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Identifying Gender: Male Female
Data: Age: 48 Unit: North Legal Status: BA 52 Allergies Tomatoes
Reason for Patient brought himself in for auditory hallucinations of voices telling him to
Admission: kill himself and with dissatisfaction with his current Assisted Living Facility
What does the patient’s topic of speech tell you about what he or she is
thinking? Patient’s topic of speech tells me that he is focused on discharge
and nothing more. He is not concerned with the current situations. His
thoughts are often short or interrupted by passersby.
2
Identify clinical behaviors that support the psychiatric diagnoses: Patient has poor critical thinking
skills, inability to care for himself, and
Purpose (for this patient): anti-convulsant for seizures and anti-manic for bipolar
What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Drowsiness- patient expresses he is still
tired shortly after waking.
Patient Teaching Needs: Do not drive while taking this medication, and talk to your
doctor if you experience thoughts of suicide with this therapy. Educate on signs of
toxicity and need for continual labs to monitor levels of Depakote.
(Vallerand, 2017)
4
Dose and Time: 200 mg IM Q4 weeks due 03/06/2017 Date Ordered: 02/06/2017
Purpose (for this patient): antipsychotic- Positive symptoms of Schizophrenia like
auditory hallucinations
What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Patient experiencing drowsiness and
has history of seizures. No other adverse effects were assessed.
Patient Teaching Needs: Do not drink alcohol, change positions slowly to avoid
orthostatic hypotension, and avoid driving after taking this medication. If signs of
EPS occur like uncontrollable movements, rolling tongue, or tremors, contact
your provider immediately.
(Vallerand, 2017)
What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Patient experiencing drowsiness but no
headache, nausea, or weakness.
Patient Teaching Needs: Do not drink alcohol, and avoid driving after taking this
medication.
(Vallerand, 2017)
What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? No, patient has not taken medication in
7 days.
Patient Teaching Needs: Do not drink alcohol, avoid driving until after familiar
with effects, and complex sleep behaviors like sleep-driving may occur.
(Vallerand, 2017)
6
What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Patient is experiencing drowsiness but
no loss of appetite or tremor.
(Vallerand, 2017)
Urinalysis
Test: Color Value:Yellow
Test: pH Value:7.0
General Chem
Test: PC Sodium Value:143
Lipids
Test: Triglyceride Value:342 (H)
Drug Levels
Test: Acetaminophen Value:<2.0
Nursing Interventions: within normal range
Special Chem
Test: Hgb A1c Value:5.3
Urine Chemistry
Test: Ur Opiates 300 Value: Neg <300
For this assignment, please focus on the psych mental health diagnoses. Your textbook and your NCP book provide excellent examples relating to a
variety of PMH diagnoses.
Use nursing assessment, measurable clinical findings, and values to formulate nursing diagnoses, patient goals, nursing interventions based on
evidence-based practice, and applicable evaluations. Evaluation – if they met goals, explain how you know this; If not, why not.
Objective:
Patient was odorous,
and his appearance was
unkempt and unclean.
18
Objective:
Patient continually
leaves the same ALF
when troubles arise.
Patient fled facility and
was returned ten days
prior to this elopement.
19
Long-term Within 1 month, the patient will: have all self-care needs met
Goals: independent of staff and demonstrate ability to cope with stress
Discharge Planning Work with case management and ALF patient will be discharged to
Issues/Considerations determine ways he can better manage himself independently. Ensure
medicine adherence to decrease psychotic episodes and elopement.
Explore other ALFs that may suit the patient, his needs, and insurance
better than his previous facility.