Plan of care.

nursing case study and need guidance to help me learn.

please follow the sample ” process recording example ” and use the information on the 2nd paper” process lolo ” background information , you can reformulate and add some medications if needed and come out with the remaining part but follow the standard of the process recording example.
Requirements: Short
Therapeutic Communication
Student’s Name: Laurence Ngonla Lonla Client’s Initials: Mrs.T.S
Date of Interaction: 27 October 2015 Therapeutic Communication
ASSESSMENT:
Background: A 49-year-old patient comes to the clinic with a history of depression and UTI. She tells the nurse that she was treated for it by a doctor in another county, but he ran out of pills a week ago and did not know how to get a refill. She could remember the name of the medication but said ‘‘it was for depression’. She also has been having trouble sleeping since her husband cheated on her and asked for a divorce. She lost 34pounds in 1 month. A family member called 911 because she was feeling uncontrollable with suicidal ideation, thoughts of overdose on medications, current denied HI. After a psychiatric evaluation, she was given a 2-week prescription for fluoxetine (Prozac) and melatonin for sleep at night, Lexapro 10 mg.
Medications
melatonin, 5mg PO nightly—for sleep
Side effects: dizziness, drowsiness, headaches, nausea, irritability, hormonal effects for long term use.
escitalopram (Lexapro), 10mg cap once PO nightly—for depression and anxiety disorders.
Side effects: Nausea, fatigue, dizziness, insomnia, constipation or diarrhea, dry mouth, sweating. Sexual side effects such as decrease libido, difficult achieving orgasm.
Fluoxetine (Prozac), 5mg tab PO nightly—for depression
Side effects: nausea, constipation, headache, anxiety, insomnia, drowsiness, dizziness, heart palpitations, weight changes, cold symptoms, dry mouth, impotence
Assess myself: I have been assigned bto work with the nurses in magnolia unit and I found this case interesting and decided to know more about this particular patient. It was a pleasure for me to note her 5 priorities values un life as love, family, honesty, respect and success.
Assess milieu: There were 12 patients on the unit that day. Many of the patients were spending time with each other in the day room, laughing and discussing. Base on the background history,
DIAGNOSIS:
Nursing diagnosis: Risk for self-directed violence, ineffective individual coping, anxiety, hopelessness, social isolation
PLANNING:
Describe a tentative goal of the TC: I want the patient to openly discuss her recurrent suicidal ideations and contemplate stressors. Hopefully I can also direct her to focus on the positives in her life, like her family and her possibilities.
By completion of the TC, the patient will:
Discuss her desire to die.
Recognize possible stressors leading to SI.
Focus on the positives and motivations in her life.
IMPLEMENTATION:
E
Therapeutic Communication
Student’s Name: Client’s Initials: M.P.
Date of Interaction: 27 October 2015 Therapeutic Communication #3
ASSESSMENT:
Background Information: M.P. is a 54yo separated Caucasian woman who was encouraged to go to ABH after sharing with her day group that she possibly overdosed the day before on one of her home medications. She has a history of major depressive disorder which has left her out of work for several years and recently she has developed suicidal ideations in the past several months.
Medications
Aripiprazole (Abilify), 15mg tab PO nightly—for psychosis
Side effects: dizziness, weakness, nausea, vomiting, fatigue, excess saliva, choking or trouble swallowing, blurred vision, headache, anxiety, weight gain, sleep problems, constipation
Diphenhydramine (Benadryl), 50mg cap PO nightly—for insomnia
Side effects: sedation, fatigue, dizziness, disturbed coordination, constipation, dry mucus membranes, blurred vision, tremor, anorexia, nausea
Fluoxetine (Prozac), 5mg tab PO nightly—for depression
Side effects: nausea, constipation, headache, anxiety, insomnia, drowsiness, dizziness, heart palpitations, weight changes, cold symptoms, dry mouth, impotence
Lithium, 300mg cap PO QID—for mood stability
Side effects: tremors, increased thirst, increased urination, diarrhea, vomiting, weight gain, impaired memory, poor concentration, drowsiness, weakness
Oxybutynin (Ditropan), 5mg tab PO BID—for bladder spasm
Side effects: dry mouth, blurred vision, constipation, diarrhea, nausea, dizziness, weakness, headache, insomnia
Propanolol (Inderal), 10mg tab PO BID—for tremors
Side effects: dizziness, fatigue, nausea, vomiting, stomach pain, vision changes, insomnia
Assess myself: While I had prepared to present my teaching project that day, I was eager to help the nurses and spend time with patients. It was my last week on Montgomery unit, so between my teaching project and interacting with patients on the unit, I was eager to have a productive day.
Assess milieu: There were 12 patients on the unit that day. Many of the patients were spending time with each other in the day room, laughing and chatting as they painted each other’s nails. Because of MP’s fluctuating SI and recent attempts to hide plastic utensils in her room, the nurse asked if I would sit with MP while she ate dinner.
DIAGNOSIS:
Nursing diagnosis: Risk for self-directed violence, ineffective individual coping, anxiety, hopelessness, social isolation
PLANNING:
Describe a tentative goal of the TC: I want the patient to openly discuss her recurrent suicidal ideations and contemplate stressors. Hopefully I can also direct her to focus on the positives in her life, like her family and her possibilities.
By completion of the TC, the patient will:
Discuss her desire to die.
Recognize possible stressors leading to SI.
Focus on the positives and motivations in her life.
IMPLEMENTATION:
EVALUATION:
Strengths and weaknesses of the interaction: She seemed honest with me about her risk for suicide, although I think I could have asked her more about that. She had good insight of her social isolation and how that contributes to her depression. Despite her openness, I am unsure if she found meaning in our conversation or if she was merely going through the motions.
Outcomes of the session: She shared her history of depression and abuse, which shows that she recognizes the negative things in her life. It was difficult to explore the problems weighing on her mind and give adequate time to redirect to the positive parts of her life. All in all, I believe that after our conversation, this client has reinforcement to build healthy relationships and fight her depression.

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