HISTORY AND MENTAL STATUS EXAM:
PT INITIALS: CJ AGE: 29 M/F: Male UNIT: Mental Health Station 1 Date of Admission: 03/16/2020
Brief explanation for this admission including legal status (including Riese and Meredith status), main complaint (by the patient or by report) acute and chronic medical issues, nursing considerations, brief background such as where patient lives and with whom:
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Personal History:
Where was patient born and circumstances of family life. Course of childhood including memorable events, relationships, medical or psychiatric issues. School life, special friends. Leaving home, work, college. Career, marriage, romantic relationships. Activities, hobbies, interests.
Psychiatric history if any, medical history. Memorable events, especially losses and disapointments.
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Developmental Age (Erikson) ________________________________________ Appropriate?
Explain how your patient does or does not meet this task:
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Maslow’s Hierarchy: Describe each stage, where is the patient currently? Where has the patient been in life? What does the future hold for this patient? Is there potential for growth into higher stages?
Physical _______________________________________________________________________________________________
Safety/Security ______________________________________________________________________________________
Love/Belonging ______________________________________________________________________________________
Self Esteem ___________________________________________________________________________________________
Self-Actualization ____________________________________________________________________________________
Cultural Implications: Do not write “none.” Where was patient born and raised? Language, religion, ethnicity, etc?
Educational level:
Teaching Needs:
Patient’s goal(s): (What does she/he want?)
Nursing Goals: What do you as the nurse think would be good goals?
What are the institution’s goals for this patient?
Any other important information such as past psychiatric history, psychosocial and/or legal issues? List medical concerns and risks here. (If not covered above.)
COLLECT THE FOLLOWING DATA: PSYCHIATRIC ASSESSMENT TOOL/MENTAL STATUS EXAM:
How does the patient make you feel?
MEDICATIONS Can use a separate paper. Include all meds: routine and PRN
| Name | Dose | Route | Time | Scheduled or PRN | Indication | Nursing Considerations |
Allergies: Penicillin
Significant Labs if any:
List 2 possible opening statements to this patient that will help you initiate a therapeutic relationship.
Primary Nursing Diagnosis:
2 Goals: 1 long term goal and 1 short term goal.
1.
2.
Interventions: 2 interventions per goal
1A.
1B.
2A.
2B.
Nursing Care Plan |
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Multidisciplinary Care/treatment Plans (Add additional pages as necessary.)
At least one short term, length of stay for example, and one long term, working toward discharge from your facility’s care).
| Assessment Data | Nursing Diagnosis | Goal/Outcome | Nursing Interventions with
Rationale |
Evaluation |
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PT INITIALS: CJ AGE: 29 M/F: Male UNIT: Mental Health Station 1 Date of Admission: 03/16/2020
Brief explanation for this admission including legal status (including Riese and Meredith status), main complaint (by the patient or by report) acute and chronic medical issues, nursing considerations, brief background such as where patient lives and with whom:
CJ was admitted because he assaulted staff, and even after receiving PRN medications, he continued to be assaultive to the staff members. He lives in Santa Cruz, CA, where he was born. He lives with his older brother as his parents had passed on. After assaulting one of the staff members, he is currently not allowed back per the 7th Ave facility. While at EPS patient presented disheveled with flat affect. He also had a lack of speech when spoken to. The patient made nonsensical statements and is known as a poor historian. The patient denied auditory hallucinations despite inappropriate laughing periodically. As a nurse, I would consider schizophrenia as the patient has poverty of speech, and even though he denied having hallucinations, he was laughing periodically at nothing. These are common symptoms of schizophrenia, and since he fought staff even after receiving the PRN medication, it is evident that the patient is delusional.
Personal History:
Where was the patient born, and circumstances of family life? The course of childhood including memorable events, relationships, medical or psychiatric issues. School life, special friends. Leaving home, work, college. Career, marriage, romantic relationships. Activities, hobbies, interests.
Born and raised in Santa Cruz, CA, CJ is the second born in a family of two. The two boys lost their parents thirteen years ago to a road accident, and they have been taking care of each other. He currently lives with his brother, who has been his guardian since the parents’ demise. Unfortunately, he did not graduate high school and dropped out before he could complete his diploma. His brother could not afford his school needs, and he had to drop out to help his brother with the bills. Talking about his parents, I remember seeing a smile on the patient’s face. Talking about his family when the parents were alive brought a smile to his face. His schizophrenia has not been treated for a while, and as a result, he has developed anxiety disorders. Unfortunately, CJ has no friends as he isolates himself from everybody else. He had a girlfriend a few months ago, and they broke up when he got violent and assaulted her. Ever since the breakup, he has not been in any romantic relationship. During his free time, he likes listening to music and playing tennis in a nearby club.
Psychiatric history, if any, medical history, Memorable events, especially losses and disappointments
He lost his parents when he was hardly 16, and since then, he has only been to the hospital once for schizophrenia treatment. He has not gotten over the death of his parents, and it still hurts him to date. However, he has a lot of good memories of the parents. It was evident because that was the only part of his life that brought a smile to his face. For instance, he remembers how Sundays were family days, and they could spend most of the day participating in different activities. He is, however, disappointed that the parents did not fight hard to leave longer, and he had to remain without them. He has a psychiatric history of psychotic disorders. For instance, the patient has developed an anxiety disorder, and he has lost touch with reality. He is delusional and has previously suffered from hallucinations.
Developmental Age (Erikson) ________________________________________ Appropriate?
According to Erikson, there are eight main stages of development. CJ lost his parents when he was in the 5th stage, adolescence. At this stage, one struggles between the fundamental conflict of role confusion and identity (Knight, 2017). As he was trying to achieve a sense of identity, he lost his parents. At this stage as well, the patient developed adolescent complications like cystic acne and hyperlipidemia. Currently, since he is 29, he is in the early adult developmental stage. At this stage, the central conflict is between intimacy and isolation. At this stage, it is expected of a young adult to develop an intimate relationship with others. In case they fail to, they are likely to develop isolation feelings.
Explain how your patient does or does not meet this task:
According to Erikson’s developmental stages, the patient is eligible for this task because he should be in an intimate relationship. If he is not in one, he is likely to suffer from isolation. CJ has no girlfriend, and his last relationship was 11 months ago. He has no friends either, and he is likely having feelings of isolation.
Maslow’s Hierarchy: Describe each stage. Where is the patient currently? Where has the patient been in life? What does the future hold for this patient? Is there potential for growth into higher stages?
Maslow’s Hierarchy is a motivational theory that focuses on the five categories of individual needs and how they impact a person’s behavior (Alajmi & Alasousi, 2019).
Physical– the physical needs, according to Maslow, are the most basic needs a person requires. These often include water, food, rest, and shelter, to mention a few. Maslow states that it is necessary to address these needs before moving to the next level.
Safety/Security-safety needs, according to Maslow, include emotional stability, protection from violence, financial and health security, and a person’s wellbeing.
Love/Belonging-among love/belonging needs are family bonds and friendships. These may include biological families like parents and siblings or chosen families like spouses and intimate partners. Both emotional and physical intimacy is essential to achieving this need. In addition to this, social group memberships also help in meeting this need.
Self Esteem-according to Maslow, higher needs like esteem are needs driven by ego. The main elements of this stage include are self-respect and self-confidence. There are two types of self-esteem: esteem from acknowledgment and respect from other people and esteem depending on self-assessment.
Self-Actualization-these needs that describe how fulfilled one is with their full potential. These needs often referred to as self-fulfillment needs, are at the top of Maslow’s pyramid. These needs include skill development needs like cooking, gardening and athletes, caring for others and, education.
The patient has experienced a lot, and he has felt love/belonging, and he has physical and safety needs. However, currently, he is in self-actualization need. In that, he feels his brother will never accept or appreciate him no matter what he does.
Cultural Implications: Do not write “none.” Where was the patient born and raised? Language, religion, ethnicity, etc.?
CJ is of Latin origin, and he was born, raised, and still lives in Santa Cruz, CA. Apart from English, he is fluent in the Spanish language as that was the first language and the language they spoke at home. He did not mention his religion.
Educational level:
Unlike most people, CJ did not graduate high school. He dropped out after the parents died as he had to work and his brother could hardly support him.
Teaching Needs:
The patient needs to learn the different ways he can manage his condition. For instance, he should learn how to control his delusions and how angry he gets to prevent him from getting into fights with others. He needs to learn that not everything is about him, and when people laugh, they are not laughing at him.
Patient’s goal(s): (What does she/he want?)
According to the patient, below are his goals
Nursing Goals: What do you as the nurse think would be reasonable goals?
In my opinion, I believe the first and the best goal would be for CJ to get better and improve on his health. Learning to control his anxiety disorder will be the first step to achieving the other goals. Therefore, I believe he should first focus on his getting well before anything else.
What are the institution’s goals for this patient?
The institution’s goals for this patient are to help him relieve mental suffering associated with schizophrenia. The institution also aims at improving the patient’s wellbeing.
Any other important information such as past psychiatric history, psychosocial and legal issues? List medical concerns and risks here. (If not covered above.)
The medical concerns associated with schizophrenia may include the following;
COLLECT THE FOLLOWING DATA: PSYCHIATRIC ASSESSMENT TOOL/MENTAL STATUS EXAM:
General appearance and attitude toward the interviewer: What the patient looks like including dress, posture, and grooming. Attitude: cooperative, friendly, guarded, paranoid, etc.
The patient was well-groomed and calmed when he came to the hospital. He was well-groomed, and without listening to reason for admission, one would believe he had no problem. He had no violent behaviors, and when asked questions, he cooperated. However, he was preoccupied during assessment and, in some cases, took long pauses to respond to the questions.
During the assessment, the patient presented bizarre and messy and would stare blankly often. He was disconnected and preoccupied with thought blocking.
When spoken to during assessment, he had a lack of speech. The patient made nonsensical statements and is known as a poor historian. When responding to questions, he took long pauses and took his time to respond.
The patient was coherent. When asked questions, he clearly expressed his thoughts in ways we could understand. For instance, when asked why he assaulted a staff member, he stated that the member laughed at him when the boss was correcting him on something he needed to work on.
If not prompted, the patient talks about how much he misses his mum. He is troubled that he was not able to protect and prevent his parents’ death. He confessed and stated that when he first learned about the parent’s death, he attempted to take his life and join his parents. After that incident, he has countlessly thought of suicide but has never done anything about it. The patient is scared of heights and driving. He has never driven a car in his life as he only uses a bicycle or bus as his means of transportation.
Even though the patient denied having auditory hallucinations, he laughed periodically at nothing. In addition to this, he presented bizarre delusion. For instance, the patient stated that he heard his mum calling him to go to him.
CJ is a very attentive patient, and his concentration is at the peak. His judgment is responsible, and he makes constructive choices in his interactions with others.
The patient is often anxious and is aware of his surroundings. When it comes to affecting, he displays restricted affect. He often blocks and numbs his emotions most of the time. He blocks his thoughts and rarely expresses himself if he does not want to.
When it comes to socialization and building relationships, the patient isolates himself from the rest of the patients. He sits at a corner and watches everybody else in what they do but never participates in any of them.
When anxious, the patient takes deep breaths as he counts from 20 downwards. His self-esteem is low, and he feels he is not enough. He also believes that his brother, who has been his guardian since the death of their parents, will never acknowledge or accept him. During difficult times, the patient distracts himself by listening to music, and sometimes he meditates. According to him, these strategies make him relax better.
How does the patient make you feel?
Having met and interacted with the patient, I feel the patient can improve and become better. He is currently blocking his emotions, but the more he stays here, the more he will open up and receive the help he needs. I feel I can influence the patient to choose his decisions wisely and educate him on the importance of taking medications. He has a history of not taking medication, and I feel I can help him change that by spending more time with him.
Conclusion: What did you find overall? Describe the significant verbal vs. nonverbal behavior. What are your feelings about your interactions with this patient?
Generally, I realized that the patient has been through a lot, and he is more vital than most people. He is a communicator, and even though he blocks his thinking, he is a coherent individual when he wants to be heard. Interacting with him, I feel he will get better sooner than I thought, and as long as he takes his prescribed medication, he will meet his goals by the time he is 33. As long as he is monitored and speaks to someone, he will be able to change his life.
MEDICATIONS Can use a separate paper. Include all meds: routine and PRN
| Name | Dose | Route | Time | Scheduled or PRN | Indication | Nursing Considerations |
| Tylenol 325mg | 2 tablets | Mouth | 4 hours | Scheduled | Used for pain. | Ask patient to report skin rash or difficulty breathing. |
| Trazadone Hcl tablet 50mg | 1 tablet | Mouth | Bedtime | Scheduled | Schizophrenia related sadness and inability to sleep. | Monitor pulse rate. |
| Risperdal tab 2mg | 1 tablet | Mouth | Twice a day | Scheduled | Responding to internal stimuli related to schizophrenia | Monitor hyponatremia with this medication |
| Prozac capsule 40 mg | 1 capsule | Mouth | Once a day | Scheduled | Depression related to schizophrenia | Look for confusion in patient. |
| Milk of magnesia. 1200mg/15mL | 30 ML | Mouth | Every 24 hours | Scheduled | Constipation | Look for severe diarrhea. |
| Ducolax suppository. | 10 mg | Rectally | Every 24 hours | Scheduled | Constipation | Irregular heartbeat. |
| Benzotropine Mesylate | 1mg tablet | Mouth | Bedtime | Scheduled | Given to decrease stiffness and tremors, control involuntary movements | Assess for palpitations. |
| Fleet enema 7-19GM/118mL | 1 inserted | Rectum | 24 hours | Scheduled | Constipation | Assess for continuous diarrhea |
| Invega Sustenna suspension. | Inject 234mg IM | Vein | Every 28 days | PRN | Internal stimuli | Look for restlessness and tremor. |
| Aplisol Solution 5 unit/0.1mL | 0.1ML | Forearm | Annually | PRN | Infection detection | Scarring of test site |
Allergies: no named allergies.
List 2 possible opening statements to this patient that will help you initiate a therapeutic relationship.
Primary Nursing Diagnosis:
The patient suffers from schizophrenia and anxiety disorders.
2 Goals: 1 long term goal and 1 short term goal.
Interventions: 2 interventions per goal
1A. for the short-term goal, we will use medication to reduce the symptoms.
1B. secondly, we will ensure that the patient undergoes no stress during this treatment time,
2A. for the long-term goal, we will enroll the patient into individual therapy. Therapy helps in normalizing thought patterns.
2B. secondly, we will provide supported employment and vocational rehabilitation. It focuses on helping individuals not only find but also keep jobs.
Nursing Care Plan |
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| Nursing Diagnosis.
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Multidisciplinary Care/treatment Plans (Add additional pages as necessary.)
At least one short term, length of stay for example, and one long term, working toward discharge from your facility’s care)
| Assessment Data | Nursing Diagnosis | Goal/Outcome | Nursing Interventions with
Rationale |
Evaluation |
|
The patient assaulted a staff twice and was still assaultive even after he received PRN medication. He is delusional and has hallucinations. Despite all, he blocks his thoughts and when one is talking to him, he seems lost and distracted most of the times. The patient presented disheveled with flat affect. He also had paucity of speech when spoken to. Patient made nonsensical statements and is known as a poor historian.
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The patient has anxiety disorders and schizophrenia, | The main goal is to help the patient control and manage his symptoms. | We will use medication to control the patient symptoms for sometimes. CJ has a bad history and is known not to fully take his prescriptions. |
Using medication will help CJ in controlling and managing his symptoms. It is so because these medications are specifically made for these purposes. He will take different medications like antidepressants to control the symptoms, and it will have to be for a few weeks before he can fully control them.
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| The long-term goal for this patient is to ensure that in the next few years, the patient will be in a position to work and live on his own. | For this to happen, the individual will have to enroll in individual therapy. The therapy might go on for years to ensure the patient does not relapse and go back to his old ways. | Doing this would be effective as it will help him learn the different ways of coping with stress and identifying relapse. In addition to this, the therapy will normalize his thought patterns and may prevent his suicidal thoughts. |
References
Alajmi, B., & Alasousi, H. (2019). Understanding and motivating academic library employees: theoretical implications. Library Management. https://www.researchgate.net/publication/323616041_Understanding_and_Motivating_Academic_Library_Employees_Theoretical_Implications
Knight, Z. G. (2017). A proposed model of psychodynamic psychotherapy linked to Erik Erikson’s eight stages of psychosocial development. Clinical psychology & psychotherapy, 24(5), 1047-1058. https://pubmed.ncbi.nlm.nih.gov/28124459/
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