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I. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)? Patient is 41 year old white male, who weighs 165 pounds and 5 feet and 7 inches high, LEOBA by Jupiter Police. BA states patient believes people are trying to poison him, using RX drugs to cause fluid to exit his hips and impair his ability to walk and plus other somatic delusions. Pt arrived in handcuffs, calm and cooperative. His mood is a little apathetic and his affect blunted at times. Pt rambles some, but most of the time is goal oriented. He stated that he lives in Pioneer ALF in Miami and does not like it much and left 2 weeks ago, and is trying to make his way to Jacksonville and then DC, where He came originally. He reported in a matter of fact way that his Achilles tendons have some special sensors and because of that he was at a hospital 3 days ago. He reports being under psych care by Dr. Flattery in Broward and that he takes no meds. Reports many psych hospitalizations in the past. He was asked to change into a gown and he complied and He was offered diner, which he ate without suspicious, however a while later he asked if the food has any muscle relaxers. He was seen at our facility in Nov. 2009 and was treated for Schizophrenia and DC in Abilify 30 mg; while he returned to his ALF in Miami. In previous admission, he also showed signs of paranoia and delusions. He denied any medical issues besides what he stated previously about his Achilles tendons. His hygiene is very poor. He has been living in the street since leaving his ALF. He denied used of ETOH or drugs. Pt. discussed with Dr. Caro and he is to be placed on assault precautions. II. PAST MEDICAL/SURGICAL HISTORY: He suffered bipolar personality disorder or Schizophrenia, Delusional, earring voices, suicidal ideation, depression, and hopelessness, sleep disturbances. Achilles tendons problems. III. ADMITTING MEDICAL DIAGNOSIS: Paranoid personality disorder, Bi-polar, General Depression disorders, Schizophrenia, Sleep disorders
PBVI 9.12.12
PBVI 9.12.12
PBVI 9.12.12
PBVI 9.12.12
PBVI 9.12.12
PBVI 9.12.12
1.
Hallucinations and delusions change an individuals perception of environmental stimuli. Patient is truly frightened and is responding out of his need to preserve his own safety.
IN one and one meeting assessment, the acknowledgment of patients fear, hallucinations noted.
Goal met. Patient showed sign of progress and has avoided hurting self or assaulting other patients.
2.
Patient was re-assured that nursing staff will help him control behavior and keep him safe. Trust begun to establish.
3. By giving patient choices, he will begin to develop a sense of control over his behavior. Seclusion and restraint are options only for persons exhibiting serious, persistent aggression. The persons safety must be protected at all times.
PBVI 9.12.12
RATIONALES
DOCUMENTATION
EVALUATION
Sincere and honest talks were established when communicating with client. No physical contact was established with client
Goal met. Client has developed trust within 1 week with at least one staff member.
2. Long-Term Goal Client will demonstrate use of more adaptive coping skills, as evidenced by appropriateness of interactions and willingness to participate in the therapeutic community.
2.
Suspicious clients may perceive touch as a threatening gesture. Suspicious clients often believe others are discussing them, and secretive behaviors reinforce the paranoid feelings. Honesty and dependability promote a trusting relationship.
3.
Avoid laughing, whispering, or talking quietly where client can see but not hear what is being said. Be honest and keep all promises
3.
4.
4.
Long term Goal not met: Client has made progress by showing sign of coping skills and willingness to participate in the therapeutic community. Will continue with the intervention and later reevaluate client.
PBVI 9.12.12
2.
Causes of perceived or actual isolation was discussed with the client. Particular barriers to social interaction were observed.
3.
3. Causes of social
PBVI 9.12.12