NURS3910 MENTAL HEALTH NURSING

NURSING ASSESSMENT FORM

Student Name: ___Tuyet Nguyen___________________Date: _____3/3/2014__________________
Patient data:
Admission
Age:
Gender:
Significant Other/marital status and children: Married and
Date: 3/1/2014
28
F
have 2 children (2 years old and 6 months old)
Educational
Primary Language:
Employment:
Pt. Legal Status: Legal history:
Stay at home
Level: College
5150
5150 d/t Dx of
Mandarin
psychotic disorder
degree in China
on February 2013
Chief complaint (What patient says prompted them to present at the hospital)
The patient was brought to St. Josephs Behavioral Center by her spouse, reporting suicidal behavior
with command auditory hallucinations telling her to cut her fingers.
What is the documented cause for hospitalization?
The patient is a danger to herself due to command auditory hallucinations telling her to cut her fingers
Patients living situation at time of admission:
The patient currently lives with her husband and 2 children (2 years old and 6 months old) in Stockton.
She stays at home to take care of her children while her husband goes to work.
DSM IV AXES from chart
I: PRIMARY: psychotic disorder, not otherwise
II: Deferred
specified. Undifferentiated type
III: None
IV: Biological, psychosocial problems (Hx of
postpartum psychosis after the 1st child)
V:(With rationale) Current GAF 30: Presence of command auditory hallucination; Impairment in
ability to communicate with others
PATIENT HISTORY
Medical History: None
Current medical issues of importance to nursing management of patient: (present all relevant
information from review of systems)
She has normal skin color and good turgor. Small scar about 1cm in length on her left little finger. She
was alert and oriented to person, place, situation, but not time. When being asked about todays date,
she stated, February 3rd. I corrected her that today was March 3rd and later on asked her again, she still
stated, February 3rd . PERRLA. Decreased extremity movements. Capillary refill < 3sec. Normal
bilateral pulses +2. No edema noted. Stable but decreased gait and balance. Normal respiratory and
cardiac functions. Heart rate (regular rate rhythm). Active bowel sounds. Last bowel movement at 9am
on 3/3/14. Reported good appetite. Denied pain.
Psychiatric history:
The patient has 1 prior hospitalization from 02/07 to 02/18 in this facility with Dx of psychotic disorder,
not otherwise specified. At that time, she was admitted because of auditory hallucinations. She was
stabilized on Zyprexa 5 mg in the morning and 15 mg at night. She is being seen in Dr. Smiths office.

According to the records, she has hx of postpartum psychosis after her 1st child. She has been
hospitalized in Sierra Vista in 2012.
Alcohol and Other Drug Abuse:
None
Abuse (physical/sexual):
None
FAMILY HISTORY
Mental Health:
None
Alcohol and Other Drug Abuse:
None
MENTAL STATUS EXAM
General Appearance:
Facial Expression: Calm; Blank stare
Dress & Grooming: Casual dress (jean, T-shirt,
and tennis shoes); Adequate grooming; No
makeup.
Posture and Gait: posture erect, sit upright,
steady gait, ambulated without assistance.

Motor behavior: Sit still and straight during

interview; Avoid eye contact; No tremor of
hands or feet, no facial tics or spastic movements

Physical Characteristics: Asian; Petite; Short hair;

No odor noted; Normal skin condition except one
scar little scar on the left little finger; Trimmed and
clean fingernails; No signs of malnutrition; No
dental problems visible; Appropriate hygiene
Attitude toward interview and mood (observed):
Calm; Cooperative

Physiological responses (tremor, nystagmus, sweating): No tremor; No nystagmus; No sweating

Affect and Mood
Appropriateness: Fair mood; Affect is
appropriate and congruent to mood

Range: Normal amount of variation during the

interview

Stability (patients report of swings, and

interviewers observation of changes): Stable
affect and mood during the interview except a
little anxious at the beginning.

Describe (e.g., anxious, depressed, disengaged,

etc.): Cooperative but a little anxious at the
beginning of interview. Calmer and engaged as the
interview went by.

Speech
Volume: appropriate

Rate (flow, speed): sparse; decreased/slow response

Thought Content

Theme: The voice is telling her that she is not

good because she did something bad to her
husband. The voice commands her to cut her
finger in order to punish herself. When I asked
her to tell me more about the reason to punish
herself, she answered, This is privacy! I dont
want to talk about it!

Delusions (persecution, influence, reference,

thought insertion): None

Phobias: None

Obsessions: None

Compulsions: None

De-realization, depersonalization: None

Disorders of Perception (give an example of those that apply)

Hallucinations (type with description):
Illusions (described as shadows, or reported as
Command auditory hallucinations telling her to misinterpretation of stimuli): None
cut her fingers. During interview, she kept
saying, No, thanks! every now and then. I
asked her if she was hearing the voice and if so
what the voice was telling her. She told me the
voice was telling her to do a bad thing, and she
knew she should not listen to the voice. That
was why she kept saying, No, thanks!
Clarity and organization: coherent, continuity
of ideas, able to link ideas, had problem with
English vocabulary but able to find the simple
words to answer the questions.

Tone/inflection: Normal voice tone; A little soft

voice tone noted when talking about sensitive topic.

Other unusual experiences

Hypnagogic phenomena: None

Dreams: None

Dj vu Experiences: None

Nightmares/Night Terrors: None

Memory & Cognition

Orientation to self: Yes
Orientation to day & date: No; stated the month
and the date incorrectly.
Attention: ability to count digits forward
(provide digits for patient to repeat): Patient
was able to count slowly forward 3, 6, 9, 12
and stopped.

Orientation to Place: Yes

Serial 3s and serial 7s: The patient was able to

slowly count backward from 100 by 7s only from
100, 93, and 86. After that, she lost track and said,
No, thanks!

Recent memory: (assess via memory for how

long has been in hospital, memory for recent
meal, home address etc.): When I asked her
how long she has been here, she said about 5
days (In fact, she has been here for 9 days since
she was admitted on 3/1/14). I then asked her
about her children. She was able to tell me she
has 2 children and approximate ages of her
children, but she kept saying today was
February 3rd . She was able to tell me her home
address and her husbands phone number. I
asked her to remember 3 words Apple, Table,
Cat and she was able to answer 2 out of 3
words (Apple, Table) five minutes later.
Fund of information: (ask general information
such as: how many days in a week, how many
months in a year, what makes water boil?
Name the four seasons of the year, where does
the sun set?): She was able to answer 7 days in
a week, 12 months in a year, 4 seasons of the
year. Basically, she could respond my
questions appropriately but with a pause (5-7
seconds) in between the questions and answers,
which sometimes makes people think that she
doesnt understand the questions. Every now
and then, I realized that her thinking process
was interrupted by the command auditory
hallucination and she responded to the voice by
saying, No, thanks!
However, when I redirected her, she was able
to answer my questions appropriately. I also
kept in mind that she has a language barrier.
She seemed to be comfortable talking to me
because English is also my second language; I
am about her age; and my culture (Vietnamese)
is very similar to her culture (Chinese).

Abstraction: ask to tell you what a proverb

means
I asked what the proverb, Dont cry over
spelled milk means. She was not able to

Confabulation: (ask patient if he has seen the

examiner before, assuming he has not or ask for
another detail which gives the patient the opportunity
to fill in the gaps of memory): After the initial
interaction with the patient, I came back 30-45
minutes later and she recognized me and was willing
to talk to me again.

Vocabulary: (observe the words used and/or present

several words and ask the patient to tell you what they
mean): Since she has a language barrier, she used
very basic English vocabulary during interaction. She
answered my questions with one to five words
combined. For example:
Tuyet: How are you doing?
Patient: Fine!
Tuyet: How did you sleep last night?
Patient: Ok!
Tuyet: So, can you tell me what brought you here?
Patient: I cut my finger.
During interactions, I could easily recognize that she
had trouble finding the words describing what she
wanted to say. I had to rephrase the questions couple
times and let her know I was not in hurry and she
could take time to think and answer me. For example,
when I asked her if she knew the reason the voice
telling her to cut her fingers, she was able to think of
the word punish after couple-minute-mindwandering. What she meant was that she cut her
fingers to punish herself because she did a bad thing
to her husband and she preferred not to tell me what
the bad thing was due to privacy.
Similarities: state two objects (orange and apple) and
ask how they are similar or alike
I asked, How are a banana and apple alike? She
responded after 5-7 seconds of a blank stare,

answer. Keep in mind that Mandarin is her

primary language and she told me that she just
came to the U.S. about 2 years ago.

Fruits!Yummy!

Judgment and Comprehension: provide

examples of common events or situations and
ask pt what he would do in those situations.

Perception and Coordination: (have patient write his

own name, copy a circle, a cross (x), a square, a
diamond or a row of dots on a blank sheet of paper.)

I asked her what she would do if she saw a

wallet with the money inside. She answered, I
dont know!...[blank stare 3-5 seconds]...No
thanks! Whenever she said, No, thanks! that
meant she was hearing the voice. I told her that
I did not hear any voice even it seemed very
real to her. She told me that she would not
listen to the voice and she would not hurt
herself.

She was able to write her own name in Mandarin and

English and copy a circle, and a square.

Suicidal Ideation:
Yes
No (If yes, complete suicide assessment)

She verbalized that she would not listen to the voice and would not hurt herself.
Homicidal Ideation:
Yes
No (If yes, complete homicide assessment)
She denied any homicidal ideation
What does this person do when angry, stressed or uptight?
She said when she comes back home with her husband and her children, if she feels angry, stressed, or
uptight, she will talk to her husband and ask for help promptly. She will not keep it inside like before.
Patients description of him/herself. What does she like best best/least about her/himself?
Like a typical Asian growing up in China, she describes herself as, shy, quiet, obey. She has been
doing an expected cultural gender role as a housekeeper. She just stays at home and takes care of her
husband and her two children. What she likes the best about herself is that she loves and is willing to
devote her life for her family. What she like the least is that she was not able to fulfill the role due to
this mental problem and she will follow and be compliant with the treatment so she can get well soon
and come back to her family.

Include real or potential strengths of the client.

When I asked her what she plans to do in the future, she told me she will go to school to learn English
and get some educations so she can work. She asked me how many years nursing program requires. She
smiled and seemed to be hopeful when talking about her future goals. She has a good support from her
husband and her husbands family. Her sister-in-law helps take care of her children during
hospitalization.
Routine Medications (including category, dose, standard dose, target effects, interactions and side
effects):
1. Olanzapine:
o Category:
 Trade name: Zyprexa
 Classes: Antipsychotic; Thienobenzodiazepines
o Dose: 5 mg PO Daily and 15 mg PO Bedtime
o Standard Dose: PO (AdultsMost Patients): 510 mg/day initially; may at weekly
intervals by 5 mg/day (target dose = 10 mg/day; not to exceed 20 mg/day).
o Target Effects:
 Action: Antagonizes dopamine and serotonin type 2 in the CNS; Also has
anticholinergic, antihistaminic, and antialpha1-adrenergic effects.
 Indications: Decreased manifestations of psychoses.
o Interactions:
 Effects may be by concurrent carbamazepine, omeprazole, or rifampin.
 hypotension may occur with antihypertensives.
 CNS depression may occur with concurrent use of alcohol or other CNS
depressants; concurrent use of IM olanzapine and parenteral benzodiazepines should
be avoided.
 May antagonize the effects of levodopa or other dopamine agonists.
 Fluvoxamine may levels.
 Nicotine can olanzapine levels.
o Side effects (CAPITALS indicate life-threatening): NEUROLEPTIC MALIGNANT
SYNDROME, SEIZURES, SUICIDAL THOUGHTS, agitation, delirium, dizziness,
headache, restlessness, sedation, constipation, dry mouth, weight loss or gain, tremor.
2. Lorazepam:
o Category:
 Trade name: Ativan
 Classes: antianxiety; sedative/hypnotic
o Dose:1 mg PO Q2H PRN
o Standard Dose: PO: (Adults) Anxiety13 mg 23 times daily (up to 10 mg/day). Insomnia
24 mg at bedtime
o Target Effects:
 Action: Depresses the CNS, probably by potentiating GABA, an inhibitory
neurotransmitter.

 Indications: Sedation; Decreased anxiety; Decreased seizures

o Interactions:
 Additive CNS depression with other CNS depressants including alcohol,
antihistamines, antidepressants, opioid analgesics, clozapine, and other
sedative/hypnotics including other benzodiazepines.
 May the efficacy of levodopa.
 Smoking may metabolism and effectiveness.
 Valproate and can levels ( dose by 50%).
 Oral contraceptives may levels.
o Side effects (CAPITALS indicate life-threatening): dizziness, drowsiness, lethargy,
APNEA, CARDIAC ARREST
Lab values:
Date
Test
Patient Value Normal Value
Nursing Implications
3/2/2014 WBC
5.7
4.8-10.8
Patients value is within normal limit -WNL
3/2/2014 RBC
4.77
4.40-6.00
WNL
3/2/2014 HGB
14.3
13.5-18.0
WNL
3/2/2014 HCT
42%
40-54%
WNL
3/2/2014 Platelet 179
130-400
WNL
3/2/2014 Na
142
136-145 mmol/L WNL
3/2/2014 K
3.9
3.6-5.1
WNL
3/2/2014 Cl
105
101-111 mmol/L WNL
Written Summary
Compared to admission, the patient is more stable and symptoms are being managed appropriately with
medications and group therapy. DSM criteria for undifferentiated Schizophrenia are congruent with
patient assessment: symptoms in criteria A (delusions, hallucinations, disorganized speech, grossly
disorganized or catatonic behavior, negative symptoms) are present but the criteria are not met for the
Paranoid, Disorganized, or Catatonic type (Townsend, 2012).
According to the record, the patient was admitted due to experiencing auditory command hallucinations
telling her to cut her fingers. It was not clear if she had delusion because she did not answer the
question. During assessment on 3/3/2014, the patient sometimes experienced the auditory command
hallucinations and kept saying, No, thanks! When I asked her to tell me more about what she meant
by saying, No, thanks! she explained that she would not listen and follow what the voice told her.
Three Nursing Diagnoses according to priority (include plan of care for each, expected outcomes,
and attach nursing care plan)
1. Risk for violence: self-directed r/t command hallucination (Townsend, 2012).
a. Outcomes: Patient will not harm self or others
b. Interventions (Townsend, 2012):
i.
Observe the patients behavior frequently (every 15 min) or 1:1 if necessary
ii.
Remove all dangerous objects from patients environment
iii.
Maintain a calm attitude toward patient
iv.
Obtain a verbal contract that patient will promptly tell staffs when feeling urge to hurt self

or others.
v.
Facilitate a trusting and therapeutic relationship with the patient by promptly attending her
needs in a timely manner (Hewitt & Coffey, 2005).
vi.
Include the patients family in the plan of care if possible because it is shown to
substantially improve the patients functioning and family well-being and prevent relapse
(Johnson, 2005).
2. Disturbed sensory perception: Auditory r/t auditory command hallucination AEB she cut her left
little finger because of the voice telling her to do so
a. Outcome: Patient will discuss the content of hallucinations during hospitalization.
b. Interventions (Townsend, 2012):
i.
Observe patient for signs of hallucinations and ask her directly if she is hearing the voice
ii.
Show the attitude of acceptance to patients situation without judgment
iii.
Encourage the patient to share the content of the hallucination
iv.
Try to distract the patient from the hallucination by teaching her the technique voice
dismissal, in which, she is taught to say loudly, Go away!
v.
Redirect the patient to reality using therapeutic communication
vi.
Facilitate a trusting and therapeutic relationship with the patient by promptly attending her
needs in a timely manner (Hewitt & Coffey, 2005).
vii.
Include the patients family in the plan of care if possible because it is shown to
substantially improve the patients functioning and family well-being and prevent relapse
(Johnson, 2005).
3. Impaired verbal communication r/t decreased/delayed thinking process AEB blank stare and pause
between questions and answers
a. Outcome: Patient will demonstrate ability to focus on one topic and improve the delayed
thinking process by answering the questions simultaneously.
b. Interventions (Townsend, 2012):
i.
Facilitate trust and understanding by maintaining staff assignments as consistently as
possible
ii.
Anticipate and fulfill the patients basic needs promptly
iii.
Spend time to talk with the patient
iv.
Allow enough time for the patient to answer the questions without any rush
v.
Ask the questions using a short and clear sentences at the patients level of comprehension

Students response to experience with this patient:

This is the first patient I had during mental health clinical rotation. I did not have to do the care plan on
her, but I found her case very interesting to me. That is why I decided to do the case study on her. I
actually chose this patient by myself when I saw her coming to nursing station to take the medications.
She had a delayed response when the nurse asked her if she knew what medication was she taking and
then answered after a blank stare with a heavy Asian accent. The nurse told me that she didnt talk
much, so she was not an ideal patient for me. I decided to give it a try by approaching her when she was
sitting alone in the day room. Surprisingly, she smiled and was willing to talk to me. Because of similar
cultures between hers and mine, I felt very calm to talk to her and was able to use many therapeutic
communication techniques, such as offering self, exploring, clarifying, voicing doubt. I felt empathic for
her situation because she was unable to take care of her infant child (6 months old) because of her
mental condition. I learned a lot of things about the disease process during interactions with her.
Overall, I had a very good experience with this patient.

Student Name: TUYET NGUYEN (SNOW)

References
Hewitt, J., & Coffey, M. (2005). Therapeutic working relationships with people with schizophrenia:
Literature review. Journal of Advanced Nursing, 52(5), 561-570.
Johnson, D. (2005). Family interventions for schizophrenia: An international view. Psychiatric
Times, 22(6), 16.
Townsend, M.C. (2012). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based
Practice (7th ed.) Philadelphia, PA: F.A. Davis Company.

NURS3910 MENTAL HEALTH NURSING

CASE STUDY (20 points)
GRADE RUBRIC
STUDENTS NAME: _______Tuyet Nguyen_____________________________
DATE: ________3/31/14_____________________________________
GRADING SCALE: 0-25
CRITERIA:
1

Your
Score:

General Patient Data (complete and appropriate to patient situation) Patient and
Family History and Physical Assessment: (thorough and appropriate to patient
situation)
1 Point
DSM-IV Axes from Chart (discuss DSM-IV criteria for each)
1 Point
Mental Status Exam
Assessment of Response to Negative Affect (anger/anxiety and stress) and
Patients Self Concept
Suicide & Homicide Assessment
8 Points
Medication Assessment
2 Points

Summary (including comparison of your findings to DSM Dx)

Nursing Plan of Care

References (evidence cited for interventions) minimum 2 references, APA

Format, grammar and spelling
2 Points

Student Response to Experience with Patient

1 Point

Oral Presentation(see grade rubric)

5 Points

2
3

Your Total Score:

4 Points
1 Point