NURS 223L - Psychiatric Nursing Process Worksheet week 3.

NURS 223L - Psychiatric Nursing Process Worksheet week 3. Student Name: NAME HERE Date 04/24/20 Client History: Name (initials only): _VR_ Age: _57_ Gender: _F_ Unit: _PSYCH Date of Admission: 04/24/20 Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Suspected voluntary admission, Family still care for patient. “Grandson and niece that is her support system and Power of Attorney” Psychiatric Diagnosis: Dementia, Depression and Anxiety Medical and (or) physical problems: CHF, DVT, Stage IV Ovarian Cancer with multiple Lymph node involvement and possible liver metastasis. Psychosocial and Environmental Problems: Lack of education only went to high school; Patient does not attend group activities. Thinking that everyone is trying to hold her hostage. (problems with primary support group, education, occupational, housing, economic, access to health care) Presenting Problem Reason for hospitalization (Client’s own words): Attempted elopement from her Memory Care Unit. patient Wanders Current stressors: Stage IV Ovarian Cancer with multiple lymph node involvement and possible liver metastasis, Anxiety, Depression. Mental Status Examination Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): Patient mental statue is inappropriate due to “terminal condition that has metastasized to the brain causing an alteration in mental status” Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): Retardation, Restlessness “Wandering into other patients’ rooms, slapping them in the face and stealing cups off the medication cart” Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Patient attitude is guarded and uncooperative with care Affect (blunted, flat, guarded, labile, expansive, sad, or other): Patient is very Sad, Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Patient is Irritable and anxious Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Patient is very soft spoken with a low tone Thought Content: Suicide Ideation (plan and/or intent): NO Homicidal Ideation (plan and/or intent): NO Hallucinations (auditory, visual, olfactory, gustatory, tactile): NO Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): Sometimes patient is Delusional Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): Ideal of influence has the perception that everyone is trying to hold her hostage. Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): Patient is confused, thought process is illogical Cognition (orientation, memory recall, concentration, attention span): Patient is Alert and oriented x 1 Insight: Poor Judgment: Poor Coordination/gait/notable movement: Patient is independently Ambulatory Cultural issues, familial concerns and religious affiliation that may affect his/her care: Patient is a Catholic, Has a good relationship with her family. Support System: Grandson and niece that is her support system and Power of Attorney. Current Physical Health: Vital Signs - T: 98.2 P: 72 R: 18 BP: 115 / 76 Pulse Oximeter reading: 97% RA. Pain (Numeric 1-10): UNKNOWN Location: N/A Character: N/A How would you describe your health: Excellent Average Good Poor Nutritional Status: Diet: Mechanical soft diet with thin liquids. Feeding supplement: Swallowing / Chewing difficulty: Elimination Pattern: Incontinent of bowel and bladder Activity-Exercise-Sleep-Rest Pattern: Sleeps up to 8 hours at night Group Attendance and Level of Participation: Substance Abuse: Substance Amount / Frequency Duration Last Used Not Applicable N/A N/A N/A Not Applicable N/A N/A N/A Not Applicable N/A N/A N/A Withdrawal symptoms: Not Applicable Other Addictions (gambling, sex, internet, shopping, internet, etc.): Gambling, “Patient use to go to Casino every Sundays when she was living at home 2 years ago. Discharge Plans: Patient Plan to go stay with her grandson upon discharge and remain on Hospice care. (date of discharge unknown.) Potential Nursing Diagnosis (Risk / Actual): 1.) Ineffective airway clearance, R/T non participation on activities, AEB Crackles and wheezing in the lower lobes. 2.) Anticipatory Grieving R/T plans to go home with her grandson upon discharge and remain on hospice, AEB recent diagnosis of Stage IV Ovarian Cancer with multiple lymph node involvement and possible liver metastasis. 3.) Ineffective coping R/T Anxiety and depression. AEB Patient been tearful and states “that everyone is trying to hold her hostage.” Planning (patient goals): 1.) Patient will Patient will maintain clear, open airways as evidence by normal carbon dioxide level, and remain at 97% 02sat at the end of my shift. 2.) Patient will remain knowledgeable of the importance of grieving AEB patient planning to go home with her grandson upon discharge and remain on hospice, and maintain functional support in the duration of my shift. 3.) Patient will remain free of anxiety AEB administration of Xanax, throughout the duration of my shift. Nursing Interventions (include patient education): 1.) Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). 2.) Encouraged verbalization of thoughts or concerns and accept expressions of sadness, anger, rejection. Acknowledge normality of these feelings. 3.) Administered anxiety medication, and Encouraged the patient to recognize his or her own strengths and abilities. Evaluation (patient response to interventions and teachings): 1.) Goal met: Patient maintained a stable gas exchange throughout my shift on 04/24/20, AEB 02 sat of 97% RA 2.) Goal met: Patient maintained a moderate good mode throughout the duration of my shift on 04/24/20. 3.) Goal met: Patient was able to remain free of anxiety, throughout the duration of my shift, on 04/24/20. MEDICATION LIST Medication (Generic / Trade) Dose / Route / Frequency / Range Aricept (Donepezil) 15 mg 1 Tab PO QHS Side Effects Food and Drug Interaction Diarrhea, loss of appetite, muscle cramps, nausea, trouble in sleeping, unusual tiredness or weakness, vomiting, Abnormal dreams, constipation, dizziness Drowsiness, fainting, frequent urination, headache. (Jones, Bartlett. 2020) Purpose / Rationale for the Patient Aricept is used to treat mild to moderate dementia caused by Alzheimer's disease. (Jones, Bartlett. 2020) Medication (Generic / Trade) Dose / Route / Frequency / Range Zoloft (Sertraline) 25 mg 1 Tab PO 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) Dose / Route / Frequency / Range Xanax (Alprazolam) 0.5 mg 1 Tab PO Q8 hour PRN Side Effects Food and Drug Interaction use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing for patients with inadequate treatment options. Avoid alcohol. (Jones, Bartlett. 2020 Purpose / Rationale for the Patient used to treat anxiety disorders and anxiety caused by depression. And panic disorders with or without a fear of places and situations that might cause panic, helplessness, or embarrassment (agoraphobia). (Jones, Bartlett. 2020) Medication (Generic / Trade) Dose / Route / Frequency / Range Lasix (furosemide) 40 mg 1 Tab PO BID. Side Effects Food and Drug Interaction Chest pain, chills, cough or hoarseness, fever, general feeling of tiredness or weakness, Headache, lower back or side pain, painful or difficult urination, shortness of breath, sore throat, sores, ulcers, or white spots on the lips or in the mouth, swollen or painful glands, (Jones, Bartlett. 2020) Purpose / Rationale for the Patient Lasix is used to treat fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome. Also used for hypertension (Jones, Bartlett. 2020) Laboratory Report: LAB DATE RESULTS REERENCE RANGE SODIUM 04/24/20 128 L 137-145 mmol/L POTASSIUM 04/24/20 3.1 L 3.5-5.3 mmol/L BUN 04/24/20 22 H 9 – 20 mg/dL CREATININE 04/24/20 1.15 0.66-1.25 mg/dL WBC 04/24/20 6.9 3.4-10.8x10E3/u1 CARBON DIOXIDE 04/24/20 26 22 – 30mmol/L Date: Hour Focus / Nursing Diagnosis D – Data A – Action R - Response Am to pm Ineffective airway clearance D- Crackles and wheezing in lower lobes A-Teach deep breathing exercise, and perform controlled coughing, as this will help increase sputum clearance if any. R-Patient verbalizes understanding Am to Pm Anticipatory Grieving D- Plans to go home with her grandson upon discharge and remain on hospice A-Take patient out for a walk and engage patient on communication to avert feeling/mood. R-Patient responded well and followed through. Am to pm Risk for impaired skin integrity D-Patient is incontinent of bowel and bladder. A-Instruct patient to let the nursing staff know when patient have Bowel movement or urine regular changing of patient. Also inform nursing staffs to turn patient every two hours when sleeping. R- All both patient and nursing staff verbalizes understanding Student Daily Journal Personal goals for the day: 1.) To be able to keep patient, without harm to self and others 2.) Encourage patient to participate on activities 3.) To make sure patient eats good amount of her meals for the day. Experience and activities of the day: 1.) Breakfast, lunch and dinner 2.) Simple conversation with patient 3.) Monitoring of patient frequently to avoid injury to self and others Thoughts about your experience today: (How did you meet your goal?) 1.) Administration of medication as ordered to calm patient mood down 2.) Took patient for a walk, and engage pt in simple conversation to avert patient mood 3.) Monitor/assist patient at meal time, to make sure patient eat sufficient amount. Your feelings about today: (How can you utilize your experience in the future?) 1.) Will get more involved in group activities 2.) Will encourage patient to eat, if not interested offer other kind of mechanical soft diet. 3.) Encourage patient to participate on group activities.