Li Na Chen Part 2 Documentation.,WELL EXPLAINED WITH CORRECT ANSWERS.

1. Document findings related to the screening of Mrs. Chen with the Hamilton Rating Scale for Depression. The Hamilton depression scale scores show: Depressed mood: 2- these feelings are spontaneously reported verbally Feelings of guilt: 1- self reproach, feels she has let people down Suicide: 1-feel life is not worth living Insomnia early: 1 complains of occasional difficulty falling asleep more than ½ hour Insomnia middle: 1 patients complains of being restless and disturbed during the night Insomnia late: 0 no difficulty Work and activities: 4 stopped working because of present illness. In hopstial, if patient engages in not activites except ward chores, or it patient fails to perform ward chores unassisted Retardation pscychomotor: 2 obvious retardation at interview Agitaiton: 1 figitiness Anxiety psychic: 2 worrying about minor matters Anxiety somatic: 0 absent Somatic symptoms GI: loss of appetite but eating wiotht staff encouragement, Heavy feeligns in abdomen Somatic symtpoms general: heaviness in limbs, back or head. Backaches, headahces, muscle aches. Loss of energy and fatigabilty General symptoms: 0 absent Hypochondirasis: 0 not present Loss of weight: definite weight loss (1kg/wk) Insight: 0 not depressed or agnknowledges being depressed/ill Diurinal variation: 0 absent in the morning Depersonalization and derealization: 0 absent Paranoid symptoms: 0 none Obsessional and compulsive symptoms: 0 absent Helplessness: 1 subjective feelings that are eleictied only by inquiry Hopelessness: 1 indications of feelings of worthlessness only on questioning Score: 23 2. Document the assessment finding related to Mrs. Chen’s suicidality at discharge. According to the suicide assessment, the patient does not have suicidal ideations upon discharge. She expressed that if she begins to feel more depressed, she will let her husband, Jack, and her therapist know about her feelings. She stated “I want to get better,” but has concerns about leaving the hospital. She fears she will not be able to take care of her family the way they deserve. 3. Document the results of Mrs. Chen’s mental status examination at discharge. 4. Identify and document key educational needs for Mrs. Chen and the family. The family needs education about medications and their side effects. She also needed education about community resources. She was educated about resources for her and her family to utilize including support groups and itnerent based resources. We educated about ways to decrease insomnia. Keeping the room dark and cool and not using electronics before bed. Also, aerobic exercise and sunlight throught the day. She also could use education about nonpharmacological ways to relieve depression. 5. Document medication reconciliation. Old medications: sertraline 100 mg, nurse lowered dose to 75 mg every day PO, adding venlafaxine 37.5 mg every day PO Discharge medications: Sertraline 50 mg PO once daily every day for 3 days, then 25 mg daily for 5 days, then DC Venlafaxine 37.5 mg PO twice daily at 0900 and 1700 6. Document patient education regarding medications and follow-up appointments. She was educated about her medications sertraline 75 mg daily and venlafaxine 37.5 mg daily. This was changed upon her admission to the current dose of sertraline 50 mg daily and venlafaxine 37.5 mg BID. We educated about how she needs to report side effects of medicaitons to her provider. We spoke aobut the importance of adhering to the mediation regimen and following up with the provider after she is discharged. 7. Document the aftercare plan and the emergency plan for Mrs. Chen when at home. Mrs. Chen stated that if she beings to feel depressed she will “let her husband and therapist know.” The plan for after hospitalization is for Li to go to a partial hospitalization program. There she will have a structured environment where she can seek treatment but also be able to be at home. 8. Document and identify positive coping skills taught to Mrs. Chen. The patient stated that if she starts to feel overwhelmed at home she will talk to her husband (Jack) and her therapist. They always helped her feel less overwhelemed before. She also expressed interest in spending time walking outside in her neighborhood every day. Exercise and time outdoors is a good way to combat depression. 9. Identify strengths of Mrs. Chen and the family. Her husband and children are very supportive of her and are willing to help her. She has a support system even in China.