Best, best

Student Name:

Week: 6

Dates of Care:

Demographics and Brief History

Patient Initials

Sex

F

Age

61

Room

SMN 15TH FL BH

Admitting Date

11/27/20

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Psychiatric evaluation. PT is a 61years old present from SFHED to SM-C for further psychiatric evaluation. Bought in by EMS found screaming on neighbor’s porch screaming and singing.

Attending physician/Treatment team:

Krushen Pillary, DO (Attending)

Precautions: High fall risk, sexual acting out, Assault

Primary Diagnosis:

Bipolar affective disorder, manic severe with psyc behavior

Co-morbidities:

Delusional

Allergies: No known allergies

Code Status: Full Code

Isolation: (type and reason)

None

Admission Height: 170.2cm (5.7)

Admission Weight: 87.ikg (192 lb)

Arm Band Location (colors & reasons) White color. For identification and medication administration.

Past Medical History: (pertinent & how managed) Anxiety, PSTD (Post traumatic stress disorder)

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)

Patient was seen this morning for fall. Assessment limited due to current mental state. Sleeping, slurring word but denies pain. Patient does not appear to be in distress.

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

General Appearance:

Assessment: Sleepy and cooperative. Appears stated age. Not in distress. Disheveled

GI:

Diet: Regular Diet. No known Allergies

Blood Glucose: (time & date) 98 11/27/20

Last bowel movement: (time & date) Pt stated

Pertinent Labs/Test: Glucose test

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Normal bowel sound, non – tender, non- distended, no masses, no diarrhea or vomiting, no constipation. PT denies any difficulty having bowel movement.

Respiratory:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Pt has even skin tone, no nasal flaring or use of accessory muscle, no cyanosis to lips or nailbeds or pallor, no clubbing, no cough, no shortness of breath. Pt denies difficulty breathing.

Neurosensory:

Alert & Orientated: Pt was AOx4 during the time of visit. She was able to state her full name, place, date and time. Pt denies

Follows commands: Pt was able to follow command

Speech Comprehensible: Normal rate, rhythm, tone, and normal volume

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness). There was no record of loss of consciousness, pupils are equal, round accommodating, no involuntary movement was observed as at the time visit.

Cardiovascular:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) Pulses are equally strong +2 with no vibration in the strength noted. Pt denies chest pain.

Musculoskeletal:

Activity: Patient stated that she likes to sing

Casts/Slings: None as at the time of visit

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers) Provide supportive environment, patient was observed walking around with good balance, the joint reveals no warmth, swelling, or any deformities. Patient denies any pain in the joint.

Renal:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill) (urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Patient denies any difficulty urinating

Skin:

Braden Score: 22

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toenails, wounds, drains, bed type) Skin color is consistent with the genetic background, no signs of Bruises, wound or skin breakdown. Skin turgor was less than 3 seconds.

Pain:

Pain score: No pain

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Patient denies having any pain

Gyn:

Gravida/Para: N/A

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

Safety:

Bed Rails: Psych unit has no bed rails

Bed alarms: There is no bed alarm but there is counsellor that always monitoring the patient and makes round every 15 minutes.

Fall risk: Maintain fall precaution

Assistive Devices: No device but there are precautions to keep the patient save.

Advance Directives/Ethical considerations:

AD: None but the chart indicated that the resources and information for advance directives will be provided at time of discharge

POA: There is no documentation to show POA

Psycho/Social Assessment

· Level of education

· Not on file

· Occupation

· Not on file

· Race/Ethnic Background or Identification

· Not on file

· Religion/Spiritual Beliefs

· Not on file

· Communication needs: (verbal, nonverbal, barriers, languages)

· Not on file

· Special Talents/Interests/Skills

· Not on file

· Environment (home and community)

· Not on file

· ADLs (sleep/rest; diet; exercise/mobility; elimination; substance use)

·

·

·

·

·

· Family Structure/History: No family history on file

Stage of Development: (Erikson’s Stage of Development, what stage is the client currently in and previous stages that the client may not have successfully completed) K.F is a 61-year-old female, he was admitted to the ER for psychiatric evaluation. Patient stated that she is 61years old and a divorcee. She was brought in by EMS found screaming on neighbor’s porch screaming and singing. Exhibiting bizarre behavior and appearing to respond to internal stimuli. However, according to Erikson’s stage of development this patient is in the stage seven. Generality vs stagnation (Middle- age; CARE) is the longest period of a human's life. It is the stage in which people are usually working and contributing to society in some way and perhaps raising their children. If a person does not find proper ways to be productive during this period, they will probably develop feelings of stagnation. The patient supposed to have family that she cares for or cared about her which could have made her feel unproductive and disconnected from the society.

Middle-age is a time to think about leaving a legacy, to be productive, and to contribute to society.

Support System: Pt with one sitter for safety

Stressors/Stress Management Practices: Pt is encouraged to verbalize thought and feelings,

Encouraged to socialize with peers,

Encourage to practice effective coping skills and talk to staff about concerns.

Pathophysical Discussion: For this section include appropriate references and use APA format

Discuss the current disease process:

Bipolar disorder is characterized by recurrent episodes of mania and depression which suggests that mood instability and an impaired regulation of emotional states may be the core of the disorder (K,Usher 2015)

PATHOPHYSIOLOGY

The symptoms include:

· Mood swings

· Elevated mood

· Anger

· Anxiety

· General discontented

· Loss of interest or, or pleasure in activities

· restlessness

· delusion

· hyperactivity

The potential risk factors for psychiatric disorders can be classified as genetic, social or psychological (e.g. personality, environmental stressors and somatic disorders).

Social characteristics, a family history of mood disorders and some personality features were analyzed as risk factors for bipolar and depressive disorders by means of logistic regression. (Angst, J 2003)

References

Stegmayer, K., Usher, J., Trost, S., Henseler, I., Tost, H., Rietschel, M., Falkai, P., & Gruber, O. (2015). Disturbed cortico-amygdalar functional connectivity as pathophysiological correlate of working memory deficits in bipolar affective disorder. European Archives of Psychiatry & Clinical Neuroscience, 265(4), 303–311. https://doi-org.resu.idm.oclc.org/10.1007/s00406-014-0517-5

References

Angst, J., Gamma, A., & Endrass, J. (2003). Risk factors for the bipolar and depression spectra. Acta Psychiatrica Scandinavica. Supplementum, 108, 15. https://doi-org.resu.idm.oclc.org/10.1034/j.1600-0447.108.s418.4.x

Discuss the etiology of the patient’s illness:

Bipolar disorder often runs in families, and research suggests that this is mostly explained by heredity—people with certain genes are more likely to develop bipolar disorder than others. Many genes are involved, and no one gene can cause the disorder.

But genes are not the only factor. Some studies of identical twins have found that even when one twin develops bipolar disorder, the other twin may not. Although people with a parent or sibling with bipolar disorder are more likely to develop the disorder themselves, most people with a family history of bipolar disorder will not develop the illness.

Also note the complications that may occur with treatments and patient’s overall prognosis:

Complications that may occur are post stroke depression, shy, guilty, hopelessness, anxiety, insomnia, insecurity, maladaptive behavior. Drug anti – depressant may increase the suicide ideation among younger adults but among older people symptoms will be reduced.

Prognosis: The natural course of bipolar disorder varies. Without treatment, manic and depressive episodes tend to occur more frequently as people get older, causing increasing problems in relationship or at work. It often takes persistence of find the most helpful drug combination that has the fewest side effect. Treatment can be very effective; many of the symptoms can be diminished and, in some cases, eliminated. As a result, many people with bipolar disorder are able to function completely normally and have highly successful lives.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article:

Patients with BD experience recurrent episodes of pathologic mood states, characterized by manic or depressive symptoms, which are interspersed by periods of relatively normal mood.  There are two major types of BD. Bipolar I disorder (BD I) is defined by the presence of at least one episode of mania, whereas bipolar II disorder (BD II) is characterized by at least one episode of hypomania and depression. The main distinction between mania and hypomania is the severity of the manic symptoms: mania results in severe functional impairment, it may manifest as psychotic symptoms, and often requires hospitalization. The duration of mood episodes is highly variable, both between patients and in an individual patient over time, but, in general, a hypomanic episode may last days to weeks, a manic episode lasts weeks to months, and a depressive episode may last months to years. Although a history of depressive episodes is not required to make a diagnosis of BD I by the DSM‐5 criteria, in practice most patients do experience depressive episodes; however, depressive episodes are required for a diagnosis of BD II.

Reference

McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530–542. https://doi.org/10.1002/2327-6924.12275

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Haloperidol

5mg

oral

PRN q6h

Treatment of Tourette syndrome and schizophrenia, EMS sedation of severity, agitated or delirious pts

Drowsiness, dizziness, urinary retention, tachycardia, hypotension, confusion, rash, nausea, and vomiting EPS

Avoid abrupt withdrawal, avoid use with alcohol, CNS depressant, avoid changing positions, wear protective cloth, and sunglasses due to photosensitivity.

Lorazepam

1mg

oral

PRN Q6r

Management of anxiety and irritability disorder in psychotics, treatment of insomnia, adjust therapy for endoscopic, procedures, relief of postoperative anxiety

Drowsiness, fatigue, ataxia, blurred vision, constipation, dry mouth, neutropenia, respiratory disorder, orthostatic hypotension

Smoking may decrease effectiveness, avoid use with alcohol, CNS depressant, may be habit-forming if used longer than 4 months. Do not discontinue abruptly after long term use.

Lorazepam Injection

1mg

intramuscular

PRN Q6h

Management of Anxiety

Drowsiness, fatigue, ataxia, blurred vision, constipation, dry mouth, neutropenia, respiratory disorder, orthostatic hypotension.

Smoking may decrease effectiveness, avoid use with alcohol, CNS depressant, may be habit-forming if used longer than 4 months. Do not discontinue abruptly after long term use.

Paliperidone

234mg

once

Management of symptoms schizophrenia

Extreme tiredness, dizziness, restlessness, agitation, headache, dry mouth, weight.

Monitor for development of neuroleptic malignant syndrome.

Assess for suicidal tendency especially during

Early therapy.

Monitor blood pressure

risperidone

Magnesium hydroxide

Antipsychotics / Antimanic agent

400mg/5ml

1mg

15ml

Oral

oral

oral

2times a day

Daily PRN

Schizophrenia/ decreased symptoms of psychoses, bipolar mania, or autism.

Constipation

Aggressive behavior,

Extrapyramidal reaction

Constipation

Diarrhea

Visual disturbances

Decreased libido.

Circulatory collapse, hypothermia, pulmonary edema, flushing, drowsiness

Monitor for development of neuroleptic malignant syndrome.

Assess for suicidal tendency especially during

Early therapy.

Monitor blood pressure.

Check serum magnesium level prior administration, Assess for drug interaction, drug incompatibility.

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Risk for violence

Screaming on neighbor’s porch

Extreme hyperactivity/physical agitation

Patient will be free of dangerous levels of hyperactive motor behavior with the aid of medications and nursing interventions within the first 24 hours.

2

Disturbed sleep pattern.

symptoms of mania.

Slurring word

Patient safety is a piority

3

Impaired social interaction

Withdrawal mood

Social isolation

The patient is unable to socialize

4

Impaired verbal communication

Altered perception

Difficulty communication

Impaired cognition

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

Interventions/

Implementations

Ongoing as nursing student will have to go back for evaluation

Social isolation related to lack of family support as evidence by patient stated that she is a divorcee

Creating a support system and ensuring close supervision.

Patient will remain safe while in the hospital with the aid of nursing intervention

Patient will attend group and stayed in day room most of the shift

Patient will demonstrate appropriate social interaction

Provide safe environment, free from harmful things for patient.

Encourage patient to talk freely about feelings

Talk to the client in a calm manner and allow her to express herself

Ongoing as nursing student will have to go back for evaluation

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

Interventions/

Implementations

Evaluation

Difficulty communication related to impaired verbal communication as evidenced by not answering question appropriately

Pt will be able to communicate in a manner that can be understood by others by the time of discharge

Patient will be able to communicate clearly and improve the ability to think clearly and more logically

Patient will express thought and feelings in a coherent, logical, goal directed manner.

Patient will spend time with one or more people in structured activity neutral topics

Patient will demonstrate reality-based thought in verbal communication

Assess if incoherence in speech is chronic or if it is more sudden, as in an exacerbation of symptoms.

Identify the duration of the psychotic meditation of the client.

Keep voice in a low manner and speak slowly as much as possible

Keep the environment calm, quiet, and as free from stimuli as possible.

ongoing. 

Partial meet

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

Interventions/

Implementations

Evaluation

Ineffective coping related to unable to care for self as evidence by helplessness

Patient will develop a new coping skill that do not involve self - harming

*Patient will be encouraged to care herself

*Patient will identify at least one goal for future

*Patient will name at least one acceptable alternative to her situation.

. *During crisis situation patients are unable to think clearly, alternatives can be considered.

*Given patient a support to dealing with strong emotions and gaining a sense of control over her live

Ongoing as nursing student will have to go back for evaluation

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome (objective, expected or desired outcomes or evaluation parameters)

Interventions/

Implementations

Evaluation

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis

Patient Goal(s)

Outcome (objective, expected or desired outcomes or evaluation parameters

Interventions/

Implementations

Evaluation

Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.

Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.

Types of data: subjective & objective

Sources of data

Nursing health history

Physical examination

Diagnostic data

“A statement of purpose describes the aim of nursing care” (Osborn et. al., p. 113)

Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis)

May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.

Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)

Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis.

Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).

Implementation – the carrying out of the planned nursing interventions (Osborn, et al., 2010)

Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.

Interventions should reflect indendent nursing practice as well as collaborative practice.

Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.

Interventions should include specific like schedules, food choices, frequency, etc….

Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).

Essentially this is a reassessment of the patient and the responses as to the interventions implemented.

Compare actual patient behaviors with expected behaviors.

Give reasons why or why not each outcome has been met.

Consider the effectiveness of the nursing intervention, time elements.