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PATIENT

48 year-old Caucasian Male

No religious preference, no related considerations pertaining
to ethnicity.

Received In ED Suicidal Ideations        

No income source. Quest Insurance.

MH-4 Legal Status with exp. date of 01/15/16

Patient appeared to be personable, open to discuss some of
his current situation and problems.

Not completely forthcoming: is withholding some information.
Denies illicit drug use despite lab results indicating this. Loose
associations.

DSM DIAGNOSIS
I

ALCOHOL USE DISORDER --SCHIZOAFFECTIVE -- BIPOLAR -DEPRESSION

II

None

III

HEP C

IV

HOMELESS, NO TRANSPORTATION, UNEMPLOYED, NO
SOCIAL OR FAMILY SUPPORT

V

GAF  10 SERIOUS ATTEMPTS IN THE PAST TO HARM SELF.

MEDICATION

Haloperidol (Haldol)

Quetiapine (Seroquel)

Trazodone (Trazodil)

Thiamine (Betaxin), vitamin B1

Diazepam (Valium)

BMI:    
Category: 
Height:     
Weight: 

22.9
Normal.
5'9" /175.26cm
155lbs./70.3 kg  

Food & fluid intake: No diet restrictions.

Patient currently eating steady diet.

Bladder & bowel status:

Last BM previous evening.

Sleep pattern:       

Stays up late usually, sleeps in late
sometimes, no complaints of difficulty
sleeping.   

Total sleep/24 hrs:                      

7.5 hours  

Hypersomnia/Difficulty falling asleep/Middle
insomnia/Early morning awakening.

None.

Number of hrs of disruption:   

None reported. 

Naps:   

None.

Total nap time:

No naps taken during clinical day.

            

AXIS III

HEP C

Nursing Interventions:
Educate patient on risks of alcohol abuse in combination
with Hepatitis C. Encourage patient to seek treatment
and medical compliance.

LAB & STUDIES
Date/Panels in which all values were normal: No normal date
available. Lab test on 1-12-16 methadone and barbiturate's
negative
Date/Any abnormal labs: 1-12-16
Labs you would expect but were not ordered: liver function
test, albumin, h + h
Glucose readings x 24h for all diabetic pts.

All drug screen findings: 1-12-16 positive for oxycodone,
opiates, benzos and alcohol 0.33

MENTAL STATUS ASSESSMENT
Behavior:
Grooming and level of hygiene lacking. Some gross motor shaking of
extremities, interacts and answers questions, makes eye contact.
Affect:

Displays full range of emotion, appropriate responses to questions.

Sensorium: Oriented to person place and time.
Imagery:

No flashbacks from trauma, no nightmares.

Cognition:

Some impairment noted, unable to name most recent presidents.

Interpersonal
relationships: Isolated from family, no significant personal relationship, gives last
roommate as only contact. Patients symptoms compared to DSM criteria.
Developmental
level:

(Assets & barriers) able to maintain conversation, some looseness of association
noted as evidenced by believing others conversation are regarding him.

Drugs:  Substance abuse or dependence:  (Include nicotine & any alcohol & drugs.  List by
drug:  Last date of use/Current acute intoxication or withdrawal signs and symptoms
when SN caring for pt./Used how long/Route/Usual amount/Negative consequences)

PROBLEMS IDENTIFIED IN HOSPITAL’S
MASTER TREATMENT PLAN
1.

Suicidal ideations

2.

Depression

3.

Chronic alcoholism, illicit drug use

4.

Homelessness

5.

Non-complaint with antipsychotic medication

CURRENT DISCHARGE PLAN:
Preparation planning for placement at Kalihi Palama, follow up
with case worker, primary care provider.

CAREPLANS
Three priorities:
Safety
Injury prevention
Alcohol withdrawal management

CAREPLAN -- SAFETY

Prevention of self harm.
• Frequent rounding every 15 minutes
• Random checks

Establish therapeutic relationship to learn reasons why
patient may want to harm himself.

Implement contract for safety with patient.

CAREPLAN – INJURY PREVENTION

Follow CIWA protocol and monitor for signs and symptoms.

Provide safety for possible seizures:
• Padded bedrails
• Lowest bed position

Administer Thiamine as ordered to prevent complications.

CAREPLAN -- ALCOHOL WITHDRAWAL
MANAGEMENT

Monitor and manage anxiety levels.

Administer anti-anxiety medications.

Provide consultation for referral to detox.

REFERENCE
Gulanick, M., & Myers, J.L. (2014). Nursing care plans:
Diagnoses, interventions, & outcomes. (8th ed.). St. Louis, MO:
Moby.