Evaluation Artifacts

Fall 2013 Clinical Evaluation Tool 

                                                                                                                                                                                                                                                                                    

NPW~Semester 2

USF College of Nursing ~ Nursing Process Worksheet NUR 3535L

Student:      Morghan Walrich Date:   9/26/12                    

Instructor:   Dr. Cadena Team: Bayfront-USF upper divsion       

Worksheet is to be completed and turned in each clinical day to your instructor

1. Identifying Statement: This is a concise, professional statement that tells the reader crucial identifying information about the client. Information should include age, gender, marital status, past and present psychiatric symptoms, housing, current work status, and any other pertinent information.  Please include chief complaint: i.e.  “I just don’t think I can go on any longer.”

The patient is a 52 year old female admitted to the Morton Plant North Bay Recovery Center on September 20, 2012. She was diagnosed with bipolar disorder and borderline anxiety. The patient was admitted involuntarily and was transferred from St. Joseph’s North. She has been admitted to the Recovery Center before for continuous self- mutilation. Upon her recent admission, the patient’s husband recommended she seek help after she put a butcher knife to her abdomen, threatening to kill herself. According to the patient, she was “just so frustrated with him and wanted to treat him a lesson.” Supposedly, she and her husband have a verbally abusive relationship, and she does not feel appreciated or loved. The patient is unemployed. She currently takes Abilify, Cogentin, Clonazepam, Haloperidol, Levothyroxine at home, and has been recently been prescribed Cipro. 

2. Type of admission :( if hospitalized)

     ____ Voluntary       __X__ Involuntary (describe):    __Baker Act (BA52)______

3.  HPI: (History of Present Illness:  What behaviors/ symptoms led to this hospitalization (if hospitalized) or what behaviors/symptoms require this mental health intervention? What symptoms are still being experienced?

The patient exhibits symptoms of bipolar disorder, including periods of mania, depression, delusions etc. She states that she hears the voice of “Jimmy the cricket from Peter Pan” who protects her. The patient believes that hospital staff wish to harm her, which is part of her delusional thought process. The patient is alert and oriented x 3 (person, place, date/year). The patient has had suicidal thoughts and threatened to end her life before coming to the hospital. She does not express these feelings still. When speaking with her, the patient is usually calm and cooperative, until she is reminded of her life at home. The patient does suffer from frequent migraines and high blood pressure. 

4. Assessment:  Write your mental status exam here to include: Appearance, Motor Activity, Mood, Affect, Cognition:  Thought process, Suicide and Homicide Assessment in a narrative format.

Appearance: The patient is 

Motor activity: The patient uses a wheelchair for stability

Mood: “I feel sad most of the time, and my husband just makes life difficult for me.”

Affect: Blunted/Manic

Cognition: Disorganized, paranoid delusions (thought people at the hospital wanted to hurt her)

Thought process: Racing thoughts and flight of ideas

Suicide/Homicidal: Yes, the patient was suicidal, but has not showed/voiced suicidal ideation since being in the hospital. 

5. Problem List:  (list 3 primary problems that you identify based on your assessment and list 1 nursing diagnosis based on the highest priority problem identified)

. History of harming herself (cutting/self mutilation)

. Depressed and stressed

. Stressed and anxious

 Priority Nursing Diagnosis-At risk for self-inflected, life-threatening injury related to psychiatric disorder as evidenced by bipolar symptoms and verbally expressed suicidal ideation

6. Planning /Outcomes (what do you want to happen):

              a. Short Term: Patient will talk about feelings and express anger appropriately during at least 2 group sessions.                      

              b. Long Term: Patient’s suicidal ideation will decrease and she will maintain self-control by the end of treatment  (upon discharge).

7. Interventions (how are you going to make it happen):

- Anxiety reduction~ Will look for effective outlets for the patient’s anger and relaxation techniques (art therapy, exercise routine, etc.) Speak with patient about possible/realistic coping mechanisms.

- Delusion management~ Will investigate the source of these delusions of hospital staff wanting to harm the patient. 

- Mood management~ Will observe, record, and report any changes in mood or behavior.

- Suicide prevention~ Will assess the client’s ability to enter into a no-suicide contract.

8. Evaluation (did it happen?):

The patient did work through some of her anger at the group session this week. It is difficult to follow her thoughts, because she does not focus on a topic well. The patient also talked about her previous wish to hurt herself and how she can now deal with some of those impulsive thoughts. The patient suffers from severe self esteem issues.