Sandra Littlefield Documentation _ Mental Health Case: Sandra Littlefield
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Mental Health Case: Sandra Littlefield
Documentation Assignments
1. Document your findings related to the focused assessment of Ms. Littlefield’s coping strategies. Include her responses
to your assessment.
Ms. Littlefield does not cope well with her situation. She is angry and accusatory and...
sandra littlefield documentation mental health case sandra littlefield
mental health case sandra littlefield documentation assignments 1 document your
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Mental Health Case: Sandra Littlefield
Documentation Assignments
1. Document your findings related to the focused assessment of Ms. Littlefield’s coping strategies. Include her responses
to your assessment.
Ms. Littlefield does not cope well with her situation. She is angry and accusatory and is feeling very lonely. She
appears to be projecting her own issues onto the staff as a defense mechanism. Further, she is convinced that
medication is the only solution to her pain and is not dismissive of and uninterested in learning relaxation techniques.
When asked about her desired outcome of treatment she said, “everyone is against me. You, the other nurses, the
provider—you all hate me.”
She did, however, state that, in the past, she has enjoyed taking walks and reading romance novels as an avenue
of stress relief.
2. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided Ms.
Littlefield. Include her response to the teaching.
I explained to Ms. Littlefield that there are several strategies she can use to decrease her anxiety, frustration, or
fear such as community support groups and regular therapist visits. I asked her what sorts of things she has done in the
past to reduce anxiety and frustration and she replied that she enjoys taking walks and reading romance novels. I
informed her of the presence of the prison library and offered to teach her some exercises she can do in prison.
While she is in the jail, I plan to work with her to identify community resources that may be of use to her.
3. Referring to your feedback log, document all nursing care provided and Ms. Littlefield’s response to this care.
I began by assessing the scene for safety. I then introduced myself, washed my hands, and ensured that I had the
right patient. I then asked, “can you tell me a little bit more about what’s going on with you today?”
She appeared agitated and said, “I am in so much pain. You are a nurse. Don’t you know how to tell when
someone is hurting?”
I used the therapeutic technique of translating to feelings and asked, “are you saying you feel hopeless?” I then
asked her if she had any pain.
She became more irritated and stated, “I’m finished. I’m done with you and your worthless medicine. Guard,
take me back now!”
I used the nontherapeutic technique of reassuring and responded, “the medicine your provider has ordered is in
your best interests.”
At this point, I assessed her vital signs. She was breathing at a rate of 16 breaths per minute with an oxygen
saturation of 98%; her radial pulse was measured at 84 beats per minute. Her blood pressure was 132/80 and her
temperature was 98.6°F. “I would like to ask you a series of questions about how you are feeling to help me better
understand how together we can start to plan your care,” I said. “These are questions I ask all of the patients I see. May I
ask you these questions?”
“Just because you are in love with the guards, you prance around like you own this place and you do not!” she
responded angrily.
I used the therapeutic technique of giving information to say, “Ms. Littlefield, you need to lower your voice now. I
am here to help you.” I then asked, “do you feel alert to answer questions?”
“Yes, I am.”
“Please tell me your name,” I said.
“My name is Sandra Littlefield,” she responded.
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