Nursing Care Plan
Cayla Wegner
Bryant & Stratton College
Mental Health
Professor Trudie Johnson
November 16, 2015 Admission Mental Status Assessment
JH was a 47-year-old Caucasian female who came to the ICU with an intentional drug overdose. Her neighbors called 911 after waking up in the middle of the night to her vomiting in the bathroom. Ambulance record: 47-year-old patient was found lying on the neighbor’s bed. Patient had 5-6 beers the night prior with her neighbors; they were good friends. There was a note found written by JH stating, “I love U ALL I’m sorry. I just can’t do this life anymore. No peace. I will be with Faith and other family members. Go on and find Jesus! Please”. JH has pneumonitis due to the inhalation of vomit and …show more content…
Patient will show a sign of hope by the end of my shift at 1500. While talking to JH, I wanted to encourage realistic hope to her. Fostering unrealistic hope is not helpful and may significantly worsen the trust the patient places in the health care provider. I wanted to encourage the dreams she has of going back to school and getting a degree to better her life. She wanted to do this in honor of her daughter. Likewise, I encouraged JH to identify her own strengths and abilities. During crisis, patients may not be able to recognize their strengths. JH told me how good she was at giving advice and helping people through tough times (Gulanick, 2007, p. 103). Patient will begin to mobilize energy on own behalf by making her own decisions by the end of my shift at 1500. During my shift, I wanted to reassess her of any signs of SI, giving up or a lack of self worth. While asking JH if she would ever do this again, she told me, “I will never do this again, I learned my lesson”. She wanted to be there for her children that are living and to continue to watch them grow up. Additionally, assessing her appetite, exercise, and sleep patterns is important because deviations from normal patterns are evident during periods of hopelessness. When asking her about her sleeping patterns and appetite she stated, “they have been getting better as the days go on” (Gulanick 2007,
Cayla Wegner
Bryant & Stratton College
Mental Health
Professor Trudie Johnson
November 16, 2015 Admission Mental Status Assessment
JH was a 47-year-old Caucasian female who came to the ICU with an intentional drug overdose. Her neighbors called 911 after waking up in the middle of the night to her vomiting in the bathroom. Ambulance record: 47-year-old patient was found lying on the neighbor’s bed. Patient had 5-6 beers the night prior with her neighbors; they were good friends. There was a note found written by JH stating, “I love U ALL I’m sorry. I just can’t do this life anymore. No peace. I will be with Faith and other family members. Go on and find Jesus! Please”. JH has pneumonitis due to the inhalation of vomit and …show more content…
Patient will show a sign of hope by the end of my shift at 1500. While talking to JH, I wanted to encourage realistic hope to her. Fostering unrealistic hope is not helpful and may significantly worsen the trust the patient places in the health care provider. I wanted to encourage the dreams she has of going back to school and getting a degree to better her life. She wanted to do this in honor of her daughter. Likewise, I encouraged JH to identify her own strengths and abilities. During crisis, patients may not be able to recognize their strengths. JH told me how good she was at giving advice and helping people through tough times (Gulanick, 2007, p. 103). Patient will begin to mobilize energy on own behalf by making her own decisions by the end of my shift at 1500. During my shift, I wanted to reassess her of any signs of SI, giving up or a lack of self worth. While asking JH if she would ever do this again, she told me, “I will never do this again, I learned my lesson”. She wanted to be there for her children that are living and to continue to watch them grow up. Additionally, assessing her appetite, exercise, and sleep patterns is important because deviations from normal patterns are evident during periods of hopelessness. When asking her about her sleeping patterns and appetite she stated, “they have been getting better as the days go on” (Gulanick 2007,