Firelands Regional Medical Center School of Nursing

2012

Individual Client Profile

Student name: Samantha Paris	Date of assignment: 7/16/12-7/17/12

Admission Date: 7/15/12

Reason for admission: Depression

Stage of development (Erickson): Early Childhood (1-3 years)

Expected: Young Adult (20-30 years)

Actual: Early Childhood (1-3 years)- Patient is able to gain trust in a basic relationships upon meeting new people, however is unable to gain self control, and independence in the environment as evidenced by his consistent drug use following his past discharges, and his is unable to comply with his prescribed medication regimen, and re-admittance to the hospital within less than a week.

What defense mechanism(s) have you identified your client using to cope? Explain.

Rationalization: He states that the only reason he tried the drugs was due to the fact that his significant other was using as well. He seemed to make it sound like he seemed it was socially acceptable to have been using drugs at the time before he quit, making his issues seem ok in others eyes. He seemed to be misleading himself with these beliefs or ideas.

Devaluation: The client put everything regarding himself personally and the care from the facility into a negative manner. His negative comments show that he was trying to downplay his issues and make it seem like the supposed poor care he was receiving was making his care worse than it might have been. It also made it hard for him to participate in group due to this negative outlook on everything as did his negative self image.

How will this influence the care you provide your client? My client will admit to having a problem with drugs and was attempting to self medicate to “detox” from them. Considering his negative attitude about himself, the medication regimen, and the facility he was in I had to alter my approach with him. I tried to be a little more understanding of his feelings and attitude but also reminded him that he was the one to seek out our facility voluntarily, and that the medications are there to help him with his issues, rather than hurt him. He asked me the value of the different therapies, I explained that they are there both for support but to also help him find some coping mechanisms so that he does not end up back in the same situation that he was in. He stated that, “I just take the medicine because they make me.” I explained the medications are there to help him and not hurt him, but that if he was not happy on the medications he was on to tell his doctor this and that are many regimens they can find to work for him. He was open about his issues so he was able to explain feelings very well, but had a negative attitude about himself and the program so I tried to find a common ground and also to remind him to think about the positives about himself, such as the fact that he realized that he had a problem and came to seek treatment and what a good thing it was. He was pretty talkative and by keeping an open mind and constant reminding about coping mechanisms I was able to communicate and care for my client pretty easily.

Axis I

Major depressive disorder
Axis II

Personality disorder
Axis III

Seizures, cerebral palsy, muscular dystrophy, scoliosis, herpes, substance abuse- alcohol, cigarettes, cannabis sativa, methamphetamines, mushrooms, “popping whippets,” cocaine, Lysergic acid diethylamide (LSD)
Axis IV

Moderate- no support system, no high school education (dropped out as a junior), no housing (lives with family members in a reportedly abrupt environment, untreated mental illness, loss of job, substance abuse, lack of finances
Axis V

GAF 30
What are the major symptoms you have observed with this client? List.	Withdrawn, quiet but cooperative, avoidant, low body energy, depression, mood swings, “flat affect”, agitation

Describe any issues of co-morbidity that exist within this client’s profile.

Shuffling unsteady gait, deformed hands, stooped posture, pain due to musculoskeletal disorders reported as 7/10, muscle spasms, constant squirming and moving when sitting due to discomfort related to disorders, left sided weakness

Medications	List & research all medications on attached medication profile. (See attached medication profile).
What interventions are in place to provide a safe environment for this client?

Safety checks Q 15 mins

Fall precautions (bed in low position, falling star in place, proper footwear) AAT

Nursing 1:1 time Q once a shift (ensures patient safety, and allows patient to address concerns)

Therapy groups (group/ individual)

Quiet Room
Write one nursing diagnosis for the client’s priority Axis I Mental Health disorder, include defining characteristics.

Axis 1: Alteration in mood r/t feelings of inability to control feelings of hopelessness and helplessness AEB:

Reported increase of depression

Avoidant behavior

Agitation behavior

Mood swings

Withdrawn behavior

SI

(use NANDA approved diagnosis)

Write one nursing diagnosis for the client’s priority Axis III medical disorder, include defining characteristics.	Axis III: impaired physical mobility r/t disease process AEB:

Musculoskeletal pain reported 7/10 on verbal pain scale

Shuffling, unsteady gait

Stooped posture

History of falls

History of several musculoskeletal disorders

Muscle spasms

Left sided weakness

(use NANDA approved diagnosis)
Collaboration: Consult with at least one staff member about this client.

Answer the questions.

1. I spoke with: Dani, whose role is: Registered nurse

What two interventions are in place that will help this client succeed in their individual treatment plan? List those interventions.

Encourage compliance with medication regimen by discharge

Identify effective coping strategies by discharge

Do you agree or disagree with those interventions? Provide an explanation for your answer.

I agree with these interventions because they are two areas the client had addressed as problems he was having. The patient had voiced several concerns about the affect the medications were having on him. These concerns were addressed to the RN. He states that he was unable to follow the prescribed medication regimen due to the amount of pills, and the cost. Those facts alone contributed to his discontinuation of his prescribed medication regimen. Encouraging him to comply the regimen will help him to realize that taking the medications will reduce the issues that he his having, and with education will hopefully improve this, and cause him less problems. The client stated that the reason he was admitted back to the hospital was because he could not handle his at home environment, and felt out of control so he resorted to more substance abuse. Helping him identify effective coping strategies will assist him with finding ways to control his anger with something that calms him and makes him feel productive, and hopefully with proper education the patient will not resort to substance abuse, and will hopefully help him to seek assistance for his drug abuse issues through a program rather than through “on the street” methods. I also was able to consult with the case manager and ensure that he was able to get his appointment for his detox care. I needed to ensure this because this patient is trying to take a step towards being drug free. This is why I advocated for him.

Are there interventions being used to treat any medical illness?

If so, explain.

Fall precautions AAT

Safety checks Q 15 mins

Medications for pain management (i.e. gabapentin (Neurontin) for musculoskeletal disorders, and possible treatment for seizure disorder)

Quiet room
Goals:

Collaborate with the assigned client to develop one short and one long term goal for this hospitalization.

Short term goal: Compliance with medication regimen by discharge

- The patient was very worried about several of the side effects of the medications that he was on. He stated “ I don’t know why I take so many pills, they don’t always make me feel better, but I just take them to make the medical staff happy.” He was worried about being able to remember to take all the medications, and remembering what the side effects were and methods of management for them are. I assisted him in going over all of his medications via skyscape and he wrote down a plan to remember all his meds, and what each potential complication each medication had. This will hopefully assist him in taking his medications on time following the prescribed regimen, and help him gain better control over his illness and lifestyle.

Long term goal: No use of illegal or otherwise illicit substances by at least one year post discharge (clients choice of timing)

- The patient explained that he resorts to these substances when he feels out of control, but needs to stop using them because he wants to feel better, and address his responsibilities in life without feeling the need to rely on drugs. I assisted him with identifying possible methods of receiving treatments in the community, or addressing these concerns to the physician. He has a positive goal of reaching this and states that he has a doctors appointment to receive treatment for his cocaine abuse, which he made on his own outside of the hospital which shows that he is starting to take steps towards receiving the care and counseling required for treating addiction to substances.

Education needs:

Identify two (2) knowledge deficits on which you can provide client education.

Effective coping strategies by discharge

- The client states that when he feels out of control he turns towards substance abuse. He realizes that this is not an affective coping mechanism. I asked him about other methods of coping that he has tried. He focused a lot on being able to write things down, almost in a journal, and then also quiet time with music alone when he feels out of control. We worked to identify several positive coping methods for him such as the journal or just taking some alone time when he is in a state of anger.

Education regarding psychotropic medications by discharge

- He was worried about being able to remember to take all the medications, and remembering what the side effects were and methods of management for them are. I assisted him in going over all of his medications via skyscape and he wrote down a plan to remember all his meds, and what each potential complication each medication had. This will hopefully assist him in taking his medications on time following the prescribed regimen, and help him gain better control over his illness and lifestyle.

Client education

I taught this client about: Identifying effective coping methods- The client states that when he feels out of control he turns towards substance abuse. He realizes that this is not an affective coping mechanism. I asked him about other methods of coping that he has tried. He focused a lot on being able to write things down, almost in a journal, and then also quiet time with music alone when he feels out of control. We worked to identify several positive coping methods for him such as the journal or just taking some alone time when he is in a state of anger. We were able to make a list of things that he could try. I gave him a list of suggested coping strategies provided by the OT. He seemed very open to many of these options and suggestions.

Attach education material and list resources you used for client education? List from OT
Evaluation	Describe the client’s learning response:

The client had a very positive learning response and was able to verbalize understanding and interest in the topics discussed. He personally identified many things he could do to work on coping methods. He also was very receptive when I suggested that he always try to make a list of positive attributes about himself. He stated he felt that this would help him remember the positive things about himself, and ignore the things that send him into a depression.

Discharge Planning:

Identify two (2) resources you would need to help this client maintain optimal level of wellness after discharge.	1. Compass Corp. Community Recovery services- This is a community resource that provides care to all, for all kinds of drugs abuse, mental illness. They are local to his area, and meet his financial criteria, as they are largely funded by donations, and many of the workers are volunteers. He has easy access to this program.

2. Follow up appointments with Dr. Gupta post discharge- The client needs to have regular visits with his primary doctor to ensure medication compliance, and stability, and it can also help give the client a chance to address his drug dependency concerns with his doctor to monitor or assist him with methods to make progress in this area.

Concept Map	Attach a concept map related to the care needs of your client.
Other:

Include any other information pertinent to the care of this client

Firelands Regional Medical Center School of Nursing

Katheraine Vanderpool

2012-07-17

samantha paris

Firelands Regional Medical Center