Sandra littlefield documentation assignment PDF

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Sandra littlefield guided reflection lippincott the point virtual simulation assignment psych nursing virtual simulation...

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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 did not have any nonpharmacologic interventions for her pain. She did have coping strategies for anxiety and frustration. She stated that in the past, “I have enjoyed taking walks and reading romance novels.” This RN offered to facilitate these coping strategies by showing the patient the library and discussing exercises that can be done on the unit. 2. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided Ms. Littlefield. Include her response to the teaching. Regarding coping I stated, “There are several strategies you can utilize to decrease feelings of anxiety, frustration or fear. For example, community support groups and regular appointments with a therapist will help you to increase self awareness and reduce the potential for destructive acting out behaviors. While you are in prison, I can assist you with identifying community resources when you are released. Is there anything you have done in the past that has helped to reduce your anxiety or frustration?”. The patient responded, “I have enjoyed taking walks and reading romance novels.” I replied, “Perhaps we can talk about some exercise you can do while in prison. There is a small library with books and magazines that is available to you here. We can walk there together.” Regarding her medications I stated, “Ms. Littlefield, you have been prescribed two medications for pain. Both are over-the- counter medications that also reduce inflammation associated with painl. You may have two 500mg tablets of acetaminophen every 6 hours, not to exceed 6 tablets per day or 3,000mg. You may also have ibuprofen 600mg, every 8 hours.” Regarding pain management I stated, “I would like to talk to you about other methods t relieve pain that don’t involve painkillers,” The patient replied, “I don’t think that will work, but what can I do?” I told her, “There are a number of interventions you could use, like applying ice packs, stretching exercises, and core strengthening, to name a few. I could show you when you are ready for that? 3. Referring to your feedback log, document all nursing care provided and Ms. Littlefield’s response to this care. I checked scene safety, introduced myself, washed my hands, identified the patient, asked about allergies. I then collected vital signs. I assessed the patient’s attention, motor activity, speech, and thought processes. I asked the patient “Can you tell me a little bit more about what’s going on with you today?” and she responded, “I am in so much pain. You are a nurse.

Don’t you know how to tell when someone is hurting?” Me: You are feeling overwhelmed? Me: 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. These are questions I ask all of the patients I see. May I ask you these questions? the patient said: Just because you are in love with the guards, you prance around like you own this place and you do not! I answered: Ms. Littlefield, you need to lower your voice now. I am here to help you. I used the therapeutic technique of giving information. Me: Do you feel alert to answer questions? The patient said: Yes, I am. Met: Can you tell me where we are? The patient said: You think you are better than me because I'm in jail. Well you are not! Me: Are you feeling as if no one cares? I used the therapeutic technique of verbalizing the implied. Me: Please tell me what today's date is. The patient said: It is the 1st. Me: How would you describe your mood? The patient said: No one has even looked at my back today. I know it's worse than it was, no matter what those tests said. Me: Let's sit together and discuss a way you can handle your frustration appropriately. I used the therapeutic technique of suggesting collaboration and formulating a plan of action. Me: Have you lost interest in activities that you once enjoyed? The patient said: I know you have some stronger pain medicine. You gave some to another patient, and she wasn't even in pain like me. I answered: We are here together today to talk about you. I used the therapeutic technique of giving information. Me: Name an activity that you enjoy. The patient said: I like listening to music. Me: Can you name the last five American presidents starting with Barack Obama and going back? The patient said: Barack Obama, George W. Bush, Bill Clinton, George H. W. Bush, Ronald Reagan. Me: Can you tell me what you ate for breakfast? The patient said: I had some coffee and a bowl of cold cereal. Me: Do you have any thoughts or wishes to harm or kill yourself? The patient said: If they don't help with my pain, I will. Me: Have you ever tried to harm or kill yourself? The patient said: I slit my wrists in the past but nobody really cared. Me: Do you think it would be better if you were not alive? The patient said: Yes. Me: Do you have any thoughts or wishes to harm anybody else? The patient said: If they don't help me with my pain, I might. Me: Have you ever tried to harm or kill somebody else? The patient said: Yes, that police officer but he deserved it. Me: Can you tell me what a desired outcome of treatment would be for you? The patient said: Everyone is against me. You, the other nurses, the provider—you all hate me. The only one who likes me is that cute guard. I answered: You feel that people hate you?

I used the therapeutic technique of restating. Me: How do you understand your problems? The patient said: I love talking to you. I wish you were here all the time. You are my favorite nurse. I answered: Is there something besides your back pain you would like to talk about? I used the therapeutic technique of broad openings. Me: How do you understand your problems? The patient said: It wasn't my fault that I ended up in this place. Me: Do you ever see or hear things that other people do not? The patient said: No, I'm not crazy. Me:: Do you find that you worry more than others? The patient said: I worry about my pain. Me: Are you frightened of anything? The patient said: You look so nice today. And you smell good. What perfume are you wearing? I answered: Are you uncomfortable when you talk about your feelings about being here? I used the therapeutic technique of making observations. Me: Have you had any changes in your appetite over the past month? The patient said: When I was in my 20s, all the men followed me around. You're cute; I bet you get looks like that too. I answered: We are here to talk about you today. I used the therapeutic technique of giving information and setting limits. Me: Do you have energy to do the normal activities necessary to get through the day? The patient said: My energy would be fine if somebody would pay attention to my pain! Me: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: It isn't easy to sleep in this place. Me: How would you rate your pain, on a scale of 0 to 10? The patient said: It changes but is always high. Now it is 8 to 9! Me: On a scale of 0 to 10, how would you rate your level of distress? The patient said: Have you seen the security guard with the blond hair? He can take me back to my cell anytime. I answered: We are here to talk about you today. I used the therapeutic technique of giving information and setting limits. Me: Where is your pain located? The patient said: In my back! Me: What other pain management strategies have you used other than medications? The patient said: No. Let's stick with the meds. It was correct to ask if the patient was using any pain management strategies other than medication. I supported the patient about relaxation techniques, pain medication. I educated about coping strategies, medications, strategies for pain management. I submitted the mental status examination form and called the provider.

4. Document all interventions associated with boundary and limit setting directed toward managing Ms. Littlefield’s manipulative behavior.

Highlighted in pink in the above question (3) Therapeutic techniques I used included giving information and setting limits. 5. Document all of Ms. Littlefield’s attempts at “splitting” and include interventions implemented to respond appropriately. Highlighted in Blue in the above question (3) Therapeutic techniques I used included giving information, restating, and using broad openings. 6. Document your handoff report in the SBAR format to communicate Ms. Littlefield’s future needs. ISBAR Introduction Your name, position, unit

RN, Corrections facility

Situation Patient’s name, age, reason for visit

Sandra Littlefield, 36yo female, she has been in the jail for one week on prostitution charges. Previously complained of back pain for which she was given ibuprofen and acetaminophen. Her visit today is in regards to unrelieved back pain

Background Patient’s primary diagnosis, date of admission, current orders for patient

Patient has been diagnosed with borderline personality disorder. Has been incarcerated in the past and has been aggressive during past incarcerations. Has a history of sexual abuse, suicide attempts, drug and alcohol problems. Patient frequently visits ER for back pain asking for stronger medications as ibuprofen and acetaminophen do not relieve her pain. Currently receiving 600mg ibuprofen Q8hr and 600mg prn also prn 1000mg tylenol

Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

BP: 132/80 HR:84 RR:16 Temp: 98.6 SPO2:98 Height: 172cm Weight:63kg Today we performed a mental status exam that avoided asking too much about physical complaints of the patient. This patient was appropriately dressed with good personal hygiene. She was able to focus,

demonstrated good insight, and goal directed thought. She did not have any inappropriate movements. She had poor personal boundaries between herself and staff. She expressed pain at a level of 8 in her back that was unmanaged with tylenol or ibuprofen. She expressed that she was uninterested in non pharmacological interventions for pain. She did have evidence of frustration in her speech. She had scars on her wrist from self harm. Recommendation Any orders or recommendations you have for this patient

I recommend this patient be encouraged to try different non pharmacological interventions for her pain. She should also be provided with access and information regarding addiction treatment services. Continue to monitor her pain levels and administer analgesics as they are prescribed and as she asks for them....