MH Sharon Cole DA PDF

Preview

Summary

SHARON COLE VSIM- DOCUMENTATION ASSIGNMENT QUESTIONS...

Description

Eduardo Flores Mental Health Case: Sharon Cole Documentation Assignments 1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute agitation. Include her responses to your assessment. She has been very loud and verbal since she came from the postoperative unit. She is somewhat oriented; she knows that she’s in the hospital, but doesn’t really remember the details of the fall. She knows her name and recognized her husband, but her recollection of the events of last night is inconsistent as she relays the story to different staff members. She does not know what day it is. She is having grandiose thoughts, her speech is pressured, and she is talking constantly, exhibiting a flight of ideas, with thoughts ranging from issues in Washington to suggestions about running the hospital better. 2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered. She has been prescribed lorazepam, 2 mg, as needed for agitation. She thinks assassins are after her but was willing to take her lorazepam 3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care. Mrs Cole was admitted last night for surgical repair of a right ankle fracture. She went to surgery this morning at 08:00 and came back from the postoperative unit at 11:30. She has responded to redirection with irritability. She has a fentanyl patient-controlled analgesia (PCA) pump for pain control. Her vital signs are stable: temperature, 37.2°C (99°F); heart rate, 88 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/70 mmHg. She denies pain, but she says she never feels pain. She has threatened to take her intravenous (IV) line out to get rid of the pain medicine, which she says makes her feel like she's "not herself." So far, we've been able to talk her into keeping it. She takes small sips of water when it is directly given to her. There is a sitter present for the patient's safety. 4. Document all interventions associated with the management of Mrs. Cole’s environment. Include her responses to the attempts to decrease environmental stimuli. The lights in her room have been dimmed and the TV has been turned off to decrease stimuli in her room. She has responded a little better but still has flight of ideas and thoughts of grandeur 5. Document all interventions associated with boundary and limit setting directed toward managing Mrs. Cole’s manic behavior. She has been constantly redirected to keep her gown on, be courteous to the tech that are helping her, and to leave her IV in while in the hospital. 6. Document your handoff report in the SBAR format to communicate Mrs. Cole’s future needs. S-Sharon Cole is a 31-year-old female who was admitted last night for surgical repair of a right ankle fracture. B-Mrs. Cole sustained the injury when she fell from the stage in a bar. she was diagnosed with bipolar disorder 6 years ago and that she had not been sleeping or eating much for the past 2 weeks. The family was worried that she was at risk of another manic episode, but she became irritable when they questioned her behavior or her compliance with her medication. Her husband reports that she is normally adherent to her medication regimen, which is lithium 600 mg twice a day. The last time she stopped her medications was 2 years ago, and she had a

From vSim for Nursing | Mental Health. © Wolters Kluwer.

manic episode after that. A psychiatric consult was initiated, and her medications and diagnosis were confirmed by her regular psychiatrist. Lithium will be restarted this afternoon. A-She has been very loud and verbal since she came from the postoperative unit. She is somewhat oriented; she knows that she’s in the hospital, but doesn’t really remember the details of the fall. She knows her name and recognized her husband, but her recollection of the events of last night is inconsistent as she relays the story to different staff members. She does not know what day it is. She is having grandiose thoughts, her speech is pressured, and she is talking constantly, exhibiting a flight of ideas, with thoughts ranging from issues in Washington to suggestions about running the hospital better. She has used the call light several times, saying that she needs to get out of here, and keeps asking whether she can use the unit phone to call Washington. So far, she has responded to redirection with irritability. She denies pain, but she says she never feels pain. She has threatened to take her intravenous (IV) line out to get rid of the pain medicine, which she says makes her feel like she's "not herself." So far, we've been able to talk her into keeping it. She takes small sips of water when it is directly given to her. There is a sitter present for the patient's safety. R-The provider wants to be called about assessments and her status. He expects she can be discharged later today, but she may need to be moved to the inpatient psychiatric unit. There is an order for lorazepam, 2 mg, as needed for agitation.

From vSim for Nursing | Mental Health. © Wolters Kluwer....