Psychiatric Diagnosis: Depression disorder

Medcal and (or) physical problems: Hypertension, Diabetes, fracture RT ankle from fall, osteoarthritis, macular degeneration.

Psychosocial and Environmental Problems:

(problems with primary support group, education, occupational, housing, economic, access to health care). Patient has problem with primary support group. Her sister is unable to visit her because she suffered from a heart attack.

Presenting Problem: patient has become increasingly quiet and withdrawn and she is not eating and has lost 5 pounds in a month or so.

Reason for hospitalization (Client’s own words): “I not fit to be by myself because of my fracture Rt ankle. Everyone that I know is dead or moved away. The only piece of joy that I left was my sister coming to visit me. I do not want to come out my room and interact with people. Please leave me alone. I do not want to eat or take a shower. I am not sleeping very well and do not have an appetite. I’m ready for Good to call me home.”

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Current stressors: Her sister not able to visit her

Mental Status Examination

Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): not showered, clothing is scruffy, hair uncombed

Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): very restless and very irritable.

Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): cooperative

Affect (blunted, flat, guarded, labile, expansive, sad, or other): Flat

Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): apathetic, sad and irritable

Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Slow soft speech with pause

Thought Content:

Suicide Ideation (plan and/or intent): denies

Homicidal Ideation (plan and/or intent): denies

Hallucinations (auditory, visual, olfactory, gustatory, tactile): denies

Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): denies

Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): denie

Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): logical

Cognition (orientation, memory recall, concentration, attention span): oriented

Insight: Good. Judgment: good – she does not feel like harming herself

Coordination/gait/notable movement: patient is using a walker

Cultural issues, familial concerns and religious affiliation that may affect his/her care: N/

Support System: nursing home.

Current Physical Health:

Vital Signs – T: 97.6 F P:81 R: 14 BP: 138/90 Pulse Oximeter reading: 98%

Pain (Numeric 1-10): 3/10 Location: Right ankle Character: dull and sharp join pain

How would you describe your health: Poor

Nutritinal Status:

Diet: normal Feeding supplement: none Swallowing / Chewing difficulty: no

Elimination Pattern: Normal

Activity-Exercise-Sleep-Rest Pattern: 5-6 hours of sleep

Grup Attendance and Level of Participation: Poor

Substance Abuse: N/A

Substance	Amount / Frequency	Duration	Last Used
N/A	N/A	N/A	N/A

Withdrawal symptoms: N/A

Other Addictions (gambling, sex, internet, shopping, internet, etc.):

Discharge Plans: nonejm

Potential Nursing Diagnosis (Risk / Actual): Impaired social interaction R/T lack of support system AEB remain in seclusion, lost appetite, sleep poorly

Planning (patient goals): Patient will participate in 1 or 2 community social activity (e.i ice cream parlor, breakfast/lunch/dinner with other residents, bingo) within 24 hours

Nursing Interventions (include patient education):

· Assess patient’s past and current coping skills.

· Help patient to identify alternative courses of action to cope with depression.

· Encourage the patient to identify other support system other than his brother

· Encourage the patient to express her feelings about social interactions

Evaluation (patient response to interventions and teachings): Goal met – patient joined other residents for breakfast and lunch at the dining hall.

MEDICATION LIST

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

N/A

Side Effects

Food and Drug Interaction

N/A

Purpose / Rationale for the Patient

N/A

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Laboratory Report:

LAB	DATE	RESULTS	REERENCE RANGE
DEPAKOTE
LITHIUM
TEGRETOL
DILANTIN
WBC

Date:

Hour	Focus / Nursing Diagnosis	D – Data A – Action R – Response


	D	Patient is 84 years old. She has been in a residential home for four months following time in hospital with a fractured femur after a fall. She is a widow and her only visitor has been her younger brother, who suffered a stroke six weeks ago and has not been able to visit her since. She looks sad and gets tearful when discussing her feelings with the GP. She admits she is very lonely since her brother stopped coming to see her and is worried that he may never be fit enough to come again. She says that she is sleeping poorly, has lost her appetite and ‘can’t be bothered’ to sit with other people in the care home


	A	Physical assessment was done, and the GP conducts a PHQ-9 (The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day) with V, and her score is 20. A physical examination (including chest and abdomen) is normal, her BP is 146/82 and a dipstick urine test is negative.

	R	Patient expressed her feelings about wanting to get better and agrees on treatment plan

West Coast

University

Patient Care Notes

Patient Identification

Student Daily Journal

Personal goals for the day:

Finish my nursing process and find a zoom meeting for AA meeting. Potentially start my community experience paper.

Experience and activities of the day:

The AA meeting was really interesting. Participants shared their struggles and success in overcoming alcohol addiction.

Thoughts about your experience today: (How did you meet your goal?)

Your feelings about today: (How can you utilize your experience in the future?)

Today, I heard testimonies from people who suffered from alcoholic addiction and how they successfully overcome their addiction. I can utilize this experience by spreading the information that AA meeting is an effective means of helping an alcoholic to stop drinking.