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Assignment: Assignment #2--WednesdayProfess...

E, K

Health Care Provider: K E

Sex: F

Weight: 125 lbs 6 oz

Code Status: 00

Isolation: 00

Food Allergies: 00

Diet: 00

Hospital Floor:

Age: 80 Y

Height: 5'

Alerts: 00

Drug Allergies: 00

Env. Allergies: 00

BMI: 24.5

Psychiatric

Student: Kacy Edsall Assignment: Assignment #2--Wednesday-Professor Peterson-RMH Submitted: 02/19/2015 21:05
Clinical Assignment Grading
Assignment Objectives
No assignment objectives entered.
Clinical Set-up Details
First Day of Clinical:

02/18/2015

Primary Diagnosis:

Bipolar I disorder,
most recent episode
manic, severe with
psychotic features

Provider Name:

E, K

Secondary Diagnosis:

Student Details:

Patient Details:

First Initial:

Identifier 1: K

Last Name:

Edsall

Identifier 2: E

Credentials:

SN

Gender:

Age:

80 Years

Pre-Clinical Manager
Patient Info Identifier: E, K

Gender: F

Age: 80 Y

Nurse Initials: K Edsall, SN

Diagnosis (1)

Primary Diagnosis:

Bipolar I disorder, most recent episode manic, severe


with psychotic features

Patho-Physiology:
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood,
energy, activity levels, and the ability to carry out daily tasks. Signs of mania include mood changes (an overly long
period of feeling "high," or an overly happy or outgoing mood, extreme irritability.) and behavioral changes (talking very
fast, jumping from one idea to another, having racing thoughts, being unusually distracted, increasing activities, such as
taking on multiple new projects, being overly restless, sleeping little or not being tired, having an unrealistic belief in your
abilities, behaving impulsively and engaging in pleasurable, high-risk behaviors.
Therapeutic Regimen:
-Current Health Problems and Related Functional Changes:
On 2/12/15, ECO following reported bullying at the residents of the independent living comples as well as erratic
behaviors. Patient was previous in ED on 2/2/15 and was released to follow up with outpatient VBM. Patient did not
stick to these follow up plans.
good
Medications (4)

Medication:Pantoprazole Delayed Release Tablet -

Classification:
Gastrointestinal agent: proton pump

(Protonix)
Route:

Oral

Frequency:once a day at 0600

inhibitor
Dose:

40 MG

Date

02/12/2015

Ordered:
Comments and Additional Medication Info:
--

Therapeutic Effect:
to treat patients acid reflex

Action:
Pantoprazole is a substituted benzimidazole proton-

Contraindications:
--

pump inhibitor (PPI) that suppresses gastric acid


secretion by inhibiting the gastric (H ,K )-ATPase
enzyme pump.
Side Effects or Adverse Reactions:

Life Threatening Considerations:

Headache or diarrhea

--

Recommended Dose Ranges:


2040 mg PO once daily

Nursing Interventions:
Monitor for GI disturbance or worsening reflex. Teach
patient not lay down for at least 30 minutes after eating.
good

Medication:Levothyroxine (T4) Tablet - (Levothroid, Levoxyl, Classification:


Hormonal agent:
Synthroid, Unithroid)
stimulant/replacement/modifying
(thyroid)
Route:
Oral
Frequency:once a day at 0600

Dose:
Date
Ordered:

Comments and Additional Medication Info:


--

Therapeutic Effect:
to treat patients hypothyroidism

Action:
Levothyroxine exhibits all the actions of endogenous
thyroid hormone. Liothyronine (T3) is the principal
hormone that exhibits these actions whereas
levothyroxine (T4) is the major hormone secreted by the
thyroid gland and is metabolically deiodinated to T3 in
peripheral tissues. Serum concentrations of T4 and TSH
are typically used as the primary monitoring parameters
for determining thyroid function.

Contraindications:
--

Side Effects or Adverse Reactions:

Life Threatening Considerations: Are these life


threatening or just s/e? Maybe it is the layout on
simchart(?)
--

Hair loss, weight gain/lose, changes in skin, possible


changes in energy

75 mcg tablet split in half


02/12/2015

Recommended Dose Ranges:


initial starting dose of 25-50 mcg/dayof levothyroxine
sodium is recommended, with gradual increments in
dose at 6-8 week intervals

Nursing Interventions:

Medication:Oxycodone Tablet - (Roxicodone)

Classification:
Analgesic: opioid

Route:
Oral
Frequency:every 6 hours PRN

Dose:
Date
Ordered:

Monitor for side effects Give at least 30 minutes before


breakfast

5 MG
02/12/2015

Comments and Additional Medication Info:

Therapeutic Effect:

--

to relieve patients chronic pain

Action:

Contraindications:

Oxycodone is a potent -opiate receptor agonist.

--

Side Effects or Adverse Reactions:

Life Threatening Considerations:

Nausea, vomiting, constipation, dry mouth, weakness,

--

sweating, lightheadedness, dizziness, or drowsiness


Recommended Dose Ranges:

Nursing Interventions: also monitor patterns for

515 mg PO every 46 hours as needed

possible addiction.
Monitor for respiratory distress, pain level, monitor for
falls and alertness good

Medication:Risperidone Tablet - (Risperdal)

Classification:
Antipsychotic: other

Route:

Dose:

0.5 MG

Frequency:twice a day at 0900 and 2100

Date
Ordered:

02/17/2015

Comments and Additional Medication Info:


date order: 2/12/15

Therapeutic Effect:
to treat patients mood disorder (bipolar)

Action:
Risperidone is a selective monoaminergic antagonist
with a high affinity for both serotonergic 5-HT2 and
dopaminergic D-2 receptors, a low to moderate affinity
for serotonin 5-HT1C, 5-HT1D, and 5-HT1A receptors,
and a weak affinity for the D-1 and haloperidol-sensitive
sigma site

Contraindications:
--

Side Effects or Adverse Reactions: possible


gynecomastia in young males,constipation

Life Threatening Considerations:


Drowsiness, dizziness, lightheadedness, drooling,
nausea, weight gain, or tiredness

Oral

-Recommended Dose Ranges:


recommended target dose of 48 mg/day

Nursing Interventions:
Monitor patients mood, risk for falls and alertness

Laboratory Tests (3)


Laboratory
Test:

Complete Blood Cell Count (CBC)

Definition and Description:


-Significance of the Test Being Ordered for this Patient:
-CBC: MPV
Test
-Result:
Result
Level:

Result Significance:
-CBC: Platelet Count
Test
--

Date of
Test:

02/12/2015

Result:

Result
Level:

Result Significance:
-CBC: Blood Smear
Test

--

Result:

Result
Level:

Result Significance:
-CBC: WBC
Test
Result:

-Result
Level:

Result Significance:
-CBC (RBC Indices): RDW
Test
-Result:
Result
Level:

Result Significance:
-CBC (RBC Indices): MCHC
Test
-Result:
Result
Level:

Result Significance:
-CBC (RBC Indices): MCH
Test
-Result:
Result
Level:

Result Significance:
-CBC (RBC Indices): MCV
Test
-Result:
Result
Level:

Result Significance:
-CBC: Hct
Test

--

Result:

Result
Level:

Result Significance:
-CBC: Hgb
Test
Result:

11.8
Result
Level:

Low
Result Significance:
good measure of the blood's ability to carry oxygen throughout the body. The range is 12.0 to 15.5. So once again the
patient wasn't extremely low however it should be monitored
CBC: RBC
Test

4.16

Result:

Result
Level:

Low
Result Significance:
If the RBC count is low (anemia), the body may not be getting the oxygen it needs. The range is 4.2 to 5.4. So patient
wasn't extremely low however it should be monitored
Laboratory
Test:

Basic Metabolic Panel

Date of
Test:

02/12/2015

Definition and Description:


-Significance of the Test Being Ordered for this Patient:
-Basic Metabolic Panel: Sodium
Test
-Result:
Result
Level:

Result Significance:
-Basic Metabolic Panel: Potassium
Test
-Result:
Result
Level:

Result Significance:
-Basic Metabolic Panel: Glucose
Test
143
Result:
Result
Level:
High
Result Significance:
This could have been based on what the patient ate before getting the test and the amount of time before the test. More
test would have to be determined to see if this was a problem

Is she diabetic?
Basic Metabolic Panel: Creatinine
Test

1.39

Result:

Result
Level:

High
Result Significance:
Patients kidneys are not functioning as well as they should this could be due to age and lifestyle
Basic Metabolic Panel: CO2
Test

--

Result:

Result
Level:

Result Significance:
-Basic Metabolic Panel: Chloride
Test
-Result:
Result
Level:

Result Significance:
-Basic Metabolic Panel: Calcium
Test
-Result:
Result
Level:

Result Significance:
-Basic Metabolic Panel: Blood Urea Nitrogen (BUN)
Test
27
Result:
Result
Level:
High
Result Significance:
Patients kidneys are not functioning as well as they should this could be due to age and lifestyle
Laboratory
Test:

Toxicology (urine) (Substance Abuse


Testing (urine))

Definition and Description:


-Significance of the Test Being Ordered for this Patient:
-Toxicology (urine) (Substance Abuse Testing (urine))
Test
Opiates
Result:
Result
Level:
High
Result Significance:

Date of
Test:

02/12/2015

This is because the patient was taking Oxycontin while at home and could have possibly be abusing it at home.
Clinical Grading:
Clinical
Grade:
Remarks:
Care Plan Details
Care Plan
Priority
1

Medical Diagnosis: Bipolar I disorder, most


recent episode manic, severe with psychotic

Created By: K Edsall 02/19/2015 | 15:35


Nursing Diagnosis: Injury, Risk for

features
Status:

Active

Type:
Actual

Related To
Physical
Psychological
Evidenced By
Psychological dysfunction signs and symptoms (specify)

Expected Outcome

Measurement/Time Frame

Comments

Patient will explain methods of preventing


injuries.

short term - name 3 methods twice during the


shift

GOOD

Patient will remain free of injuries.

long term - until time of discharge.

Interventions

Rationale

Comments

Maintaining bed in a low


position

Check 3 times during the shift to maintain optimal safety


so patient has less risk falling out of the bed or getting int
o the bed since she has limited range of motion

EXCELLE
NT

Removing all possible hazards


in environment

Checking for hazards at the beginning of each shift. With


out hazardous material the patient has less of a chance o
f hurting herself

EXCELLE
NT

Reviewing the drug profile for


potential side effects that could
increase the risk of injury

Before giving the drugs and teaching patient of possible


side effects. antipsychotics can lead to drowsiness whic
h can increase the risk of falls. Monitor for alertness and
put fall precautions in place

EXCELLE
NT

Priority
2

Medical Diagnosis: Bipolar I disorder, most


recent episode manic, severe with psychotic
features

Status:

Active

Created By: K Edsall 02/19/2015 | 15:50


Nursing Diagnosis: Noncompliance

Type:
Potential

Related To
Knowledge relevant to the regimen behavior
ADDED-Lack of judgement of thinking there is a problem
ADDED-Lack of insight to their mental illness
Evidenced By
Behavior indicative of failure to adhere
Failure to keep appointments
Failure to progress

Expected Outcome

Measurement/Time Frame

Comments

Patient will collaborate with

Long term: Before discharge. Patient will incorport

GOOD

healthcare providers to decide


on a therapeutic regimen that is

ate the 3 ways they previously discussed with nurs


ing staff to manage therapuetic regimen to come u

congruent with health goals and


lifestyles.

p with a plAn that the patient can adhere to.

Patient will verbalize ability to


manage therapeutic regimens.

Short term: During shift. Patient will name 3 ways t


hey could manage the therapuetic regimen.

Maybe 3 ways wou


ld be a bit much bu
t it is measurable.

Interventions

Rationale

Comments

Assessing the patient for


barriers to follow-up of
treatment recommendations

Name at least 2 ways patient could avoid those barriers to m


ake sure they get to follow up appointments so that treatment
can continue and be maintained.

good

Exploring the meaning of the


person's illness experience

Patient does not believe they have mental illness. Very much
in denial. First step is to get patient out of the denial phase a
nd work towards goals set by the patient to come to terms wit
h the mental illness so than progress can be made towards tr
eatment. Try to explore the meaning twice everyday until pati
ent comes to terms.

good

Identifying the reasons for


actions that are not

Patient needs to name a least one alternative to each reason


that is not therapeutic to improve adherence

good

therapeutic and discussing


alternatives

Priority
3

Medical Diagnosis: Bipolar I disorder, most


recent episode manic, severe with psychotic
features

Status:

Active

Created By: K Edsall, SN 02/19/2015 | 20:32


Nursing Diagnosis: Ineffective coping

Type:
Actual

Related To
Inadequate level of confidence in ability to cope
Inadequate social support created by characteristics of relationships
Uncertainty
Evidenced By
Change in usual communication pattern

Destructive behavior toward others


Difficulty organizing information
Lack of resolution of problem
Poor concentration

Expected Outcome

Measurement/Time Frame

Comments

Patient will seek help from a

after discharge - patient will attend all outpatient and do

good

healthcare professional as

ctors appointments that are necessary(as scheduled)

appropriate.
Patient will use effective coping

Patient will identify 3 coping stratigies at the beginning

strategies.

of the shift and use them through out they day.

good

Interventions

Rationale

Comments

Discussing the patient's and family's

Patient needs to accept the fact that she has a ment

good

power to change a situation or the


need to accept the situation

al illness so that she can more forward with recover


y. Will discuss this with patient twice during shift.

Offering instruction regarding


alternative coping strategies

Over the patient information on coping strategies to


help the patient pick the 3 coping strategies the wan
t to try to incorporate during the day for the short ter
m outcome.

good

Using verbal and nonverbal


therapeutic communication
approaches

Using these so that I can have a more effective relati


onship with the client to accomplish more task. I will
use this throughout the entire shift.

good

Care Plan Grading:


Care Plan
Grade:
Remarks:
Charting Details
History and Physical
Created By: K Edsall 02/19/2015 | 15:08
Modified By: K Edsall, SN 02/19/2015 | 21:04
Psychiatric History
Patient Information
Chief Informant:

patient

Chief Complaint:

patient stated, " I don't know why I am here."

History of Current
Problem:

Patient was brought in to the ED by ECO from independent living facility because of
bullying other patient and erratic behavior.

Allergies:

gabapentin (reaction?)

Psychiatric History
Past Psychiatric History:

Previous Psychiatric Hospitalizations:

--

--

Suicide History:

Outpatient Treatment:

--

--

Alcohol Use:

Substance Use:

--

patient could possibly be abuse the oxycotin


prescribed for her chronic pain. This was neither
confirmed or denied.

Electroconvulsive Therapy (ECT):


-Family History:

-Past Medical History


Previous Illnesses:

Contagious Diseases:

--

--

Injuries or Trauma:

Surgical History:

--

Neck surgery in 2012

Dietary History:

Other:

--

--

Social History:

Current Medications:

--

--

Current Medications:
-Review of Systems good
Integument:

HEENT:

WNL

WNL

Cardiovascular:

Respiratory:

WNL

WNL

Gastrointestinal:

Genitourinary:

WNL

WNL

Musculoskeletal:

Neurologic:

Patient has chronic pain and had neck surgery where


plates and screws where put in. Patient had limited
range of motion but was ambulatory by herself.

WNL
Endocrine:
WNL

Genitalia:

Lymphatic:

WNL

WNL

Mental Status excellent

Mental Status Examination


Appearance:

Behavioral Activity:

pt. was appropriately dressed for the weather.

Cooperative, argumentative, and negative/sarcastic.

However, patients hygiene was poor. Hair was matted

No extrapyramidal symptoms.

to her head and had not showered since she has been
at BHU if though nurses have offered assistance and

Speech:

alternatives.

clear, loose, labile, excessive. Pt. would jump from one


point to a completely other point for no clear reason.

Thought Form:

Thought Content:

Flight of ideas. Jumping from one subject to the next

Possible delusions and very loose content.

for no clear reason.


Suicidal Impulses:
Denies SI.
Homicidal Impulses:

Orientation:

Denies HI.

Orientation to time, person, and place. But has poor


judgement and insight in to the situation at hand.

Memory:

Mood:

Patient has good long term memory but short term


memory is a little off sometimes.

pt. states "i feel perfectly fine."


Affect:
pt. was a little flat but other wise was congruent with
her mood. good eye contact.

Judgment and Insight:

Attention:

very poor. pt. states "I don't know why I'm here. I don't
have a mental illness."

Patient is alert and maintains good eye contact.

Physical Examination
Physical Exam
General:

Vital Signs:

--

--

Integument:

HEENT:

--

--

Cardiovascular:

Respiratory:

--

--

Gastrointestinal:

Genitourinary:

--

--

Musculoskeletal:

Neurologic:

--

--

Developmental:

Endocrine:

--

--

Genitalia:

Lymphatic:

--

--

Impressions
Impression:

--

Plan:

--

Provider Signature:

--

Date:

01/01/0001

Time:

--

Special Charts - Miscellaneous Nursing Notes


Miscellaneous Nursing Notes

Created By: K Edsall, SN 02/18/2015 | 10:16

Axis I: Bipolar, manic with psychosis


Axis II: deferred
Axis III: thyroid issues, bladder mesh, chronic pain
Axis IV: problems with primary support. Pt. has a conflict with brother. Economic problems, limited income and
unknown about of debt. Also, possible financial exploitation of male friend. Patient has poor follow-up with
outpatient services. Struggles at current independent living environment because of bullying other residents and
complaints from those residents.
Axis V: GAF: 52 at admittance. I believe now she is at 40. I believe this due to her impairment in reality testing. Pt.
states she doesn't know why she is here. Patient is refusing medication and any hygiene treatment. She has
serious social issues with being to intrusive with the patients on the unit as well as bullying residents at her
independent living facility. Patients communitcation is loose and laible as well. good
Special Charts - Miscellaneous Nursing Notes
Miscellaneous Nursing Notes

Created By: K Edsall 02/19/2015 | 15:26

Information about Axis I: (also located in diagnosis): Bipolar disorder, also known as manic-depressive illness, is a
brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out daily tasks.
Signs of mania include mood changes (an overly long period of feeling "high," or an overly happy or outgoing
mood, extreme irritability.) and behavioral changes (talking very fast, jumping from one idea to another, having
racing thoughts, being unusually distracted, increasing activities, such as taking on multiple new projects, being
overly restless, sleeping little or not being tired, having an unrealistic belief in your abilities, behaving impulsively
and engaging in pleasurable, high-risk behaviors. excellent!
Patient shows extreme signs of mania. She is talking excessive and jumping from one thought to another. She also
is very unrealistic in her thought process and understanding in what is going on.
Special Charts - Miscellaneous Nursing Notes
Miscellaneous Nursing Notes

Created By: K Edsall, SN 02/19/2015 | 20:57

On 2/18/15. Patient had a TDO hearing where she ultimately got involuntarily committed to the unit. During the
hearing (i was able to observe) she seemed very manipulative and said everything the judge wanted to hear. She
was very in control and her thought process seemed really clear which was total opposite of what she seemed like
on the unit. she was good wasn't she???
Special Charts - AIMS
AIMS
Facial and Oral Movements

Created By: K Edsall 02/19/2015 | 15:22

Muscles of Facial Expression:

0 = None

Lips and Perioral Area:


Jaw:

0 = None
0 = None

Tongue:

0 = None

Extremity Movements
Upper (arms, wrists, hands, fingers):

0 = None

Lower (legs, knees, ankles, toes):

0 = None

Trunk Movements
Neck, shoulders, hips:

0 = None

Global Judgements
Severity of abnormal movements
overall:

0 = None

Incapacitation due to abnormal


movements:
Patient's awareness of abnormal
movements:

0 = None
1 = Aware, no distress

Dental Status
Current problems with teeth and/or
dentures:
Are dentures usually worn:
Do movements disappear in sleep:

No
No
No

Vital Signs
Chart Time

Temperature
(F)

Respirations
(Resp/min)

Pulse
(Beats/min)

Blood Pressure
Oxygenation
(mmHg)

Entry By

02/19/2015
20:52

98.2
Site:
Tympanic

18

77
Site:
Monitor

121/78
Site: Left
arm
Position:
Sitting

K Edsall,
SN

Height/Weight
Chart Time

Weight (Pounds/Kgs)

Height (Feet
Inches/cm)

Entry By

02/19/2015 20:53

125 lbs / 56 kgs


Standing scale

5' / 152.4 cm

K Edsall, SN

Patient Card
Order
Description
Date/Time

Category

Status

Last
Discontinued Entry By
Performed By

02/19/2015 Bipolar I disorder,


| 15:35
most recent episode
manic, severe with
psychotic featuresInjury, Risk for

Care Plan

Active

--

----

K Edsall
02/19/2015
15:35

02/19/2015 Bipolar I disorder,


| 15:50

Care Plan

Active

--

----

K Edsall

most recent episode

02/19/2015

manic, severe with

15:50

psychotic featuresNoncompliance
02/19/2015 Bipolar I disorder,
| 20:32

Care Plan

Active

--

----

K Edsall,

most recent episode

SN

manic, severe with

02/19/2015

psychotic featuresIneffective coping

20:32

Charting Grading:
Charting
Grade:
Remarks:
Competencies
No competencies entered.
5

Remarks:

Overall Grading:
Care Plan
Grade:

Pre-Clinical Manager Grade:

Charting
Grade:

Overall Grade:

15/15

Remarks:

SUBJECTIVE/OBJECTIVE-Excellent job with all your data in this section.4/4 ANALYSIS & NURSING DIAGNOSISExcellent job with your diagnoses! Good job with description of all the axis 4/4 PLAN/OUTCOME- All your outcomes
were appropriate and measurable and in SMART format. 3/3 INTERVENTIONS- Medications and interventions well
done.4/4 Exceptionally well done note that included all the pertinent data. GOOD JOB !

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