NURS 223L - Psychiatric Nursing Process Worksheet week 3.

NURS 223L - Psychiatric Nursing Process Worksheet week 3. Student Name: NAME HERE Date 04/24/20 Client History: Name (initials only): _VR_ Age: _57_ Gender: _F_ Unit: _PSYCH Date of Admission: 04/24/20 Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Suspected voluntary admission, Family still care for patient. “Grandson and niece that is her support system and Power of Attorney” Psychiatric Diagnosis: Dementia, Depression and Anxiety Medical and (or) physical problems: CHF, DVT, Stage IV Ovarian Cancer with multiple Lymph node involvement and possible liver metastasis. Psychosocial and Environmental Problems: Lack of education only went to high school; Patient does not attend group activities. Thinking that everyone is trying to hold her hostage. (problems with primary support group, education, occupational, housing, economic, access to health care) Presenting Problem Reason for hospitalization (Client’s own words): Attempted elopement from her Memory Care Unit. patient Wanders Current stressors: Stage IV Ovarian Cancer with multiple lymph node involvement and possible liver metastasis, Anxiety, Depression. Mental Status Examination Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): Patient mental statue is inappropriate due to “terminal condition that has metastasized to the brain causing an alteration in mental status” Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): Retardation, Restlessness “Wandering into other patients’ rooms, slapping them in the face and stealing cups off the medication cart” Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Patient attitude is guarded and uncooperative with care Affect (blunted, flat, guarded, labile, expansive, sad, or other): Patient is very Sad, Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Patient is Irritable and anxious Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Patient is very soft spoken with a low tone Thought Content: Suicide Ideation (plan and/or intent): NO Homicidal Ideation (plan and/or intent): NO Hallucinations (auditory, visual, olfactory, gustatory, tactile): NO Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): Sometimes patient is Delusional Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): Ideal of influence has the perception that everyone is trying to hold her hostage. Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): Patient is confused, thought process is illogical Cognition (orientation, memory recall, concentration, attention span): Patient is Alert and oriented x 1 Insight: Poor Judgment: Poor Coordination/gait/notable movement: Patient is independently Ambulatory Cultural issues, familial concerns and religious affiliation that may affect his/her care: Patient is a Catholic, Has a good relationship with her family. Support System: Grandson and niece that is her support system and Power of Attorney. Current Physical Health: Vital Signs - T: 98.2 P: 72 R: 18 BP: 115 / 76 Pulse Oximeter reading: 97% RA. Pain (Numeric 1-10): UNKNOWN Location: N/A Character: N/A How would you describe your health: Excellent Average Good Poor Nutritional Status: Diet: Mechanical soft diet with thin liquids. Feeding supplement: Swallowing / Chewing difficulty: Elimination Pattern: Incontinent of bowel and bladder Activity-Exercise-Sleep-Rest Pattern: Sleeps up to 8 hours at night Group Attendance and Level of Participation: Substance Abuse: Substance Amount / Frequency Duration Last Used Not Applicable N/A N/A N/A Not Applicable N/A N/A N/A Not Applicable N/A N/A N/A Withdrawal symptoms: Not Applicable Other Addictions (gambling, sex, internet, shopping, internet, etc.): Gambling, “Patient use to go to Casino every Sundays when she was living at home 2 years ago. Discharge Plans: Patient Plan to go stay with her grandson upon discharge and remain on Hospice care. (date of discharge unknown.) Potential Nursing Diagnosis (Risk / Actual): 1.) Ineffective airway clearance, R/T non participation on activities, AEB Crackles and wheezing in the lower lobes. 2.) Anticipatory Grieving R/T plans to go home with her grandson upon discharge and remain on hospice, AEB recent diagnosis of Stage IV Ovarian Cancer with multiple lymph node involvement and possible liver metastasis. 3.) Ineffective coping R/T Anxiety and depression. AEB Patient been tearful and states “that everyone is trying to hold her hostage.”