Connecticut community college nursing program (ct-ccnp)

CONNECTICUT COMMUNITY COLLEGE NURSING PROGRAM (CT-CCNP) Capital Community College, Gateway Community College, Norwalk Community College, Naugatuck Valley Community College, Three Rivers Community College Psychiatric Clinical Learning Experiences NUR*203 Psychiatric Clinical Learning Experience Workbook (CLEW) CLEW Component Holism, Caring: Nursing Assessment Date/s of Care: Marital Status: S Religious Preference: Christian/ Baptist Occupation: student Allergies: Penicillin, Environmental, Latex Code status: Full Code Admitted from: Emergency Department of medical hospital Admitted: Involuntarily Multiaxial Diagnosis: Axis 1: bipolar disorder, nos (296.80); PTSD (309.81) DCF, conflict with family, trauma history current 25, past numbers included 30, 40 GAF Scores: Current: 25 Over the last year: 30, 40 How do these scores compare? Client had several admits with varying levels of progress and different family/situational conditions. Reason for admits included aggressive behaviors (GAF 20), harming self and others (GAF 20), inability to perform basic hygiene / did not shower for 2 weeks (GAF 20), hallucinations (GAF 30), major impairment in mood, interactions with others (GAF 40). Perhaps her GAF score dropped because her mom removed her from the hospital AMA just a few weeks earlier and she has been completely off psych medications. Client Admission Profile: Patient was taken off Geodon 2 weeks earlier due to EKG changes. She was not put on any other psych medications. Her mom and boyfriend found her banging her head at home. She was asked to bath and then flipped out. She began slapping her hands, but felt no pain. She hit her mother’s boyfriend and threw an eraser at him. Patient assaulted her mother. The police were called and subsequently brought her to a medical hospital by ambulance. The hospital transferred her to this behavioral health facility. She was found to have red hands seemingly from hand wringing and pounding when at home. Significant past Psychiatric history: Summarize relevant components of the client’s behavioral history. (i.e., past hospitalizations, smoking, substance use, violence): This client does not smoke, drink alcohol, or use any illegal substances. Tests came back negative for pregnancy and substance use. She has a history of sexual assault, aggressive behavior, and multiple hospitalizations for uncontrolled behavior. Her most recent in-patient psychological stays at this facility were in and . Her last stay was abruptly and prematurely ended by the mother because the mother felt the facility wasn’t providing adequate care. She was also an in-patient at other facilities in the past (dates not known) and currently attends a special behavior health school during the day. She was apparently doing well at school – she is of normal intelligence. Patient is known to be dangerous to herself and others; to be self destructive; has a history of trauma and neglect; impulsive; hopeless; poor coping skills. Mental Status Examination: (Appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, ideas of harming self or others): Appearance, hygiene, motor, appetite, comprehension, thought process – within normal limits Interpersonal – cooperative Mood – depressed, impulsive; Affect – constricted, irritable, labile Sleep – DFA, MNA, insomnia; Energy – high ADLs – changes (sometimes cooperative, sometimes refuses) Suicide/homicide ideation – not present; Risk – head banging, hand pounding, wringing Attention, concentration – impaired; Judgment, insight – fair CLEW Component Safe and Competent Practice: Pertinent Laboratory and Diagnostic Studies Key Nursing Assessments for this Client (consider primary medical diagnosis and co morbid conditions; note lab values to check) For asthma, check – breathing (effort, use of accessory muscles, SOB, etc.); lung sounds For obesity, check – appetite, nutrition (I&O), weight, knowledge base For cardiovascular, check – EKG, labs (esp. K+, H&H), heart sounds, blood pressure, O2 sats For hygiene, check – appearance, cleanliness, hair, brush teeth, shower, etc. For sleep, check – amount, tiredness, aggravating/alleviating factors, level of energy For neuro, check – body movements – involuntary/adverse effect of prior medications (Geodon) For mental status, check - level of stress/anxiety/agitation, level of attention/distractibility For emotional status, check – lability, level of depression/socialization Priority Nursing Interventions for this Client Keep safe – from self and towards others Help patient set goals (i.e. to stop hitting, stop expressing anger inappropriately, talk about feelings) Teaching/learning goals for the day (Include measurable objectives and outcomes): Verbalize 3 positive coping skills within 7 days (i.e. taking space, verbalize feelings calmly, ignore negativity/distractions) Deny any thoughts of suicide / homicide within 7 days Demonstrate 2 new positive coping skills by discharge How did you implement your teaching? (Include who was taught, setting, your methods/approaches.) Implementation of teaching is done via individual goal setting (at group goal setting meeting); CRS activities (creative rehab services) Evaluation of learning: (Did you meet stated goals, what could you do different?) Patient and others remain safe Patient verbalizes and uses coping skills Patient denies thoughts of suicide/homicide Discharge planning: (Include recommended referrals, support systems, obstacles.) The discharge plan is still unknown and under discussion with DCF, mom, health care workers, and child. The mom does not want child to return home – she wants DCF or foster care to handle her. The child is considering her options – one option that she would like available is to live with her maternal grandmother. It is not known whether or not the grandmother is willing and able to accommodate the child. CLEW Component Critical Thinking: Nursing Care Plan Priority Problem (Nsg. Dx Label): Ineffective individual coping R/T and AEB Patient banging head against wall at home Observe patient behavior in milieu therapy Patient slapping/pounding/wringing hands at home Observe patient behavior within family dynamics Verbalize 3 positive coping skills within 7 days (i.e. taking space, verbalize feelings calmly, ignore Patient verbalizes and uses coping skills Patient denies thoughts of suicide/homicide Deny any thoughts of suicide / homicide within 7 days Demonstrate 2 new positive coping skills by discharge Priority Problem (Nsg. Dx Label): Risk of injury R/T and AEB Patient banging head against wall at home Observe patient behavior in milieu therapy Patient slapping/pounding/wringing hands at home Observe patient behavior within family dynamics Patient’s hand heals (is no longer red) Priority Problem (Nsg. Dx Label): Chronic low self-esteem Patient stating that she always makes mistakes Patient stating that she is fat; “I weigh almost 200 lbs.” Assist patient in identifying positive attributes Patient erasing and correctly work over and over Accept client’s negativism (don’t bring conflict) Patient having difficulty completing work because she ran out of time (due to fixing “errors”) Goal(s): Patient identifies at least 1 positive attribute Patient stated that she was good at math, art Patient will complete 1 project without erasing Patient finished 1 art project – no erasing ADRs= headache, palpitations, abdominal pain, muscle Assess = LS, bp, pulse; s/s paradoxical bronchospasm Teach = proper technique for use of powder inhalation; do not exhale into diskus; hold device in a level horizontal position; mouthpiece should be kept dry; does not treat acute symptoms Use Cautiously = liver disease, concurrent use of other ADR = drowsiness, dry mouth, confusion, weight gain erify patient specific use of drug, s/s of discontinue for 4 days . Teach = Avoid alcohol, other CNS depressants; call MD if s/s don't go away; use sunscreen; take as directed; good oral hygiene to avoid dry mouth Use Cautiously = acute asthma attacks; phenylketonuria ADRs=fatique, headache, weakness, cough, abd pain, abruptly; For asthma, once daily in eve; not to be used for allergies and asthma 5 mg PO daily . M/E = liver, renal O = < 24 hr P = 3-4 hr D = 24 hr Patient was taking Geodon; but she experienced an abnormal EKG 2 weeks earlier and Geodon treatment was discontinued. She was no longer on medication for her psych disorders. Zyprexa was tried in the past, but it is not being used currently (chart did not state reason). Contraindicated = hx of QT prolongation, Mood stabilizer . Hypokalemia or hypomagnesemia . M/E = liver SYNDROME, seizures, dizziness, drowsiness, restlessness, extrapyramidal reactions, syncope, tardive dyskinesia, constipation, diarrhea, nausea . Assess = mental sts, weight, cardia, labs, rash, BP, pulse, orthostatic hypotension, s/s of ADR . Lab = K, Mg, glucose, cholesterol throughout therapy . Teach = do not stop abruptly; follow-up important; s/s of NMS, ADRs
Bibliography/Works Cited:
Varcarolis, Elizabeth M., Carson, Verna Benner, and Shoemaker, Nancy Christine. Foundations of
Psychiatric Mental Health Nursing, 5th Edition. Saunders Elsevier, 2006.

Deglin, Judith Hopfer, Vallerand, April Hazard. Davis’s Drug Guide for Nurses, 11th Edition. F. A.
Davis Company, 2007.

Source: http://www.trcc.commnet.edu/div_academics/alliedhealth/Accreditation_Docs/N203-PsyCLEW.pdf