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According to the records, she has hx of postpartum psychosis after her 1st child. She has been
hospitalized in Sierra Vista in 2012.
Alcohol and Other Drug Abuse:
None
Abuse (physical/sexual):
None
FAMILY HISTORY
Mental Health:
None
Alcohol and Other Drug Abuse:
None
MENTAL STATUS EXAM
General Appearance:
Facial Expression: Calm; Blank stare
Dress & Grooming: Casual dress (jean, T-shirt,
and tennis shoes); Adequate grooming; No
makeup.
Posture and Gait: posture erect, sit upright,
steady gait, ambulated without assistance.
Speech
Volume: appropriate
Thought Content
Phobias: None
Obsessions: None
Compulsions: None
Dreams: None
Dj vu Experiences: None
Fruits!Yummy!
or others.
v.
Facilitate a trusting and therapeutic relationship with the patient by promptly attending her
needs in a timely manner (Hewitt & Coffey, 2005).
vi.
Include the patients family in the plan of care if possible because it is shown to
substantially improve the patients functioning and family well-being and prevent relapse
(Johnson, 2005).
2. Disturbed sensory perception: Auditory r/t auditory command hallucination AEB she cut her left
little finger because of the voice telling her to do so
a. Outcome: Patient will discuss the content of hallucinations during hospitalization.
b. Interventions (Townsend, 2012):
i.
Observe patient for signs of hallucinations and ask her directly if she is hearing the voice
ii.
Show the attitude of acceptance to patients situation without judgment
iii.
Encourage the patient to share the content of the hallucination
iv.
Try to distract the patient from the hallucination by teaching her the technique voice
dismissal, in which, she is taught to say loudly, Go away!
v.
Redirect the patient to reality using therapeutic communication
vi.
Facilitate a trusting and therapeutic relationship with the patient by promptly attending her
needs in a timely manner (Hewitt & Coffey, 2005).
vii.
Include the patients family in the plan of care if possible because it is shown to
substantially improve the patients functioning and family well-being and prevent relapse
(Johnson, 2005).
3. Impaired verbal communication r/t decreased/delayed thinking process AEB blank stare and pause
between questions and answers
a. Outcome: Patient will demonstrate ability to focus on one topic and improve the delayed
thinking process by answering the questions simultaneously.
b. Interventions (Townsend, 2012):
i.
Facilitate trust and understanding by maintaining staff assignments as consistently as
possible
ii.
Anticipate and fulfill the patients basic needs promptly
iii.
Spend time to talk with the patient
iv.
Allow enough time for the patient to answer the questions without any rush
v.
Ask the questions using a short and clear sentences at the patients level of comprehension
References
Hewitt, J., & Coffey, M. (2005). Therapeutic working relationships with people with schizophrenia:
Literature review. Journal of Advanced Nursing, 52(5), 561-570.
Johnson, D. (2005). Family interventions for schizophrenia: An international view. Psychiatric
Times, 22(6), 16.
Townsend, M.C. (2012). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based
Practice (7th ed.) Philadelphia, PA: F.A. Davis Company.
Your
Score:
General Patient Data (complete and appropriate to patient situation) Patient and
Family History and Physical Assessment: (thorough and appropriate to patient
situation)
1 Point
DSM-IV Axes from Chart (discuss DSM-IV criteria for each)
1 Point
Mental Status Exam
Assessment of Response to Negative Affect (anger/anxiety and stress) and
Patients Self Concept
Suicide & Homicide Assessment
8 Points
Medication Assessment
2 Points
1 Point
5 Points
2
3
4 Points
1 Point