Mental Health Case: Sandra Littlefield

Mental Health Case: Sandra Littlefield Documentation Assignments 1. Document your findings related to the focused assessment of Ms. Littlefield’s coping strategies. Include her responses to your assessment. Ms. Littlefield does not cope well with her situation. She is angry and accusatory and is feeling very lonely. She appears to be projecting her own issues onto the staff as a defense mechanism. Further, she is convinced that medication is the only solution to her pain and is not dismissive of and uninterested in learning relaxation techniques. When asked about her desired outcome of treatment she said, “everyone is against me. You, the other nurses, the provider—you all hate me.” She did, however, state that, in the past, she has enjoyed taking walks and reading romance novels as an avenue of stress relief. 2. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided Ms. Littlefield. Include her response to the teaching. I explained to Ms. Littlefield that there are several strategies she can use to decrease her anxiety, frustration, or fear such as community support groups and regular therapist visits. I asked her what sorts of things she has done in the past to reduce anxiety and frustration and she replied that she enjoys taking walks and reading romance novels. I informed her of the presence of the prison library and offered to teach her some exercises she can do in prison. While she is in the jail, I plan to work with her to identify community resources that may be of use to her. 3. Referring to your feedback log, document all nursing care provided and Ms. Littlefield’s response to this care. I began by assessing the scene for safety. I then introduced myself, washed my hands, and ensured that I had the right patient. I then asked, “can you tell me a little bit more about what’s going on with you today?” She appeared agitated and said, “I am in so much pain. You are a nurse. Don’t you know how to tell when someone is hurting?” I used the therapeutic technique of translating to feelings and asked, “are you saying you feel hopeless?” I then asked her if she had any pain. She became more irritated and stated, “I’m finished. I’m done with you and your worthless medicine. Guard, take me back now!” I used the nontherapeutic technique of reassuring and responded, “the medicine your provider has ordered is in your best interests.” At this point, I assessed her vital signs. She was breathing at a rate of 16 breaths per minute with an oxygen saturation of 98%; her radial pulse was measured at 84 beats per minute. Her blood pressure was 132/80 and her temperature was 98.6°F. “I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care,” I said. “These are questions I ask all of the patients I see. May I ask you these questions?” “Just because you are in love with the guards, you prance around like you own this place and you do not!” she responded angrily. I used the therapeutic technique of giving information to say, “Ms. Littlefield, you need to lower your voice now. I am here to help you.” I then asked, “do you feel alert to answer questions?” “Yes, I am.” “Please tell me your name,” I said. “My name is Sandra Littlefield,” she responded. “Can you tell me where we are?” I asked. “You think you are better than me because I’m in jail. Well you are not!” I used the therapeutic technique of verbalizing the implied and responded, “are you feeling as if no one cares?” She correctly identified the date as the 20th upon my request. I then asked, “how would you describe your mood?” “No one has even looked at my back today. I know it’s worse than it was, no matter what those tests said,” she responded with frustration. I responded with the therapeutic technique of suggesting collaboration and formulating a plan of action by saying, “let’s sit together and discuss a way you can handle your frustration appropriately.” I then asked, “do you have any thoughts or wishes to harm or kill yourself?” She responded, “if they don’t help with my pain, I will.” “Do you think it would be better if you were not alive?” I asked. “Yes,” she stated quietly. “Do you have any thoughts or wishes to harm anybody else?” I asked. “If they don’t help me with my pain, I might,” she responded simply. “Can you tell me what a desired outcome of treatment would be for you?” I requested. “Everyone is against me. You, the other nurses, the provider—you all hate me. The only one who likes me is that cute guard.” “I used the therapeutic technique of restating to ask, “you feel that people hate you?” I then asked, “do you ever see or hear things that other people do not?” “No, I’m not crazy,” she responded. “Do you find that you worry more than others?” I asked. “The security guard, the one with the blond hair, he believes me. He’s the only one I have anymore.” I used the therapeutic technique of verbalizing the implied to ask, “are you saying you feel lonely?” “Are you frightened of anything?” I asked. “You look so nice today,” she said suddenly. “And you smell good. What perfume are you wearing?” I used the therapeutic technique of making observations to redirect and asked, “are you uncomfortable when you talk about your feelings about being here?” I submitted the MSE; educated about coping strategies, medications, and strategies for pain management. I also asked her what pain management strategies she has used other than