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Room NA
Patient/Age/Sex MD 37 Female
Date of evaluation 2/11/
Allergies Gluten
Admit date 12/24/
Diagnosis Schizoaffective disorder
Legal status Conservatorship
Chief complaint/concern (CC) (quoted: “In the patient’s words) Patient stated, “I was homeless and suicidal.”
Past psychiatric history The patient was diagnosed with schizoaffective at age 14.
History of Present Illness (HPI) Pt states that she was originally placed at another long term care facility “ but the staff wasn’t good at the other facility” and was “moved to this facility.”
Alcohol/Tobacco/Drug history : Alcohol Barbiturates Tobacco Cocaine Marijuana Heroin Vaping Inhalants Other: LSD Methamphetamines PCP IV Opioids
Medical history
- Hypothyroidism
- Scoliosis
- Sleep apnea
- Prediabetes
Diet
The patient has a poor diet due to his poor diabetic management as evidenced by his weight loss.
Family history Mom was previously diagnosed with bipolar 1 & 2, and schizophrenia Sister was diagnosed with anxiety, and PTSD
Social history Educational level:
College
Employment history: Teacher’s assistant in an Elementary School
Interpersonal relationships/support system:
Patient states she has a good support system with her grandmother and one of her grandmothers close friend.
Constitutional review Temp: 97.6 Height: 172.72cm
Hr:78 Weight: 161lb
BP & MAP: 130/
Resp rate: 20 Musculoskeletal Examination
Muscle tone No impairment Dystonia Hypertonic/myoclonus Rigidity Flaccid
Gait Grossly normal Antalgic Limping In wheelchair Wide-based
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Attitude Cooperative Guarded Irritable Withdrawn Other: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
Insight WN Imp
Mood Euthymic Depressed Anxious Irritable Other:
Affect Full (agitated) Constricted (no change) Flat (no emotion) Labile (mood fluctuates) Other:
Orientation Time Person Place Situation
Perception WNL Delusions Obsessions Phobias Other:
Memory test (3 Items) 3 2 1 0 out of 3 in 3 min
Judgem WN Imp
Plan of Care (Clinical Judgment Plan)
Priority problem #1 [hypothesis]:
At risk for suicide as evidence by her past suicidal ideations.
S.M.A.R.T. goal/outcome #1 [solution]:
Patient will be kept safe and under observation during my shift.
Interventions with frequency & rationale [actions]: Assess/monitor: Assess if the patient has a history of suicide attempts.
Manage: Implement suicide precautions.
Educate: The patient will be educated on his depression medication and the importance of medication adherence.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met):
Goal was met patient’s safety was maintained during my shift.
Priority problem #2 [hypothesis]:
Impaired coping strategies as evidence by her auditory hallucinations
Patient states that she is able to teleport to wherever she wants or where the voices tell her to go next.
S.M.A.R.T. goal/outcome #2 [solution]:
Patient will take all her prescribed medications to keep her hallucinations controlled during my shift. Interventions with frequency & rationale [actions]: Assess/monitor: Administer antipsychotic medication as directed and teach the patient new coping mechanisms like reality checking.
Manage: The nurse will work with the patient to identify cognitive distortions that may trigger his loss in interest to care for himself.
Educate: The nurser will educate the patient on prediabetes management and adequate diet.
Evaluation [evaluate]: Met / Not met Recommendations (If goal/outcome not met):
Goal was met the patient took all her prescribed medications and
Patient strengths
Steady employment, fin stability Housing Stability Able to vocalize needs Motivation, ready for ch Knowledge of medicatio Awareness of substance issues Other:
Patient limitations
Medication non-complia Intellectual impairment Lack of social supports Pathological/unsupporte environment Complicated medical ill No interests Legal issues Other:
Pertinent assessment data [cues]:
Pertinent assessment data [cues]:
Mental Status Examination (MSE)
was taught how to do self-reality checks, pt. reported not having any hallucinations today during my shift.
