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NR602 I HUMAN CASE WEEK 6 SARAH JAMIESON WHO PRESENTS FOR MOOD ASSIGNMENT CHAMBERLAIN UNIVERSITY 2024
Typology: Exams
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Current VS: WILDA Pain Assessment (5thVS) T: 99.1 F/37.3 C (oral) Words: Pt temp is slightly elevated P: 110 (regular) Intensity: HR is elevated could be a result to his manic episode R: 28 (regular) Location: Pt could be hyperventilating due to the recent episode of being brought into the hospital by the police
46 Mental Status Examination: APPEARANCE: (^) Is disheveled, and according to his mother he has not showered in several days. He is unshaven and has a significant odor coming from his body and/or clothes. His clothes are not consistent with the weather, it is 95 degrees and is wearing multiple layers of clothing and has winter boots on. MOTOR BEHAVIOR: Psychomotor agitation present, appears restless; he is unable to sit still SPEECH: Talking fast with pressured speech. MOOD/AFFECT: Appears ecstatic, bright affect THOUGHT PROCESS: Delusional, flight of ideas/jumping from one idea to another THOUGHT CONTENT: (^) Believes that the CIA is controlling the nurses’ actions and following him and that he must get to the CIA headquarters immediately PERCEPTION: Denies hallucinations INSIGHT/JUDGMENT: (^) Has lack of insight into current condition and reason for inpatient hospitalization COGNITION: (^) Oriented to person and place but not to time, his immediate and recall were intact but remote memory is not INTERACTION: Approaches others, but does not engage in conversation SUICIDAL/HOMICIDAL: Denies homicidal/suicidal ideation What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
All labs are in WNL for now. Nurse will continue to monitor these values wbc relevant - show if there’s infection /inflammation… will increase Neutrophils - first responders to bacterial infection Hemoglobin- anemia , blood loss Platelets- helps your blood clot Lithium can increase WBC count so it's important to monitor the CBC levels regularly
SODIUM, K, Creatinine Sodium deficiency can be secondary to lithium medication because it decreases the abortion in the kidneys. Hyponatreima can result in toxic levels of lithium. If dehydration sodium will be affected Potassium - important for electrical conduction of heart Creatinine - for kidney
Admit to unit and engage Patient in milieu Urine drug screen Lithium 600 mg PO BID Depakote 375 mg PO BID Trazodone 100 mg PO PRN Sleep Lorazepam 1mg PO BID
Urine drug screen Lithium 600 mg PO TID Depakote 375 mg PO BID Trazodone 400 mg PO PRN sleep Lorazepam 1 mg PO BID Admit to unit and engage patient in milieu admit to the unit and engage patient in milieu lithium depakote Trazodone Lorazepam urine drug test
Self Care Deficit Assist pt in proper grooming and hygiene in order to perform own regimen independently
Pt will be encouraged and educated on different coping skills for many situations he may face
7. What nursing assessments will identify this complication EARLY if it develops Monitor neurological status and pt behavior. Pt may become agitated and frustrated, along with aggressive behavior (screaming , getting in your face , getting ready to hit ). 8. What nursing interventions will you initiate if this complication develops?
Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two hours later… The nurse observes the patient yelling and banging on the door of the unit. They need to let him out because he has to get to the CIA headquarters to stop a terrorist attack. The staff tries to reorient him and the more they talk with him, the more agitated he becomes. Current Assessments: GENERAL APPEARANCE: Agitated and delusional. Is restless and agitated.
1. Has the status improved or not as expected to this point? The patients status has not improved, the pt is still experiencing delusions and agitated 2. Does your nursing priority or plan of case need to be modified in any way after thisevaluation assessment? Yes because the patient is still experiencing manic episodes, is agitated, experiencing delusions and is also restless. The pt is still at risk to self harm/others. 3. Based on your current evaluation, what are your nursing priorities and plan of care? the priority is getting the pt to calm down and call the provider to think about an another medication that could work better. Offer to talk , remind the pt he’s safe
Nurse to Physician SBAR for Change in Status: Situation: This is the nurse and I’m contacting you because the pt is becoming more agitated, paranoid, and delusional Background: Pt is a 35 y/o male admitted this morning involuntary by the police because his mother was afraid he would hurt himself because he was trying to take her car to go to the CIA in Virginia and fire everyone working. Pt also recently experience episode of insomnia hasn’t slept for 4 days, Assessment: Pt thinks he is in the CIA, and that mother is trying to poison him and the nursing staff is a terrorism group. Pt continues to be agitated and is trying break out of the door on the unit Recommendation: The pt should be put in an seclusion/quiet area for monitoring and he should also be prescribed ativan to calm him. 52 Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will discuss withBrenden about his medical condition to prevent future readmission with the same problem? For this patient, I would stress the importance of medication compliance. This patient has a history of not remaining on his regimen and having continuous readmissions. Maybe a nurse can come to the home to assist with medication. I would also stress the importance of coping skills, possibly a therapist or support group
