Sharon Cole Documentation .,WELL EXPLAINED WITH VERIFIED ANSWERS.

1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute agitation. Include her responses to your assessment. The findings related to Sharon Cole’s s/s of acute agitation are that she has bipolar disorder type 1. She has stopped her medication, which has caused an imbalance in her behavior and she is experiencing a manic episode. She is known for stopping her medication and the last time she had a manic episode was 2 years ago. Her husband noted that she has not been sleeping well or eating well for the past 2 weeks. 2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered. The interventions for Sharon Cole’s management of acute agitation with medication was successful. She was experiencing panic when stating she can’t think with all the racing thoughts or that fact that the nurse is forcing her to stay in the hospital and she can’t get any of her work done. Her responses were that she would take any medication because the nurse was pretty. 3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care. outcome of treatment would be for you? 3:25 The patient said: Look, I need to get out of here. The whole thing is going to fall apart. I can't get to Washington. Don't you people care about all the soldiers who are going to die without my help? Nobody can see it, but I can! They are going to waste all the money on the wrong things! I have to get out of here. Allen can drive there. This thing on my leg is in the way. You answered: Mrs. Cole, I am your nurse today and I am here to help you. You just had surgery. Please stay in the bed. You used the therapeutic technique of presenting reality. 3:36 You supported the patient about rest and healing. 3:46 You supported the patient about racing thoughts. 4:02 You educated about discharge. 4:48 You asked the patient: Do you have any pain? 5:07 The patient said: And you, because of you I can't do my work. You keep me downtown all the time in this bed. You answered: Mrs. Cole, I'll be glad to sit with you and talk awhile. You used the therapeutic technique of offering self. 5:11 You asked the patient: How would you rate your pain, on a scale of 0 to 10? The patient said: I don't have any pain. 5:22 You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with her to get an understanding of this. 5:42 The patient said: There's too much work to be done. I can't do it here and you can't make me stay here. I'm going to call the police and have you arrested. You are keeping me prisoner. I'm leaving now. You answered: You are in the hospital for treatment. Please stay in the bed. You used the therapeutic technique of giving information. 6:22 You measured the blood pressure. 6:41 You measured the temperature. 6:57 You checked the pulse oximetry. 7:14 You assessed the respiration. 7:25 You checked the radial pulse. 7:44 You assessed the patient's IV. 8:03 You administered lorazepam. 8:31 You educated about medications. 9:07 You educated about the psychiatric diagnosis. 9:31 You supported the patient about going back to work. 9:43 You supported the patient about racing thoughts. 10:0 2 You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? 10:1 7 The patient said: I'm the type of person who can get everything done. I don't need sleep; I'll sleep when I'm dead!nYou answered: Let's talk more about the importance of sleep. nYou used the therapeutic technique of focusing. 10:2 4 You asked the patient: Approximately how many hours of sleep do you get each night? The patient said: I don't need to sleep. 10:3 2 You asked the patient: Do you have any trouble falling asleep? The patient said: No. 10:3 7 You asked the patient: Do you nap during the day? If so, how often and for how long? The patient said: No, I have no time to sleep. 10:4 8 You asked the patient: Do you have energy to do the normal activities necessary to get through the day? 11:0 9 The patient said: Let me use the phone and I'll stay in bed as long as you want me to. I promise I'll be good. You are so pretty. I'll take my medicine and everything. I just need to make one little tiny phone call.nYou answered: Now is not the time to use the telephone. nYou used the therapeutic technique of giving information. 11:1 1 You asked the patient: Do you have energy to do the activities that give you enjoyment? 11:3 1 The patient said: It was you! You are the one who called the assassins to get me. You told them where I was, you bitch! You broke my foot. This is all your fault!nYou answered: Mrs. Cole, I am a nurse here at the hospital where you had surgery. nYou used the therapeutic technique of giving information. 11:4 0 You asked the patient: Have you had any changes in your appetite over the past month? 12:0 0 The patient said: That guy who took my blood pressure, now he's a hot one! He got my blood pressure way up. Next time I see him I'm going to show him a thing or two about love.nYou answered: He is the nursing assistant. You need to behave appropriately with hospital staff. nYou used the therapeutic technique of giving information. 12:0 5 You asked the patient: Do you get hungry? The patient said: No. 12:0 8 You asked the patient: Have you lost or gained weight over the past month? The patient said: I don't know. 12:1 5 You asked the patient: Do you notice that your clothes are fitting looser or tighter than they were a few weeks ago? 12:4 1 The patient said: Where is my bag? Allen likes it when I dress up. This hospital gown is down, down, down. I 4. Document all interventions associated with the management of Mrs. Cole’s environment. Include her responses to the attempts to decrease environmental stimuli. The lights were dimmed which reduced the overall environmental stimuli. She responded positively towards this intervention. 5. Document all interventions associated with boundary and limit setting directed toward managing Mrs. Cole’s manic behavior. Reminded Sharon Cole that she must keep her hospital gown on, treat hospital staff appropriately, and must remain in bed in order to protect herself from harm due to her manic state and surgically recovering fractured ankle. 6. Document your handoff report in the SBAR format to communicate Mrs. Cole’s future needs. Situation: Sharon Cole is a 31 year old female, who is diagnosed with bipolar disorder. She is postop following a surgical repair of a right ankle fracture. Sharon is in a manic state and reports no pain. The patient has stopped her medication at home and has not been eating or sleeping well for the last few weeks. Background: Sharon Cole was brought by EMT following a 911 call made after falling off of a stage while experiencing a manic episode. Sharon Cole has stopped taking her medication, Lithium 600 mg twice a day, and her husband reports she has not been eating or sleeping well the last two weeks. Sharon’s vital signs are stable, they are as follows: Temperature 99 F, 91 beats/min, 19 respirations/min, BP 133/75 mmHg, Sp02 99%, IV site was normal with no signs of redness, swelling, infiltration or phlebitis. Assessment: Sharon is experiencing a manic episode related to her stopping her medication. Sharon is unstable currently and seems to think the hospital staff is holding her against her will. Her thoughts are racing, unfocused, and grandiose. Sharon was educated that she is post-operative for a right ankle fracture. Recommendation: Sharon should not be left unsupervised. A request for a 1:1 would be appropriate. Lorazepam has been administered and should be assessed again in 30 minutes.