Focused Exam: Schizophrenia Results | Turned In
Mental Health - Spring 2021, NUR 320
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Focused Exam: Schizophrenia Results | Turned In
Mental Health - Spring 2021, NUR 320
Return to Assignment (/assignments/436833/)
Your Results
Reopen (/assignment_attempts/9006699/reopen Lab Pass (/assignment_attempts/9006699/lab_pass.p
Overview Transcript
Subjective Data Collection
Documentation / Electronic Health Record
Flowsheets Documentation
Objective Data Collection Education & Empathy QSEN Competencies
Documentation
Nursing Admitting Note
Student Documentation Model Documentation
Chief Complaint
Care Plan Reflections
Eric Ford is a 28 year old African American male who was brought into the ER for auditory hallucinations
Eric Ford is a 28-year-old African American man who was broug the ER by his mother for acute auditory hallucinations and paran
History of Present Illness
Eric Ford has a history of chronic paranoid schizophrenia since age
23. He has been hopsitalized 3 times in the past 2 years and reported attempting suicide one time at age 25. His mother reports he has not been sleeping or eating well.
Eric denies homicial or suicial ideation and uses music as a coping stategy to stop "listening to the voices. He reports the auditory voices command him to do things but blocks them out.
Eric is disheveled and has not taken care of his ADL's for a week.
Eric Ford has a history of chronic paranoid schizophrenia, onset
23. Three previous hospitalizations with the most recent 2 years History significant for a suicide attempt by overdose at age 25, requiring ICU admission. Patient has not been sleeping or eating well. His mother reports that he ran out of medication 9 days ag and is concerned for his safety.
He denies suicidal intent and states that he sometimes listens to music to avoid paying attention to the voices. Denies homicidal ideation. Does not initiate conversation. Presence of + auditory command hallucinations. Appears to be limited in ability to com activities of daily living, disheveled with soiled clothing.
Allergies
None NKA / NKDA
Past Medical History
Diagnosed with schizophrenia since age 23 attempted suicide age 25
Schizophrenia, since age 23
Past Surgical History
No surgieries No previous surgeries
Medication History
Risperadol 2mg 1 tab PO BID for psychotic symptoms Trazadone 25mg 1 tab PO QHS for insomnia
Risperdal 2 mg P.O. b.i.d. For Psychotic Symptoms Trazodone 25 mg P.O. Q HS for Insomnia
Family History
No family history of scitzophrenia, depression or anxiety No known history of family mental illness
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