NURS 223L PSYCHIATRIC NURSING PROCESS

NURS 223L PSYCHIATRIC NURSING PROCESS

Norma James is 81 years old. She has been in a nursing home for 8 months following time in hospital with a fractured right ankle after a huge fall. She lost her husband about 4 year ago. The only person who comes to see her is her youngest sister, who had a heart attack 9 weeks ago and has not been able to visit her since. N.J has become increasingly quiet and withdrawn. It has been reported that she is not eating and do not want to come out of her room. Her weight has dropped by 5lbs in the last month or so.

Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Volunteer

Psychiatric Diagnosis: Depression disorder

Medical and (or) physical problems: Hypertension, Diabetes, fracture RT ankle from fall, osteoarthritis, macular degeneration.

Psychosocial and Environmental Problems:

(problems with primary support group, education, occupational, housing, economic, access to health care). Patient has problem with primary support group. Her sister is unable to visit her because she suffered from a heart attack.

Presenting Problem: patient has become increasingly quiet and withdrawn and she is not eating and has lost 5 pounds in a month or so.
Reason for hospitalization (Client’s own words): “I not fit to be by myself because of my fracture Rt ankle. Everyone that I know is dead or moved away. The only piece of joy that I left was my sister coming to visit me. I do not want to come out my room and interact with people. Please leave me alone. I do not want to eat or take a shower. I am not sleeping very well and do not have an appetite. I’m ready for Good to call me home.”

Current stressors: Her sister not able to visit her

Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): not showered, clothing is scruffy, hair uncombed

Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): very restless and very irritable.

Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): cooperative

Affect (blunted, flat, guarded, labile, expansive, sad, or other): Flat

Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): apathetic, sad and irritable

Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Slow soft speech with pause

Thought Content:

Suicide Ideation (plan and/or intent): denies

Homicidal Ideation (plan and/or intent): denies

Hallucinations (auditory, visual, olfactory, gustatory, tactile): denies

Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): denies

Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): denies

Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): logical

Cognition (orientation, memory recall, concentration, attention span): oriented

Insight: Good. Judgment: good – she does not feel like harming herself

Coordination/gait/notable movement: patient is using a walker

Cultural issues, familial concerns and religious affiliation that may affect his/her care: N/A

Support System: nursing home. NURS 223L PSYCHIATRIC NURSING PROCESS

Current Physical Health:
Vital Signs – T: 97.6 F P:81 R: 14 BP: 138/90 Pulse Oximeter reading: 98%

Pain (Numeric 1-10): 3/10 Location: Right ankle Character: dull and sharp join pain

How would you describe your health: Poor

Nutritional Status:

Diet: normal Feeding supplement: none Swallowing / Chewing difficulty: no

Elimination Pattern: Normal

Activity-Exercise-Sleep-Rest Pattern: 5-6 hours of sleep

Group Attendance and Level of Participation: Poor

Substance Abuse: N/A

Substance

Amount / Frequency

Duration

Last Used

N/A

N/A

N/A

N/A

Withdrawal symptoms: N/A

Other Addictions (gambling, sex, internet, shopping, internet, etc.):

Discharge Plans: nonejm

Potential Nursing Diagnosis (Risk / Actual): Impaired social interaction R/T lack of support system AEB remain in seclusion, lost appetite, sleep poorly

Planning (patient goals): Patient will participate in 1 or 2 community social activity (e.i ice cream parlor, breakfast/lunch/dinner with other residents, bingo) within 24 hours

Nursing Interventions (include patient education):

· Assess patient’s past and current coping skills.

· Help patient to identify alternative courses of action to cope with depression.

· Encourage the patient to identify other support system other than his brother

· Encourage the patient to express her feelings about social interactions

Evaluation (patient response to interventions and teachings): Goal met – patient joined other residents for breakfast and lunch at the dining hall.

MEDICATION LIST

Medication

(Generic / Trade)

Dose / Route / Frequency / Range NURS 223L PSYCHIATRIC NURSING PROCESS

N/A

Side Effects

Food and Drug Interaction

N/A

Purpose / Rationale for the Patient

N/A

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Laboratory Report:

LAB

DATE

RESULTS

REERENCE RANGE

DEPAKOTE

LITHIUM

TEGRETOL

DILANTIN

WBC

Date:

Hour

Focus / Nursing Diagnosis

D – Data A – Action R – Response

D

Patient is 84 years old. She has been in a residential home for four months following time in hospital with a fractured femur after a fall. She is a widow and her only visitor has been her younger brother, who suffered a stroke six weeks ago and has not been able to visit her since. She looks sad and gets tearful when discussing her feelings with the GP. She admits she is very lonely since her brother stopped coming to see her and is worried that he may never be fit enough to come again. She says that she is sleeping poorly, has lost her appetite and ‘can’t be bothered’ to sit with other people in the care home NURS 223L PSYCHIATRIC NURSING PROCESS