Reference no: EM133723407

Mental Health Clinical

A. IDENTIFYING DATA: (Patient Initials, Hospital Unit, Length of Stay, Age, Sex, Marital Status, Employment, Living Situation)
J O, 42-year-old male, admitted 4 days ago in 3 west, single, carpenter, currently homeless
B. REASON FOR HOSPITALIZATION: suicidal ideation
C. BRIEF HISTORY OF PRESENT ILLNESS & RELATED PSYCHIATRIC HISTORY:
Suicidal ideation, polysubstance abuse, depression
D. DSM V (psychiatric diagnoses)
1. Primary psychiatric diagnosis: major depressive disorder
2. Secondary psychiatric diagnoses (if any): polysubstance abuse
3. Other Psychiatric Diagnoses (personality disorders,
neurodevelopmental disorders and/or neurocognitive disorders):
4. Pertinent non-psychiatric diagnosis (physical health problems): none

D. MENTAL STATUS ASSESSMENT (describe and provide evidence to
support)
1. General Appearance:
a. Characteristics: Disheveled
Eye Contact: Direct

2. Psychomotor Behavior:
a. Gait/Movement-normal
b. Abnormal Movements-none
c. Posture-relaxed
d. Rate of Movement-normal

3. Mood and Affect
a. Mood or Feelings-calm
b. Affect
c. Range of Affect-normal
d. Stability of Affect-labile
e. Attitude Toward Staff-cooperative

4. Speech:
a. Rate of Speech-slow
b. Flow of Speech-appropriate
c. Intensity of Volume-ordinary
d. Clarity-clear

5. Cognition
a. Concentration-good
b. Memory-remote
c. Orientation Level-person, situation, place
d. Insight
e. Judgment

6. Thought Patterns
a. Clarity/Relevance-relevant to topic
b. Flow-blocking
c. Content
d. Level of Consciousness-x4

7. Behavior
a. Exhibited Behavior-appropriate to situation

C. NANDA, NOC, and NIC:

1. NURSING DIAGNOSES: (List 2) ACTUAL (three part: diagnosis,
related to, as evidenced by) Should be related to psychiatric and/or
psychosocial needs.
Labile emotions related to sadness as evidenced by crying suddenly
2. Disheveled appearance related to homelessness as evidenced by facial hair
2. NURSING OUTCOMES (List 2) Must be time specific and include the
words "patient will"
patient will have noticeable reduction in symptoms of depression
patient will no longer self harm
3. NURSING INTERVENTIONS: (List 2 done observed during clinical. Include
the words "nurse will")
nurse will give medications on time
nurse will cooperate with patient for therapy

E). SBAR note
S Patient voluntarily admitted with suicidal ideation with a plan to jump off a bridge
B Patient has history of worsening depression, polysubstance abuse, medication non-compliance
A Temp- 36.9, blood pressure-128/88, pulse-85
R Patient continue to the current therapy plan

F. What therapeutic communication skills did you use? (list at least two). How did you use them?

I used open ended questions to the patient so he could explain more about how he feels. I also clarify statements that are not clear.

G. Observe and give a specific example of a defense mechanism you saw used today. Document the defense mechanism, who used it, and how was it used. (Do not write about a defense mechanism you wrote about previously)
None

H. What therapy group did you attend today? (list one). What was the purpose of the group? What was the name and the title of the group leader? What is your evaluation of this group? How could you use something in this group in your patient care?
We attended a community and goal therapy. It is for patients' short term and long-term goals. The leader was prof. Rey. This group therapy was overall successful, everyone was attentive and interactive.

I. Spend some time observing and talking to one of the RNs on the unit. What does she/he do in a typical shift? How many patients is she/he assigned to? What does he/she like the best and the least about the job? Compare and contrast the role of the RNs in your med/surg clinical to the role of the RNs in this clinical.

Today's nurse came to work after 4 days off, so he was not familiar with most of the patients he got assigned. He was assigned to 6 patients. He likes psych floor more than med surg.

K. Process and journal your thoughts/feelings regarding your clinical experience (such as observations about patients, the hospital, mental health/mental illness etc.)

Today's clinical was a great experience for me. We got assigned to nurse and had 6 patients. We started passing medication to patients around 8am. One of the patients was a sexually inappropriate patient who was staring at us and was doing masturbation in the hallway. He calmed down after his pills. This was disturbing for me. I also got a chance to interview one of my patients for the care plan assignment which was a first experience for me. We attended 2 group therapy today, one for community and goal, and another one for adverse childhood experience. We took information for care plan for next clinicals.