Professional Documents
Culture Documents
Danielle Reed
Admission
Date:
2/23/15
Admission Type (voluntary or
committed)
Clinical
Date:
2/23/15
Ag
e:
36
Patient came to the ER for a cut on his hand.
Voluntary
Gender:
Male
Race:
Caucasian
Marital
Status:
Divorced
Allergie
s:
NKA
NUB 430
Mental Health Nursing
Support System:
The patient lives with his father. His mother lives nearby and he visits
with her daily. He doesnt have any siblings.
Cultural/Spiritual Background
The patient is a Christian. He attends a Church of Christ on Sundays.
NUB 430
Mental Health Nursing
Educational Background:
The patients graduated from high school, and then joined the military
after he graduated. After he served in the military he obtained a
certificate of drafting.
NUB 430
Mental Health Nursing
NUB 430
Mental Health Nursing
The patient is a 36 year old, Caucasian male. He served in the Army for 8 years. He is
divorced and has no children. Patient has a history of depression, but is no longer
experiencing symptoms of depression. When he was experiencing depression he was
prescribed antidepressants. The drugs successfully treated the symptoms the patient
was experiencing. The patient lives at home with his father. He enjoys doing manual
labor on farms and cars. Patient claims to be happy about being divorced, but I was not
convinced he is happy about being alone. Patient has some trouble sleeping and eats
one meal a day. Patient does socialize with friends a lot during his spare time. The
patient was alert and oriented to time, place, and person. He came to the ER because
he had a cut on his hand that had not healed and was painful.
NUB 430
Mental Health Nursing
Patient Goals
(include a minimum of
one long term and two
short term measurable
goals
per nursing diagnosis)
Goals should be
measurable, timelimited and realistic
Planned Nursing
Interventions and
Rationale
(minimum of 5
interventions &
rationale
per nursing diagnosis)
Disturbed sleep
pattern related to
lifestyle disruption as
evidenced by difficulty
falling asleep and
awakening after short
periods of sleeping.
NUB 430
Mental Health Nursing
Nursing Diagnosis
(NANDA)
Include R/T (etiology),
AEB
(signs/symptoms/
defining
characteristics) for 2
priority nursing
diagnoses
Patient Goals
(include a
minimum of one
long term and
two short term
measurable goals
per nursing
diagnosis)
Goals should be
measurable,
time-limited and
realistic
Planned Nursing
Interventions and
Rationale
(minimum of 5
interventions & rationale
per nursing diagnosis)
Social isolation
as related to
divorce as
evidenced by
desire to interact
with more
people
The patient
admitted that since
Encourage patient to
his divorce he had
verbalize feelings. This will
become socially
help to identify the cause of
withdrawn. He
the social isolation.
expressed a desire
to have more
Assist to identify causative
friends and
and contributing factors. This participate in more
will help the patient to
NUB 430
Mental Health Nursing
relationships during
my shift.
Identify appropriate
diversional activities
over the next 4
weeks
recreational
activities.
NUB 430
Mental Health Nursing
MEDICATIONS
Drug Name
(generic &
trade)
Drug Class
& Dose
Reason
Prescribed
Pt.
Understanding
of Drug &
Nurse
Education
( Include
education
important for
patient to
know)
Nursing
Considerations
Most Common
Side Effects &
Most Common
Serious Effects
Hydrocodon
e
325 mg
tab
Pain in
knee and
foot
Patient
understands
that this drug
is to be used
to treat pain
he
experiences
due to a foot
injury
Monitor hepatic,
renal status during
long-term therapy,
bleeding (GI, GU,
skin/mucous
membranes) with
long-term, highdose therapy, signs
of OD, (sweating,
gastric irritation
chills, cyanosis,
oliguria, jaundice,
come, convulsions,
death from
respiratory failure).
Assess hx of
hypersensitivity,
Anemia,
leukopenia,
neutropenia,
pancytopenia,
hemolytic anemia,
methemoglobinema
,
Migraines
Patient
understands
this
medication
relieves pain
caused by
migraines
Drowsiness,
hangover,
palpitations,
tachycardia.
Analgesic
ASA
Butalbital
nonopioid
analgesic
s
Caffeine
325mg
50mg
40mg
NUB 430
Mental Health Nursing
J. Perceptual Disturbances- The patient was not experiencing any perceptual disturbances.
K. Intellectual Functioning
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NUB 430
Mental Health Nursing
Sensorium
Memory- The patient was able to recall short term and long term
memories such as places traveled, his parents names, and
current city of residence.
Intellectual capacity
L. Judgement- The patient is able to use common sense to make reasonable decisions
M. Insight- The patient was aware that he cut his hand a few weeks ago, and that the
wound had not healed. He was also aware that he suffered from depression in the past.
N. Motivation for treatment- The patient is motivated to get his hand healed because it is
interfering with his ability to work.
References:
Varcarolis, E. M. (2013). Foundations of Psychiatric Mental Health Nursing , 10rd. Ed.
Philadelphia: W.B. Saunders.
Vallerand, April Hazard, Cynthia A. Sanoski, Judith Hopfer Deglin, and Holly G.
Mansell. Davis's Drug Guide for Nurses. N.p.: F. A. Davis, 2014. Print
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