Students are responsible for thoroughly assessing their patient in order to provide safe care during current and future clinical experiences. Students are responsible for planning, implementing, and evaluating their own nursing interventions each day during their assigned rotation.
Provide supporting behavioral examples for any categories checked belowyou can expand and type in the boxes below
PATIENT DEMOGRAPHICS (Check applicable fields and fill in the blanks)
Patient Initials: BB Age:75 Date of admission: 10/12/17 Psych Diagnosis: Major depressive disorder, Anxiety, Mania with no psychosis Medical Diagnosis: CAD, DM, PVD, Obesity
Gender: Male _x_Female__ Status: Voluntary _x_Involuntary __ (Patient was transferred voluntarily from the DVAMC ER. He came in with his wife. Patient has had suicidal ideation and has been depressed a lot more lately. He has not been sleeping at night, and his anxiety has increased. He is feeling sad, hopeless, and helpless. He threatened to shoot himself with the shotgun he had brought but thought, "it will be too messy for her to clean it up," he then decided to drink anti-freeze before his wife into getting out of the ER. Legal Problems Y__N_x_Type:
Ethnicity Caucasian __Hispanic __Black _x_Asian __Native American __Other:
Symptoms Anxiety_x_ Depressed Mood _x_Anhedonia _x_Sleep disturbance _x_ Fatigue __
Appetite Change __ Racing thoughts __ Guilt__ Grief __Hopelessness _x_Worry __ Hallucinations __Crying Spells __Risky behavior __Irritability_x_ Other: Worthlessness, exhausted
The patient was in the day room and had just woke up; he looked despondent and worried. He stated that he did not sleep well and wanted to know what time the group session was starting and if his wife was able to join him. He said that he ate most of his breakfast (according to his nurse he ate about 90%) He said his wife always cooked him his favorite breakfast and was missing her. He sat there flipping the paper with a seemingly agitated look on his face. When asked about what makes him happy, the patient mentioned the long walks he would take alongside his wife.
Psychosocial Stressors Support _x_Family _x_Abuse __Housing __Economic _x_Employment__ Trauma __
Education __Life-cycle transition __Healthcare access __ Other: Low-class working/poor
Patient currently lives with his wife in Dallas. He has a problem with his wife paying most of the bills and him not being able to do anything about it. He said he is depressed and feels worthless.
Family History Depression __Suicide __Violence __Anger __Homicide __Bipolar __ ADHD __
Schizophrenia __PTSD __Anxiety __Alcohol abuse _ Other substance abuse __
Personality Disorder __ Dementias___ Psychosis____ Other: Patient stated that neither one of his parents had a history of depression or any substance abuse. His mother died at the age of 77 with ovarian cancer, and his father died at the age 65 due to a heart attack.
Healthy Behaviors Diet __Exercise __Spiritual Practice _x_ Socialization __Traditions __ Other: Attending church services and socializing. He is a passionate Christian. He became religious after quitting alcohol at age 38.
(Patient stated he liked being around people and often reminisced his days in the church. Most of his friends are "having health complications or have died." Church services help him engage in healthy interactions once in a while.
Behaviors Caffeine: Y__N_x_amt: __Tobacco: Y_x_N__amt: __Alcohol: Y_x_N__amt: __
Street Drugs: Y__N_x_amt: __type ___ Prescription Drugs: Y__N_x_amt: __ type ___
MENTAL STATE EXAM
Appearance Appears younger _x_older than age __Scars __Piercings __Tattoos __
Well-nourished _x_Malnourished __Obese _x_ Other:
The patient is black and seems obese. He has no visible signs of aging, tattoos piercings, or visible scar marks. The patient was wearing brown pants and open shoes, his hair well-combed towards the back. His eyes were red and looked tired as he gazed on the paper, he made every attempt not to make eye contact.
Grooming Well-kempt _x_Self neglect __Disheveled __Malodorous__ Flamboyant __Other:
(Patient was decently dressed and groomed for his age. He had nobody or oral odor; he displayed signs of body and cloth hygiene. His nails and beard were well trimmed. From the short session, the patient appeared to have given up on himself but still cared for his wife and children. Had it not been for his wife and the love he felt for her, he would have gone ahead to shoot himself using the gun he claimed to have brought.
Attitude Cooperative _x_Uncooperative __Hostile __Aggressive __Inappropriate __Other:
Provide Supporting Data:
At the beginning of each encounter, the patient looks calm but not collected, he responds well to questions but gets temperamental with time. He seemed restless and anxious when asked about his stay and how he is progressing. His attitude was resentful throughout the session. The patient depicted feelings of anger and disappointment towards himself.
Speech Clear __Coherent __Normal __Pressured __Soft-spoken _x_Stuttering __Profanity __ Impoverished __Monotone _x_Mumbled _x_Slurred __Animated/Excited __ Abrupt __
Difficulty finding words __Spontaneous speech __Confabulation __ Loud__ Soft _x_
Impressionistic __ Little detail ___ Hesitant/Halting __Slurring words __No speech __
Poor articulation ___ Perseveration ___ Other:
The patient is fluent and speaks with a normal tone and pace. He often mumbles softly and likes to laugh at his thoughts. When asked about it, he makes pauses amid his speech and takes a deep breath before expressing his resentment towards himself.
Psychomotor Normal gait _x_Propulsive gait __Shuffling gait __ Ataxic __Uncoordinated __ Grimaces __
Abnormal movements __ Tics _Hand wringing __Posture stooped __Hyperactive __ Bradykinesia__ Retarded __Agitated __Clumsy __ Unsteady __Falls easily__ Other:
BB has a normal gait and calm demeanor. He makes focused motions and does not seem to struggle while doing small tasks like getting from bed or taking a drink.
Mood Euthymic __ Depressed _x_Elevated __Reserved __Irritable __Sad _x_ Angry __
Despondent ___ Anxious __ Blunted__ Melancholic __ Tearful __ Other:
Provide Supporting Data:
The patient seemed okay with his progress and stated that he is "doing well." He said he was glad someone was taking care of him and visiting him regularly. However, he still thinks he is useless, I think it would be better if I am not around," he says. Also, he does not see anything wrong with his appetite, "My appetite has been the same, nothing has changed."
Affect Normal Range__ Flat __Tearful _x_Labile __Normal Range__ Blunt __Constricted__
Sad _x_ Depressed _x_Bright __ Broad __Restricted __Inappropriate __ Congruent __
The patient looked restless as he flipped through the paper back and forth. At times he would stare blankly at the table like he was deep in thought. He breaks the silence by saying I think it would be better if I am not around as if his life does not mean much.
Thought Process Organized _x_ Clear/understandable_x_ Logical __ No formal thought disorder __
Concrete __ Illogical __Paranoia __ Simplistic _x_ Strained __ Loose associations __ Preoccupations __Perseveration __Some disorganization __ Disorganized __ Suspiciousness __ Obsessive thoughts__ Tangential __Circumstantial __ Neologisms __
Clang associations __Word salad__ Difficult to follow __ Other:
BB has a linear and coherent thought processes. However, he is not goal-oriented; this makes real interactions with him random at times. He can make clear associations of his current reality and his actions in the past. His thought process is logical, for instance, he knows shooting himself would create a horrible scene which would be likely to haunt his wife. He said he did not want his wife "to clean up the mess."
Thought Content Delusions __Illusions __Audio Hallucinations __Visual Hallucinations __
Phobias __Compulsions __Obsessions __ Preoccupations __Suicide _x_
Homicide __Aggression __Paranoid ideation __Depersonalization ___ Other:
Provide Supporting Data: Has a low self-esteem. He expresses despair and hopelessness.
The patient thinks his life is worthless and that he is helpless. He said I think it would be better if I am not around and "I feel helpless and worthless, and I don't see the point anymore." This observation indicates that that the patient is suicidal and still contemplates about ending his life.
Insight Good __ Fair _x_ Poor __ Awareness of behavior and impact on others: Y_x_ N__
Understanding problems related to illness: Y_x_ N__
Agrees that illness requires treatment Y_x_ N__ Other:
When asked about what makes him happy, he reminisced about the long walks he would take with his wife. This response suggests that the patient is regretful for having the happy moments escape his life. He would, therefore, wish to have similar activities in future, probably after recovery. From the interview, it is evident that the patient enjoyed golfing, this suggests that he would wish to do the same in future.
Judgement Right, _x_ Fair __ Poor __ Difficulty predicting results of choices Y__ N_x_
Able to learn from some experiences Y_x_ N__ Able to anticipate outcomes Y_x_ N__
Ready to use feedback & learn from mistakes Y_x_ N__ Other:
The patient is fully aware of his actions and that his obesity has resulted from lifestyle choices. He thinks ending his life will take away the sadness he feels. He understands this will make his family sad and disappointed. However, he believes if he shoots himself his wife would be left to clear up the whole mess alone. From his judgment, shooting himself does not seem to be the right option to take.
Cognition Alert and oriented Y_x_ N__ No distractibility _x_Distracted __High distractibility __
Short-term memory intact Y_x_ N__ Long-term memory intact Y_x_ N__ Other:
The patient is alert, not easily distracted and highly oriented. He remembers what had happened before he was brought to the VA and similar cases that had occurred before, like him spending a lot of time in bed and eventually carrying a gun to take his life.
Intellectual Ability Average _x_Above average __Below average __ Intellectual Disability Diagnosis Y__ N__
The patient can collect information and use it in a meaningful way. He, for instance, compares his current situation with his previous life when asked about what makes him happy. In this case, the patient suggests that he finds it better to go for long walks with his wife instead of spending lonely times in bed.
The patient thinks he is not making a meaningful contribution to his marriage and should, therefore, be allowed to die. He is however intellectual enough to conceive the consequences of his actions especially if he goes ahead to shoot himself. Also, the patient understands that it is essential to make meaningful contributions to his family as the head. However, he overthinks about his role in life and ends up having negative thoughts.
Denies __Ideation: Y_x_ N__ Plan: Y_x_ N__ Lethality: Y__ N_x_ Past History: Y__ N_x_
Suicide risk: Low__ Medium __High_x_
Patient agrees that he is depressed. He thinks his suicidal thoughts are justified because he is not able to help his wife anymore. Previously, he had threatened to shoot himself using the gun he had brought to his house.
Denies __Ideation: Y__ N_x_ Plan: Y__ N_x_ Lethality: Y__ N_x_ Past History: Y__ N_x_
Homicide Risk: Low_x_ Medium __High__
Patient denies having had any homicide ideation. He thinks of himself as the problem that needs to be eliminated. Currently, the patient is happy with the relationship he has with the wife and family; he thinks they are supportive and deserving b...
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