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LAGUARDIA COMMUNITY COLLEDGE
City University of New York
SCR 200
Psychiatric Mental Health Nursing
Student Name: Louise Margaret Tomas
Clinical Date: 03/20/2008
Biographic Data:
Client’s Initials: T.W. Room: A5-12 Age: 30
Sex: Female
Religion: Not Specified
Occupation: Unemployed
Cultural/Ethnic Background: Caucasian
Admitting Date: 02/27/2008
Reason for Admission: Client’s psychiatrist called
emergency services due to “unsafe” conditions in
client’s place of residence.
Data: S = Subjective
O = Objective
R
E
S
T
&
A
C
T
I
V
I
T
Y
E
L
I
M
I
N
A
T
I
O
N
S - Client stated that she didn’t sleep well last
night. “I think it’s the medications because when I
started taking it I began have sleep problems.”
Admitting Diagnosis: Schizoaffective Disorder Bipolar Type;
Manic
Secondary Diagnosis: None
Surgical Procedure: None
Date: N/A
Health History: Client has history of Cerebral Palsy;
Lymphoedema; Hypothyroidism and Hepitis C
DATA ANALYSIS
-
Some clients with Schizophrenia may lack energy for
daily tasks. (Videbeck pg 286)
-
Hallucinations may stimulate clients, resulting in
insomnia. Other times, clients are suspicious and
believe harm will come to them if they sleep.
(Videbeck 312)
S – “I am tired.” “I think I want to take a nap for a
little bit.”
NURSING DIAGNOSIS
-
Disturbed sleep pattern r/t medication as
evidenced by “I think it’s the medications
because when I started taking it I began to
have sleep problems.”
-
Fatigue r/t psychological demands as
evidenced by client’s increased need to rest.
-
Risk for constipation r/t medication side
effects as evidenced by client is taking
antipsychotic medication.
O- Client is observed yawning.
-
S—Client reports no problems with bowel
movement at present.
-
O – Ct stated, “I am taking Abilify.” One of
the side effects of Abilify is constipation.
-
O- Client not observed taking ingesting any
water or liquid.
-
Some medications cause constipation because they
decrease gastrointestinal activity through their action on
the central nervous system (Kozier, p. 1229).
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Data: S = Subjective
O = Objective
A
C
C
E
P
T
A
N
C
E
O – Client was observed leaving social activity
after staying for less than 10 mins.
O – Client’s hair was uncombed; and her clothes
were slightly soiled.
S – When asked if any of her friends came to visit
she said, “I didn’t want any of my friends to visit
me.”
O – Client is a 30 year old female who has never
been married and doesn’t presently have a
boyfriend.
A
C
C
E
P
T
A
N
C
E
S- Client states “I don’t like going to group
activities.”
DATA ANALYSIS
-
Schizophrenia can exhibit odd or bizarre behaviors.
They may appear disheveled and unkempt with no
obvious concern for their hygiene. (Videbeck p. 286)
-
Deterioration of the concept of self is a major problem
NURSING DIAGNOSIS
-
Social Isolation r/t failure to establish trust
as evidenced by client was in her room
lying down, avoidance of social activities
with other residents and she has never been
married before and she doesn’t have a
boyfriend.
-
Self- esteem disturbance r/t personal
identity as evidenced by poor hygiene,
uncombed hair and soiled attire.
-
Risk for loneliness r/t client inability to
participate in group activities as evidenced
by “I don’t like going to group activities.”
in Schizophrenia. (Videbeck 290)
-
Relating to others is difficult when one’s selfconcept is not clear. Clients have problems with
trust and intimacy, which interfere with the ability
to establish satisfactory relationships with others
and the environment. These clients lack
confidence, feel strange or different from other
people and don’t believe they are worthwhile.
The result is avoidance of other people.
(Videbeck 290)
2
Data: S = Subjective
O = Objective
DATA ANALYSIS
S
A
F
E
T
Y
O – Client is taking Abilify which causes
confusion, lightheadedness, orthostatic
hypotension and abnormal gait.
-
Non-neurologic side effects of medications include
sedation and anti-cholinergic symptoms. (Videbeck
282)
O- Clients’ level of anxiety is low to moderate
when she was talking to me.
-
S
A
F
E
T
Y
O- Client was observed wearing a white short
sleeved shirt and black pants, the shirt was soiled
and her hair was disheveled.
Clients with Schizophrenia may have significant selfcare deficits. Inattention to hygiene and grooming
needs is common, especially during psychotic
episodes. (Videbeck pg 290)
NURSING DIAGNOSIS
-
Risk for falls r/t medication as evidenced by
side effects to medications like abnormal
gait, lightheadedness and orthostatic
hypotension.
-
Self-Care deficit r/t hygiene as evidenced
by uncombed hair, wearing soiled clothes.
S- Client denies any suicidal ideations; stating “No
I do not feel like I want to kill myself.”
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Data: S = Subjective
O = Objective
O
X
Y
G
E
N
A
T
I
O
N
N
U
T
R
I
T
I
O
N
DATA ANALYSIS
NURSING DIAGNOSIS
O- Pt appears to have no breathing disturbances.
Pt is taking several medications.
.
A variety of medications can decrease the rate the depth of
Risk for ineffective breathing pattern r/t side
respirations. The most common medications with this effect effects of medications as evidence by client is
are the benzodiazepine sedative hypnotics, and anti-anxiety taking multiple medications.
drugs, valium, dalmane,… . (Kozier & Erb, p. 1296)
S – “ I usually eat all my food.”
Weight gain accompanies many antipsychotic medications.
(Videbeck pg 31)
Imbalanced Nutrition: more than body
requirements r/t excessive food intake as
evidenced by client stating “I usually eat all my
food.” and client’s BMI is classified as obese.
O- Client’s height is 5 feet and weight is 229lbs.
Her Body Mass Index is 44.7; which classifies her
as obese.
Medications:
1. Abilify:
The recommended starting and target dose for ABILIFY is 10 mg/day or 15 mg/day administered on a once-a-day schedule without
regard to meals. ABILIFY has been systematically evaluated and shown to be effective in a dose range of 10 mg/day to 30 mg/day,
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when administered as the tablet formulation; however, doses higher than 10 mg/day or 15 mg/day were not more effective than 10
mg/day or 15 mg/day. Dosage increases should not be made before 2 weeks, the time needed to achieve steady state
Side Effects:

Use in Elderly Patients with Dementia-Related Psychosis

Clinical Worsening and Suicide Risk.

Neuroleptic Malignant Syndrome (NMS)

Tardive Dyskinesia

Hyperglycemia and Diabetes Mellitus]

Orthostatic Hypotension

Seizures/Convulsions

Potential for Cognitive and Motor Impairment

Body Temperature Regulation

Suicide

Dysphagia
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The most common adverse reactions in adult patients in clinical trials ( ≥ 10%) were nausea, vomiting, constipation, headache,
dizziness, akathisia, anxiety, insomnia, and restlessness.
2. Synthriod
The goal of replacement therapy is to achieve and maintain a clinical and biochemical euthyroid state. The goal of suppressive therapy
is to inhibit growth and/or function of abnormal thyroid tissue. The dose of SYNTHROID that is adequate to achieve these goals
depends on a variety of factors including the patient's age, body weight, cardiovascular status, concomitant medical conditions,
including pregnancy, concomitant medications, and the specific nature of the condition being treated. Hence, the following
recommendations serve only as dosing guidelines. Dosing must be individualized and adjustments made based on periodic assessment
of the patient's clinical response and laboratory parameters.
SYNTHROID is administered as a single daily dose, preferably one-half to one-hour before breakfast. SYNTHROID should be taken
at least 4 hours apart from drugs that are known to interfere with its absorption.
Due to the long half-life of levothyroxine, the peak therapeutic effect at a given dose of levothyroxine sodium may not be attained for
4-6 weeks.
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Caution should be exercised when administering SYNTHROID to patients with underlying cardiovascular disease, to the elderly, and
to those with concomitant adrenal insufficiency
Side Effects:
Symptoms of low thyroid levels include fatigue, muscle aches, constipation, dry skin, weight gain, slow heart rate, sensitivity
to cold, or dry brittle hair that tends to fall out easily. These symptoms should disappear as your body adjusts to the medication. If they
persist or become bothersome, notify your doctor promptly.
Headache, nervousness, trembling, sweating, increased appetite, diarrhea, weight loss or insomnia may occur. If any of these
effects persist or worsen, notify your doctor promptly.
In rare instances, some hair loss may occur during the first few months of starting this drug. This effect is usually temporary as
your body adjusts to this medication. If this effect persists or worsens, notify your doctor promptly.
Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than
the risk of side effects. Many people using this medication do not have serious side effects. Seek immediate medical attention if you
have any of these very unlikely but serious side effects: chest pain, rapid or irregular heartbeat, shortness of breath, seizures.
An allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of an allergic reaction
include: rash, itching, swelling, dizziness, trouble breathing.
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