely about feelings and help plan alternative ways of handling disappointment, anger, and frustration.

-Encourage the client to avoid decisions during the time of crisis until alternatives can be considered.

-Arrange for the client to stay with family or friends. A hospitalization is considered if there is no one is available especially if the person is highly suicidal.

-The patient engages more in social activities.

-The patient can express her feelings and insecurities.

-The patient can perform her activities of daily living.

-The patient recognizes the importance of counseling and regularly attends one

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis

Patient Goal(s)

Outcome (objective, expected or desired outcomes or evaluation parameters

Interventions/

Implementations

Evaluation

Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.

Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.

Types of data: subjective

& objective

Sources of data

Nursing health history

Physical examination

Diagnostic data

“A statement of purpose describes the aim of nursing care” (Osborn et. al., p.

113)

Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis)

May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.

Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)

Stated realistic behavioral terms that can be observed, measured and

relevant to the identified nursing diagnosis.

Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).

Implementation – the carrying out of the planned nursing interventions (Osborn, et al.,

2010)

Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.

Interventions should reflect indendent nursing practice as well as collaborative practice.

Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.

Interventions should include specific like schedules, food choices, frequency, etc….

Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).

Essentially this is a reassessment of the patient and the responses as to the interventions implemented.

Compare actual patient behaviors with expected behaviors.

Give reasons why or why not each outcome has been met.

Consider the effectiveness of the nursing intervention, time elements.