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Room 26-C
Patient/Age/Sex M.V 53 Female
Date of evaluation 2/11/
Allergies Codeine Coconut Phenobarbital Phenytoin
Admit date 1/27/
Diagnosis Schizophrenia Depression
Legal status Conserved Riesed
Chief complaint/concern (CC) (quoted: “In the patient’s words) Patient stated “The Dr thinks I overdosed, that’s why I am here”
Past psychiatric history The patient was diagnosed with schizophrenia and depression.
History of Present Illness (HPI) Patient's has a history of self-harm, seizures, high cholesterol, COPD, GERD, and chronic back pain.
Alcohol/Tobacco/Drug history : Alcohol Barbiturates Tobacco Cocaine Marijuana Heroin Vaping Inhalants Other: LSD Methamphetamines PCP IV Opioids
Medical history
Schizophrenia Depression GERD COPD seizures
Diet
The patient has a poor diet due to her depression evidenced by her loss of appetite and weight loss.
Social history Educational level:
High School
Employment history: Unemployed
Interpersonal relationships/support system:
Family history Family history unable to be obtained.
Constitutional review Temp: 100.4 Height: unable to obtain
HR: 75 Weight: unable to obtain
BP & MAP: 132/
Resp rate: 16
The patient has no family support. But stated she had 1 son, and 2 daughters that were taken by CPS when they were little.
Musculoskeletal Examination
Muscle tone No impairment Dystonia Hypertonic/myoclonus Rigidity Flaccid
Gait Grossly normal Antalgic Limping In wheelchair Wide-based (walker)
Station Grossly normal Unsteady In wheelchair
Abnormal/Involuntary movements None Tremors Spasms Tics
Strength Greater than antigravity (>3/5) in all extremities Weakness:
Appearance Well-groomed Casual Disheveled Other:
Psychomotor behavior WNL Agitation Retardation EPS/tremors Involuntary movements Hyperactivity
Speech Spontaneous Slow Loud Rapid Other:
Attitude Cooperative Guarded Irritable Withdrawn Other:
Intelligence Average Above Below
Insig W Im
benzoisothiazole associated with bipolar I disorder (as monotherapy or in combination with lithium or valproate).
orthostatic hypotension
syncope
tachycardia
Pruritus
Rash
blurred vision
Hyperglycemia
hyperprolactinemia
Plan of Care (Clinical Judgment Plan)
Priority problem #1 [hypothesis]:
At risk for chronic low self esteem as evidence by her stating she has no support.
S.M.A.R.T. goal/outcome #1 [solution]:
Patient will do therapeutic visualization techniques that help the patient replace negative self images with more positive ones during my shift.
Interventions with frequency & rationale [actions]: Assess/monitor: Assess if the patients current mood through out my shift so we can prevent her negative self imaging behavior from being triggered.
Manage: Implement and work with the patient on
Priority problem #2 [hypothesis]:
Nutrition imbalance, less than body requirements as evidence by her low weight due to her depression and loss of selfcare patient stated she did not eat any breakfast that she doesn’t get hungry.
S.M.A.R.T. goal/outcome #2 [solution]:
Interventions with frequency & rationale [actions]: Assess/monitor: Assess mood of sadness, loneliness, diminished interest, and despair.
Manage: I the nurse will work with the patient to identify cognitive distortions that may trigger her loss in interest to care for herself and diet.
Educate:
Patient strengths
Steady employment, financial stability Housing Stability Able to vocalize need Motivation, ready for Knowledge of medica Awareness of substance is Other:
Patient limitations
Medication non-comp Intellectual impairment Lack of social support Pathological/unsuppor environment Complicated medical No interests Legal issues Other:
Pertinent assessment data [cues]:
Pertinent assessment data [cues]:
Mental Status Examination (MSE)
areas that need improvement to help promote a higher level of self-esteem.
Educate: The patient will be educated on how she can manage her depression and self imaging, as well as medication and the importance of medication adherence to help maintain her mood stabilized and depression under control.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met):
Goal was met patient was able to practice positive reinforcement of her self during my shift.
The nurser will educate the patient on ways to maintain an adequate diet.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Goal was met patient was reminded she needed to eat during lunch time, and ate 50% of her meal before the end of my shift.
