University:
University of New Hampshire
Course:
NURS 813 | Health Assessment and Clinical Nursing Theory
Academic year:

2021
Views:

249

Pages:

2
Author:

Trevon Bernard

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 in a hospital gown and hair is unbrushed. She was constantly moving around and agitated. Her speech was loud/clear and thoughts were heard all over the place and she exhibited grandious behavior. 2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered. I administered Lorazapam 2mg to reduce her agitation. 3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care. I took her vitals signs: temperature, 37.2°C (99°F); heart rate, 86 beats/min; respiratory rate, 16 breaths/min; blood pressure, 136/70 mmHg. I assessed her cast and skin integrity. I assessed her IV access which was intact. 4. Document all interventions associated with the management of Mrs. Cole’s environment. Include her responses to the attempts to decrease environmental stimuli. I turned down the lights to reduce external stimulation and I also kept only the IV line intact on her to minimize any feeling of being restricted or confined. 5. Document all interventions associated with boundary and limit setting directed toward managing Mrs. Cole’s manic behavior. She made a noticeable remark about how the male tech had her BP elevated. I told her that he is the nursing assistant. Tell her to need to behave appropriately with hospital staff. 6. Document your handoff report in the SBAR format to communicate Mrs. Cole’s future needs. Situation: Sharon Cole is a 31-year-old female who was admitted last night for surgical repair of a right ankle fracture. She went to surgery this morning at 08:00 and came back from the postoperative unit at 11:30. Background: Mrs. Cole sustained the injury when she fell from the stage in a bar. According to the paramedics she was ranting about the government and talking about how she was the only one who could help rectify Washington's problems. She jumped up on the stage and grabbed the microphone from the band leader, and in the struggle that ensued, she fell off of the stage and fractured her ankle. Assessment: . Her vital signs are stable: temperature, 37.2°C (99°F); heart rate, 88 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/70 mmHg. She denies pain, but she says she never feels pain. She has threatened to take her intravenous (IV) line out to get rid of the pain medicine, which she says makes her feel like she's "not herself." So far, we've been able to talk her into keeping it. She takes small sips of water when it is directly given to her. There is a sitter present for the patient's safety. Recommendation: Complete assessment; mental status examstatus. He expects she can be discharged later today, but she may need to be moved to the inpatient psychiatric unit.

Sharon Cole Documentation Final

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