Student Name: G .M

Week:

Dates of Care: 2/3/2023

Demographics and Brief History

Patient Initials

M. C

Sex

F

Age

44

Room

227-1

Admitting Date 1/27/2023

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

The client was brought in by her mother after the patient had a falling out with her son and had an escalating amount of difficulty with impaired thought process and hallucination over the course of the past weeks.

Attending physician/Treatment team:

Lozano, Cosme. OMD

Precautions:

Seizure and suicide ideation precautions.

Primary Diagnosis:

Psychosis

Co-morbidities:

Seizure

Allergies:

No known allergies

Code Status:

Full code

Isolation: (type and reason)

No isolation

Admission Height:

69.2 inches

Admission Weight:

74.3 kg

Arm Band Location (colors & reasons)

White band on the right arm

Past Medical History: (pertinent & how managed)

The client has a past medical history of seizures

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

The client had no significant events during this hospitalization

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

General Appearance

· Grooming/Clothing

· Patient appeared cleaning and her hair was well combed.

· Hygiene

· Patient presents herself to be cleaning and performing proper hygiene.

· Posture

· Patient isn’t bent over but rather sits up.

· Gait

· Patient has stable gait.

· Obese/average or normal/ underweight

· Patient is around average weight.

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

· There was no evidence of scars, abrasions, bruises, tattoos, or other marking present on the patient.

Activities of Daily Living

· Sleep/rest

· Patient was able to sleep well.

· Diet

· Patient reports eating three square meals and some snacks each day.

· Exercise/mobility

· Patient walks perfectly without any assistance.

· Elimination

· Patient has regular and normal bowel movement.

· Hygiene

· Patient reports showering twice a day along with brushing her teeth twice and changing her clothes daily.

GI

Diet: Regular

Blood Glucose (time & date): 74 (2/3)

Last bowel movement (time & date): 6:30 am (2/3)

Pertinent Labs/Test:

Assessments:

· Stool

· 2/3/23

· Bowel sounds

· Present in all 4 quadrants

· Tenderness, distention

· No tenderness or distention

· Appetite, nausea, vomiting

· Patient had a good appetite and no nausea or vomiting.

Respiratory:

Assessments:

· Lung sounds

· Clear on anterior and posterior lobes

· Cough, sputum

· Not present

· SOB

· Not present

Neurosensory:

Alert & Orientated: A&O x 4

Follows commands: Follows commands well

Speech Comprehensible: Speaks well without stutoring

Pertinent Labs/Test:

Assessments:

· LOC

· X4

· Pupils

· normal

· Glascow Coma Scale

· 15

· Dizziness

· Denies

· Headaches

· Denies

· Tremors

· No signs of tremors

· Tingling weakness, paralysis, or numbness

· Denies

Interventions:

Cardiovascular:

Pertinent Labs/Test: Potassium level, ADLs, Cholesterol, and Triglycerides

Assessments

· Peripheral pulses

· 2+ bilaterally

· Heart sounds (murmurs or bruits)

· Normal heart sounds no murmurs or bruits

· Edema

· No edema present

· Chest pain, discomfort, palpitations

· Denies

Interventions:

Musculoskeletal:

Activity:

Casts/Slings: Not present

Assessments:

· Strength, weakness

· Normal +5

· ROM

· Normal

· Gait (documented under appearance)

Normal gait

· Pain

· No pain

· Fractures, amputations, or transfers

·

Renal:

Pertinent Labs/Test:

Assessments:

· Bruit, thrill, location

· Bruit, thrills are present

· Urine-quality

· Clear without odor

· Burning with urination, hematuria

· Denies

· Incontinent, continent, I & O

· Normal

Skin:

Braden Score: -24

Pertinent Labs/Test: T.B test quantiforon

Assessments

· Bruising, wounds, drains

· No bruises, wounds, or drains present

· Turgor

· Normal

· Surgical incisions

· Non present

· Finger & toenails

Normal

Pain:

Pain score:

Assessments/Interventions:

· Scale used

· 0/10

· Location, duration, intensity, character

·

· Exacerbation, relief

·

Gyn:

Gravida/Para:-N/A

LMP:-N/A

Last Pap:-N/A

Breast exam:-N/A

Pertinent Labs/Test:

Assessment

· Bleeding

· Denies bleeding

· Discharge

· Denies discharge

Safety:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Advance Directives/Ethical considerations:

AD:

POA:

Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)

10 Panel Toxicology/Drug Screen: if available

Blood Alcohol Level/Ethyl Serum Level: if available

Psycho/Social Assessment

· Level of education: Some collage

· Occupation: Unemployed

· Race/Ethnic Background or Identification :

· Religion/Spiritual Beliefs : Christian

·

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

·

· Special Talents/Interests/Skills

·

· Environment (home and community)

·

· Family Structure/History:

Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)

Support System:

Stressors/Stress Management Practices:

Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article.

Discuss the current disease process:

Psychosis

Discuss the etiology of the patient’s illness:

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

Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:

.

References

Freq

Significant Side Effects / Adverse Reactions

Nursing Implications

Acetaminophen

Pain Medication

650mg

P O

Q4

PRN

Pain and fever

Rash, Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric, diarrhea.

-Monitor for signs and symptoms

-Monitor potential abuse from psychological dependence

Simethicone

Gastrointestinal agents

15mg

P O

Q 6

Dyspepsia

Severe dizziness, trouble breathing, rash, itching, swelling

– assess pt for abdominal pain, distention, and bowel sounds prior to and periodically throughout the course of therapy- frequency of belching and passage of flatus should be assessed

Benztropine

Mesylate

Anticholinergic

2mg

I M

Q12H

PRN

Extrapyramidal

Symptoms

Drowsiness, dizziness, nausea, vomiting, constipation, blurred vision, and tachycardia

-Access therapeutic effectiveness

-Monitor for muscle weakness

-Monitor for signs and symptoms

Gabapentin

Anticonvulsants

300mg

P O

Nightly

It appears to interact with GABA cortical neurons, but its relationship to functional activity as an anti-convulsant is unknown. Used in conjunction with other anticonvulsants to control certain types of seizures in patients with epilepsy. Effective in treating painful neuropaths.

Drowsiness, fatigue, dizziness

Monitor of therapeutic effectiveness; may not occur until several weeks following initiation of therapy, in those treated for seizure disorders , assess frequency of seizures: In rare cases, the drug has increased the frequency of partial seizures, Monitor dizziness and CNS depression, monitor for changes in behavior that may be indicative of suicidal ideation

Haloperidol

Psychotherapeutic

5 mg

Oral

Q 6

Psychotic symptoms

-Weakness, insomnia, tachycardia, blurred vision, respiratory depression, diaphoresis

-Monitor for therapeutic effectiveness and exacerbation of seizure activity

Lamotrigine

Anticonvulsants

200mg

P O

Bid

Stabilizes neuronal membranes by inhibiting sodium transport.

Ataxia, dizziness, headache, behavior changes, depression, drowsiness, insomnia, tremor

Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.

Lorazepam

Anxiolytic

2mg

I M

Q 6

Mild agitation

-Sedation, weakness, nausea, vomiting, anorexia, hypertension or hypotension, confusion, and anterograde amnesia

-Sedation, weakness, nausea, vomiting, anorexia, hypertension or hypotension, confusion, and anterograde amnesia

-Do not drink large volumes of coffee or alcoholic beverages

-Supervise patient who exhibits depression with anxiety

Magnesium

Hydroxide

Saline and Osmotic Laxative

30ml

P O

Daily

Pulls water into colon to produce watery stool & causing peristalsis.

Evacuation of the colon & Hypermagnesemia

Take 2 hours apart from other drugs

Pravastatin Sodium

HMG-CoA Reductase Inhibitor

40mg

PO

Daily

increase in LDL receptors, which bind and remove circulating LDL-cholesterol, results. Production of LDL-cholesterol decreases because of decreased production of VLDL-cholesterol or increased VLDL removal by LDL receptors.

Rhabdomyolysis, tendon rupture

Assess any joint pain, or muscle pain, tenderness, or weakness, especially if accompanied by fever, malaise, and dark-colored urine

Topiramate

Mood stabilizer

200mg

PO

Bid

Blockage of sodium channels in neurons.Enhancement of GABA (gamma-aminobutyric acid), an inhibitory neurotransmitter. Prevention of activation of excitatory neurons.Decreases neurotransmission.

Seizures, dizziness, drowsiness, fatigue, lower concentration/memory, nervousness, psychomotor slowing, speech problems, sedation, aggressive reaction, agitation, anxiety, cognitive disorders, confusion, depression, malaise, abnormal vision, diplopia, nystagmus, acute myopia, nausea

Increase blood levels of phenytoin and amitriptyline. May decreases effect of hormonal contraceptives, risperidone, lithium, or valproic acid. Risk of CNS depression.

Trazodone HCI

Serotonin antagonist reuptake inhibitor (SARI).

50mg

P O

PRN

Alters effects of serotonin in CNS.

Suicidality, drowsy, confusion, dizzy, fatigue, hallucination, headache, insomnia, nightmares, slurred speech, syncope, low BP, weakness, blurry, increase BP, tinnitus, arrhythmias, chest pain, palpitations, QT increase, increase HR, dry mouth

BP. Pulse. ECG. Sexual dysfunction. Serotonin syndrome.Assess for depression. CBC. Renal/hepatic function

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Impaired Verbal Communications

Psychological borders

Difficulty communicating thoughts

2

Disturbed thought process

Overwhelming stressful life events

Delusions & Hallucinations

3

Defensive Coping

Perceived threat to self

Denial of obvious problems

4

Interrupted family Process

Situational Crisis

Inability to mee the needs of the family

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set