psychiatric nursing

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psychosocial assessment

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NURS 386 - Psychiatric- Mental Health Nursing Evaluation of Clinical Case Presentation Date Student Name Faculty Grade Clinical Site A. Brief description of the client 5 Points B. Summary of Psychosocial Assessment 20 Points C. Summary of Literature Review 20 Points D. Treatment Plan (Top 2 Nursing Diagnoses) 40 Points E. Medication Chart Classification 5 Points 10 Points F. Format for Presentation Breakdown: APA Style (2) Spelling, grammar, punctuation Logical, clear writing (2) Organization eferences appropriate Logical/Clear Abstract 2 Points 2 Points 2 Points 2 Points 2 Points 2 Points Total Points iii. ii. One meta-analysis pertaining to either nursing or psychiatric diagnosis/treatment State rationale for selecting each article, including a statement of how it applies to patient's diagnosis and/or treatment.. iv. Briefly summarize each article including a description of the purpose, sample, methods, findings, implications for practice, and conclusions of the authors. V. iv. Cite all references in APA format 3. Psychosocial Case Presentation (See Handout) 20% (With the clinical instructor's permission, students can perform assignments 2 an 3 in dyads.) 4. Interaction Process Recording (See Handout) 10% 5. Clinical Evaluation Tool 40% present to identify who is already well educated in the topic to be discussed and who is not. Also evaluate after the presentation to identify who might need further clarification. 2. Psychosocial Assessment (written) 20% a. Introduction In the introduction provide an account of the patient and his/her illness from his/her perspective. Briefly describe how he has dealt with the diagnosis/treatment and how he has lived in the past/ present. b. Complete a full biopsychosocial assessment including the mental status assessment (See chapter in Boyd, The Psychaitric Nursing Process. c. Identify client's DSM V diagnoses - describe the observed behaviors that meet the DSM criteria. d. Identify Nursing Diagnoses and list in order greatest to least priority. e. Write a care plan for the top two nursing diagnoses. f. Present the results of a Mini Mental Status Examination (MMSE) OR any appropriate psychiatric assessment tool (CAGE, MAST, SANS, etc...) conducted during your one-to-one interview with the client. g. Include six to ten references references which are further explained below. h. Etiology, S/S, manifestations, of the psychiatric diagnosis. i. Nursing interventions pertaining to nursing diagnoses. OVOM DATE OF ADMISSION January 28, 2018 PAST PSYCHIATRIC HISTORY He has had at least 10 psychiatric hospitalizations. 5 of which were at Spring Grove for competency evaluations between 2006 and 2016. He also has been hospitalized at Perkins, Springfield, Sheppard Pratt, and Maryland General He has a history of multiple arrests for first and second degree assaults. He has been on disability for a diagnosis of schizophrenia for 30 years. Been on multiple antipsychotics at various times He has had at least 6 suicide attempts. His most recent attempt was about a year ago when he put his head in the oven after turning on the gas. He also has attempted to hang himself and run into traffic in the past. His suicide attempts have always been when in the community, when off medication, and usually after periods of abusing alcohol and/or drugs. He has not attempted to hurt himself in a facility such as a jail or a hospital During his most recent Spring Grove hospitalization from 1/16 to 5/16 his psychosis was treated with risperidone at 8mg/day, along with depakote for the mood component of his presentation which included pressured speech, mood swings and agitation. He developed gynecomastia and so his risperidone was changed to prolixin. He was opined competent and at his court hearing he was placed on probation. He was discharged to SPEF with discharge diagnoses of schizoaffective disorder, alcohol and cocaine use disorders, hypercholesterolemia, xerosis, GERD, and chronic foot pain due to congenital deformity. Discharge medications were prolixin decanoate 25mg IM 92 weeks, prolixin 10mg q am and hs, seroquel 50mg q am and hs, benztropine 2mg bid, depakote 500mg q am and hs, and atorvastatin 20mg q hs TRAUMA HISTORY Has a history of childhood physical abuse, being burned on his leg and back when he was 2 years old SUBSTANCE ABUSE HISTORY He has a longstanding history of substance abuse. Prior to his arrest he was drinking a fifth of vodka daily, along with using significant amounts of crack cocaine and heroin almost daily. The last time he was in a substance abuse program was about 10 years ago. SG-B DATE OF ADMISSION January 25, 2018 SOMATIC HISTORY Hypertension Hypercholesterolemia Gastroesophageal Reflux Disease. Chronic bruxism Chronic foot pain due to congenital deformity status post surgical correction History of gynecomastia while on risperidone History of CVA 4-5 years ago and History of xerosis Allergies Morphine gives hives Intolerances Risperidone gives gynecomastia SOCIAL/DEVELOPMENTAL/FAMILY HISTORY Mr was born and raised in Baltimore, raised by his maternal grandparents. He Lad ditficulty with reading and comprehension that required special education, and dropped out of the 9th grade. He has not worked in 30 years and has since been on disability for schizophrenia. His pastor is his payee. He had been living at the Homewood group home. He is separated from his wife and their 10 year old son was deceased but he has a brother and 2 adult children living in Maryland, but has limited taken away from them by DSS because they were unfit parents. His parents are contact with them. His brother has been diagnosed with schizophrenia and substance PATIENT RESOURCES AND OTHER STRENGTHS He is accepting treatment and open to staff's support. He is verbal and future oriented. MENTAL STATUS EXAMINATION М. ris alert and oriented to the year, month, date, place, and situation. No psychomotor changes. Speech was slightly slurred. He reports drooling. His thoughts were linear. Affect was full range, appropriate, pleasant and cooperative. He has suicidal ideation without a plan. Understood and agreed with the explanation that it would be harmful to his brothers and children if he were to commit suicide, and wants to be alive if his children or grandchildren were ever to come looking for him. He indicates he will seek help from staff before he would attempt to hurt himself. He wants to learn his competency information so can be competent to stand trial. He is having intermittent hallucinations about hurting others but is able to resist these. No delusions GROV SG-98-
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