Nursing homework help

P. R

Client believes in God use to go to church but has stopped

Client was admitted to the hospital through emergency with the complaints of depression, suicidal ideation to hang or stub himself.

Lymphoma

· Grooming/Clothing

· Level of hygiene

· Pupil dilation or constriction

· Facial expression

· Height, weight, nutritional status

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

· Relationship between appearance and age

· The client wore sweatpants, sweaters and hospital socks.

· The client’s eye was normal it dilates about 2 to 4 mm and they are equal.

· The client’s skin color was pink and usual for ethnicity.

· The client ambulates independently with a steady gait.

· The client has no abrasions, bruises, tattoos or any other physical markings on his skin.

· The client weighs 174 lb., and his height was 5.2inches, which looks appropriate for his age.

· Excessive or reduced body movements

· Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance, and gait)

· Abnormal movements: (e.g., tardive dyskinesia, tremor/ tics/ abnormal movements)

· Level of eye contact (keep cultural differences in mind)

· Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia

-No evidence of tremors/tics/abnormal movements.

-There was no psychomotor retardation observed.

– He was able to follow instructions

The client-maintained eye contact throughout the interview stated that: “I feel happy talking to you” but I normally don’t talk to people I do not know.

· Ability to follow commands

· Ability to provide reliable information.

Possible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian.

-Reliably reported information and remembered clearly the events preceding his admission to the hospital.

· Rate: slow, rapid, normal

· Volume: loud, soft, normal

· Disturbances (e.g., articulation problems, slurring, stuttering, mumbling)

· Cluttering (e.g., rapid, disorganized, tongue-tied speech)

-The client spoke clearly and with a medium volume.

– client spoke with an even tone and rhythm and communicated information coherently

Affect

· How the client outwardly is expressing emotion

· Appropriateness to situation

· Congruency with mood

· Congruency with thought

· Other descriptors include broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate

Mood

· How the patient describes what they are feeling

· Possible descriptors include labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable

The client affect was appropriate to the situation. He was clear and consistent with his thoughts.

MOOD:

-I observed the patient was in positive mood as evidenced by patient displaying willingness to talk.

-During conversation, he was accommodative and actively participated.

He had a pleasant mood but became anxious when he discussed the future and fears associated with the unknown.

Also, I noted that his mood and affect had changed as compared to that on admission which on his chart had been indicated to be irritable.

He was a bit anxious and clearly expressed his fears about the future. His affect was congruent with mood. The client stated that he feels sad about not working due to his health condition.

Process

· Describes the rate of thoughts, how they flow and are connected

· Possible descriptors: Linear, goal-directed, disorganized, circumstantial, tangential, loose associations, flight of ideas, coherent, incoherent, evasive, racing, thought blocking, perseveration, neologisms.

Content:

· Refers to the themes that occupy the patient’s thoughts and perceptual disturbances

· Possible descriptors: preoccupations, ideas of reference, delusions, obsessions, suicidal/homicidal ideation, rumination

The client provided direct and appropriate answers to questions and conversation.

-Patient experiences were realistic –patient had some small memory lapses especially on things that happened 2 to 3 years ago.

Chart stated patient has difficultly concentration due to flight of ideas.

· Hallucinations (e.g., auditory, visual)

· Illusions

· Orientation: time, place, person

· Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose)

· Memory: remote, recent, immediate

· Attention/concentration: performance on serial sevens, spelling a word backwards

· Abstract vs concrete thinking: proverbs, involving similarities

Judgment

· Good, fair, or poor

· Impulse control

Insight

· Good, fair, partial, poor

Adaptive Coping Strategies vs Defense Mechanisms

Possible defense mechanisms:

Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression

-The client looked relaxed during first contact

-The client had no trouble remembering things that happened several years ago

-The clients have good judgement fair insight throughout the interview, e.g. I asked him if it was fair for the doctor to admit him in the hospital and he said yes he caused it if he had taken his medication he would not be depressed ,therefore he caused it,

-The client coping mechanism is suppression because he feels depressed for not being able to work due to his medical condition.

The client also said he sometimes talk to friends and family to relieve him of his depression.

I was able to assess his short- and long-term memory based the answers he gave me during questioning. He also appears to have good judgement and has fair insight. He reports that he avoids thinking about bad things as his life is full of those. However, this time things got really had that why he was contemplating to commit suicide prior to admission.

Risk of Self/Suicidal/Self-Injury

· Fully assessed-no indicators of risk

· If yes, then

· Suicidal ideation (current, past)

· Suicide attempts (hx of)

· Plans to attempt (current, past)

· Access to means

· Family history

· Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present?

· Unintentional (when delusions, demented, intoxicated, in manic stages) present?

Harm to Others/Aggression

· Fully assessed- no indication of risk identified

· If yes, then

· Plan (current, past) to assault

Property Destruction

· Fully assessed- no indication of risk identified

· If yes then

· Current admission

· Hx of

The client stated that he occasionally has thought of harming himself whenever he gets depressed.

The client said he had a history of property destruction when he was a toddler, he uses to throw their TV remote away and break it.

The client admitted having suicide by trying to harm himself with any sharp he get hold of.

The client currently has no thought of harming himself or anyone.

The client use to throw way their TV remotes and destroy them

.

The client denial thought of harming himself and others at the hospital.