Holistic Assessment of Client in Psychiatric Unit

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21st May 2020 Nursing Case Study Reference this

Tags: nursingcymbaltapsychiatric

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Holistic Assessment of Client in the Psychiatric Unit of North Vista Hospital

Purpose

This student assessed an 85-year-old female diagnosed with neurocognitive disorder with behavioral disturbances. The mental status assessment interview was conducted in the day room at North Vista Hospital in Las Vegas, Nevada on Saturday, September 21, 2019. The instructor for the clinical day was Ms. Corine Watson.

Demographics

Personal Information

The patient’s initials are J.R. The patient’s race is Caucasian. The patient’s admission date is 9/18/19. The chart states the patient’s medical history and comorbidities are essential HTN, CAD in native artery, angina pectoris, CVA with residual deficit, DVT lower extremities bilaterally, and moderate episode of MDD. The chart states the patient’s surgical history is an artificial knee joint. The chart states the patient has no pertinent family history.

Allergies

The chart states the patient’s allergies are benzodiazepines, cephalosporins (cefdinir), Haldol (haloperidol), sulfa antibiotics, and trimethoprim.

Vital Signs

The chart states that on 9/18/19, the patient’s blood pressure was 132/90 mmHg, and heart rate was 92 bpm. No temperature, respirations, O2 sat, or pain level were in the paper chart.

Labs

The chart states hemoglobin is 11.8 g/dL and hematocrit is 33.7%; both are low, suggesting anemia and risk for stroke which may be significant for the patient because of the history of cerebrovascular accident. Potassium is low at 3.3 mEq/L which may contribute to weakness; the patient uses the assistive equipment for motor function such as a wheelchair. BUN is 7.0 mg/dL and albumin 2.4 g/dL, both of which are low indicating malnutrition and possible impaired liver function. AST (SGOT) is high at 40 units/L suggesting liver disease and acute hemolytic anemia.

Diagnostic Tests

The chart states the patient had a chest x-ray on 9/4/19. The patient’s history is precordial chest pain. The finding was the heart size is normal. The lungs and pleural spaces are clear. Hilar and mediastinal structures are within normal limits. The impression was no acute intrathoracic process.

Commitment Information

There is no Legal 2000 on file.

Review of Systems

Neurological

Alert and oriented to person, place and time. Pupils equal, round, and reactive to light and accommodation. Cranial nerves II-XII grossly intact. No focal deficits. No visual loss, blurred vision, double vision, or sclera. No hearing loss, sneezing, congestion, runny nose or sore throat. No headache, dizziness, or syncope. Oropharynx clear, mucous membranes moist.

Cardiovascular

Trachea midline. Neck supple, full ROM. No chest pain, chest pressure, or chest discomfort. No palpitations. Normal heart sounds. No thrills. Regular rate and rhythm, no murmurs, rubs or gallops.

Respiratory

No shortness of breath, cough or sputum. Lung sounds clear to auscultation. No wheezing, rales, or rhonchi.

Gastrointestinal

No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood in stool.

Urogenital

No burning micturition. No urinary frequency or incontinence. No change in bowel or bladder control. No costovertebral angle tenderness.

Musculoskeletal

No muscle pain, back pain, joint pain or stiffness. Deep tendon reflexes 2+ bilaterally. Flexor plantar response. Moves all extremities spontaneously. No pedal edema

Integumentary

No rash or itching. No lesions.

Immune

No information was obtained.

Activities

Sleep

The chart did not have information on sleep patterns.

Nutrition

The chart states the patient does not have history of anorexia. The student observed the patient is not overweight. The patient stated she had breakfast on the clinical day of 9/21/19 and recalled the items she ate.

Interpersonal

The chart states the patient is married and has a daughter, both whom support her when living at home.

Coping and Stress Management

The chart did not have information on coping and stress management.

Spirituality

The chart states the patient is of Methodist denomination.

Cultural

The patient states she is eager to be discharged.

Substance Abuse and Domestic Violence

The chart states the patient denies tobacco, illicit drugs, and alcohol. The chart states there is no history of substance abuse. The chart states there is no history of domestic violence.

Mental Assessment Findings

Appearance

The patient appeared in good hygiene, mildly disheveled, hair not combed, and clothed in a gown. The patient appeared as stated age.

Motor/Behavior

Student observed patient is sitting in a wheelchair. The patient’s posture was slumped to the side with shoulders slouched inward. The patient had moderately good eye contact, became fleeting sometimes with distractions by looking around a few times but rejoined the interview when student continued asking questions.

Speech

The patient was calm, talking slow and in a low volume. Student observed articulation is decreased.

Mood/Affect

The student observed the patient was sad and facial expression was congruent. The student observed anergia, and the patient did not display anger or irritability.  The student observed affect is congruent with mood.

Orientation

The patient was alert and oriented to person and. The patient stated the correct month but not the correct day or year. The patient did not state what led to being hospitalized.

Cognitive Function

The patient was given a task to subtract 7 from 100. The patient correctly answered, “93, 86, and 79.” The patient stopped there.

Attention Span

The patient recalled two of three objects the student asked the patient to remember after answering two questions to assess recent and remote memory.

Ability to Abstract

The patient did not respond to the student’s request to interpret the parable “People who live in glass houses should not throw stones”. The patient became distracted and shifted attention to others in the surrounding area by looking in their direction. The student regained the patient’s attention by moving on to the next question.

Insight

The patient did not answer when asked to talk about her illness. The patient did not answer when asked to describe her symptoms. The patient did not answer when asked to describe her treatment. The student observed the patient’s eyes pointed downward and head leaned sideway when asked the previously stated three questions. The student asked what the patient’s goals were, and the patient stated her goal was to “go home”.

Judgement

The student asked the patient, “if you found an envelope on the ground that had a stamp on it and was addressed to someone else, what would you do with the envelope?” The patient answered, “I would mail it.”

Content of Thought

The patient stated she is not anyone important, indicating absence of delusions of grandeur. The patient stated she does not believe she is being watched nor does she believe someone is out to get her.

Form of Thought

The patient does not exhibit word salad, clanging, or echolalia. The student observed flight of ideas, loose associations, and tangentiality.

Perception

The patient states she does not see things that other people do not see. The patient states she does hear voices. The patient states the voices tell her to “get better”.

Suicidal Status

The patient states she has had thoughts of harming herself. The patient states she has tried to harm herself. The patient did not state what she has tried to do to harm herself. The patient states that she currently does not have thought of harming herself.

Functional and Chronological Developmental Stage

According to Erik Erikson, the patient is in Stage 8 late adulthood. This stage is defined by ego integrity versus despair. During this phase, older adults reflect on the life they have lived. Ego integrity describes those who feel fulfilled by their lives can face death and aging proudly. Despair describes people who have disappointments or regrets may fall into despair (Varcarolis, 2017).

Patient’s Current Medications

Cymbalta (Trade)/duloxetine (generic)

Cymbalta is an antidepressant and the actions is a serotonin-norepinephrine reuptake inhibitor (SNRI). Common side effects are headache, nausea, and abnormal vision.

Namenda (Trade)/memantine (generic)

Namenda is an anti-Alzheimer’s agent and its action is an NMDA (amino acid derivative) receptor antagonist. Common side effects include dizziness and confusion.

Provigil (Trade)/modafinil (generic)

Provigil is a CNS stimulant and its action is a racemic compound (similar to sympathomimetic action). Common side effects are headache, rhinitis, and dyspnea.

Risperdal (Trade)/risperidone (generic)

Risperdal is an antipsychotic whose action is mediated through both dopamine type 2 (D2) and serotonin type 2 antagonism. Common side effects are extrapyramidal symptoms, pseudoparkinsonism, and tardive dyskinesia.

Conclusion

The patient’s diagnosis is neurocognitive disorder with behavioral disturbances and history of major depressive disorder. The chart states once on psychotropic interventions, the patient became more appropriate to the milieu of the unit. The chart states the patient had augmentation of symptoms and decreased ambulatory response with mild change in mental status, and was recommended for continued care in the geri-psych unit. The progress of the patient is evidence that with continued care, the patient can improve the quality of her life. The student would provide education on nonpharmaceutical methods of coping with depression such as being active and exercising, as well as spending time with other people such as trusted friends and relatives (NIMH). The National Institute of Mental Health suggests educating oneself will help the depressed patient feel less alone, that depression affects people in different ways, and it is treatable.

References

  • National Institute of Mental Health. (2019). Information on depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression/index.shtml
  • Varcarolis, E. M. (2017). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (3rd ed.). Saint Louis, MO: Elsevier.

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