NURSING 326 MENTAL HEALTH CLINICAL SHEETS

NURSING 326 MENTAL HEALTH CLINICAL SHEETS History Taking Patient Identification Patient’s initials:____J.D____Age:____61_____Sex:____F______Marital Status:__Single_____ Highest level of education: High School ...

NURSING 326 MENTAL HEALTH CLINICAL SHEETS History Taking Patient Identification Patient’s initials:____J.D____Age:____61_____Sex:____F______Marital Status:__Single_____ Highest level of education: High School Languages spoken: English only Type of Admission: Voluntary or Involuntary Patients Diagnosis: o DSM: Schizoaffective disorder; bipolar type o Comorbid Illness o History of substance abuse o Any supporting Lab reports: etoh & thyroid Reasons for seeking admission, State in patients own word: “Because I am sick and I need help” Discharge Plan: Continue current medication regime, monitor patient’s progress to medications History of Present Illness (predisposing, precipitating and perpetuating factors) Write narratively and in chronological fashion: • Predisposing factors- patient states that her “sickness” began in her 20’s, she does not know specifically when • Precipitating factors- Ever since her mother passed away she has felt like the world is against her • Perpetuating factors-Patient was reported to be aggressive toward neighbors behaving oddly, burning and burying her mail and sticking branches into the electrical outlets to “protect herself”. Past medical History: Arthritis, mild emphysema, seasonal allergies, nicotine dependent, COPD Past Psychiatric history: Several psychiatric hospitalizations due to chronic issues leading to her present mental illness Medications, compliance to treatment: Compliant to all medications; Acetominophen, Albuterol Sulfate, Aspiriin, Benzotropine Mesylate, Diphenhydramine HCl, Lamotrigine, Olanzapine, Trazadone HCl, Liprasidone Family History (Draw a genogram): Patient J.D Maternal Paternal Grandmother Grandfather Grandmother Grandfather Bipolar Mother Aunt Uncle Father Aunt Depression Depression Patient J.D Brother Premorbid personality: According to patient chart, patient’s behavior prior to recent psychiatric admission is social to only familiar individuals such as family and one neighbor. Brother states that she is still paranoid toward family and the one neighbor but, “she will talk to us and them occasionally”. Patient J.D has always been kempt and appropriately clothed for weather, does not usually like to leave home except for groceries. Mental Status Examination Catherine Poornaselvan, MScN; M.A. (Psy); M.Phil. (N). General Appearance and Behavior: Appropriately groomed, appropriate eye contact, attire and hygiene. Patient J.D was wearing a pink shirt, calve length jeans and white socks to her calves shoes with no laces. Patient J.D’s appearance was kempt and appropriate for the weather. Speech: Rate is ordinary, Flow is expansive, Intensity of volume - loud, Clarity relevant, Mood and Affect (Mention Congruent or Incongruent): o Objective: annoyed and anxious o Subjective: affect was full and congruent with her mood Perception: Homicidal ideations, belief of individuals wanting to kill her Hallucination: o Auditory: States that the auditory hallucinations of burning her mail and sticking branches in the electrical sockets with “Keep her safe.” o Visual: No visual hallucinations o Gustatory: No gustatory hallucinations o Olfactory: No olfactory hallucinations o Tactile: No tactile hallucinations Disorders of Thought Process: Delusions of persecution Stream of Thought: Perseverative that people are trying to kill her so she is only trying to protect herself Content of thought: +recurring thoughts and delusions that someone wants to kill her, +paranoia Possession of thought: Overwhelming thoughts of being killed Cognitive Function: Poor insight and judgement Consciousness: Responsive to verbal stimuli and touch Attention and Concentration (DF and DB): Short span of attention, poor or adequate concentration, preoccupation Memory: o Remote Average for past years regarding birthday and important dates o Recent Average for recent events of last few hours and days; specifically regarding activities and groups she attended during her stay at Carrier o Immediate Average for what she ate and drank an hour before interview General Knowledge and Intelligence: Patient recognizes there is a problem but projects blame; presents intellectual and emotional awareness. Abstract ability and proverb testing: Unable to concrete think; unable to think abstractly – very uninterested in questions Judgement: Impulsive behavior during interview; standing up, speaking loudly, aggravation. Capable of coming up with appropriate conclusions; however they lead to unrealistic decisions ie; burning mail, putting branches in electrical outlets Insight: Does not deny illness, aware and cooperative with treatment options Short term goal: “I need a little anger management, but I think I have good reason sometimes when I get mad” Long term goal: “I want to get my own place and live by myself, I can’t live with my brother anymore.” Process Recording Identification Data: Patient name: J.D Age: 61 Sex: female Marital Status: single Admission type: Involuntary Diagnosis: Schizoaffective disorder; bipolar type Confidentiality: HIPAA measures in place. Ensured patient’s confidentiality by requesting to move to a secluded area in either courtyard or exam room located on unit. Description of the environment: Outside in the courtyard of the general adult unit (GAU) of Carrier Clinic located in Belle Meade, NJ. Patient J.D was sitting in the furthest corner of the courtyard away from everyone in the courtyard. There were 14 patients smoking including patient J.D, either standing against the wall closest to the entrance or sitting in chairs. The weather was warm and dry. Goal or purpose of your interaction: To address my concern about Pt’s health and emotional state, determine factors leading to patient’s admission to Carrier Clinic Process: (this content is from the beginning of the interview with Patient J.D) Persons Involved (Dialogue & Process) Nonverbal Cues Therapeutic Technique Used Student Nurse “How are you feeling today?” Eye contact Active listening Patient J.D “Ok I guess, you’re sitting a little bit too close to me.” Territoriality of space Crossed arms Active listening Nurse “Oh I’m very sorry, I will move back. I apologize.” Head nodding Focusing Patient “Ya, I don’t like when people are in my zone.” Unpleasant facial expressions Silence Nurse “I understand. Would you like to continue this interview inside away from your peers?” Eye contact Close ended questions, Patient “No I’d rather stay out here, I need a smoke.” Head down, eyes forward Responding disapprovingly Nurse “Ok, wherever is comfortable for you. If you have any questions throughout the interview, please feel free to ask them at any time. I do not mind at all.” Eye contact, head nodding Giving information, focusing List the problems identified: Aggressively voices when her space is violated. List three interventions: 1. Set realistic goals with client, perform a planned interaction, brief, frequent and not demanding. 2. Gradually encourage patient J.D to interact with her peers in a non-threatening situation 3. Clarification of any meaning ambiguous or not clearly related to client communication Mention goal met or not met: Goal met, determined why the patient set certain goals, whether she understands her admission, condition and factors leading to her current illness If the goal is not met – State why? Not Applicable CONCEPT MAP: