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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). 1 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.” 3 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, 4 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 5 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. 6 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. 7