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Assignment: Assignment #2--WednesdayProfess...

B, M

Health Care Provider: M B

Sex: F

Weight: 121 lbs 4 oz

Code Status: 00

Isolation: 00

Food Allergies: 00

Diet: 00

Hospital Floor:

Age: 77 Y

Height: 5' 4"

Alerts: 00

Drug Allergies: 00

Env. Allergies: 00

BMI: 20.8

Psychiatric

Student: Mackenzie Beeler Assignment: Assignment #2--Wednesday-Professor Peterson-RMH Submitted: 02/19/2015 21:37
Clinical Assignment Grading
Assignment Objectives
No assignment objectives entered.
Clinical Set-up Details
First Day of Clinical:

02/18/2015

Primary
Diagnosis: ????

Provider Name:

B, M

Secondary Diagnosis:

Student Details:

Patient Details:

First Initial:

Identifier 1: M

Last Name:

Beeler

Identifier 2: B

Credentials:

SN

Gender:

Age:

77 Years

Pre-Clinical Manager
Patient Info Identifier: B, M

Gender: F

Age: 77 Y

Nurse Initials: M Beeler, SN

Medications (6)
Medication:Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis)

Classification:
Psychotherapeutic Agent:
Antipsychotic

Route:
Oral
Frequency:QHS

Dose:
Date
Ordered:

Comments and Additional Medication Info:


--

Therapeutic Effect:
Target symptoms: agitation, depression, delirium

Action:
The exact mechanism by which olanzapine exerts its
antipsychotic effect is unknown. However, this effect may
be mediated through a combination of dopamine and
serotonin 5-HT 2 antagonism. Olanzapine is a selective
monoaminergic antagonist with a strong affinity for
serotonin 5-HT2 receptors, and dopamine D1, D2, D3,
and D4 receptors. Olanzapine weakly binds to GABA A,
benzodiazepine, and beta-adrenergic receptors.

Contraindications:
No specific contraindications indicated.

Side Effects or Adverse Reactions:


Life Threatening Considerations:

Orthostatic hypotension, peripheral edema,


hypercholesterolemia, hyperglycemia, increased
appetite, weight gain, constipation, xerostemia,

2.5 mg
01/01/1900

akathisia, dizziness, somnolence, tremor( these are the


s/e but I think simechart lined them up incorrectly as
life threatening.)

Elderly patients with dementia-related pschosis treated


with antipsychotic drugs are at an increased risk of
death, Sudden cardiac death, venous
thromboembolism, pulmonary embolism, diabetic
ketoacidosis
Recommended Dose Ranges:
--

Nursing Interventions:
The nurse should obtain a thorough personal and family
history of obesity, diabetes, and cardiovascular disease
as well as obtain a baseline blood glucose, lipid profile,
blood pressure, and waist line. Nurse should monitor for
signs of tardive dyskinesia. Nurse should educate
patient of side effects, partcularly hypotension and
dizziness and to get up slowly to reduce the risk for falls.
GOOD

Medication:Lisinopril Tablet - (Prinvil, Zestril)

Classification:
Hypotensive Agent

Route:
Oral
Frequency:DAILY

Dose:
Date
Ordered:

Comments and Additional Medication Info:


--

Therapeutic Effect:
Target symptoms: high blood pressure

Action:
Lisinopril is a long-acting angiotensin-converting
enzyme (ACE) inhibitor. ACE inhibition prevents the
conversion of angiotensin I to angiotensin II which is a
potent vasoconstrictor. Decreased angiotensin II leads
to decreased vasopressor activity and decreased
aldosterone secretion, thus leaving vessels dilated
reducing the arterial pressure.

Contraindications:
Drug interaction: aliskiren, alteplase, amiloride,
candesartan cilexetil, olmesartan medoxomil,
potassium, telmisartan, valsartan

Side Effects or Adverse Reactions:


Chest pain, hypotension, syncope, dizziness, headache,
cough,

Life Threatening Considerations:


severe hypotension, Stevens-Johnsons syndrome, Toxic
epidermal necrolysis, hyperkalemia, intestinal
angioedema, acute renal impairment or failure, head
and neck angioedema

Recommended Dose Ranges:


--

Nursing Interventions:
Nurse should obtain blood pressure before and after
administration. Nurse should assess laboratory results
to detect changes in renal function and serum potassium
levels. Educate patient of common side effects including
cough and headache. Educate to move slowly to reduce

10 mg
01/01/1900

risk of dizziness and falls. EXCELLENT!!!!


Medication:Sertraline Tablet - (Zoloft)

Classification:
Angiotensin-converting enzyme
(ACE) Antidepressant

Route:
Oral
Frequency:DAILY

Dose:
Date
Ordered:

Comments and Additional Medication Info:


--

Therapeutic Effect:
Target symptoms: Major depression

Action:
Sertraline HCl is serotonin reuptake inhibitor (SSRI).

Contraindications:
--

100 mg
01/01/1900

The mechanism of action as antidepressant may be due


to its inhibition of CNS neuronal uptake of serotonin. It
has only very weak effects on norepinephrine and
dopamine neuronal uptake.
Side Effects or Adverse Reactions:

Life Threatening Considerations:

Nausea, vomiting, constipation, diarrhea, dizziness,

Increased risk of suicidal thoughts and behavior,

headache, insomnia, somnolence, tremor, abnormal


ejaculation and reduced libido, fatigue, hyponatremia,

Stevens-Johnsons syndrome, serotonin syndrome

rhabdomyolysis, depression
Recommended Dose Ranges:

Nursing Interventions:

--

Monitor glucose levels. Periodically monitor thyroid


function. Skin assessments to watch for signs of
Stevens-Johnsons syndrome. Assess for worsening
signs of depression, suicidality, or unusual changes in
behavior. Monitor patient for signs of serotonin
syndrome within several hours of first administration.
good

Medication:Haloperidol Lactate Solution for Injection (Haldol)

Classification:
Antipsychotic agent

Route:
Intramuscular
Frequency:Q4H PRN agitation

Dose:
Date
Ordered:

Comments and Additional Medication Info:


--

Therapeutic Effect:
Target symptoms: agitation, hallucinations, delusions,
paranoia, social or communication difficulties

Action:
Although the complex mechanism of the therapeutic
effect is not yet clearly established, haloperidol is known
to produce a selective effect on the central nervous
system (CNS) by competitive blockade of postsynaptic
dopamine (D2) receptors in the mesolimbic
dopaminergic system and increased turnover of brain
dopamine to produce its tranquilizing effects. Blockade
of dopamine receptors in the nigrostriatal dopamine
pathway produces extrapyramidal motor reactions;
blockade of dopamine receptors in the
tuberoinfundibular system decreases growth hormone
release and increases prolactin release by the pituitary.
There is also some blockade of alpha-adrenergic
receptors of the autonomic system.

Contraindications:
Parkinson's disease, severe toxic CNS depression,
concomitant diazepam, lorazepam, clonazepam, or
alprazolam administration.

Side Effects or Adverse Reactions:


hypotension, constipation, xerostemia, akathisia,
dystonia, extrapyramidal disease, somnolence, blurred
vision, paralytic ileus, seizure, tardive dyskinesia,
priapism

Life Threatening Considerations:


prolonged QT interval, sudden cardiac death, Torsades
de Pointes, agranulocytosis, neuroleptic malignant
syndrome

Recommended Dose Ranges:


--

Nursing Interventions:
Monitor HR and BP. Monitor ECG. Monitor for
constipation or ileus with GI assessments. Offer hard
candy or water for relief of dry mouth. Monitor for signs
of neuroleptic malignant syndrome (hyperpyrexia,

2 mg
01/01/1900

muscle rigidity, altered mental status, and autonomic


instability), monitor for development of extrapyramidal
symptoms or tardive dyskinesia. Monitor WBC and RBC
for signs of agranulocytsis, although it is rare. Assess IV
site for extravasation or irritation.
Medication:Haloperidol Lactate Oral Solution - (Haldol)

Classification:
Antipsychotic agent

Route:
Oral
Frequency:TID PRN agitation

Dose:
Date

2 mg
01/01/1900

Ordered:
Comments and Additional Medication Info:

Therapeutic Effect:

--

Target symptoms: hallucinations, delusions, paranoia,


social and communication difficulties

Action:

Contraindications:

Although the complex mechanism of the therapeutic

Parkinson's disease, severe toxic CNS depression,

effect is not yet clearly established, haloperidol is known


to produce a selective effect on the central nervous
system (CNS) by competitive blockade of postsynaptic
dopamine (D2) receptors in the mesolimbic
dopaminergic system and increased turnover of brain
dopamine to produce its tranquilizing effects. Blockade
of dopamine receptors in the nigrostriatal dopamine
pathway produces extrapyramidal motor reactions;
blockade of dopamine receptors in the
tuberoinfundibular system decreases growth hormone
release and increases prolactin release by the pituitary.
There is also some blockade of alpha-adrenergic
receptors of the autonomic system

concomitant diazepam, lorazepam, clonazepam, or


alprazolam administration

Side Effects or Adverse Reactions:


hypotension, constipation, xerostemia, akathisia,
dystonia, extrapyramidal disease, somnolence, blurred
vision, paralytic ileus, seizure, tardive dyskinesia, priapis

Life Threatening Considerations:


neuroleptic malignant syndrome

Recommended Dose Ranges:


--

Nursing Interventions:
Monitor HR and BP. Monitor ECG. Monitor for
constipation or ileus with GI assessments. Offer hard
candy or water for relief of dry mouth. Monitor for signs
of neuroleptic malignant syndrome (hyperpyrexia,
muscle rigidity, altered mental status, and autonomic
instability), monitor for development of extrapyramidal
symptoms or tardive dyskinesia. Monitor WBC and RBC
for signs of agranulocytsis, although it is rare

Medication:Trazodone Tablet

Classification:
Antidepressant

Route:
Oral
Frequency:QHS PRN insomnia

Dose:
Date
Ordered:

Comments and Additional Medication Info:


--

Therapeutic Effect:
Target symptom: depression

Action:
Trazodone represents a class of antidepressants known
as triazolopyridines. Structurally, it does not bear any

Contraindications:
Coadministration with an MAOI pr saquinavir/ritonavir,

50 mg
01/01/1900

similarity to tricyclic antidepressants, tetracyclic


antidepressants, or MAO inhibitors. The mechanism of
antidepressant action is not fully understood, but it is
suspected to be related to its potentiation of
serotonergic activity in the CNS. Preclinical studies
have shown that trazodone selectively inhibits neuronal
reuptake of serotonin and acts as an antagonist at 5HT
2A/2C serotonin receptors. Due to its alpha 1
adrenergic receptors antagonistic property, trazodone is
associated with postural hypotension.
Side Effects or Adverse Reactions:
constipation, diarrhea, nausea, vomiting, xerostemia,

Life Threatening Considerations:


Increased risk of suicidal thoughts and behavior,

backache, confusion, dizziness, headache, insomnia,

prolonged QT interval, torsades de pointes, cardiac

somnolence, blurred vision, dream disorder, nervous


feeling, fatigue, postural hypotension, priapism

dysrhythmias, serotonin syndrome

Recommended Dose Ranges:


--

Nursing Interventions:
Nurse can administer sugar free gum, water, or hard
candy if patient complains of dry mouth. Nurse should
monitor EKG and BP. Educate patient to get up slowly
to reduce risk of orthostatic hypotension dizziness, and
falls. Nurse can give antiemetic or laxative if nausea,
vomiting, or constipation occur. Monitor for signs of
serotonin syndrome. excellent

Laboratory Tests (3)


Laboratory
Test:

Complete Blood Cell Count (CBC)

Date of
Test:

02/17/2015

Definition and Description:


-Significance of the Test Being Ordered for this Patient:
-CBC: RBC
Test
4.03
Result:
Result
Level:
Low
Result Significance:
Low RBC count can sometimes be attributed to malnutrition. Given that this patient's albumin levels are also low this is
the most likely the cause.
CBC: Hgb
Test
Result:

10.9
Result
Level:

Low
Result Significance:
Low Hgb count can sometimes be attributed to malnutrition. Given that this patient's albumin levels are also low this is
the most likely the cause.
CBC: Hct
Test

35.3

Result:

Result
Level:

Low
Result Significance:
Low Hct count can sometimes be attributed to malnutrition. Given that this patient's albumin levels are also low this is
the most likely the cause.
CBC (RBC Indices): MCV
Test
-Result:

Result
Level:

Within Normal Limits


Result Significance:
-CBC (RBC Indices): MCH
Test

--

Result:

Result
Level:
Within Normal Limits
Result Significance:
-CBC (RBC Indices): MCHC
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC (RBC Indices): RDW
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: WBC
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: Blood Smear
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: Platelet Count

Test

--

Result:

Result
Level:

Within Normal Limits


Result Significance:
-CBC: MPV
Test
-Result:

Result
Level:

Within Normal Limits


Result Significance:
-Laboratory

Basic Metabolic Panel

Test:
Definition and Description:
-Significance of the Test Being Ordered for this Patient:
-Basic Metabolic Panel: Blood Urea Nitrogen (BUN)
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Calcium
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Chloride
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: CO2
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Creatinine

Date of
Test:

02/17/2015

Test

--

Result:

Result
Level:

Within Normal Limits


Result Significance:
-Basic Metabolic Panel: Glucose
Test
-Result:

Result
Level:

Within Normal Limits


Result Significance:
-Basic Metabolic Panel: Potassium
Test

--

Result:

Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Sodium
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Laboratory
Test:

Albumin

Date of
Test:

02/17/2015

Definition and Description:


-Significance of the Test Being Ordered for this Patient:
-Albumin
Test
Result:

3.2
Result
Level:

Low
Result Significance:
Patient is most likely not meeting her nutritional needs while in the hospital due to her demented state. goood job with
labs
Diagnostic Tests (2)
Diagnostic
Test:

CT: Brain without Contrast

Definition and Description of the Test:


Axial contiguous slices through the brain without contrast.
Significance of the Test Being Ordered for this Patient:

Date of
Test:

02/03/2015

Delirium is often associated with changes in brain...Comparison was made to previous study dated 10/30/2014.
Significant Findings and Results:
There is decreased attenuation present in the preventricular and deep white matter of both cerebral
hemispheres. Diffuse small vessel ischemic disease and volume loss, similar to previous study. No CT evidence of
acute infarct, mass, or hemorrhage.
Deleted By: M Beeler 02/18/2015 11:27
Diagnostic
Test:

X-Ray: None

Date of
Test:

02/03/2015

Definition and Description of the Test:


-Significance of the Test Being Ordered for this Patient:
-Significant Findings and Results:
-Clinical Grading:
Clinical
Grade:
Remarks:
Care Plan Details
Care Plan
Priority
Created By: M Beeler, SN 02/19/2015 | 21:21

1
Nursing Diagnosis: ADDED-Risk for suicide
Status:

Active

Type:
Potential

Related To
ADDED-perceived legal problems
ADDED-improper adherence to medication regimen
ADDED-marked changes in attitude and behavior
Evidenced By
ADDED-Patient is paranoid that she is going to jail for killing someone
ADDED-Husband report that in confused state patient would stop taking meds and then take multiple doses
ADDED-Due to patient's improper adherence to medication regimen, previous signs of severe depression and
psychoses have redeveloped

Expected Outcome

Measurement/Time
Frame

Comments

ADDED-Patient will not harm self

during stay in hospital

good

ADDED-Patient will discuss suicidal ideations if present and


seek help from staff

during stay in hospital

good

ADDED-Patient will adhere to medication regimen

during stay in hospital

good

Interventions

Rationale

Comments

ADDED-Nurse will assess for suicidal ideation

Nurses and clinicians should be alert for

good

at beginning of every shift

suicidal thoughts and behaviors when pat


ient has history of depression and psych
oses.

ADDED-Nurse will assign client to a room

Close assignment increases ease of obs

located near the nursing station.

ervation and availability for a rapid respo


nse in the event of a suicide attempt.

ADDED-Nurse will verify that the client has taken


medications ordered by conducting mouth

The client may attempt to hoard medicati


ons for a later suicide attempt. This partic

checks after administration.

ular client may have trouble swallowing in

good

confused state.
ADDED-Before discharge from the hospital, the

Clients may be discharged before they h

nurse will ensure that the client has a supply of

ave recovered substantial functional abilit

ordered medications, has a plan for outpatient


follow-up understands the plan or has a
caregiver able and willing to follow the plan, and
has the ability to understand and aid in
medication administration as well as provide
transportation to outpatient treatment.

y and may have difficulty concentrating on


the plan for follow-up. They may need the
assistance of others to ensure that prescr
iptions are filled, that they attend any app
ointments, or that they have transportatio
n to outpatient care settings.

good

Priority
Created By: M Beeler, SN 02/19/2015 | 21:08

2
Nursing Diagnosis: Imbalanced nutrition, less
than body requirements
Status:

Active

Type:
Actual

Related To
ADDED-Neurologic impairment
Evidenced By
ADDED-Low albumin and RBC levels
ADDED-Pt consuming less than 50% of meals

Expected Outcome

Measurement/Time
Frame

Comments

ADDED-Patient will eat 50-75% of all meals

by end of shift today

good

ADDED-Patient will be free from signs of


malnutrition

by end of week

put your specific s/s her


e

ADDED-Patient will eat 50-75% of all meals

until discharge

Interventions

Rationale

Comments

ADDED-Nurse will note laboratory test


results as available: serum albumin,
prealbumin, serum total protein, serum
ferritin, transferrin, hemoglobin,
hematocrit, and electrolytes.

These tests are good indicators of nutritional inta


ke. A serum albumin level of less than 3.5 is con
sidered an indicator of risk of poor nutritional sta
tus.

good

ADDED-Nurse will monitor food intake

Documentation of dietary intake is helpful for bot

and record percentages of served food

h the client and the nurse to examine patterns of

that is eaten (25%, 50%, 75%, 100%).

eating.

ADDED-Nurse will monitor for signs of


malnutrition.

Signs that could indicate malnutrition are: brittle


hair that is easily plucked, bruises, dry skin, pale

good

good

skin and conjunctiva, muscle wasting, marked de


crease in body fat, smooth red tongue, cheilosis,
and a "flaky paint" rash over lower extremities.
ADDED-Nurse will observe and provide

Mealtime usually is a time for social interaction a

companionship and help with feeding if

nd clients often will eat more food if other people

necesssary to encourage nutritional

are present at mealtimes. If client is having diffic

intake.

ulty feeding themselves or recognizing the food t


hen the nurse can assist with this during mealtim
es.

Priority
Created By: M Beeler, SN 02/19/2015 | 21:21
Modified By: M Beeler, SN 02/19/2015 | 21:36

3
Nursing Diagnosis: ADDED-Risk for falls
Status:

Active

Type:
Potential

Related To
ADDED-Age 77
ADDED-Diminished mental status
ADDED-CNS depressing medications
Evidenced By

Expected Outcome

Measurement/Time Frame

ADDED-Patient will remain free from falls

during time in hospital

Comments

Interventions

Rationale

Comments

ADDED-Nurse will assist unsteady indvidual with ambulation.


Be sure to lock the bed and sufficient personnel to protect the
client from falls. When rising from a lying position, have the
client change positions slowly, dangle legs, and stand next to
the bed prior to walking to prevent orthostatic hypotension which
is common in older adults and may be a side effect of
medications.

These will all help to reduc


e the risk of falls.

excelleny

ADDED-Nurse will use a "high-risk fall" armband/bracelet and


fall risk room sign to alert staff for increased vigilance and
mobility assistance.

These steps alert the nurs


ing staff of the increased r
isk of falls.

excellent

ADDED-Evaluate the client's medications to determine whether


medications increase the risk of falling.

Medications such as benz


odiazepines, antidepress
ants, neuroleptics, sedativ
es, and diuretics can incr
ease the risk for falls.

excellent

ADDED-Nurse will routinely assist the client with toileting on his

A study found that falls we

excellent

or her own schedule. Always take the client to the bathroom on

re most commonly associ

awakening and before bedtime. Keep the path to the bathroom

ated with toileting, especi

clear, label the bathroom, and leave the door open.

ally falling on the way from


bed or chair to the bathro
om.

ADDED-Nurse will place client in a room that is near the nurses'

Such placement allows m

station.

ore frequent observation


of the client and quicker a
ssistance.

Priority
Created By: M Beeler, SN 02/19/2015 | 21:21

-Nursing Diagnosis: ADDED-Risk for suicide


Status:

Active

Type:
Potential

Related To
ADDED-perceived legal problems
ADDED-improper adherence to medication regimen
ADDED-marked changes in attitude and behavior
Evidenced By
ADDED-Patient is paranoid that she is going to jail for killing someone
ADDED-Husband report that in confused state patient would stop taking meds and then take multiple doses
ADDED-Due to patient's improper adherence to medication regimen, previous signs of severe depression and
psychoses have redeveloped

Expected Outcome

Measurement/Time
Frame

ADDED-Patient will not harm self

during stay in hospital

ADDED-Patient will discuss suicidal ideations if present and


seek help from staff

during stay in hospital

ADDED-Patient will adhere to medication regimen

during stay in hospital

Interventions

Rationale

ADDED-Nurse will assess for suicidal ideation


at beginning of every shift

Nurses and clinicians should be alert for


suicidal thoughts and behaviors when pat
ient has history of depression and psych
oses.

ADDED-Nurse will assign client to a room


located near the nursing station.

Close assignment increases ease of obs


ervation and availability for a rapid respo
nse in the event of a suicide attempt.

ADDED-Nurse will verify that the client has taken


medications ordered by conducting mouth
checks after administration.

The client may attempt to hoard medicati


ons for a later suicide attempt. This partic
ular client may have trouble swallowing in
confused state.

ADDED-Before discharge from the hospital, the


nurse will ensure that the client has a supply of
ordered medications, has a plan for outpatient

Clients may be discharged before they h


ave recovered substantial functional abilit
y and may have difficulty concentrating on

Comments

Comments

follow-up understands the plan or has a

the plan for follow-up. They may need the

caregiver able and willing to follow the plan, and

assistance of others to ensure that prescr

has the ability to understand and aid in

iptions are filled, that they attend any app

medication administration as well as provide

ointments, or that they have transportatio

transportation to outpatient treatment.

n to outpatient care settings.

Priority
Created By: M Beeler, SN 02/19/2015 | 21:36

-Nursing Diagnosis: ADDED-Risk for falls


duplicate to priority 1
Status:

Active

Type:
Potential

Related To
ADDED-Age 77
ADDED-Diminished mental status
ADDED-CNS depressing medications
Evidenced By

Expected Outcome

Measurement/Time Frame

ADDED-Patient will remain free from falls

during time in hospital

Interventions

Rationale

ADDED-Nurse will assist unsteady indvidual with ambulation.


Be sure to lock the bed and sufficient personnel to protect the
client from falls. When rising from a lying position, have the
client change positions slowly, dangle legs, and stand next to
the bed prior to walking to prevent orthostatic hypotension which
is common in older adults and may be a side effect of
medications.

These will all help to reduc


e the risk of falls.

ADDED-Nurse will use a "high-risk fall" armband/bracelet and


fall risk room sign to alert staff for increased vigilance and
mobility assistance.

These steps alert the nurs


ing staff of the increased r
isk of falls.

ADDED-Evaluate the client's medications to determine whether


medications increase the risk of falling.

Medications such as benz


odiazepines, antidepress
ants, neuroleptics, sedativ
es, and diuretics can incr
ease the risk for falls.

ADDED-Nurse will routinely assist the client with toileting on his


or her own schedule. Always take the client to the bathroom on
awakening and before bedtime. Keep the path to the bathroom
clear, label the bathroom, and leave the door open.

A study found that falls we


re most commonly associ
ated with toileting, especi
ally falling on the way from
bed or chair to the bathro
om.

ADDED-Nurse will place client in a room that is near the nurses'


station.

Such placement allows m


ore frequent observation
of the client.

Comments

Comments

Care Plan Grading:


Care Plan
Grade:
Remarks:
Charting Details
History and Physical
Created By: M Beeler, SN 02/18/2015 | 11:02
Modified By: M Beeler, SN 02/18/2015 | 13:30
Psychiatric History
Patient Information
Chief Informant:

Husband of Pt

Chief Complaint:

"Confusion."

History of Current
Problem:

Pt was brought to emergency room by husband for worsening confusion and


psychosis. Husband reported that pt was recently discharged from RMH BHU in
2014 where she was admitted for major depressive disorder with psychotic
features and delirium secondary to UTI. The husband reported that following
discharge, pt was doing well but after about a month decided to stop taking
medications stating "I don't need them." Pt has progressively worsened mentally
and now constantly reports that people are listening to them at home, that the house
is bugged, and that her husband is talking too loud even when he is whispering and
that their conversation is going to be picked upon. Pt talso reportedly has an
obsession that her social security number is being used by someone and that she
has comitted a crime for this. Pt was brought to ED for further evaluation

Allergies:

Benzodiazepines reaction?

Psychiatric History really good job here


Past Psychiatric History:

Previous Psychiatric Hospitalizations:

Pt has history of depression and suicidal ideation.

Patient was hospitalized in November 2014 at RMH


BHU for major depressive disorder with psychotic
features and delirium secondary to UTI. Was
discharged in November 2014.

Suicide History:

Outpatient Treatment:

History of sucidial ideation but no attempts.

--

Alcohol Use:

Substance Use:

Pt denies alcohol use

Pt denies substance use

Electroconvulsive Therapy (ECT):


-Family History:

Unable to collect family history as the pt refused to talk


Past Medical History

Previous Illnesses:

Contagious Diseases:

Pt has history of depression and suicidal ideations. No


pertinent past medical history.

None
Injuries or Trauma:
None

Surgical History:

Dietary History:

None

Deferred

Other:

Social History:

--

Pt lives with husband in private home.

Current Medications:

Current Medications:

--

--

Review of Systems
Integument:

HEENT:

--

--

Cardiovascular:

Respiratory:

--

--

Gastrointestinal:

Genitourinary:

--

--

Musculoskeletal:

Neurologic:

--

--

Endocrine:

Genitalia:

--

--

Lymphatic:
-Mental Status
Mental Status Examination good job
Appearance:

Behavioral Activity:

Patient is dressed appropriately in own clothes, pink


top and black sweat pants. Does not appear to have
showered today.

Patient was sitting on bed for assessment. Pt was


cooperative.
Speech:
Soft

Thought Form:

Thought Content:

Linear

Patient reported auditory hallucinations of dogs


barking "I think". Pt denies VH.

Suicidal Impulses:

Homicidal Impulses:

Patient denies SI

Patient denies HI

Orientation:

Memory:

Patient is oriented x4.

Poor. Answers "I don't know" and is confused about


many questions when asked. Exhibits paranoid
delusions, believes that she is going to go to jail for
murder and social security fraud, stating "

Mood:

Affect:

Calm. Seen smiling during group therapy activity of

Fair eye contact. Flat affect during PE. Cheerful and

painting wooden peace signs.

slightly anxious during group therapy activity of painting


peace signs. Pt was worried that she was not doing it
right and that others thought it was ugly.

Judgment and Insight:

Attention:

Poor insight into illness.

Patient able to sit still and focus on questions and


therapy group activity of painting wooden peace signs.

Physical Examination good job


Physical Exam
General:

Vital Signs:

Pt is seemingly healthy other than cognitive and


neurological functioning. See mental status for more
detailed description of examination.

WNL. Blood pressure was high last week (168/81) Pt


was started on Lisinopril, has been effective in
lowering BP to WNL (136/75)

Integument:

HEENT:

WNL.

WNL. PEERLA. Pt has no complaints.

Cardiovascular:

Respiratory:

WNL. Cap refill <3 sec

Clear. WNL.

Gastrointestinal:

Genitourinary:

WNL. Bowel sounds active in all 4 quadrants.

WNL

Musculoskeletal:

Neurologic:

WNL

--

Developmental:

Endocrine:

Deferred

Deferred

Genitalia:

Lymphatic:

Deferred

Deferred

Impressions
Impression:

--

Plan:

--

Provider Signature:

--

Date:

01/01/0001

Time:

--

Special Charts - Miscellaneous Nursing Notes


Miscellaneous Nursing Notes

Created By: M Beeler, SN 02/18/2015 | 11:26

AXIS I:
1. Delirium, secondary to urinary tract infection
2. Major depressive disorder, severe, with psychotic features.
This axis identifies the patient's primary diagnosis.
Delirum is defined as a transient, usually reversible, state caused from cerebral dysfunction and manifests clinically
with a wide range of neuropsychotic abnormalities. It can occur at any age, but it occurs most commonly in patients
who are elderly and have compromised mental status. Symptoms include: clouding of consciousness, difficulty in
maintaining or shifting attention, disorientation, illusions, hallucinations, fluctuating LOC, dysphasia, dysarthria,
tremor, asterixis in hepatic encephalopathy and uremia, and motor abnormalities.
The exact cause of major depressive disorder is unknown. People with psychotic depression have symptoms of
depression and psychosis (hallucinations and delusions).
AXIS II:
Deferred.
This axis identifies diagnosis as it pertains to patient.
AXIS III:
Urinary tract infection.
This axis lists any medical diagnoses patient has.
UTI could have caused some of the psychotic features and delirum that the patient was exhibiting. It was believed
to have been causing a waxing and waning effect on her mood and behavior. The infection has since been
resolved with antibiotics.
AXIS IV:
Nonadherence with treatment
This axis identifies psychosocial stressors.
Patient stopped taking medications, after which her depression, hallucinations, and paranoia resumed and
progressively worsened.
AXIS V:
Current GAF 5 to 10.
This axis identifies patient's Global Assessment Functioning (GAF) score that is used by mental health clinicians
and physicians to subjectively rate the social, occupational, and psychological functioning of adults.
Patient had a GAF of 5 to 10 upon admission which states that patient is in persistent danger of harming self or
others or has persistent inability to maintain minimal personal hygiene.
I believe that since patient has been in hospital for 2 weeks her GAF score is now 11-20 because she is still failing
to maintain personal hygiene and has gross impairment in communication, but she is no longer at persisent
danger of severely hurting self or others. I believe GAF may be a bit higher than this. she doesn't seem to have
gross impairment with speech and hygiene. Based on info you have provided she may be more in the low 30s
Special Charts - AIMS
AIMS

Created By: M Beeler, SN 02/18/2015 | 09:03

Facial and Oral Movements


Muscles of Facial Expression:
Lips and Perioral Area:
Jaw:
Tongue:

0 = None
0 = None
0 = None
0 = None

Extremity Movements
Upper (arms, wrists, hands, fingers):
Lower (legs, knees, ankles, toes):

0 = None
0 = None

Trunk Movements
Neck, shoulders, hips:

0 = None

Global Judgements
Severity of abnormal movements

0 = None

overall:
Incapacitation due to abnormal

0 = None

movements:
Patient's awareness of abnormal

1 = Aware, no distress

movements:
Dental Status
Current problems with teeth and/or

No

dentures:
Are dentures usually worn:
Do movements disappear in sleep:

Yes
No

Vital Signs
Chart Time

Temperature
(F)

Respirations
(Resp/min)

Pulse
(Beats/min)

Blood Pressure
Oxygenation
(mmHg)

Entry By

02/18/2015
10:43

97.1
Site:
Tympanic

16

67
Site:
Monitor

136/75
Site:
Right arm
Position:
Lying

M Beeler,
SN

Height/Weight
Chart Time

Weight (Pounds/Kgs)

Height (Feet
Inches/cm)

Entry By

02/18/2015 09:02

121 lbs / 55 kgs


Standing scale

5' 4" / 162.6 cm

M Beeler, SN

Patient Card
Order
Description
Date/Time

Category

Status

Last
Discontinued Entry By
Performed By

02/19/2015 -Imbalanced nutrition,


| 21:08
less than body
requirements

Care Plan

Active

--

----

M Beeler,
SN
02/19/2015
21:08

02/19/2015 -ADDED-Risk for


| 21:21
suicide

Care Plan

Active

--

----

M Beeler,
SN
02/19/2015
21:21

02/19/2015 -ADDED-Risk for


| 21:21
suicide

Care Plan

Active

--

----

M Beeler,
SN
02/19/2015
21:21

02/19/2015 -ADDED-Risk for falls

Care Plan

Active

--

----

M Beeler,

| 21:36

SN
02/19/2015
21:36

02/19/2015 -ADDED-Risk for falls


| 21:36

Care Plan

Active

--

----

M Beeler,
SN
02/19/2015
21:36

Charting Grading:
Charting
Grade:
Remarks:
Competencies
No competencies entered.
5

Remarks:

Overall Grading:
Care Plan
Grade:

Pre-Clinical Manager Grade:

Charting
Grade:

Overall Grade:

15/15

Remarks:

SUBJECTIVE/OBJECTIVE- Good job with MSE and PE. All labs testing results present. 4/4 ANALYSIS &
NURSING DIAGNOSIS- Well done sections with your nursing diagnoses. Good definition of each Axis 4/4
PLAN/OUTCOMES-Outcomes measurable and good plan for this pt. 3/3 INTERVENTIONS- Good job with your
medication list. Interventions measurable and realistic for this pt. 4/4 Excellent job on this note!

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