MENTAL HEALTH

STUDENT-Schizophrenia-SKINNY_Reasoning.pdf

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SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data

History of Present Problem: Jeremy Brown is a 30-year-old Caucasian male who was brought to the emergency department (ED) by the police after

being involved in an altercation at work. Jeremy was at work today, and he threw a large piece of metal at a coworker and

began yelling, “Stop following me, I know what you have been up to!” Because Jeremy was very agitated and upset, and

the police were called.

Since arriving in the ED, he has been agitated, displaying rapid pressured speech and repeating the phrases he hears

the police and others in the ED said. Jeremy reported that he recently stopped taking his risperidone and citalopram

because he believed his coworkers have been breaking into his house and poisoning his medications. Jeremy’s manager

reports that he was diagnosed with schizophrenia five years ago.

Personal/Social History: Jeremy graduated from college with a 4.0 GPA and was in his first year at law school when he experienced the first

episode of acute mental illness and was diagnosed with schizophrenia. He had to drop out of law school at age 24 and

never finished. Jeremy lives at home with his mother and father and recently broke up with his girlfriend.

Jeremy likes his job at the foundry but feels he is a disappointment because both of his sisters are lawyers, as is his

father. Jeremy has no close friends and only a few acquaintances. Jeremy’s mental health had been stable up until the last

three months. He has been feeling more paranoid the past three months and experienced a dramatic increase in symptoms

when he stopped taking all of his medications one month ago.

What data from the histories are RELEVANT and have clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment: T: 97.8 F/36.6 C (oral) Provoking/Palliative: Denies pain

P: 100 (regular) Quality:

R: 22 (regular) Region/Radiation:

BP: 130/84 Severity:

O2 sat: 98% room air Timing:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT VS Data: Clinical Significance:

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:

RELEVANT Mental Status Exam Data: Clinical Significance:

Current Assessment:

GENERAL

APPEARANCE: Calm, body relaxed, no grimacing, appears to be resting comfortably

RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,

equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill

NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow

SKIN: Skin integrity intact, skin turgor elastic, no tenting present

Mental Status Examination: APPEARANCE: Diaphoretic, uncombed shoulder-length, somewhat greasy hair; cloths are stained and torn.

Cooperative with the admission process.

MOTOR BEHAVIOR: No abnormal muscle movements

SPEECH: Rapid and pressured. Client often repeats words and phrases he hears others in the

emergency room say. The client says, “He was brought to the emergency room” over and

over again when he is not distracted or engaged in conversation.

MOOD: Reports feeling very upset

AFFECT: Becomes agitated/anxious when talking about his co-workers and his meds; guarded and

suspicious, mood and affect are congruent.

THOUGHT PROCESS: Linear but irrational

THOUGHT CONTENT: Displays paranoid delusions that coworkers are following him to hurt him and are poisoning

his medication.

PERCEPTION: Denies auditory or visual hallucinations, or feelings of depersonalization (feeling detached

from self or environment)

INSIGHT: Poor-believes he was brought in to the emergency room for protection from his coworkers

JUDGMENT: Poor-stopped meds and is acting aggressively towards co-workers

COGNITION: Alert and oriented times 4 (person, place, time and purpose), is easily distracted

INTERACTIONS: Is in good control when talking with nursing staff, his boss, and police.

SUICIDAL/HOMICIDAL: Denies any suicidal thoughts or thoughts of self-harm. Stated he wants to “punish” his co-

workers.

Diagnostic Results: BMP: Sodium (135–145) Potassium (3.5–5) Glucose (70–110) Creatinine (0.6–1.2)

Current: 130 3.5 160 1.1

Prior: 135 3.8 128 1.0

CBC: WBC (4.5-11) Neutrophil (42-72%) Hgb (12-16) Platelets (150-450)

Current: 6.5 60 12.5 250

Prior: 8.2 68 12.8 289

What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT

Diagnostic Data:

Clinical Significance: TREND:

Improve/Worsening/Stable:

Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem?

(Management of Care/Physiologic Adaptation)

Problem: Pathophysiology in OWN Words:

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)

Medical Management: Rationale: Expected Outcome: Admit to the inpatient mental

health unit on a voluntary

status

Risperidone 2mg PO BID

Citalopram 20mg PO at HS

Lorazepam 1mg PO every 6

hours PRN for anxiety or

agitation

Haloperidol 5mg IM every 4

hours PRN for severe

agitation

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care)

Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?(Psychosocial Integrity)

Psychosocial Priorities:

Nursing Interventions: Rationale:

5. What can you do to engage yourself with this patient’s experience, and show that he matters to you as a person? (Psychosocial Integrity/Basic Care and Comfort)

RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
RELEVANT Data from Social HistoryRow1:
Clinical SignificanceRow1_2:
Current VS:
PQRST Pain Assessment:
P 100 regular:
Denies painQuality:
R 22 regular:
Denies painRegionRadiation:
BP 13084:
Denies painSeverity:
Denies painTiming:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_3:
Current Assessment:
Calm body relaxed no grimacing appears to be resting comfortably:
RESP:
CARDIAC:
NEURO:
Alert oriented to person place time and situation x4:
GI:
GU:
Voiding without difficulty urine clearyellow:
SKIN:
Skin integrity intact skin turgor elastic no tenting present:
Mental Status Examination:
APPEARANCE:
No abnormal muscle movements:
SPEECH:
MOOD:
Reports feeling very upset:
AFFECT:
Linear but irrational:
THOUGHT CONTENT:
PERCEPTION:
INSIGHT:
JUDGMENT:
COGNITION:
SUICIDALHOMICIDAL:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_4:
RELEVANT Mental Status Exam DataRow1:
Clinical SignificanceRow1_5:
BMP:
Current:
Prior:
CBC:
Current_2:
Prior_2:
RELEVANT Diagnostic DataRow1:
Clinical SignificanceRow1_6:
TREND ImproveWorseningStableRow1:
ProblemRow1:
Pathophysiology in OWN WordsRow1:
RationaleAdmit to the inpatient mental health unit on a voluntary status Risperidone 2mg PO BID Citalopram 20mg PO at HS Lorazepam 1mg PO every 6 hours PRN for anxiety or agitation Haloperidol 5mg IM every 4 hours PRN for severe agitation:
Expected OutcomeAdmit to the inpatient mental health unit on a voluntary status Risperidone 2mg PO BID Citalopram 20mg PO at HS Lorazepam 1mg PO every 6 hours PRN for anxiety or agitation Haloperidol 5mg IM every 4 hours PRN for severe agitation:
Nursing PRIORITY:
PRIORITY Nursing Interventions:
Expected OutcomeRow1:
Psychosocial Priorities:
Rationale:
Nursing InterventionsRow1:
RationaleRow1:
Answer5: