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Room Unable to obtain
Patient/Age/Sex JG 47 Male
Date of evaluation 2/25/
Allergies Seafood Iodine Mercury Codeine Lithium
Admit date 02/15/
Diagnosis Schizoaffective
Legal status State Conserved
Chief complaint/concern (CC) (quoted: “In the patient’s words) Patient stated “I was brought here from my last facility due to an incident I had their”
Past psychiatric history The patient was diagnosed with schizophrenia and Bipolar Disorder.
History of Present Illness (HPI) Patient's has a history of hypertension.
Alcohol/Tobacco/Drug history : Alcohol Barbiturates Tobacco Cocaine Marijuana Heroin Vaping Inhalants Other: LSD Methamphetamines PCP IV Opioids
Medical history
Schizophrenia Bipolar Disorder COPD ITP (Idiopathic Thrombocytopenic Purpura)
Diet
Patient has a regular diet.
Social history Educational level:
High School drop out (12th)
Employment history: Thrift Store Employee
Interpersonal relationships/support system:
Family history Adopted, Family history unable to be obtained.
Constitutional review Temp: 97.3 Height: 72in
HR: 76 Weight: 257lb
BP & MAP: 124/
Resp rate: 20
The patient has 1 brother, 3 sisters, mom and dad but has no family support. Patient states they don’t visit him and that when he last spoke to his mom she said “she will see him when the time is right”.
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:
pearance Well-groomed Casual Disheveled her:
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Attitude Cooperative Guarded Irritable Withdrawn Other: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
Insight WNL Impa
hypotension rash Diarrhea Nausea Vomiting Arthralgias Arthritis Dizziness Drowsiness Headache peripheral neuropathy
periodically durin therapy. About 50–65% of Caucasians, Black, South Indians, and Mexicans are slow acetylators at risk toxicity, while 80– 90% of Inuit, Japanese, and Chinese are rapid acetylators at risk decreased levels a treatment failur
azadone T: antidepressants 150mg
PO Daily at bedtime
Schizophrenia. Depressive episodes associated with bipolar I disorder (as monotherapy or in combination with lithium or valproate).
Bradycardia
orthostatic hypotension
syncope
tachycardia
Pruritus
Rash
blurred vision
Hyperglycemia
hyperprolactinemia
Monitor behavioral changes Monitor wt and BMI Monitor Bp
n of Care (Clinical Judgment Plan) ority problem #1 [hypothesis]: nxiety as evidence by his statement ”I scared that I am having a surgery on, I need my anxiety medication but y won't give it to me”
M.A.R.T. goal/outcome #1 [solution]:
he goal is to have patient express his concerns garding his upcoming surgery so that we can dress his concerns before the end of my shift.
erventions with frequency & rationale [actions]: sess/monitor: e nurse will provide reassurance to the patient at will help the patient reduce their anxiety.
nage: ovide the patient with the prescribed anxiety dications. Implement and work with the patient areas that need improvement to help promote a her level of self-soothing coping mechanism hniques.
ucate:
he patients concerns will be addressed to help m his anxiety that comes as a result from his rries regarding his upcoming surgery; as well as dication and the importance of medication herence to help maintain his anxiety stabilized d under control.
aluation [evaluate]: Met / Not met commendations (If goal/outcome not met):
Priority problem #2 [hypothesis]:
Risk for suicide as evidence by his recent suicidal attempt “ patient locked himself up and stabbed himself in the lower abdomen with a pen"
S.M.A.R.T. goal/outcome #2 [solution]: Patient will be closely monitored, and not allowed alone time during my shift.
Interventions with frequency & rationale [actions]: Assess/monitor: The nurse will assess for any suicidal ideation’s, and encourage the patient to reframe negative thinking into neutral objective thinking.
Manage: The nurse will stay one to one with the patient until the patient is no longer considered a risk for suicide or harm to self.
Educate: The nurser will educate the patient on the importance of medication adherence for his medical diagnosis, as well as encourage him to express his triggers that cause suicidal thoughts.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met): Goal was met patient was given their scheduled medications throughout my shift and patient was able to role play adaptive coping strategies.
Patient strengths
Steady employment, financial stability Housing Stability Able to vocalize needs Motivation, ready for change Knowledge of medication Awareness of substance issue Other:
Patient limitations
Medication non-complian Intellectual impairment Lack of social supports Pathological/unsupported environment Complicated medical illn No interests Legal issues Other:
Pertinent assessment data [cues]:
