Nursing MN-664, week-4 , Assignment

Week-4 Assignment SOAP and question answer from Case study

Unit 4 Assignment

Read the case study and complete a SOAP note and Follow the instruction below.

Crisis Intervention and Safety Planning for the Adult/Geriatric Patient

Read the case study located in the reading document.

Complete a SOAP Note on the patient. (In your SOAP note: Give an example of documentation for the PMHNP provider; (include prescription details as well as instructions for staff to give medication and monitor patient))

In your SOAP note, design a treatment plan that includes PRN medications in case the patient continues to be agitated.

Answer the questions listed below:

· What medications would you prescribe? Why?

· What doses?

· Would you have these listed as standing orders for the nursing home staff or would you want to be notified before given to verify and determine need?

· Would you want to visually see the patient before having the medications given?

· What monitoring would need to be provided after medication is given?

· What documentation would need to be provided and how often for the medication to be continued?

· Would the medication be considered chemical restraints? Why or Why not?

Please see the  template provided to guide your writing of SOAP notes.

To view the Grading Rubric for this assignment, please visit the Grading Rubrics section of the Course Resources.

Submit your assignment to the unit Dropbox before midnight on the last day of the unit.

Case Study

(Crisis Intervention and Safety Planning for the Adult/Geriatric Patient

Mr. Z, age 68, is a new resident of a long-term care facility in the Alzheimer Unit. He was recently taken by his family for evaluation in the Emergency Department after he was found to be confused, physically aggressive with family members, threatening to burn the house down, and paranoid that someone was trying to kill him. The medical work up in the ED was unremarkable. He was discharged from the ED and since arriving at the facility, he has been verbally aggressive with staff, depressed, throwing food, wanders around, and tries to leave. He does not answer most questions when asked by staff and appears agitated. Psychiatry is consulted for management of his behavioral and psychological symptoms.

Medical History: Diagnosed with Alzheimer’s Disease 2 years ago (diagnosed based on symptoms and amyloid PET scan), hyperlipidemia (HLD), presbycusis, osteoarthritis (OA)

Social History: Former smoker 1/2 pack per day x 20 years, no substance abuse. ETOH 2-3 drinks on the weekends x 10 years. Married. Previously employed as accountant

Family History: No history of dementia or mental health disorders. Mother deceased from colon cancer. Father deceased from MI. Son is 31 and healthy.

Medications: Donepezil 5 mg PO HS, Prazosin 1 mg PO HS, Crestor 20mg PO at HS

Allergies: NKDA

Physical Exam Notes

Constitutional: Appears agitated. Not cooperative. Speech noted is rapid and confused. Inattentive and distracted. Appears slightly hyperactive. Pacing hallways at times.

Head: Normocephalic, atraumatic

Cardiac: RRR, no murmurs noted

Lungs: CTA A/P

Abdomen: BS x active x 4, soft/non-tender, LBM 2 days ago

Musculoskeletal: Moves all extremities, abnormal/unsteady gait

Neuro: Cranial nerves appear grossly intact but patient not cooperative enough for complete testing. DTRs 1+ symmetric. Disoriented to place and time. Is able to state his name. Unable to complete MMSE.

Vitals: T: 98.8, P 88, R 18, BP 132/78)

Please follow directions and answer the questions outlined in the Unit 4 Assignment 2 area of your classroom.3

SOAP Note Template

Use the soap note templet supplied.

Patient Name: XXX

MRN: XXX

Date of Service: 01-27-2020

Start Time: 10:00 End Time: 10:54

Billing Code(s): 90213, 90836

(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

Accompanied by: Brother

CC: follow-up appt. for counseling after discharge from inpatient psychiatric unit 2 days ago

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues: He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

Reviewed Allergies: NKA

Current Medications: Fluoxetine 10mg daily

ROS: no complaints

O-

Vitals: T 98.4, P 82, R 16, BP 122/78

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

Labs: CBC, lytes, and TSH all within normal limits

Results of any Psychiatric Clinical Tests: BAI=34

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

A - with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses

2.

3.

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

P- Continue Fluoxetine increasing dose to 20mg.

Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Non-pharmacological Tx: Psychotherapy Modality used: CBT

Pharmacological Tx: (be specific and give detailed Rx information)

Education: discussed smoking cessation

Reviewed medication side effects and adherence importance

Follow-up: in one week or earlier if any depressive symptoms worsen.

Referrals: none at this time