Mental Health Case: Sharon Cole

Documentation Assignments
1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute
agitation. Include her responses to your assessment.
Sharon Cole was found agitated, restless, hair unbrushed and talking excessively. Additionally, the patient who
was continuously talking loudly showed signs of grandiose behaviour.
2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration.
Include her responses to the medication administered.
2mg of Lorazepam, a benzodiazepine was administered to the patient. Within 8 hour of administration of the
drug, there was a reduced state of agitation in the patient.
3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care.
On checking the patient’s vitals; Bp was 136/70 mmHg, temp. 37.2 degrees celcius, heart rate 87 beats per
minute, respiratory rate 15 breaths per minutes.
4. Document all interventions associated with the management of Mrs. Cole’s environment. Include her
responses to the attempts to decrease environmental stimuli.
Addressing the unmet needs such as toileting needs, hunger and fear. Use of calm voice, limiting the number of
individuals in the area, reducing noise by turning off TV and adjusting alarms. Using nightlight, limiting restraints
and removing sharp objects from the room.
5. Document all interventions associated with boundary and limit setting directed toward managing Mrs. Cole’s
manic behavior.
I alerted the patient to behave appropriately with the health practitioners after I noticed her flirting with the
nurses.
6. Document your handoff report in the SBAR format to communicate Mrs. Cole’s future needs.
Situation: Mrs. Cole, a female aged 31, was administered last night for surgical repair of her fractured right
ankle. At 8: 00 am, she was taken for surgery and was back at 11: 30 am from the postoperative unit.
Background: She fractured her right ankle, while on a demonstration towards rectifying Washington’s problems.
She sustained the injury when she fell from a bar stage while struggling to have the microphone.
Assessment: The patient’s vital signs are stable; Bp was 136/70 mmHg, temp. 37.2 degrees celcius, heart rate 87
beats per minute, respiratory rate 15 breaths per minutes. Her agitated condition are now calming down as
compared to when she was admitted, she wanted to get rid of IV because it was making her uneasy. After
convincing her, she has been able to keep up with it. For her safety, there has been a family caregiver.
Recommendation: As a medical practitioner, I recommend mental status exam on the patient before being
discharged.

From vSim for Nursing | Mental Health. © Wolters Kluwer.