NURS 223L - Psychiatric Nursing Process Worksheet.

Course: NURS 223L NURS 223L - Psychiatric Nursing Process Worksheet. PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 1 Student Name: NAME HERE Date: 04/08/20 Client History: Name (initials only): _M.M _ Age: _31 Gender: F Unit: _Psych_ Date of Admission: 01/27/20. Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Not know, Mother care for patient 5150 Advisement (quote): “Here mother usually comes by on Tuesdays to bring clean clothes for patient” Psychiatric Diagnosis: Suicidal ideation, Depression, Anxiety, Post- traumatic stress disorder. Medical and (or) physical problems: Diabetes, Hypertension, Renal Disease which leads to kidney failure, infection, and Substance abuse, Psychosocial and Environmental Problems: Access to health care, Problem with primary care support, Lack of education. (problems with primary support group, education, occupational, housing, economic, access to health care) Presenting Problem: Reason for hospitalization (Client’s own words): Recent suicide attempt Current stressors: Depression, Anxiety, Post traumatic stress disorder and Infection. Mental Status Examination Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): Patient wearing dirty clothes, her hair tangled and lots of black eyeliner. Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): Angry, refused eye contact by facing away and starring at the wall Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Angry, guarded and later cooperative Affect (blunted, flat, guarded, labile, expansive, sad, or other): Blunted and later become verbal that was when she requested for some sheet and pain medication. Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Angry, Anxious and Apathetic Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Very low tone Thought Content: Suicide Ideation (plan and/or intent): Attempt Homicidal Ideation (plan and/or intent): Unknown Hallucinations (auditory, visual, olfactory, gustatory, tactile): Unknown Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): N/A Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): Withdrawn patient does not like to participate in group therapy Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): Logical, Coherent. AEB patient asking for Ambien, that she does not want, to make the nurse understand how her feeling. Cognition (orientation, memory recall, concentration, attention span): Oriented and have good concentration/attention span Insight: Knows little about present illness Judgment: does not have good Judgment. Coordination/gait/notable movement: Unknown Cultural issues, familial concerns and religious affiliation that may affect his/her care: Unknown Support System: Patient Mother Current Physical Health: Vital Signs - T: 98.6 P: 88 R: 22 BP: 140 / 88 Pulse Oximeter reading: 99% -RA Pain (Numeric 1-10): Yes Location: N/A Character: N/A How would you describe your health: Excellent Average Good Poor Nutritional Status: Poor nutrition, AEB patient eating only 25% of her meal (Lunch and Dinner), Pt is dehydrated as evidence by cracked Lips. Weight gain. Diet: Unknown Feeding supplement: Not known. Swallowing / Chewing difficulty: Unknown Elimination Pattern: Continent. Activity-Exercise-Sleep-Rest Pattern: Pt takes medication to help with insomnia. Pulmonary crackles and decrease breath sound related to lack of exercise, Group Attendance and Level of Participation: Patient does not like group therapy, and does not exercise. Substance Abuse: Substance Amount / Frequency Duration Last Used Alcohol everyday 6 months 01/27/20 Marijuana Everyday 6 months 01/27/20 Withdrawal symptoms: Yes, AEB by lack of eye contact, not participating in group therapy and Anxiety Other Addictions (gambling, sex, internet, shopping, internet, etc.): N/A Discharge Plans: 1 Month Potential Nursing Diagnosis (Risk / Actual): 1) Infection R/T dirty cloth, tangled hair AEB Isolation for MRSA and VRE. 2) Risk for Suicide R/T recent suicide attempt AEB 1:1 care with a CAN 3) Pain R/T to Tylenol #3, 10mg-325mg, AEB Patient request for pain medication. Planning (patient goals): 1) Patient will have no complication of infection in the duration of my shift. 2) Patient will remain safe in the duration of my shift. 3) Patient will remain pain free in the duration of my shift. Nursing Interventions (include patient education): 1) Wound care will be performed, IV antibiotics will be administered as ordered, teach patient the risk for infection and the need for regular hand hygiene. 2) Remove all harmful product form patience reach, Put patient on 1:1 for close monitoring. To ease detachment and provide safety and solace, and to provide an area free of harmful materials. 3) Advice patient to call at the onset of pain, and administer pain medications as ordered to prevent the pain from becoming severe. As this might triggers patient psychiatric problem. Evaluation (patient response to interventions and teachings): 1) Patient infection remains without complications as evidence by no fever spike at the end of my shift, 2) Patient remained safe throughout my shift, as evidence by no suicidal attempt carried out. 3) Pt remained pain free throughout my shift as evidence by patient verbalization of no pain. MEDICATION LIST Medication (Generic / Trade) Dose / Route / Frequency / Range Risperidone (Risperdal) 1mg Po QD Side Effects Food and Drug Interaction Drowsiness, Lightheadedness, Nausea, Weight gain, Dizziness. Antihypertensive: increase antihypertensive effect, Clozapine: decrease risperidone clearance with long-term concurrent use, Alcohol: additive CNS depressant, Carbamazepine: increase risperidone clearance with long-term concurrent use, (Jones, Bartlett. 2020) Purpose / Rationale for the Patient Antipsychotic Medication (Generic / Trade) Dose / Route / Frequency / Range Sertraline (Zoloft) 25mg 1-tab QD Side Effects Food and Drug Interaction Seizure, Blurred vision, tunnel vision, eye pain. Increase risk for MOA inhibitor if taken within 14 days, impair metabolism if taken with antidepressant resulting in toxicity. (Jones, Bartlett. 2020) Purpose / Rationale for the Patient Antianxiety, Antidepressant, Anti-post-traumatic stress disorder. (Jones, Bartlett. 2020) Medication (Generic / Trade) Valproic Acid (Valproic) 500mg 1 tab PO QD Dose / Route / Frequency / Range Side Effects Food and Drug Interaction Side effects: Runny nose, Diarrhea, Headache, Sore throat, N/V, Interact with Aspirin, Keppra, Lithium, Abilify etc. (Jones, Bartlett. 2020) Purpose / Rationale for the Patient To treat manic episode associated with bipolar disorder. (Jones, Bartlett. 2020) Medication (Generic / Trade) Dose / Route / Frequency / Range Lorazepam (Ativan) 0.5 mg 1 tab PO q6hrs PRN Side Effects Food and Drug Interaction Drowsiness, N/V, Dizziness, headache, Hives, dry mouth. Drug interactions are, Hydrocodone, Methadone, Morphine, Oxycodone. (Jones, Bartlett. 2020) Purpose / Rationale for the Patient Anxiety disorder and Seizure disorder. (Jones, Bartlett. 2020) Laboratory Report: LAB DATE RESULTS REERENCE RANGE DEPAKOTE 01/27/20 78 50 – 125 LITHIUM N/A N/A N/A TEGRETOL N/A N/A N/A DILANTIN N/A N/A N/A WBC N/A N/A N/A VANC TROUGH LEVEL 01/27/20 17 15.0 – 20.0 Date: Hour Focus / Nursing Diagnosis D – Data A – Action R - Response Am Focus assessment A - took place in patient room, Pt requested for bed sheet and pain medication. Pm Lunch A- Patient ate 25 % of lunch 3;00pm Request for Ambien R- Requested for Ambien for sleep. Pm Group Therapy R- Patient refused group therapy, because she doesn’t like it. Student Daily Journal Personal goals for the day: My goal for the day is to be able to keep patient safe, without harm to self. Make pt free from Pain Encourage patient to participation on activities Experience and activities of the day: Breakfast and Lunch Simple conversation with staffs Range of motion exercise in the room Thoughts about your experience today: (How did you meet your goal?) Patient was able to have reasonable conversation with myself and other staffs Patient ADL were taken care of Your feelings about today: (How can you utilize your experience in the future?) To encourage communication and participation in group activities. Will get more involved in group activities Will ask more questions about patient and get facts instead of labelling individuals wrongly. E.g. “The nursing staff was incorrectly viewing this as drug-seeking behavior “