UNFOLDING Clinical Reasoning Case Study

History of Present Problem: Jeremy Brown is a 30-year-old Caucasian male who was brought to the emergency department (ED) by the police after being involved in an altercation at work. Jeremy was at work today, and he threw a large piece of metal at a coworker and began yelling, “Stop following me, I know what you have been up to!” Because Jeremy was very agitated and upset, and the police were called. Since arriving in the ED, he has been agitated, displaying rapid pressured speech and repeating the phrases he hears the police and others in the ED said. Jeremy reported that he recently stopped taking his risperidone and citalopram because he believed his coworkers have been breaking into his house and poisoning his medications. Jeremy’s manager reports that he was diagnosed with schizophrenia five years ago. Personal/Social History: Jeremy graduated from college with a 4.0 GPA and was in his first year at law school when he experienced the first episode of acute mental illness and was diagnosed with schizophrenia. He had to drop out of law school at age 24 and never finished. Jeremy lives at home with his mother and father and recently broke up with his girlfriend. Jeremy likes his job at the foundry but feels he is a disappointment because both of his sisters are lawyers, as is his father. Jeremy has no close friends and only a few acquaintances. Jeremy’s mental health had been stable up until the last three months. He has been feeling more paranoid the past three months and experienced a dramatic increase in symptoms when he stopped taking all of his medications one month ago. What data from the histories are RELEVANT and have clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Pt has been agitated, displaying rapid pressured speech and repeating phrases he hears others say: the patient is exhibiting symptoms of his diagnosis, and is having an episode. Stopped taking medications: not adhering to drug regimen, which is why he is having symptoms of schizophrenia. Believes coworkers have been breaking into his house and poisoning his medications: having delusions and hallucinations. RELEVANT Data from Social History: Clinical Significance: pt feels disappointment because he is not a lawyer like his sisters and father: the patient is exhibiting self-disappointment and is unable to achieve goals due to his illness. Recently broke up with his girlfriend, has no friends and only a few acquaintances: pt is experiencing social isolations that could be caused from illness. Pt has been feeling more paranoid the past three months and experienced a dramatic increase in symptoms when he stopped taking medications a month ago: the nurse is able to identify the onset of exacerbation of symptoms and that the patient has stopped taking medications. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain P: 100 (regular) Quality: R: 22 (regular) R egion/Radiation: BP: 130/84 S everity: O2 sat: 98% room air Timing: © 2018 Keith Rischer/www.KeithRN.com What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: His temperature, pulse, and O2 are all normal. The BP at 130/84 and respirations at 22 are both most likely due to the alterations Jeremy had caused by his blood to start pumping faster because he was agitated and upset. Current Assessment: GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present Mental Status Examination: APPEARANCE: Diaphoret