Mental Status Evaluation
Please help me type up a care plan for this simulated patient, Andrew Davis! More detailed instructions and patient info is included in the attached files along with the Care plan /MSE template that needs to be filled out. His diagnosis is Alcohol withdrawal syndrome, I believe, unless otherwise noted in his patient information.
Solution
| SEATTLE CENTRAL COLLEGE REGISTERED NURSE PROGRAM
NURS 142 BEHAVIORAL HEALTH CARE PLAN FORM |
DATE: | STUDENT: | Page 1 | |||||
| RELEVANT LABORATORY VALUES | ||||||||
| PATIENT DATA | DIAGNOSES | Date | Test | Result | Normal/
Abnormal: |
Significance | ||
| Pt Initials: AD
Age: 56 years
Gender: Male
Admit Date: March 7, 2022
Precautions: Risk for others –Directed violence and aggression
Level/Privileges:
Ethnicity: Unknown Reason for Admission: Davis was admitted after his family asked him to move out of their home
Psychiatric History: None |
Alcohol withdrawal syndrome | March 7 2022
March 7 2022 March 7 2022 March 7 2022 March 7 2022 |
Serum Albumin
ALP AST Bilirubin EtOH |
3.1
125 44 1.1 50 |
Abnormal
Normal Abnormal Abnormal Normal |
Kidney and liver condition
Liver condition Liver damage Health of liver Alcohol amount |
||
| PATHOPHYSIOLOGY OF DIAGNOSES
Alcohol withdrawal syndrome or discontinuation syndrome occurs among people who have developed physiological dependence on drugs or alcohol and who discontinue or minimize their use. Individuals often experience mental and physical problems when they stop or significantly cut back their consumption. Symptoms can range from mild to serious. The depressive effect of alcohol on the body system slows brain function and alters how nerves send messages back and forth. When the central nervous system adjusts to alcohol being around all the time, it works harder to keep the nerves talking to each other. When an individual stops drinking, the brain is affected and stays in a keyed up state, leading to withdrawal. Patients are often anxious, shaky, confused, and sweaty. |
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| STUDENT PLAN FOR DAY | ||||||||
| Instruct the patient and family about alcohol withdrawal syndrome, including the mental and environmental links to the syndrome. Teach them how to address withdrawal symptoms like anxiety, aggression, and confusion. Educate family and patient about the need for patient to undergo rehab, and importance of family support. Ensure that they have contact information to the rehab facility and the healthcare team, including the psychiatric practitioner. Document the patient’s behavior, including aggression, non-compliance, agitation, and confusion. Record medication prescribed and any adverse reactions, and document family and patient education, their understanding, and follow-up. | ||||||||
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| NURS 142 BEHAVIORAL HEALTH CARE PLAN FORM | Page 2 | ||||
| NURSING DIAGNOSIS #1
Mental, behavioral disorders, and impairment in social, occupation, and family functioning Related to: agitation and aggression
As evidenced by: patient becoming angry and directing racial and ethnic slurs at students and their family members. Dysfunctional interaction with family as patient is kicked out of family home.
|
EXPECTED OUTCOME/PLAN (SMART)
(List only 1 )
Patient behavior is appropriate and he engages appropriately with other people, including staff, and patient shows control of actions and maintains appropriate conduct in social environments. |
NURSING INTERVENTIONS
1. Conduct a mental state assessment 2. Establish good communication with the patient 3. Use language that shows consideration and provide sensitive patient-centered care |
RATIONALE/SOURCE
(for each intervention) 1. To identify potential underlying disorders or co-occurring conditions like depression or stress
2. Maximize potential for interaction while minimizing agitation and aggression levels
3. Patient feels understood and his interests are met.
|
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| NURSING DIAGNOSIS #2
Anxiety/ Fear
Related to: Cut back of alcohol intake/physiological withdrawal
As evidenced by: patient expresses intense and out of proportion anger and aggression
|
EXPECTED OUTCOME/PLAN (SMART)
(List only 1 )
Express sense of regaining some control of situation/life. |
NURSING INTERVENTIONS
1. Determine cause of anxiety. Explain withdrawal increases anxiety and uneasiness. 2. Develop trusting relationship through honest and nonjudgmental conversations. 3. Maintain a calm environment with minimal noise.
|
RATIONALE/SOURCE
(for each intervention)
1. Withdrawal leads to anxiety and patients are unable to identify and accept what is happening. High anxiety levels increase agitation. 2. Offers patient a sense of humanness, helping minimize paranoia and distrust. 3. Reduces stress |
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| NURSING DIAGNOSIS #1 | NURSING DIAGNOSIS #2 | RATIONALE/SOURCE | |||
| Evaluation: | Evaluation: | ||||
|
The goal was met. The patient showed decreased anxiety and appropriate behavior, engaging appropriately with staff. Determining the cause of anxiety, developing trusting relationship, and maintaining a calm environment were effective. (Describe if and how expected outcome/goal was met or not met, and which interventions were effective in meeting the goal) Goal Met Yes:___ No:___ In Process:____ |
The goal was met. Patient demonstrated appropriate behavior and normal interaction with staff members. Establishing good communication and maintaining a language of consideration were extremely helpful. (Describe if and how expected outcome/goal was met or not met, and which interventions were effective in meeting the goal) Goal Met Yes:___ No:___ In Process:____ |
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| NURS142 BEHAVIORAL HEALTH CLINICAL NURSING PROCESS FORM | Page 3 | ||||||
| MEDICATION LIST | |||||||
| TIME DUE | MEDICATION, DOSE,
ROUTE, FREQUENCY |
NORMAL DOSE | DRUG ACTION | SPECIFIC RATIONALE FOR PT | ADVERSE REACTIONS/
SIDE EFFECTS |
NURSING RESPONSIBILITIES | |
| 18:00 | Thiamine, orally once daily | 100g | Thiamine combines with adenosine triphosphate (ATP) in the liver, kidneys, and leukocytes to produce thiamine diphosphate. Thiamine diphosphate acts as a coenzyme in carbohydrate metabolism | To help the body turn foods into energy to boost body function. | Warmth, severe allergic reactions, skin discoloration, sweating, itching, hives, rapid swelling of skin, restlessness. | Record patient dietary history. Inquire about kidney disease. | |
| 18:00 | Multivitamin orally once daily | 1 tablet | Provide vitamins that are not taken in through the diet | To treat and prevent vitamin deficiency due to withdrawal effects. | Constipation, diarrhea, upset stomach, uneven heart rate, muscle weakness, increased urination, and confusion. | Inquire about medical conditions and allergies. | |
| 18:00 | B12 orally once daily | 2000mcg | B12 binds to the protein in the foods we eat | Correct vitamin B12 deficiency and improve symptoms and laboratory abnormalities. | Mild diarrhea, itching, skin rash, dizziness, nausea, vomiting, and headache. | Monitor for allergies. | |
| 18:00 | Diazepam orally every 2 hours PRN | 10mg | Diazepam is a benzodiazepine that exerts anxiolytic, sedative, musclerelaxant, anticonvulsant and amnestic effects. | Treat anxiety and alcohol withdrawal | Drowsiness, dizziness, tiredness, muscle weakness, headache, nausea, and constipation. | Evaluate blood pressure, pulse, and respiration. | |
Mental Status Examination – Using Memory Aid “OLA SAMI PAT JIM”
Orientation –
Level of Consciousness –
Alert and oriented
Appearance –
Speech –
Steady
Affect –
Mood –
Angry, frustrated, anxious
Intelligence –
Posture –
Rigid, hunched
Attention Span –
Intact, engages in conversation without distractions
Thought content & process –
Judgment –
Insight –
Memory
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Regards,
Cathy, CS.