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B, M
Sex: F
Code Status: 00
Isolation: 00
Food Allergies: 00
Diet: 00
Hospital Floor:
Age: 77 Y
Alerts: 00
Drug Allergies: 00
Env. Allergies: 00
BMI: 20.8
Psychiatric
Student: Mackenzie Beeler Assignment: Assignment #2--Wednesday-Professor Peterson-RMH Submitted: 02/19/2015 21:37
Clinical Assignment Grading
Assignment Objectives
No assignment objectives entered.
Clinical Set-up Details
First Day of Clinical:
02/18/2015
Primary
Diagnosis: ????
Provider Name:
B, M
Secondary Diagnosis:
Student Details:
Patient Details:
First Initial:
Identifier 1: M
Last Name:
Beeler
Identifier 2: B
Credentials:
SN
Gender:
Age:
77 Years
Pre-Clinical Manager
Patient Info Identifier: B, M
Gender: F
Age: 77 Y
Medications (6)
Medication:Olanzapine Orally Disintegrating Tablet (Zyprexa Zydis)
Classification:
Psychotherapeutic Agent:
Antipsychotic
Route:
Oral
Frequency:QHS
Dose:
Date
Ordered:
Therapeutic Effect:
Target symptoms: agitation, depression, delirium
Action:
The exact mechanism by which olanzapine exerts its
antipsychotic effect is unknown. However, this effect may
be mediated through a combination of dopamine and
serotonin 5-HT 2 antagonism. Olanzapine is a selective
monoaminergic antagonist with a strong affinity for
serotonin 5-HT2 receptors, and dopamine D1, D2, D3,
and D4 receptors. Olanzapine weakly binds to GABA A,
benzodiazepine, and beta-adrenergic receptors.
Contraindications:
No specific contraindications indicated.
2.5 mg
01/01/1900
Nursing Interventions:
The nurse should obtain a thorough personal and family
history of obesity, diabetes, and cardiovascular disease
as well as obtain a baseline blood glucose, lipid profile,
blood pressure, and waist line. Nurse should monitor for
signs of tardive dyskinesia. Nurse should educate
patient of side effects, partcularly hypotension and
dizziness and to get up slowly to reduce the risk for falls.
GOOD
Classification:
Hypotensive Agent
Route:
Oral
Frequency:DAILY
Dose:
Date
Ordered:
Therapeutic Effect:
Target symptoms: high blood pressure
Action:
Lisinopril is a long-acting angiotensin-converting
enzyme (ACE) inhibitor. ACE inhibition prevents the
conversion of angiotensin I to angiotensin II which is a
potent vasoconstrictor. Decreased angiotensin II leads
to decreased vasopressor activity and decreased
aldosterone secretion, thus leaving vessels dilated
reducing the arterial pressure.
Contraindications:
Drug interaction: aliskiren, alteplase, amiloride,
candesartan cilexetil, olmesartan medoxomil,
potassium, telmisartan, valsartan
Nursing Interventions:
Nurse should obtain blood pressure before and after
administration. Nurse should assess laboratory results
to detect changes in renal function and serum potassium
levels. Educate patient of common side effects including
cough and headache. Educate to move slowly to reduce
10 mg
01/01/1900
Classification:
Angiotensin-converting enzyme
(ACE) Antidepressant
Route:
Oral
Frequency:DAILY
Dose:
Date
Ordered:
Therapeutic Effect:
Target symptoms: Major depression
Action:
Sertraline HCl is serotonin reuptake inhibitor (SSRI).
Contraindications:
--
100 mg
01/01/1900
rhabdomyolysis, depression
Recommended Dose Ranges:
Nursing Interventions:
--
Classification:
Antipsychotic agent
Route:
Intramuscular
Frequency:Q4H PRN agitation
Dose:
Date
Ordered:
Therapeutic Effect:
Target symptoms: agitation, hallucinations, delusions,
paranoia, social or communication difficulties
Action:
Although the complex mechanism of the therapeutic
effect is not yet clearly established, haloperidol is known
to produce a selective effect on the central nervous
system (CNS) by competitive blockade of postsynaptic
dopamine (D2) receptors in the mesolimbic
dopaminergic system and increased turnover of brain
dopamine to produce its tranquilizing effects. Blockade
of dopamine receptors in the nigrostriatal dopamine
pathway produces extrapyramidal motor reactions;
blockade of dopamine receptors in the
tuberoinfundibular system decreases growth hormone
release and increases prolactin release by the pituitary.
There is also some blockade of alpha-adrenergic
receptors of the autonomic system.
Contraindications:
Parkinson's disease, severe toxic CNS depression,
concomitant diazepam, lorazepam, clonazepam, or
alprazolam administration.
Nursing Interventions:
Monitor HR and BP. Monitor ECG. Monitor for
constipation or ileus with GI assessments. Offer hard
candy or water for relief of dry mouth. Monitor for signs
of neuroleptic malignant syndrome (hyperpyrexia,
2 mg
01/01/1900
Classification:
Antipsychotic agent
Route:
Oral
Frequency:TID PRN agitation
Dose:
Date
2 mg
01/01/1900
Ordered:
Comments and Additional Medication Info:
Therapeutic Effect:
--
Action:
Contraindications:
Nursing Interventions:
Monitor HR and BP. Monitor ECG. Monitor for
constipation or ileus with GI assessments. Offer hard
candy or water for relief of dry mouth. Monitor for signs
of neuroleptic malignant syndrome (hyperpyrexia,
muscle rigidity, altered mental status, and autonomic
instability), monitor for development of extrapyramidal
symptoms or tardive dyskinesia. Monitor WBC and RBC
for signs of agranulocytsis, although it is rare
Medication:Trazodone Tablet
Classification:
Antidepressant
Route:
Oral
Frequency:QHS PRN insomnia
Dose:
Date
Ordered:
Therapeutic Effect:
Target symptom: depression
Action:
Trazodone represents a class of antidepressants known
as triazolopyridines. Structurally, it does not bear any
Contraindications:
Coadministration with an MAOI pr saquinavir/ritonavir,
50 mg
01/01/1900
Nursing Interventions:
Nurse can administer sugar free gum, water, or hard
candy if patient complains of dry mouth. Nurse should
monitor EKG and BP. Educate patient to get up slowly
to reduce risk of orthostatic hypotension dizziness, and
falls. Nurse can give antiemetic or laxative if nausea,
vomiting, or constipation occur. Monitor for signs of
serotonin syndrome. excellent
Date of
Test:
02/17/2015
10.9
Result
Level:
Low
Result Significance:
Low Hgb count can sometimes be attributed to malnutrition. Given that this patient's albumin levels are also low this is
the most likely the cause.
CBC: Hct
Test
35.3
Result:
Result
Level:
Low
Result Significance:
Low Hct count can sometimes be attributed to malnutrition. Given that this patient's albumin levels are also low this is
the most likely the cause.
CBC (RBC Indices): MCV
Test
-Result:
Result
Level:
--
Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC (RBC Indices): MCHC
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC (RBC Indices): RDW
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: WBC
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: Blood Smear
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-CBC: Platelet Count
Test
--
Result:
Result
Level:
Result
Level:
Test:
Definition and Description:
-Significance of the Test Being Ordered for this Patient:
-Basic Metabolic Panel: Blood Urea Nitrogen (BUN)
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Calcium
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Chloride
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: CO2
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Creatinine
Date of
Test:
02/17/2015
Test
--
Result:
Result
Level:
Result
Level:
--
Result:
Result
Level:
Within Normal Limits
Result Significance:
-Basic Metabolic Panel: Sodium
Test
-Result:
Result
Level:
Within Normal Limits
Result Significance:
-Laboratory
Test:
Albumin
Date of
Test:
02/17/2015
3.2
Result
Level:
Low
Result Significance:
Patient is most likely not meeting her nutritional needs while in the hospital due to her demented state. goood job with
labs
Diagnostic Tests (2)
Diagnostic
Test:
Date of
Test:
02/03/2015
Delirium is often associated with changes in brain...Comparison was made to previous study dated 10/30/2014.
Significant Findings and Results:
There is decreased attenuation present in the preventricular and deep white matter of both cerebral
hemispheres. Diffuse small vessel ischemic disease and volume loss, similar to previous study. No CT evidence of
acute infarct, mass, or hemorrhage.
Deleted By: M Beeler 02/18/2015 11:27
Diagnostic
Test:
X-Ray: None
Date of
Test:
02/03/2015
1
Nursing Diagnosis: ADDED-Risk for suicide
Status:
Active
Type:
Potential
Related To
ADDED-perceived legal problems
ADDED-improper adherence to medication regimen
ADDED-marked changes in attitude and behavior
Evidenced By
ADDED-Patient is paranoid that she is going to jail for killing someone
ADDED-Husband report that in confused state patient would stop taking meds and then take multiple doses
ADDED-Due to patient's improper adherence to medication regimen, previous signs of severe depression and
psychoses have redeveloped
Expected Outcome
Measurement/Time
Frame
Comments
good
good
good
Interventions
Rationale
Comments
good
good
confused state.
ADDED-Before discharge from the hospital, the
good
Priority
Created By: M Beeler, SN 02/19/2015 | 21:08
2
Nursing Diagnosis: Imbalanced nutrition, less
than body requirements
Status:
Active
Type:
Actual
Related To
ADDED-Neurologic impairment
Evidenced By
ADDED-Low albumin and RBC levels
ADDED-Pt consuming less than 50% of meals
Expected Outcome
Measurement/Time
Frame
Comments
good
by end of week
until discharge
Interventions
Rationale
Comments
good
eating.
good
good
intake.
Priority
Created By: M Beeler, SN 02/19/2015 | 21:21
Modified By: M Beeler, SN 02/19/2015 | 21:36
3
Nursing Diagnosis: ADDED-Risk for falls
Status:
Active
Type:
Potential
Related To
ADDED-Age 77
ADDED-Diminished mental status
ADDED-CNS depressing medications
Evidenced By
Expected Outcome
Measurement/Time Frame
Comments
Interventions
Rationale
Comments
excelleny
excellent
excellent
excellent
station.
Priority
Created By: M Beeler, SN 02/19/2015 | 21:21
Active
Type:
Potential
Related To
ADDED-perceived legal problems
ADDED-improper adherence to medication regimen
ADDED-marked changes in attitude and behavior
Evidenced By
ADDED-Patient is paranoid that she is going to jail for killing someone
ADDED-Husband report that in confused state patient would stop taking meds and then take multiple doses
ADDED-Due to patient's improper adherence to medication regimen, previous signs of severe depression and
psychoses have redeveloped
Expected Outcome
Measurement/Time
Frame
Interventions
Rationale
Comments
Comments
Priority
Created By: M Beeler, SN 02/19/2015 | 21:36
Active
Type:
Potential
Related To
ADDED-Age 77
ADDED-Diminished mental status
ADDED-CNS depressing medications
Evidenced By
Expected Outcome
Measurement/Time Frame
Interventions
Rationale
Comments
Comments
Husband of Pt
Chief Complaint:
"Confusion."
History of Current
Problem:
Allergies:
Benzodiazepines reaction?
Suicide History:
Outpatient Treatment:
--
Alcohol Use:
Substance Use:
Previous Illnesses:
Contagious Diseases:
None
Injuries or Trauma:
None
Surgical History:
Dietary History:
None
Deferred
Other:
Social History:
--
Current Medications:
Current Medications:
--
--
Review of Systems
Integument:
HEENT:
--
--
Cardiovascular:
Respiratory:
--
--
Gastrointestinal:
Genitourinary:
--
--
Musculoskeletal:
Neurologic:
--
--
Endocrine:
Genitalia:
--
--
Lymphatic:
-Mental Status
Mental Status Examination good job
Appearance:
Behavioral Activity:
Thought Form:
Thought Content:
Linear
Suicidal Impulses:
Homicidal Impulses:
Patient denies SI
Patient denies HI
Orientation:
Memory:
Mood:
Affect:
Attention:
Vital Signs:
Integument:
HEENT:
WNL.
Cardiovascular:
Respiratory:
Clear. WNL.
Gastrointestinal:
Genitourinary:
WNL
Musculoskeletal:
Neurologic:
WNL
--
Developmental:
Endocrine:
Deferred
Deferred
Genitalia:
Lymphatic:
Deferred
Deferred
Impressions
Impression:
--
Plan:
--
Provider Signature:
--
Date:
01/01/0001
Time:
--
AXIS I:
1. Delirium, secondary to urinary tract infection
2. Major depressive disorder, severe, with psychotic features.
This axis identifies the patient's primary diagnosis.
Delirum is defined as a transient, usually reversible, state caused from cerebral dysfunction and manifests clinically
with a wide range of neuropsychotic abnormalities. It can occur at any age, but it occurs most commonly in patients
who are elderly and have compromised mental status. Symptoms include: clouding of consciousness, difficulty in
maintaining or shifting attention, disorientation, illusions, hallucinations, fluctuating LOC, dysphasia, dysarthria,
tremor, asterixis in hepatic encephalopathy and uremia, and motor abnormalities.
The exact cause of major depressive disorder is unknown. People with psychotic depression have symptoms of
depression and psychosis (hallucinations and delusions).
AXIS II:
Deferred.
This axis identifies diagnosis as it pertains to patient.
AXIS III:
Urinary tract infection.
This axis lists any medical diagnoses patient has.
UTI could have caused some of the psychotic features and delirum that the patient was exhibiting. It was believed
to have been causing a waxing and waning effect on her mood and behavior. The infection has since been
resolved with antibiotics.
AXIS IV:
Nonadherence with treatment
This axis identifies psychosocial stressors.
Patient stopped taking medications, after which her depression, hallucinations, and paranoia resumed and
progressively worsened.
AXIS V:
Current GAF 5 to 10.
This axis identifies patient's Global Assessment Functioning (GAF) score that is used by mental health clinicians
and physicians to subjectively rate the social, occupational, and psychological functioning of adults.
Patient had a GAF of 5 to 10 upon admission which states that patient is in persistent danger of harming self or
others or has persistent inability to maintain minimal personal hygiene.
I believe that since patient has been in hospital for 2 weeks her GAF score is now 11-20 because she is still failing
to maintain personal hygiene and has gross impairment in communication, but she is no longer at persisent
danger of severely hurting self or others. I believe GAF may be a bit higher than this. she doesn't seem to have
gross impairment with speech and hygiene. Based on info you have provided she may be more in the low 30s
Special Charts - AIMS
AIMS
0 = None
0 = None
0 = None
0 = None
Extremity Movements
Upper (arms, wrists, hands, fingers):
Lower (legs, knees, ankles, toes):
0 = None
0 = None
Trunk Movements
Neck, shoulders, hips:
0 = None
Global Judgements
Severity of abnormal movements
0 = None
overall:
Incapacitation due to abnormal
0 = None
movements:
Patient's awareness of abnormal
1 = Aware, no distress
movements:
Dental Status
Current problems with teeth and/or
No
dentures:
Are dentures usually worn:
Do movements disappear in sleep:
Yes
No
Vital Signs
Chart Time
Temperature
(F)
Respirations
(Resp/min)
Pulse
(Beats/min)
Blood Pressure
Oxygenation
(mmHg)
Entry By
02/18/2015
10:43
97.1
Site:
Tympanic
16
67
Site:
Monitor
136/75
Site:
Right arm
Position:
Lying
M Beeler,
SN
Height/Weight
Chart Time
Weight (Pounds/Kgs)
Height (Feet
Inches/cm)
Entry By
02/18/2015 09:02
M Beeler, SN
Patient Card
Order
Description
Date/Time
Category
Status
Last
Discontinued Entry By
Performed By
Care Plan
Active
--
----
M Beeler,
SN
02/19/2015
21:08
Care Plan
Active
--
----
M Beeler,
SN
02/19/2015
21:21
Care Plan
Active
--
----
M Beeler,
SN
02/19/2015
21:21
Care Plan
Active
--
----
M Beeler,
| 21:36
SN
02/19/2015
21:36
Care Plan
Active
--
----
M Beeler,
SN
02/19/2015
21:36
Charting Grading:
Charting
Grade:
Remarks:
Competencies
No competencies entered.
5
Remarks:
Overall Grading:
Care Plan
Grade:
Charting
Grade:
Overall Grade:
15/15
Remarks:
SUBJECTIVE/OBJECTIVE- Good job with MSE and PE. All labs testing results present. 4/4 ANALYSIS &
NURSING DIAGNOSIS- Well done sections with your nursing diagnoses. Good definition of each Axis 4/4
PLAN/OUTCOMES-Outcomes measurable and good plan for this pt. 3/3 INTERVENTIONS- Good job with your
medication list. Interventions measurable and realistic for this pt. 4/4 Excellent job on this note!