Psychiatric Nursing Assessment Essay

2204 words - 9 pages

{text:bookmark-start} Psychiatric Nursing Assessment {text:bookmark-end} Identifying Data Client T. S. is a single 55 year-old-female. She is Caucasian. She is not employed. T. S. was referred from Roanoke Memorial Hospital emergency room by Dr. Thomas Bolton with a temporary detention order, which resulted in an involuntary commitment. She had active hallucinations, paranoia, delusions, and noncompliance with medications, she missed her appointment with Dr. Mussleman at Blue Ridge Behavioral Health. Chief Complaint Her chief complaint as she stated, “I hear voices of children in my head and they never stop.” Previous Psychiatric History T. S. has had fourteen hospitalizations ...view middle of the document...

The CSB worker checked on her and found that she was totally unable to care for herself. She had decompensated. She was not taking her medications and she was not eating properly. She was having auditory and visual hallucinations, her thoughts were very disorganized. She denied having any suicidal or homicidal ideations or intent. She was readmitted to Catawba on April 21, 2008. She has no history of ECT or similar treatment. Family History T. S. is estranged from her family. Her chart states that she had a son that was put up for adoption at birth. She does have a payee but does not always cooperate with the payee, because she is paranoid that the payee is stealing her money. Personal History T. S. was born and raised in The Roanoke Valley. She attended school through the ninth grade. She is unemployed. She tells me that she was adopted, but there is no mention of this in her chart, only that she is estranged from her family, and that she had a son that was put up for adoption at birth. She has a significant history of alcohol, marijuana, cocaine and tobacco abuse. She states that is has been fifteen years since she last used any alcohol or illegal drugs. I believe that T. S. is in Erikson’s Stage of Trust versus Mistrust, because she does not view the world as safe and reliable. The formation of trust is essential, mistrust the negative outcome of this stage, will impair the person’s development throughout his or her life. Once she is discharged she will live in the community in her own apartment. T. S. stated she did not have any friends. Upon observation, I believe T. S. to be a loaner with poor social skills. She does not trust anyone. Medical History T. S. gives a history of being in reasonably good health. She does have a diagnosis of diabetes, depression, asthma, gerd, and diverticulosis. She has an allergy to Penicillin, Cephalosporin’s, Haldol, Phenothiazine, which type of reaction is unknown. Previous surgery she had a bilateral tubal ligation per her last admission documentation. She has a history of positive PPD. She has a body mass index of twenty-six. Mental Status of Client Relationship to Nurse/Staff/Peers General Appearance and Grooming T. S.’s clothes were appropriate for the season, and she was always neat and well groomed. She would wear crocks without socks most of the time. Her hair is cut very short to her head. She has upper dentures and her own lower teeth that are in good condition. Her nails are short and clean. She always appears to be freshly bathed, as I have not noticed any body odor. C.) Motor Behavior T. S.’s motor movements are smooth, but slow. She displays no wringing of hands, tics, twitches, or tremors. There is no hyperactivity and her movements seem purposeful. D.) Posture T. S. walks tall and straight with no slouching. When she sits, however, it is relaxed and somewhat sprawled out and hangs her legs and feet over the arm of the chair. If she is...

Other Papers Like Psychiatric Nursing Assessment

Director of Nursing Essay

1064 words - 5 pages . She attended school with three of her daughters, all who became nurses. She obtained a Bachelor of Science in Nursing and a Bachelor of Arts in English in 1994. The interviewee is an experienced, advanced practice nurse with 4 years RN and 13 years advanced practice experience, including three years’ experience in healthcare management. She is credentialed by ANCC as a Psychiatric Mental Health Nurse Practitioner (PMHNP) and as a

Mental Health Health Essay

3254 words - 14 pages Mental Status Examination (MSE) is another important diagnostic tool used by psychiatric team, in the assessment and diagnosing of a psychiatric disorder as it provides the information to make an accurate diagnosis (Wilson,2008). In addition the DSM-IV-TR recognizes catatonic, paranoid, disorganized, residual and undifferentiated schizophrenia. Nursing care for the person with schizophrenia requires an understanding of the patient’s experiences

Watson's Theory Of Human Caring

1782 words - 8 pages psychiatric and mental health nursing in 1966, and a Ph.D. in educational psychology and counseling in 1973, all from the University of Colorado at Boulder. (McEwen & Wills, 2007). Today she serves as a legendary Professor of Nursing and holds an endowed Chair in Caring Science at the University of Colorado and is a Fellow in the American Academy of Nursing. She is the author of more than 14 books on caring and holds six honorary doctorates

The Effects Of Seclusion And Restraints On The Treatment Outcomes Of Patients In Mental Health Ward

2196 words - 9 pages . Clarke Ross, E. (2001). Seclusion and Restraint. Journal of Child and Adolescent Psychiatric Nursing , 14 (3), 103 – 104. Gaskin, C. J., Elsom, S. J., & Happell, B. (2007). Interventions for reducing the use of seclusion in psychiatric facilities. The British Journal of Psychiatry , 191, 298-303. Gust, L. V., & Sianko, N. (2012). Can policy reform reduce seclusion and restraint of schoolchildren? The American journal of orthopsychiatry , 82

Caring, Partnership, Meaningful Engagement

3888 words - 16 pages Mental Health Services. This will be done by analysing concepts consolidated in the Literature about Recovery and their application to practice, in the light of some existentially important experiences lived by Nike in a Trust committed to a Recovery Approach and Strategy (NELFT, 2011) [Names and locations were changed in order to keep confidentiality, as by the Nursing and Midwifery Council (NMC) guidelines (2008)]. The process of Assessment will

Business Management

3948 words - 16 pages al (2004) these competency frameworks were used for the development of knowledge and skills specific to critical and acute care. These frameworks provide guidance of personal development to nurses within critical care and also facilitate the assessment of individuals learning needs in nursing. Certain performance criteria are established and competency requirements are based on these criteria. Competency levels are attained when the criteria are

Nursing Research Utilization Project Proposal

4321 words - 18 pages from 2 to 22 units, which included a total of 124 units. Unit inclusion criteria were (1) an average patient length of stay 2 days or more and (2) a patient population older than 18 years. Exclusion criteria were (1) short stay units (≤23 hours) and (2) pediatric, women’s health, perioperative, and psychiatric units. All patient care units in the hospitals that met the inclusion criteria agreed to participate in the study. The total nursing staff

Bipolar Disorders

3646 words - 15 pages find evidence-based information beneficial. Diagnostic Challenges Differential assessment must include consideration of alternate psychiatric and medical conditions and comorbidities, which should be assessed, considered, and ruled out. Substance abuse, posttraumatic stress disorder, anxiety, and dementias are among the psychiatric diagnoses that may be seen in older adults with bi- polar disorder (Sajatovic, Blow, & Ignacio, 2006). Manic

Hat Task 2

1043 words - 5 pages care nursing. The World Health Organization (WHO) defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” B. Strategies Improving Mrs. Thomas

Holistic Care

2400 words - 10 pages socially. Lack of interest and inability to maintain a relationship will hinder that person holistically.Care was delivered to meet the needs/problems of Miss White via an initial assessment; a care plan was then derived from this. The assessment that facilitates the care plan used is of an eclectic approach; by using various models put together it encompasses the individual's needs in a more holistic tactic. There are five main sections to the nursing

Discuss the Concept of Holistic Health in Relation to Mental Health

2827 words - 12 pages [online].UK: D.o.h [accessed 12 November].Available at: › Home › Publications. Dimond, B. (2008) Legal aspects of Nursing, (5th edition) Harlow England: Pearson Education Limited. Faculty of Public Health (2007) assessment and surveillance of health [online] [accessed 2 November].Available at 30535248.pdf References Continued Fontaine, L, K. (2009

Related Essays

The Competent Nurse: The Movement Towards Baccalaureate Degree Nursing

943 words - 4 pages needs to have only one entry level into becoming a practicing registered nurse. That entry level should be the Baccalaureate of Science and Nursing. In supported reports, a baccalaureate registered nurse is more advanced in their skills of assessment and ability to collaborate care (Education and Practice. First report, 2001). This is fully supported in the example presented in this paper. It is in the best interest of the associate registered

Educational Preparation Essay

1189 words - 5 pages , understand that clients at a psychiatric facility are often poor historians, thus their account is not always reliable. The BSN went ahead to conduct thorough assessment of the patient’s hydration status, mental status, the duration of condition and the presence of blood or mucus in the stool. She moved on to make a nursing diagnosis from the assessment, after which she created a plan on the best trajectory to restore the client to normalcy and

Management Essay

1555 words - 7 pages Introduction Health assessment means different things to different people. Barkauskas, Stoltenberg-Allen, Baumann and Darling-Fisher (2002) consider health assessment as the systematic collection of data that health professionals, such as nurses, can use to make decisions about how thy will intervene to promote, manintain or restore health. In this paper, discussion about nursing assessment form of Queen Elizabeth Hospital (figure 1) and

Explored Differences Of Adn Prepared Nurses Vs. Bsn

1144 words - 5 pages education classes to prepare for the program. The nursing classes also consist of learning the basic principles of nursing in adult health, maternal/newborn and pediatrics. Most but not all of the programs include psychiatric, community health and gerontology classes. There is very limited introduction to any nursing theory. They are prepared to practice at “the bedside” in direct patient care positions. With the ADN degree they are at a level the can