Marbe12

this is the assessment i did Ego Integrity Subjective What kind of person do you think you are? (positive, negative, etc) positive "at least I try to be". What do you think of your body? "I feel like I should be running and working out", patient states she doesn't feel happy with her body at this time. How would you rate your self esteem?(1-10 scale, with 10 being highest) 4/10, " I am working on it". What are moods that you feel are problems for you? Depressed_X_Guilty __Unreal _____ Ups/Downs _X__Apathetic___Detached__X__ Separated from the world__X__ Sense of connectedness to others: yes, she feels like she can make friends really easy. Are you a nervous person? Yes Are your feelings easily hurt? yes When was the last time you used drugs or alcohol? What did you use?patient states that she hasn't use drugs in her life, but she does drink alcohol couple months ago when she was in college. Stress factors: school, a lot of assignments, working full-time Previous patterns of handling stress: patient states that she usually takes some time for herself, exercise, play's soccer and attends church on Sundays. Financial concerns: No Work hx/military service: worked as a server at the porch while she was in college, no military service. Relationship status ( S M D W, significant other): Single. Ethnicity/Ethnic factors: Caucasian White Lifestyle: Patient states she was living alone in while she was in college and working, but now that she is sick, she lives with her parents. Recent changes: "coming to the Emergency room and being here". Religion/Practicing? Christian Significant losses/changes/date: having these problems and having to come back to town to live with my parents and now being here since February 1 2018. Stages of grief/manifestations of loss: She said she is sad because she is here in 1N. " I was really sad that I have bipolar one and I was pretty bad about it". She continually keeps saying that she is sad. Feelings(check those that apply): Helplessness__X___ Powerlessness___X__ Hopelessness__X___ Restive _______ Passive _____ Dependent _____ Euphoric____ Angry __ Other____ Objective Emotional status (check all that apply): Calm__X__ Friendly__X__ Cooperative __X__ Evasive________ Fearful_____ Anxious __________ Irritable________ Withdrawn__X Patient is cooperative and friend but she only responds when spoken to, she seems withdraw and talks very slow. Defense Mechanisms: Acting out _____ Compensation ______ Denial __X__ Displacement ____ Dissociation___ Humor ___ Intellectualization ___ Projection ___ Rationalization___ Projection___ Rationalization ___ Reaction Formation ___ Regression ___ Repression __ Sublimation ___ Suppression _X__ When she is stressed or feeling bad she likes to work out so she doesn't have to think about it. Consistency of behavior: Verbal _X_ Non-verbal ___ Speech characteristics: Slow yes_ Rapid_no_ Volume_no_ Pressured _no_- patient's speech was very slow. was not pressured, or rapid. Her affect was flat, almost looks like she doesn't want to show her true feelings. Aphasia___none___ Impairments___none______ Motor behaviors: Posturing___normal___ Restless_none___Under/overactive___no___ Stereotypic__none__Tics/tremors____none__Gait patterns_normal gait_ Coping strategies observed (include data that supports your assessment) Suppression: When she has stress in life she stated that she likes to workout, play soccer, or stay active so she doesn't have to think about it. Neurosensory Subjective Dreamlike states: yes Walking in sleep: yes" I walked into another person room the second night I was here". Do you ever believe you are another person? No, "not in my right state of mind" Do you think you are different from other people? no Ability to follow directions (describe): no, patient was not able to count from 100 by 9 backwards. Patient reports she has a hard time concentrating on things. Ability to perform calculations (describe): States she is able to do simple math like 4x4. Ability to accomplish ADLs: Patient is able to bath, dress herself, and ask for medication. She is dress appropriate for the situation and temperature. She walks around the unit without assistance. Fainting spells/dizziness: yes Blackouts: yes Seizures: none Sleep Difficulties: yes Average hours of sleep per night over last month: sleeps 5 or 6 hours a night; because of school work. Objective Mental status (note duration of change): Oriented/disoriented Time: yes Person: yes Place: yes Able to state her name and where she was. Check all that apply: Alert____Drowsy__X_____ Lethargic_________Stuporous_______ Unresponsive_____Cooperative__X__Combative____Delusions___ Hallucinations_____ Memory: Immediate_______ Recent __X_______ Remote_______ Patient was able to recall events that lead to her current hospitalization. But her nurse reported that she has been having trouble with her short term memory. Nurse stated that she keeps asking them the same questions. Thought processes (assess through speech): Patterns of speech (spontaneous/sudden silences): her thought process is slow. Patient has a hard time vocalizing words. Didn't initiate conversations or give input in group on her own. No flight of ideas. She had tangential associations. Change in topic: yes, during the interview she kept changing the topic. She kept going back that the only reason she was here was because she was in college and she didn't had no one that could help her. Rate or flow of speech: slow Clear, logical progression: provides concise information that clear and easy to understand. Expression: made eye contact, appeared sad Flight of ideas: none Ability to concentrate: no, could not focus on the topics during the interviewing questions Attention span: She had a hard time being able to concentrate during interview, she had to be coloring. Delusions (describe): None; denies ever having delusional thought such as being someone else, having thought that are not her own, paranoia, or other false beliefs. Hallucinations (describe): Patient stated that she did had hallucinations when she came into the ER. She stated that she could see god and she could hear voices telling her that she "sucked" at everything she loves to do. Illusions (describe): None during the interview. Mood: depressed, sad. Affect (describe): flat affect, patient stated that she was sleepy and tired. Appropriateness of mood/affect: Appropriate, is sad about events that lead to her hospitalization. Intensity: low, did not seem passionate about any of the subjects. Insight: Understands her role in how she got in the situation and has plans avoiding coming back. She stated that once she gets discharged she plans to look for her PCP to help her find the resources she needs to manage her disorder. Misperceptions: none Memory: Immediate: normal, remembers introductions and my purpose is to interview her. Recent: impaired, able to recall the events that lead to her hospitalization, but sometimes she has a hard time retaining new information. Remote: normal, she remembers significant life events like when she graduated from high school, she also stated that she remember that she had a bipolar episode in 2016 when she was in Iowa, but she didn't seek help for it. Comprehension (describe how tested): impaired. Many questions needed to be re-asked or reworded. Calculation skills (include how tested): impaired patient was unable to count from 100 by 9 backwards. Ability to follow directions (include how tested): Explained the directions for serial 9's test, patient was unable to complete task without having me re-explain the directions. Judgment (include specific data): Patient doesn't exhibit impaired judgment, wants to get help to have a "positive environment", plans on looking for resources in her community to help her. Problems solving (include specific data): the patient accepts that she suffers from bipolar and that she wasn't received the treatment that she needed to manage it. She stated that now that she understands what she has she plans to try something different and be able to manage it with the help of the resources available. Impulse control: Aggression: none. Patient does not exhibit any during group, interactions or interview. Hostility: none Affection: None. Sexual feelings: none reported Teaching/Learning Subjective Dominant language (specify): English Second language: Spanish Literate: yes Education Level: College level " 3rd year in college". Learning disabilities: none reported Cognitive limitations: none reported Where born: Leavenworth, WA If immigrant, how long in this country? n/a Health and illness beliefs/practices/customs: patient can't think of any, she stated that she had never been seen for mental health problems. Discharge Plan Considerations: Anticipated date of discharge: unknown- had court today and it got continued Anticipated living facility: home with her parents. Resources available: Persons: mother, sister Support Groups: Outpatient mental health services and will receive a list of support resources with discharge. Plans to also look for resources in her area (cashmere). Areas that may require assistance : Food preparation : ____ Shopping : ______ Transportation: _______ Medication: _______ Other: housing Ego Integrity Division Ineffective coping r/t inadequate support system AEB: 1.Inadequate problem solving 2.Rate self-esteem 4/10 3.Feeling of helplessness, hopelessness. hopelessness r/t prolonged isolation AEB: 1.Decreased affect 2.Feeling depressed 3.Decreased appetite 4.Sleep disturbances Powerlessness r/t loss of control over life decisions AEB: 1.Feeling of hopelessness 2. Feeling of Depression 3.Reluctant to express true feelings 4.Patient stating that she can't make decision of what medicine she can take and what not to take Low self-esteem r/t hospitalization AEB: 1.Expression of helplessness 2.Indecisive behavior 3.disturbed body image Neurosensory Division (also consider diagnoses from other divisions, eg Safety) Disturbed thought process r/t psychological conflict AEB: 1.mental diagnosis of bipolar 1 disorder 2.low self-esteem 3.sleep disturbance 4.hallucinations Disturbed sleep pattern r/t bipolar 1 AEB: 1.patient complaining of fatigue 2.inability to concentrate 3.patient sleeping during the day impaired memory r/t excessive environmental disturbance AEB: 1.inability to retain new information 2.unable to follow directions 3.reports experiences of forgetting Impaired verbal communication R/T: slow thought process AEB: 1.difficulty vocalizing words 2.disturbance in cognitive associations Teaching/Learning Division Health-seeking behavior r/t bipolar 1 AEB: 1.express desire to know more about the disorder 2.verbalizes the desire for increase control of health Readiness for enhanced coping r/t seek social support to deal with bipolar AEB: 1.Attending group sessions 2.Expressing willingness to use a support group as appropriate

Hello I am having a hard time coming up with some collaborative care for some of the nursing diagnosis for patients in the psychiatric unit. 1. I have sleep pattern disturbance r/t bipolar 1, fatigue. 2. Impaired verbal communication r/t slow thought process. 3. Altered thought process r/t biochemical imbalances for sensory distortion ( hallucination). 4. Impaired social interaction r/t sleepiness.

Hello I am having a hard time coming up with some collaborative care for some of the nursing diagnosis for patients in the psychiatric unit. 1. I have sleep pattern disturbance r/t bipolar 1, fatigue. 2. Impaired verbal communication r/t slow thought process. 3. Altered thought process r/t biochemical imbalances for sensory distortion ( hallucination). 4. Impaired social interaction r/t sleepiness.