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SOAPIE # 1
Student Name:
SInitials: *** Unit/Room# ****
Admission Date: *****
Diagnoses: Psych, Personality
disorders, medical diagnoses
Bipolar disorder (manic phase) with
psychotic symptoms, borderline
intellectual functioning, narcissistic
personality trait
Chief Complaint
I dont know
Nicole Rossi
Date: 11/09/15
Age: 53
Gender: Female
HT: 54 Wt: 275 lbs
BMI: 47
VS:
Temp- 98.4 (temporal)
Pulse- 98 (radial)
BP- 143/90 (right arm, sitting)
O2 Sat- 100% room air
Respirations- 19
MSE:
Allergies/Response:
ACE inhibitors, Penicillin, Sulfa
antibiotics (all rash)
Severe Parkinsonian symptoms with
high dose Haldol, peripheral edema
when on Depakote
WRAP/Safety Plan:
Did not have a WRAP/safety plan nor
an advanced directive that I could tell
on chart and did not want to discuss
mental health condition
Psychiatric & Medical History:
Hypertension, type 2 diabetes,
vitamin D and B12 deficiency, Hx UTI,
hyperlipidemia, bipolar disorder with
psychotic symptoms, narcissistic
personality traits, declining
intellectual functioning
Psychiatric symptoms began after
high school
Admissions in WSH, Central State,
SVMHI (1981), VBH
Current Symptoms:
Needy, attention-seeking, minor
Parkinsonian gait, high glucose levels,
agitation
Current Stressors:
Being at WSH gives her stress, does
risks with 3-4 pertinent nursing goals and interventions. Address Axis I & III at a minimum.)
Patient Outcomes
ASSESSMENT Intervention
ACTION Intervention
SMART goals
(assess/monitor for)
Pt will allow others to speak
first during question and
answer time within group at
least 80% of the time
before stating her own
opinion by discharge.
TEACHING Intervention
Knowledge Deficit
Ineffective self-health
maintenance related to cognitive
impairment and inability to make
appropriate judgments/lack of
insight to health conditions as
evidenced by demonstrated lack
of knowledge about basic health
practices, history of multiple
readmissions, and lack of
interest in improving health
behaviors.
Rationale
Nursing Implications
Metformin
(Glucophag
e)- oral
antidiabetic
agent
(Biguanide)
Recommendedsince concurrent
insulin therapy,
start off at 500 mg
then increase
every week by 500
mg until glycemic
control achieved
Pts Dose- 1000
mg
Route- oral tablet
Time- Q 0730,
1700
Possible- headache,
hypoglycemia, hypokalemia,
hypersensitivity reaction, flu-like
symptoms
Decreases liver
glucose production,
decreased GI
absorption of
glucose, improves
insulin sensitivity
Metoprolol
(Lopressor)Beta-Blocker
antihyperte
nsive
Clozapine
(Clozaril)Antitypical
antipsychoti
c
24 hour control on
the liver, skeletal
muscle, and adipose
tissue to regulate the
metabolism of
carbohydrates,
protein, and fats
(stimulation of
glycogen synthesis
in the liver, storage
in adipose,
triglyceride
hydrolysis inhibition)
Possible- hypoglycemia,
diarrhea, limb pain, flu-like
symptoms, headache.
Pharyngitis, rhinitis
Recommended50-100 mg BID
unless extended
release then 25100 mg
Pts Dose- 25 mg
Route- oral tablet
Time- BID
Selectively inhibits
beta 1 adrenergic
receptors to
decrease
sympathetic activity
on the heart
(decrease HR, BP)
Possible- hypotension,
bradycardia, chest pain,
dizziness, fatigue, headache,
constipation or diarrhea, nausea
and vomiting, musculoskeletal
pain, blurred vision, tinnitus
Recommendedstart with 25 mg
daily then increase
by 25 mg daily
until effective (but
max is 550 mg
Antagonizes
dopamine type 2
receptors and
serotonin type 2 A
receptors (in addition
to alpha-adrenerfic,
For pts
psychotic issues,
especially during
manic phase
(disrobing,
agitation,
Possible- tachycardia,
drowsiness, dizziness,
hypotension, constipation,
nausea and vomiting, heartburn,
headache, seizures,
leukopenia/agranulocytosis, EPS,
Haloperidol
(Haldol)typical
antipsychoti
c
Recommended0.5-5 mg 2 to 3
times daily (for
psychosis)
Pts Dose- 5 mg
Route- oral tablet
Time-BID
Losartan
(Cozaar)Angiotensin
II Receptor
Blocker
antihyperte
nsive
RecommendedPts Dose- 50 mg
Route- oral tablet
Time-once daily
Cholecalcife
rol (Vitamin
D)- Vitamin
D Analog
histamine H1,
cholinergic
receptors) to
decrease positive
and negative
psychotic symptoms
restlessness,
confusion,
deficient selfcare, loose
associations)
Blocks dopimergic
D2 receptors in the
brain to mainly work
for positive psychotic
symptoms
Antagonizes
angiotensin II to help
decrease blood
pressure
Supplement to
increase amounts of
Vitamin D3 in the
body
Possible- hypervitaminosis D
(hypercalcemia, headache,
nausea, vomiting, lethargy,
confusion, sluggishness,
abdominal pain, bone pain,
polyuria, polydipsia, weakness,
Haloperidol
Deconateinjection
typical
antipsychoti
c
Recommendationmaximum of 100
mg or 10-15 times
daily oral dosage
Pts Dose- 100
mg/mL (1 mL)
Route- IM
Time- Q4W1600
For pts
psychotic
symptoms,
especially since
hx of
management
nonadherence
Furosemide
(Lasix)- loop
diuretic
Recommendation20-80 mg dose
Pts Dose- 20 mg
Route-oral tablet
Time- once daily
Inhibits reabsorption
of sodium and
chloride in ascending
loop of Henle and
distal renal tubule
Lorazepam
Recommendation-
Enhances inhibitory
effect of GABA
issues and
agitation (as
stated on chart),
anxiety
Benztropine
(Cogentin)AntiParkinsons
agent,
anticholiner
gic
Anticholinergic and
antihistaminic
effects to help
decrease EPS
Magnesium
hydroxide
(milk of
magnesium)
- laxative
Recommendation30-60 mL/day
Pts Dose-2400 mg
(30 mL)
Route- oral
solution
Time- Q12H PRN
Promotes bowel
evacuation by
causing osmotic
retention of fluid
which increases
peristaltic activity
For pts
constipation
PRN, especially
given the many
medications that
she is on that
can cause
constipation
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Resources:
Access Behavioral Health. (n.d.). Global assessment of functioning. Retrieved from
https://www.omh.ny.gov/omhweb/childservice/mrt/global_assessment_functioning.pdf
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to planning care (10th ed.). Maryland Heights, MO: Mosby Elsevier.
Lexi-Comp Online. (n.d.) Retrieved from http://online.lexi.com/ Hudson, OH: Lexi-Comp, Inc.
Townsend, M.C. (2014). Essentials of psychiatric mental health nursing (6th ed.). Philadelphia, PA: F.A. Davis Company.
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