University:
Shawnee State University
Course:
ANDR 1254 | Nursing Care / Behavioral Health Client
Academic year:

2020
Views:

201

Pages:

2
Author:

grosikesf4

Mental Health Case Documentation Assignments 1. Document your findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment. Lung sounds are clear and equal bilaterally however patient felt heavy when breathing. Heart rate and rhythm regular without murmurs; however, pulse was strong and regular at 110 bpm. She felt like her heart was racing and states she feels like she is going to die. 2. Document your findings related to the focused assessment of Ms. Waterfall’s signs and symptoms of acute anxiety. Include her responses to your assessment. Linda shows signs of concer, worry, anxiety, impending doom, restless nights to past experiences that were traumatizing related to her mother’s death of surgical complications. She says she can’t go into surgery without her medicine bundle because this is part of her tradition and culture. Linda’s family lives far away so her support system is very limited with her cousin Alice. 3. Referring to your feedback log, document all nursing care provided and Ms. Waterfall’s response to this care. -checked for safety -assessed BP, pulse, temperature, O2 sat, RR -auscultate lung sounds, heart sounds -provided therapeutic communication -asked if patient was in pain -asked if patient had difficulty breathing -asked if patient has trouble sleeping -assessed patients physical appearance -educated about possibilities and further care, advocated 4. Document all interventions associated with the management of Ms. Waterfall’s anxiety as they are included into her plan of care. Include interventions especially focused on her spiritual and cultural needs, as well as those demonstrating nursing advocacy. Because she was anxious and said it was hard to breath, I did a short breathing exercise to calm her nerves down. We talked about how the medicine bundle was important to her I allowed her to express her concerns. She talked about her mother’s death and how she went into surgery without the medicine bundle. I reassured her that if she did not feel comfortable receiving the surgery, I can let the surgeon know. 5. Document your handoff report in the SBAR format to communicate Ms. Waterfall’s future needs. Situation-Linda waterfall 48 year old female, Dr. Samuel’s patient. Schedule for left mastectomy at 8:30 am. She changed her mind and does not want to follow through the surgery. Background- native American woman diagnosed with an aggressive form of breast cancer after a biopsy just a few days ago. Very nervous and anxious about the procedure. Stopped taking all of her medicationan and wants her medicine bundle. Assessment- Vitals BP-140/80 Pulse- 80bpm Respirations- 18 breaths/min Temperature- 99 02 sat- 100% Physical assessment pain- none experiences difficulty breathing recommendations- meet with primary care provider and discuss future medical care and interventions teach patient relaxation techniques, stay with patient to ease anxiety

Mental Health Case

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