Mental Health Case Randy Adams

Mental Health Case: Randy Adams Documentation Assignments 1. Document your findings related to assessments of Mr. Adams’ cognition, symptoms of concussion, and symptoms of posttraumatic stress disorder. Today I assessed the patient using the B portion of the ACE, screened the patient for PTSD, and administered a mini cog exam Using the ACE the patient reported headache, and sensitivity to light and noise, difficulty concentrating. He also reported being irritable, more emotional, nervous, and sleeping less than usual. He stated he was at a 1 out of 6 for how different he was acting compared to his usual self. His total score was an 8 During the PTSD screening the patient reported experiencing a traumatic event, that he did not want to think about, that he had nightmares or thought about, that caused him to be on guard looking for exits, and made him feel detached. On the mini cog he scored a 4 because he forgot one of the three words. This is the same as his minicog score a week ago. 2. Identify and document key nursing diagnoses for Mr. Adams. Anxiety, altered social interaction, chronic low self esteem, insomnia, knowledge deficiency, risk for suicide, impaired coping, 3. Referring to your feedback log, document all nursing care provided and Mr. Adams’ response to this care. I checked scene safety, washed my hands, identified the patient, obtained consent for the support person to be present. 01:06You asked the patient: Is it OK for your wife to be here, while we talk? It was correct to let the patient give his consent for letting his wife be a part of the interview. 01:17The patient said: I'm not sure what I would do without Joy. You answered: It sounds like your relationship with your wife is very important to you. You used the therapeutic technique of encouraging expression. 03:04You said: I would like to ask you some questions related to your concussion that will help me to better assess you. May I ask you these questions? 03:23The patient said: This is a lot. Why are you asking so many questions? I can't answer this many questions. You answered: It's important that I ask you these questions to complete your assessment. You used the therapeutic technique of giving information. 03:56The patient said: The lights; they make my headache worse. You answered: Intolerance to light is a common symptom related to a head injury. You used the therapeutic technique of giving information. 05:00The patient said: I can't help Joy when the boys cry; the sounds are too painful. You answered: Is the pain before or after you hear loud noises? You used the therapeutic technique of placing the event in time or sequence. 05:46The patient said: You'll have to ask Joy about answering the questions. You answered: I think you should answer these questions. You used the nontherapeutic technique of giving advice. 06:22The patient said: I can't relax; a good soldier is always prepared to act. You answered: Tell me more about that. You used the therapeutic technique of exploring. 06:53The patient said: I really don't need much sleep. You answered: Are you saying that you don't sleep well? You used the therapeutic technique of verbalizing the implied. 10:29You completed the ACE Part B. Symptom Check List (Lovell & Collins, 1998 JHTR) assessment tool. Some of your assessment answers were incorrect.Regarding the indicator "COGNITIVE": You should have indicated "Difficulty concentrating" and "Difficulty remembering."Regarding the indicator "EMOTIONAL": You should have indicated "Irritability," "More emotional," and "Nervousness."Regarding the indicator "Exertion: Do these symptoms worsen with: Cognitive Activity": You should have indicated "Yes." 10:40You said: Is it okay if I ask a few questions related to any traumatic experiences you may have encountered? There are four questions, and they will help to better clarify what might be causing some of your symptoms. The patient said: Ok. Go ahead. 12:31The patient said: Every time I go somewhere, I immediately look for the exits. You answered: I'm not sure I understand. You used the therapeutic technique of seeking clarification. 13:11You completed the Primary Care PTSD screening assessment tool. The tool is correctly completed. 13:15You said: I would like to ask you a few questions and for you to draw a specific thing, which will help me to better assess you. May I ask you these questions? The patient said: Yes. 14:47You completed the Mini-Cog© assessment tool. The tool is correctly completed. 16:34You educated about PTSD. 17:52You called the provider. This is reasonable at this point. 18:36The patient said: I don't want to talk about my time in the Army. You answered: You seem uncomfortable. You used the therapeutic technique of making observations. 4. Document instances of therapeutic communication and Mr. Adams’ response to this intervention. Highlighted in yellow above 5. Document the patient teaching related to posttraumatic stress disorder and concussion, as well as medications, that you provided to Mr. Adams and his wife before discharge. Regarding patient education on PTSD, I stated, “Mr. and Mrs. Adams, I’d like to talk to you about posttraumatic stress disorder, also known as PTSD. PTSD occurs following a life-threatening or traumatic event. It can cause you to experience anxiety, distressing thoughts, and anger. The assessment I conducted today indicated you may have PTSD, and Dr. Reynolds will be evaluating you for PTSD today.” The patient asked, “What happens if I have PTSD?” I responded, “Dr. Reynolds will determine if you require a referral to a behavioral health specialist. A treatment that has been successful in people diagnosed with PTSD is a support group. In your case, a support group composed of veterans who have had similar experiences may be beneficial.” 6. Document your handoff report in the SBAR format to communicate Mr. Adams’ future needs.