NUB 430 Clinical Paperwork and Nursing Care Plan

Nursing Assessment Guide

Student Name:

Danielle Reed

Clinical Date:

2/23/15

Admission Date:

2/23/15

Age:

36

Admission Type (voluntary or committed)

Patient came to the ER for a cut on his hand. Voluntary

Gender:

Male

Race:

Caucasian

Marital Status:

Divorced

Allergies:

NKA

Admitting Diagnosis (as designated in chart):

Axis I:

Major Depression

Axis II

Axis III

Infected cut on hand

Axis IV

Axis V (current documented GAF)

Events Leading to Current Admission

The patient came to the ER because he cut his hand while working a few weeks ago. He noticed that he cut was not healing and was painful. He suspected the cut was infected.

Patients Psychiatric History:

The patient stated that he had a history of depression while he was in the military. He was prescribed antidepressants. He no longer takes the antidepressants because he isnt experiencing any symptoms of depression.

Familys Psychiatric History:

The patient lives at home with his Father. He claims that his family does not have a history of Psychiatric diagnosis.

Substance Use/Abuse (current and past history, including drug(s) of choice, how much, how often, ect. ):

The patient smokes 1 pack of cigarettes a day. He has been smoking since 1998. He has not plans to quit smoking. Patient denies use of any other substances.

Sleeping Patterns:

Patient states he has some trouble sleeping at night, and occasionally used over the counter sleep aids.

Appetite, Diet, and Eating Patterns:

Patient eats one meal a day. He eats at night. Diet consists of ramen noodles, lean meat, and fat free foods.

Elimination (bowel and bladder):

Patient voids and eliminates naturally. He stated that he doesnt suffer from constipation or having the urge to urinate frequently.

Personal Hygiene and ADLs:

Patient is able to perform ADLs independently. The patient appeared to be clean, and his facial hair was shaved.

Support System:

The patient lives with his father. His mother lives nearby and he visits with her daily. He doesnt have any siblings.

Cultural/Spiritual Background

The patient is a Christian. He attends a Church of Christ on Sundays.

Educational Background:

The patients graduated from high school, and then joined the military after he graduated. After he served in the military he obtained a certificate of drafting.

Work and Leisure Activities:

In his spare time the patient enjoys watching TV and doing manual labor on farms and cars.

Pertinent Physical Assessment:

The patient appeared much older than his actual age. He was 36 years old and looked to be in his late 40s. His skin looked tough from years of doing manual labor. He teeth were decaying. His skin tone was normal for his ethnicity. His hair was groomed. He was wearing his own clothing. His speech was clear, and his tone was loud.

Pertinent Lab Values /Diagnostic procedures (abnormal values, rationale, and all lab values associated with psychotropic medications.)

*We did not get the chance to access the patients chart. He was being treated for a cut on his hand, and I didnt observe the nurse draw labs on this patient.

Growth and Development (Eriksons current stage with rationale, ie. Patients chronological age with usual developmental task and psychosocial crisis; Was the crisis successfully or unsuccessfully resolved. Why or why not?

(Table on page 23.)

The patient faces the crisis Generativity vs. self-absorption. During this stage he is concerned with fulfilling life goals that involve family, career, and society. The patient is divorced, and has no children. I dont believe he has successfully resolved this crisis because he doesnt socialize much, and has yet to remarry and build a family.

Defense Mechanisms (provide examples) (Table on page 283)

I believe this patient is in denial about being unhappy about his current living situation, being divorced, and not having children. The patient stated that he wanted children but his marriage was unsuccessful. I think that he uses his work to compensate for a lack of a social life, and friends.

Patient Symptoms/DSM-IV-TR Criteria

1. With Axis I and II, define each diagnosis(es) and give symptoms of diagnosis(es). Use your text for this information and give page.

The patient has a history of major depression. He was prescribed medication when he was experiencing symptom of depression. The patient states that he would sleep for long periods of time, and couldnt eat when he was suffering from depression. According to Halter (2014) major depression, is characterized by a persistently depressed mood lasting for a minimum of two weeks (p. 250). The depressed mood is accompanied by a lack of interest in previously pleasurable activity, also known as anhedonia ; fatigue; sleep disturbances; changes in appetite; feelings of hopelessness or worthlessness; persistent thoughts of death or suicide; an inability to concentrate or make decisions; and a change in physical activity (Halter, p. 250).

2. In your definition of diagnosis and symptoms of the three axes, highlight the diagnosis and symptoms that your patient has demonstrated.

Anhedonia- The patient stated that when he was depressed he became withdrawn and no longer enjoyed socializing, reading, and watching TV

Changes in appetite- when he was depressed he was unable to eat. He lost about 30 pounds.

Change in physical activity- The patient was no longer physically active, and was sleeping for long periods of time.

A

Sample Charting (Brief summary of patients mental status, written in paragraph form)

NUB 430

Mental Health NursingClinical Paperwork and Nursing Care Plan

The patient is a 36 year old, Caucasian male. He served in the Army for 8 years. He is divorced and has no children. Patient has a history of depression, but is no longer experiencing symptoms of depression. When he was experiencing depression he was prescribed antidepressants. The drugs successfully treated the symptoms the patient was experiencing. The patient lives at home with his father. He enjoys doing manual labor on farms and cars. Patient claims to be happy about being divorced, but I was not convinced he is happy about being alone. Patient has some trouble sleeping and eats one meal a day. Patient does socialize with friends a lot during his spare time. The patient was alert and oriented to time, place, and person. He came to the ER because he had a cut on his hand that had not healed and was painful.

6

Nursing Care Plan

Nursing Diagnosis (NANDA)

Include R/T (etiology), AEB (signs/symptoms/ defining characteristics) for 2 priority nursing diagnoses

Patient Goals

(include a minimum of one long term and two short term measurable goals

per nursing diagnosis)

Goals should be measurable, time-limited and realistic

Planned Nursing Interventions and Rationale

(minimum of 5 interventions & rationale

per nursing diagnosis)

Patient Response and Your Evaluation of Interventions

Disturbed sleep pattern related to lifestyle disruption as evidenced by difficulty falling asleep and awakening after short periods of sleeping.

The patient will demonstrate an optimal balance of rest and activity A.E.B. 6-8hours of uninterrupted sleep at night with in 7 days.

The patient will remain awake during the day for the next 7 days.

The patient will exercise at least 3 times a week over the next 3 months.

The nurse will:

Explore with patient potential contributing factors such as caffeine use, lack of exercise, and anxiety. This will help identify the cause of the sleep problems, and help the patient identify a solution.

Help the patient identify and establish a bedtime routine per patient preference such as a desired bedtime and sleep environment (darkness, night light, music). A routine will help the patient mentally prepare for sleep and form a habit for resting.

Encourage the patient to ask his PCP for a sleep aid if the problem persists. The patient may need a sleep aid if the problem persist longer than 3 months

Encourage the patient to void before retiring. Voiding before bedtime will help the patient avoid waking up to go use the bathroom.

Help the patient identify ways to be physically active (exercise) at least 3 times a week. Planning to exercise will help the patient to establish a workout routine, and help relieve stress that may interfere with sleep.

The patient was receptive to my suggestions. He agreed that he needs to address his sleep problem, and that it affects his job.

Nursing Diagnosis (NANDA)

Include R/T (etiology), AEB (signs/symptoms/ defining characteristics) for 2 priority nursing diagnoses

Patient Goals

(include a minimum of one long term and two short term measurable goals

per nursing diagnosis)

Goals should be measurable, time-limited and realistic

Planned Nursing Interventions and Rationale

(minimum of 5 interventions & rationale

per nursing diagnosis)

Patient Response and Your Evaluation of Interventions

Social isolation as related to divorce as evidenced by desire to interact with more people

The patient will:

Identify the reasons for his/her feelings of isolation during my shift.

Identify ways of increasing meaningful relationships during my shift.

Identify appropriate diversional activities over the next 4 weeks

The nurse will:

Encourage patient to verbalize feelings. This will help to identify the cause of the social isolation.

Assist to identify causative and contributing factors. This will help the patient to determine ways to address the problems and develop solutions for the causative and contributing factors.

Assist to identify diversional activities such as joining clubs, going to bars/parties, being active in church groups, and try online dating. Finding activities will help the patient to socialize more, and hopefully make new friends.

Encourage the patient to perform volunteer activities. This may help the patient to gain a sense of fulfillment and purpose by giving to others.

Encourage the patient to keep a daily journal of his activities. This will help the patient to keep track of his progress in becoming more socially active.

The patient admitted that since his divorce he had become socially withdrawn. He expressed a desire to have more friends and participate in more recreational activities.

Medications

Drug Name (generic & trade)

Drug Class & Dose

Reason Prescribed

Pt. Understanding of Drug & Nurse Education ( Include education important for patient to know)

Nursing Considerations

Most Common Side Effects & Most Common Serious Effects

Hydrocodone

325 mg tab

Analgesic

Pain in knee and foot

Patient understands that this drug is to be used to treat pain he experiences due to a foot injury

Monitor hepatic, renal status during long-term therapy, bleeding (GI, GU, skin/mucous membranes) with long-term, high-dose therapy, signs of OD, (sweating, gastric irritation chills, cyanosis, oliguria, jaundice, come, convulsions, death from respiratory failure). Assess hx of hypersensitivity,

Anemia, leukopenia, neutropenia, pancytopenia, hemolytic anemia, methemoglobinema,

ASA

Butalbital

Caffeine

nonopioid analgesics

325mg

50mg

40mg

Migraines

Patient understands this medication relieves pain caused by migraines

Assess type, location, and intensity of pain before and 60 min following administration.

Prolonged use may lead to physical and psychological

dependence and tolerance. This should not prevent patient from receiving adequate analgesia. Most patients who receive butalbital compound for pain do not develop psychological dependence.

Assess frequency of use. Frequent, chronic use may lead to daily headaches in headache-prone individuals

because of physical dependence on caffeine

and other components. Chronic headaches from overmedication are difficult to treat and may require hospitalization for treatment and prophylaxis.

Drowsiness, hangover, palpitations, tachycardia.

Mental Status Exam

A. Appearance- The patient was well groomed and wore his own clothing. He facial hair was shaved. His posture was upright. His weight was appropriate for his height. He maintained normal level of eye contact (he wasnt always looking down or staring into my eyes for long periods of time. His hair was brown and straight. He had a few moles on his face, I didnt notice any scars or tattoos. He appeared much older than his chronological age of 36. He appeared to be in his late 40s.

B. Behavior/motor activity- The patient was very friendly toward me. He initiated conversation, and lead into new topics without being asked. He seemed eager to talk to me. His gait pattern was steady and fast. He had freedom of movement and wasnt limited by mobility problems.

C. Attitude toward interviewer- The patient was cooperative and friendly toward me. He asked me questions about myself. He told a few jokes and overall seemed pleasant.

D. Speech- The patient participated in the content of the conversation when I asked him about his life, condition, and how he was feeling. He spoke at a moderate pace and loud tone.

E. Mood- When I asked the patient how he was doing he expressed that he was ok and that he was visiting the VA for a cut on his hand. He chatted briefly about the weather and that he was looking forward to summer.

F. Affect The patients facial expression was congruent with his mood. He appeared calm and cooperative. He was not constricted or blunted. His affect was appropriate for his mood.

G. Thought Process- The patients thought process was logical and sequential, and his answered were in response to the correct question. The patient was able to concentrate on the topic of discussion.

H. Thought Content- The patient was oriented x3. We discussed his family, religious beliefs, military background, and his divorce. He claimed to be happy about being divorced, but I wasnt convinced because of his current social isolation.

I. Suicidal/homicidal ideation (address both)- The patient denies SI and HI.

J. Perceptual Disturbances- The patient was not experiencing any perceptual disturbances.

K. Intellectual Functioning

Sensorium

Orientation- The patient is oriented to time, place, and person

Memory- The patient was able to recall short term and long term memories such as places traveled, his parents names, and current city of residence.

Intellectual capacity

Intelligence- The patient seemed to have an average level of intelligence. His highest level of education was high school and then he received a certificate in drafting.

Abstract or Concrete Thinking- The patient has abstract thinking. When I asked what does the phrase cant judge a book by its cover his response was that You have to get to know a person to truly understand them.

Comprehension of current events- The patient is aware of current events. We discussed his activities at work, and the weather.

L. Judgement- The patient is able to use common sense to make reasonable decisions

M. Insight- The patient was aware that he cut his hand a few weeks ago, and that the wound had not healed. He was also aware that he suffered from depression in the past.

N. Motivation for treatment- The patient is motivated to get his hand healed because it is interfering with his ability to work.

References:

Varcarolis, E. M. (2013). Foundations of Psychiatric Mental Health Nursing , 10rd. Ed. Philadelphia: W.B. Saunders.

Vallerand, April Hazard, Cynthia A. Sanoski, Judith Hopfer Deglin, and Holly G. Mansell. Davis's Drug Guide for Nurses. N.p.: F. A. Davis, 2014. Print