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1-( Assess scene safety) as soon as you walk in the patient seems paranoid and says “I need to get out of here”. Pt looks anxious, paranoid and panicked? -I introduce myself saying “Mrs. Cole, I am here today to assess your physical and mental status. I’m going to be checking your leg and asking you several questions about your health. It’s important that you try to answer my questions as best as you can.” 2-Washed hands 3-identified pt 4-allergies --- Patient States “allergies?, I don’t have any allergies, NO! 5- Can you tell me about a little bit about w hats going on with you today? ---- Pt: “there is too much work to be done. I can’t do it here and you can’t make me stay here. I’m going to call the police and have you arrested. You are keeping me prisoner. I’m leaving now.” I answered: “You are in the hospital for treatment. Please stay in bed.” 6- Vital signs -BP- Pt answered “All this pressure! From everywhere.” -BP: 155/90 -Assess respiration (she is breathing at 24 per minute. The chest is moving equally”) -Attach O2 (Pt states “ All these wires” –Pulse O2 shows 99%) -Assess radial pulse ( pt states “my pulse is fine! There is nothing wrong!) -- Patient pulse was 104 -Assess temp – 7- Observed appearance—(Gown and hair is un combed) 8-Assessed for attention—(pt is not able to focus) 9-You observed the motor activity.---(The patient is restless) 10-You assessed the speech.---(speech is pressured and loud) 11-You assessed the thought processes. (the pt is suspicious and demonstrates flight of ideas and delusion of grandeur) 12- You educated about the psychiatric diagnosis. (Ms cole. A mental health provider is going to be here soon to evaluate your mental status. You have been diagnosed with bipolar disorder in the past and your safety is our primary concern. ) “pt: ill be safer if you let me out to do my work” I answered “ I understand you have concerns. Your safety is our primary concern. If the mental health provider deems it necessary, you may be transferred to the hospital’s mental health unit for the remainder of your recovery.”

13-Assessing pain Pt : “And you, because of you I cant dot my work. You keep me downtown all the time in this bed” I answered “Ms cole. Ill be glad to sit with you and talk a while.” 14- Pain from 0-10 Pt “I don’t have any pain” 15- I would like to dim the lights, so they are less disturbing. Pt “ Good Idea” - I have dimmed the lights in order to minimize outside stimuli. 16-Assess cast Pt: “ hurry up! I don’t have time for this.” (The cast is correctly placed. No pain from any pressure of the cast. Normal skin color. Vascular and Neurological assessment are intact) 17-Let me just assess your IV pt “ Come on! Is all good!” (the aite has no redness, swelling, inflirtation, bleeding, or drainage. The dressing is dry and intact. 18-Perform medication reconciliation ( I am going to take a good look at your medication to make sure everything is correctly updated) Pt: “ I can manage without medications” ( I have performed medication reconciliation to make sure your current list of medications is as complete and accurate as possible.) 19-Ask for allergies 20- Administer Lorazepam 2 MG- Pt: “I like you; you are pretty, so I’ll take it. 21- Over the past year, when di you feel your best? Pt “you know if I wanted to I could run this hospital. I know the president, and I can make it happen. I like you; you remind me of my family. You can come to dinner with us. I make the best BBQ pork in the world. Allen is not a good cook.” ( how can you run this hospital if you are a patient) Pt “ because I am the boss of you and everyone.” 22-You asked the patient: 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: Who put all these wires on me? I don't like them; they remind me of snakes. Take them off! You answered: This is your IV for your medicine. Please leave it alone. You used the therapeutic technique of giving information. 23 You asked the patient: Do you feel alert to answer questions? The patient said: This little red button is a direct line to Washington. If I keep pushing it, then someone will come save me. Don't tell anyone; it's a secret. You answered: That is your nurse call button. It calls the nurse's station. You used the therapeutic technique of presenting reality. 24You asked the patient: Can you tell me where we are? The patient said: Last night seems like a dream. I don't think I was even there. You answered: What seemed to lead up to you going to the bar? Pt “I remember being at the mall; then I saw the bar sign and through there might be fun people there.” You used the therapeutic technique of placing the event in time.

25- You asked the patient: Please tell me what today's date is. The patient said: I don't know. All of the days go together. 26- You asked the patient: How would you describe your mood? The patient said: My mood is great. 27- You asked the patient: Have you lost interest in activities that you once enjoyed? The patient said: My only interest is getting to Washington. They are going to waste all the money on the wrong things! I have to get out of here! 28- You asked the patient: Name an activity that you enjoy. The patient said: That guy who took my blood pressure, now he's a hot one! He got my blood pressure way up. Next time I see him I'm going to show him a thing or two about love. You answered: He is the nursing assistant. You need to behave appropriately with hospital staff. You used the therapeutic technique of giving information. 29- You asked the patient: Can you name the last five American presidents starting with Barack Obama and going back? The patient said: Barack Obama, George W. Bush.... They are in Washington, and I need to get there! 30- You asked the patient: Can you tell me what you ate for breakfast? 08:48The patient said: I can't believe you are doing this to me. This is all your fault. Why are you so mean? You answered: Are you feeling that no one understands? Pt: “ Yes, I feel line everyone is out to get me.” You used the therapeutic technique of translating to feelings. 31- You asked the patient: Do you have any thoughts or wishes to harm or kill yourself? The patient said: Look, I need to get out of here. The whole thing is going to fall apart. I can't get to Washington. Don't you people care about all the soldiers who are going to die without my help? Nobody can see it, but I can! They are going to waste all the money on the wrong things! I have to get out of here. Allen can drive there. This thing on my leg is in the way. You answered: Mrs. Cole, I am your nurse today and I am here to help you. You just had surgery. Please stay in the bed. You used the therapeutic technique of presenting reality. 32-Have you ever tried to harm or kill yourself? Pt: “no!” 33-Do you think it would be better if you were not alive? Pt “of course not” 34- You asked the patient: Do you have any thoughts or wishes to harm anybody else? The patient said: There was an assassin who pushed me last night. He pushed me off that building and broke my foot. Take this off me. I have to go find him and kill him before he gets to us.

You answered: You are in the hospital. Please stay in the bed. You used the therapeutic technique of encouraging description of presenting reality. 35-Can you tell me what a desired outcome of Tx would be for you? Pt “I would be in Washington! You have to let me out of here before the whole thing falls apart!” 36-How do you understand your problem? Pt “ look, this is not my fault. I think someone tried to assassinate me.” 37- Do you ever see or hear things that other people do not? Pt “ they are all just jealous because I am rich and smart and the president wants me to work for him! You are too slow! You want to be just like me!!” (Ms. Cole. Please lower your voice. Lets sit and take some deep breaths.) 38- Do you find that you worry more than other? Pt “ Tell me the president that I am ready to speak to him. Ill be waiting here in the ballroom until he gets here. Get me my gown crown and some red. Off with you!” ( I understand you believe that; however, I see your situation differently) 39- You asked the patient: Are you frightened of anything? The patient said: If you come near me again, I'm going to cut myself with this fork. It's true blue. I'll do it.... Stay away! You answered: Mrs. Cole, you will not hurt yourself. If you cannot control yourself, we will help you. You used the therapeutic technique of giving information. 　 40-Checked skin. There is normal elasticity of the skin. Her color is normal and she is not sweating. There are bruises and abrasions on the arms and knees. 41-educate about meds Pt “ I don’t have any pain; I just need to get out of here.” 42-educated about discharge pt “but first I got to go to Washington.” 43- I am going to call your provider. Pt: “Can he do anything about this?” 44...