Li Na Chen Part 1 PDF

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Li Na Chen VSim Mental Health Documentation Assignment Part 1...

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Mental Health Case: Li Na Chen, Part 1 Documentation Assignments 1. Document the search of Mrs. Chen and her belongings on admission. After introducing myself I searched Mrs. Chen and her belongings. I removed a nail file, tweezers, travel sewing kit, decorative pill box, personal cell phone, belt, shoelaces, and a string from her hoodie. 2. Document the safety checks for Day 1. The scene was checked for safety and was deemed safe as the nurse could exit if needed. 3. Document the findings of the mental status examination of Mrs. Chen on admission. Mrs. Chen is appropriately dressed for age and weather. She is clean and well-kept other than her hair which is slightly disheveled. She has a slumped posture with no automatisms, such as tics, tremors, akathisia, or restlessness. Her mood is sad and depressed and her affect is congruent with her thought content. She does not have any indications of speech variations, like neologisms (newly coined word/expression), aphasia (loss of ability to understand or express speech), or pressured speech (talking fast). Her thought content involved worries, frustrations, hopelessness/ helplessness. She denies hallucinations. Thought process is goal-directed. She acknowledges suicide urges as well as acknowledging death wish without suicidal intent. She denies homicidal ideation. She is positive for anhedonia (inability to feel pleasure). Mrs. Chen is orientated X3 with long-term memory deficits but a focused attention span. Her insight is good (understanding of situation).

4. Document the findings of the suicide assessment of Mrs. Chen. Mrs. Chen stated her feelings of hopeless, lack of energy, and depression aided her decision to attempt suicide. She feels that her failure to die is due to her inability to do anything right and that she has let her husband down, “I cannot even do one thing right.” Mrs. Chen stated “I don’t want help, I just want to get away from this pain” as well as “I don’t think I can go on.” This assessment finds Mrs. Chen to still be at risk for suicide. 5. Identify and document key nursing diagnoses for Mrs. Chen. Risk for suicide related to feelings of hopeless as evidenced by patient’s attempt to take her life. Ineffective Coping. Helplessness. 6. Referring to your feedback log, document all nursing care provided and Mrs. Chen’s response to this care.

I checked the scene for safety then washed my hands and introduced myself. I confirmed the patient’s identity and then asked if it was ok if her support person stayed during the interview. Mrs. Chen confirmed her husband could stay stating, “Jack has always been there for me and I have let him down.” I explained to Mrs. Chen at her request why I was searching her belongings and confirmed the potentially unsafe items that I removed. I then moved in to my assessment, first starting by doing a medication reconciliation and confirming any allergies. I assessed her respiration, pulse ox, pulse, blood pressure, and temperature all of which were within normal limits. I observed and noted her appearance, attention, motor activity, speech, and thought process then asked if I could ask her some assessment questions. Mrs. Chen replied, “ Can you finish these questions later?” I replied, “I realize this must be tiring; however, I need to finish your assessment now.” I asked Mrs. Chen a series of assessment questions the results of which are in answers 3 and 4. I also asked and confirmed that Mrs. Chen had a diminished appetite, sleeps all the time but does not feel rested, and does not have the energy to do normal ADLs. I supported the patient and her husband then provided education about the psychiatric diagnosis and gave report to the charge nurse. Throughout the interview Mrs. Chen was low-energy and struggled to get through the interview. Her husband was supportive and admitted to the stress that his wife’s depression causes him and his family.

7. Document patient education regarding medications. I provided patient with education indicating that her healthcare team would work with her to create a medication and therapy regime that would help balance her. I reinforced that this would be a collaborative effort between patient and health care team. 8. Document your handoff report in the SBAR format to communicate the care plan for Mrs. Chen to the nurse on the next shift. Situation: Li Na Chen is a 40-year-old Chinese female who was admitted to the ER following an attempted suicide utilizing prescription ibuprofen and acetaminophen. She has been admitted to the psych ward with major depression and suicide attempt after gastric lavage in the ER. Background: Mrs. Chen was diagnosed three years ago with depression and has used drugs to facilitate suicide twice in the last two years, last attempt being one year ago. She sees a nurse practitioner who recommended two weeks ago to start tapering her sertraline and start a trial of venlafaxine. Since then, the NP has been unavailable and Mrs. Chen visited her community clinic three times complaining of difficulty sleeping through the night, headaches, and back pain.

She was prescribed extra strength ibuprofen and extra strength acetaminophen which is what she used to overdose. Additionally, she has lost 10lbs due to lack of appetite. Assessment: Mrs. Chen has stated feelings of hopelessness, depression, and lack of energy interfering with her every day life. She is dressed appropriately for the weather, is clean, and well-kept with the exception of disheveled hair. Her affect is congruent with her thought process, she has no speech variations or hallucinations. She confirms suicidal ideation and denies homicidal ideation. Recommendation: Keep strict suicide precautions and begin patient on medication therapy....