SOAP Note - SOAP Notes for Psych PDF

Preview

Summary

SOAP Notes for Psych...

Description

SOAP Note Patient #1 S: Subjective 37-year-old patient states that he “came to the hospital for his depression, and suicidal thoughts and ideations” after having suicidal thoughts and ideations about drowning himself and/or hanging himself. Patient states he feels lonely and has been trying to manage his depression since November 2019. The patient states that what troubles him the most with his depression is the sadness and deep void he feels inside of him. The patient says that his depression usually lingers and then when something happens in his life, it takes over and makes him want to kill himself, but he “doesn’t want to be sad anymore.” O: Objective Vital Signs Temp: 98.9 BP: 125/81 HR: 84 RR: 18 O2 Sat: 99% on room air Height: 5’8” Weight: 175 lbs. Diet: N/A 1. Appearance: Good hygiene, neat appearance, looks stated age 2. Behavior: Calm, focused, eye contact intermittent 3. Attitude: Cooperative, friendly, open to discussion 4. Level of Consciousness: Awake and Alert 5. Orientation: Oriented to person, place, and time 6. Speech and Language: Soft, clear, and coherent 7. Mood: Appropriate to context 8. Affect: Mildly restricted, congruent with mood 9. Thought Process/Form: Organized and goal directed, logical 10. Thought Content: Depression, suicidal thoughts 11. Suicidality and Homicidality: Prior suicidal/homicidal thoughts, denies any suicide attempts 12. Insight and Judgment: Insight deemed good; judgement is fair 13. Attention Span: Appropriate for age and adequate to needs of outpatient program 14. Memory: Recent and remote memory intact 15. Intellectual Functioning: Intellectually capable Relevant Screening Tools: - Patient Health Questionnaire (PHQ-9): 14 - Columbia Suicide Severity Rating Scale (C-SSRS): Low risk Support: Patient lives with his sister and mother, but states that he does not talk to them about his mental health. He chose to be a part of the outpatient program to address his suicidal thoughts and depression.

Erickson’s Stage: Intimacy vs. Isolation Patient is in a state of isolation. Patient has faced a lot of rejection beginning in his early childhood, as well as abandonment from his father. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Struggling at this stage, can result in feelings of loneliness and isolation. A: Assessment Primary medical diagnosis: Depression with suicidal thoughts and ideations Medical/Surgical history: N/A Nursing Diagnoses: 1. Hopelessness related to symptoms of depression, as evidenced by decreased judgement. 2. Disturbed thought processes related to depressed mood, as evidenced by negative ruminations. 3. Chronic low self-esteem related to impaired cognitive self-appraisal as evidenced by selfnegating verbalizations. P: Plan and Rationale Plan of care: Assess positive and negative symptoms. Assess mental status and support system. Establish trust and rapport to maximize patient’s level of functioning. Promote social skills through group therapy. Assist client to deal with current situation, promote wellness, and provide for meeting psychological needs. Interventions + Rationales: 1. Hopelessness: a. Assess individual signs of hopelessness. i. This focuses attention on aspects of individual needs. These signs may include social withdrawal, decreased physical activity, and comments made by patient that indicate despair and hopelessness. b. Assess destructive behaviors used to handle with feelings such as withdrawal, avoidance, substance abuse. i. The patient may have tried to overcome feelings of hopelessness with harmful and ineffective behaviors. Acknowledging these behaviors provides an opportunity for change. c. Express hope to the patient with realistic comments about the patient’s strengths and resources. i. Patients may feel hopeless, but it is helpful to hear positive expression from others. 2. Disturbed thought processes: a. Allow the client to have plenty of time to think and frame responses. i. Slowed thinking necessitates time to formulate a response. b. While the client is severely depressed, minimize client’s responsibility. i. Decreases feelings of guilt, anxiety, and pressure. c. Help the client identify negative thinking/thoughts. Teach the client to reframe and/or refute negative thoughts.

i. Negative ruminations add to feelings of hopelessness and are part of a depressed person’s faulty thought processes. Intervening in this process helps in healthier and more useful outlook in life. 3. Chronic low self-esteem: a. Allow the patient to engage in simple recreational activities, advancing to a more complex activities in a group environment. i. Patient may feel overwhelmed at the start when participating in a group setting. b. Teach visualization techniques that can help the client replace negative selfimages with more positive images and thought. i. To promote a healthier and more realistic self-image by helping the client choose more positive thoughts and actions. c. Involve the client in activities that he or she wants to improve by using problemsolving skills. Assess and evaluate the need for more teaching in this area. i. Feelings of low self-esteem can interfere with usual problem-solving abilities....