Depression/Overdose with Psychosis

Depression/Overdose with Psychosis

Jenna Taylor is an 18-year-old woman who is brought to the emergency department by ambulance after she admitted to her mother that she had taken a “handful” of dextroamphetamine/amphetamine (Adderall) this morning. Mom noted that there are 20 tablets missing. Jenna admits that she has been hearing voices telling her that she is worthless and would be better off dead. She denies visual hallucinations.

As the primary nurse explores these comments further, Jenna states, “The devil is in the place! I can feel it! The voices are telling me that I am going to hell forever.” Jenna appears fearful, anxious and does not maintain eye contact. When she briefly glances and looks your way, she appears to be looking through you.

Personal/Social History:

She was hospitalized three weeks ago for depression and suicidal ideation and was discharged ten days ago. Jenna lives with her mother. Her parents were divorced 12 years ago. She graduated from high school, has few close friends, and has no current plans for her future.

What data from the histories is RELEVANT and has clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:
 

 

 

 

 

 

 

 

 

 

RELEVANT Data from Social History: Clinical Significance:
 

 

 

 

 

 

 

 

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect.)

PMH: Home Meds: Pharm. Classification: Expected Outcome:

Attention deficit hyperactivity disorder (ADHD) Depression with psychosis Anxiety 1. Dextroamphetamine/amphetamine XR

20 mg PO daily

2. Clonazepam 0.5 mg PO BID

3. Bupropion HCL SR 100 mg PO BID

 

 

One disease process often influences the development of other illnesses. Based on your knowledge of

pathophysiology, (if applicable), which disease likely developed FIRST, then initiated a “domino effect” in Jenna’s life?

· Circle the PMH problem that likely started FIRST.

· Underline at PMH problem(s) FOLLOWED as domino(s).

Patient Care Begins:

Current VS: WILDA Pain Assessment (5th VS):
T: 99.2 F (37.3 C) oral Words: Denies
P: 92 (regular) Intensity:
R: 20 (regular) Location:
BP: 118/70 Duration:
O2 sat: 98% RA Aggravate: Alleviate:

 

What VS data is RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT VS Data: Clinical Significance:
 

 

 

 

ORDER A PLAGIARISM FREE PAPER NOW

Current Assessment:
GENERAL

APPEARANCE:

Appears comfortable, no acute distress
RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort
CARDIAC: Pink, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert and oriented to person, place, time, and situation (x4), flat affect
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:
 

 

 

 

 

 

Mental Status Examination (MSE):
APPEARANCE: Dressed in casual clothes, no make-up; no body odor; appears tired and appears stated age; cooperative during interview
MOTOR BEHAVIOR: Psychomotor agitation, restless
SPEECH: Speech is rapid, pressured
MOOD/AFFECT: Appears anxious/fearful
THOUGHT PROCESS: Illogical and not linear (thoughts do NOT make sense and are disorganized
THOUGHT CONTENT: Evidence of psychotic thinking and loss of contact with reality. States, “The devil is in the place! I can feel it! The voices are telling me that I am going to hell forever.” Hearing voices telling her that she is worthless and would be better off dead.
PERCEPTION: Auditory hallucinations present
INSIGHT/JUDGMENT: Does not have insight, judgment is impaired
COGNITION: Alert and Oriented x3, has difficulty concentrating
INTERACTIONS: Has been isolating from friends and family over the last two days
SUICIDAL/HOMICIDAL: Denies homicidal thoughts, is currently suicidal, and acted on this ideation by taking overdose of medication.

 

What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?

RELEVANT Assessment Data: Clinical Significance:
 

 

 

 

 

 

 

 

 

Lab Results:

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Complete Blood Count (CBC:) Current: High/Low/WNL?
WBC (4.5–11.0 mm 3) 5.2
Hgb (12–16 g/dL) 14.2
Platelets (150-450 x103/µl) 229
Neutrophil % (42–72) 58

 

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance:
 

 

 

 

 

 

Basic Metabolic Panel (BMP:) Current: High/Low/WNL?
Sodium (135–145 mEq/L) 140
Potassium (3.5–5.0 mEq/L) 3.6
Glucose (70–110 mg/dL) 125
Creatinine (0.6–1.2 mg/dL) 0.5

 

RELEVANT Lab(s): Clinical Significance:
 

 

 

 

 

 

 

Misc. Labs: Current: High/Low/WNL?
Acetaminophen 0.00
Salicylate 0.00
Urine pregnancy Neg
RELEVANT Lab(s): Clinical Significance:
 

 

 

 

Urine Drug Screen: Current:
Opiates
Benzodiazepines
THC
Amphetamines
Cocaine

 

RELEVANT Lab(s): Clinical Significance:
 

 

 

 

Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting with?

2. What is the underlying cause/pathophysiology of this concern?

Collaborative Care: Medical Management

Care Provider Orders: Rationale: Expected Outcome:
Acetaminophen level

 

Salicylate level

 

 

Complete blood count

(CBC)

 

Basic metabolic panel

(BMP)

 

Urine drug screen

 

Urine pregnancy

 

 

Establish peripheral IV

 

Diazepam 5 mg IV PRN for seizure activity

 

 

1:1 watch

Check for items of harm

 

Cardiac monitor

 

 

 

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:
Establish peripheral IV

 

1:1 watch

 

Check for items of harm

 

Cardiac monitor

 

Collaborative Care: Nursing

3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY)

4. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:
 

 

 

 

 

 

 

 

 

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

6. What is the worst possible/most likely complication to anticipate?

7. What nursing assessments will identify this complication EARLY if it develops?

8. What nursing interventions will you initiate if this complication develops?

9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?

10. How can the nurse address these psychosocial needs?

Evaluation: Two hours later…

Jenna has become more restless with increased pacing in room. She cries out loudly in a shriek. As the nurse enters the room, Jenna is sitting on the bed and states fearfully, “I told you the devil is in this place! Please help me!” She suddenly becomes unresponsive, her body becomes rigid and she begins to have rhythmic tonic/clonic movements of her entire body.

Current VS: Most Recent: Current WILDA:
T: 99.8 F (37.6 C) oral T: 99.2 F (37.3 C) oral Words: Denies
P: 140 (regular) P: 92 (regular) Intensity:
R: 24 R: 20 (regular) Location:
BP: 158/90 BP: 118/70 Duration:
O2 sat: unable to obtain O2 sat: 98% RA Aggravate: Alleviate:
Current Assessment:
GENERAL

APPEARANCE:

Rigid body posture
RESP: Loud, snoring respirations, oral secretions bubbling out of mouth
CARDIAC: Pale, warm and dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Unresponsive, tonic/clonic movements lasted 60 seconds and have now stopped, lethargic, not responsive to verbal commands
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU: n/a
SKIN: Skin integrity intact

1. What clinical data is RELEVANT that must be recognized as clinically significant?

RELEVANT VS Data: Clinical Significance:
 

 

 

 

 

RELEVANT Assessment Data: Clinical Significance:
 

 

 

 

 

 

2. Has the status improved or not as expected to this point?

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

4. Based on your current evaluation, what are your nursing priorities and plan of care?

Jenna is going to be admitted to intensive care for close assessment and monitoring. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will care for this patient:

Situation:
Name/age:

 

BRIEF summary of primary problem:

 

 

Background:
Primary problem/diagnosis:

 

 

RELEVANT past medical history:

 

Assessment:
Most recent vital signs:

 

 

RELEVANT body system nursing assessment data:

 

 

RELEVANT lab values:

 

 

How have you advanced the plan of care?

 

Patient response:

 

INTERPRETATION of current clinical status (stable/unstable/worsening):

 

Recommendation:
Suggestions to advance the plan of care:

.

Education Priorities/Discharge Planning

1. What will be the most important discharge/education priorities you will reinforce with her medical condition to prevent future readmission with the same problem?

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

2. What can you do to engage with this patient’s experience, and show that she matters to you as a person?

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.

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