VSIM bipolar disorder, Sharon Cole Documentation-Brenau University

VSIM bipolar disorder, Sharon Cole Documentation-Brenau University-Sharon Cole. Bipolar disorder Documentation Assignments 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. Mrs. Cole is oriented x2 to person and place. She doesn’t really remember her fall incident as much and cannot tell the date. She is constantly moving around and agitated. She is dressed in a hospital gown with uncombed hair. She is not focused and restless. Her speech is pressure, loud, and she’s constantly talking. She is suspicious and has flight of ideas. She also shows delusion of grandeur with thought of needing to solve issues in Washington and running the hospital. 2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered. Lorazepam 2mg was administered as needed per order to reduce patient’s agitation. She was hesitant but took her medication. 3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care. ● I took her vital signs: RR 24, SpO2 99%, HR 104, BP 155/90, temp 99.0F ● Auscultated heart and lungs sound. Lungs are clear and normal heart rhythm. ● I assessed her skin and cast. There are bruises and abrasions on her arms and knees. ● Checked her cast. It is correctly placed. No pain or pressure. Intact vascular and neurological assessments. ● Did mental status exam ● Assessed IV and administered lorazepam 2mg as needed for agitation ● Notified provider of findings 4. Document all interventions associated with the management of Mrs. Cole’s environment. Include her responses to the attempts to decrease environmental stimuli. This study source was downloaded by from CourseH on :44:27 GMT -05:00 This study resource was shared via CourseH I dimmed the light to reduce external stimulation but she’s still agitated and has flight of ideas and grandeur thoughts. 5. Document all interventions associated with boundary and limit setting directed toward managing Mrs. Cole’s manic behavior. ● When patient said that she thinks a male technician that took her BP is hot, I explained to her that he is the nursing assistant and she needs to behave appropriately with hospital staff. ● Patient wants to take the wires off because they remind her of snakes. I explained to her that those are IV for her medicine so they should be left alone. ● Patient wants to get out of the hospital because she has to take care of some issues in Washington. I presented reality to her by saying that I’m her nurse and she needs to stay in bed. 6. Document your handoff report in the SBAR format to communicate Mrs. Cole’s future needs. S- Sharon Cole is a 31 year old female admitted for surgical repair of a right ankle fracture. She is postoperative and is agitated and with delusion of grandeur of wanting to leave the hospital because she has to take care of some issues in Washington. B- Patient has an injury from a fall at a stage in the bar and fractured her ankle. She has a past medical history of bipolar disorder and has not been sleeping or eating much for the past 2 weeks. She stopped her lithium 600mg bid two years ago and had a manic episode after that. Psychiatrist is consulted. A- Vital signs are stable at RR 24, SpO2 99%, HR 104, BP 155/90, temp 99.0F. She denies any pain or difficulty breathing. A sitter is present for patient’s safety. Her skin has bruises and abrasions on arms and knees. Her hair is uncombed and she’s not able to focus. She is restless with pressure and loud speech. She is suspicious and has flight of ideas. She has delusion of grandeur of wanting to go to Washington to solve some issues and that she can run this hospital better. She is alert and oriented x2 to person and place. She doesn’t not remember the date. R- Continue to have the sitter to monitor patients for safety. Continue to offer her snacks since she has not been eating. Monitor vital signs especially her elevated blood pressure. Contact provider for any changes in status. Follow up with psychiatrist consultation. Guided Reflection Questions How did the simulated experience of Sharon Cole’s case make you feel? I was feeling a little frustrated and confused because the patient was so agitated with me. I know it’s not me personally but she made me nervous seeing her so restless and agitated. She has flight of ideas that made my mental status exam difficult. Talk about what went well in the scenario. I was able to use therapeutic communication techniques to limit setting and reorient the patient so that our communication can be smoother. Although she was agitated, she responded to all my questions. She didn’t get violent with me and allowed me to complete my assessments. Reflecting on Sharon Cole’s case, were there any actions you would do differently? If so, what were these actions and why? This study source was downloaded by from CourseH on :44:27 GMT -05:00 This study resource was shared via CourseH There was one statement the patient made and I chose silence as a response. I would use therapeutic communication the next time. Also, I should have offered her something to drink or eat since she has not been eating. I didn’t educate patient on lorazepam medication so I would do education before I administer her any drugs. What issues have you identified that could be barriers to a successful treatment for Sharon Cole? Medication compliance. She has a history of bipolar disorder and she stopped taking lithium for 2 years. Also, patient was hesitant in taking the lorazepam for her agitation because she’s suspicious of the staff. How would you address the manic state? I would stay calm, set limits and boundaries, reorient the patient, make sure the milieu is safe, and use therapeutic communication techniques. Identify a support group that would be beneficial to Sharon Cole’s husband. NAMI family support group is a peer-led support group available for anyone with a family member that has symptoms of mental health conditions What action should be initiated due to Sandra Cole’s medication regimen? Educate patient on the importance of medication compliance to help and control her symptoms. Teaching should be done when patient is calm and not in a manic state. How would you apply the skills and knowledge gained in the Sandra Cole case to an actual patient situation in different acute care units (emergency room, intensive care unit, obstetrics unit, etc.)? I would use therapeutic communication techniques to talk to patient. I will make sure that I stay calm and be patient with the patient. Recognize that silence is an effective response and assure patient that I will stay with her to make her feel safe and cared for. Patients that are in a manic state can harm themselves so make sure to monitor them closely and don’t take things they say personally. This study source was downloaded by from CourseH on :44:27 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()