NURSING PROCESS RECORD
NUR 203
Psychiatric Nursing
In narrative form discuss:
Patient relevant past psychiatric history: patient is a 39 year old female with a history if psychosis, depression, and bipolar disease. She had two psychotic episodes, one 14 years ago and another one a year ago. She was admitted with diagnosis of psychosis and postpartum depression. When she was admitted she was violent and was hitting walls and doors causing her self trauma. She stated she feels tired, sleepy, and has muscle weakness. She stated that she doesn’t want to harm herself now. She stated that the reason she got depressed and had a psychotic episode is the birth of a baby girl (2.5 month prior to admission) and because she was “thinking too much.” She said she didn’t have problem raising her older children (teenagers now) because her parents were helping her. she moved to New York 10 years ago, her mother stayed in Chicago, her father passed away 6 years ago. She thinks that loose of support system caused the break down.
Behavior on admission, type of admission: on admission patient was violent hurting herself by hitting walls and doors. She has 3 wounds (on right arm and on both legs) that she acquired during violent outbreak. Her husband brought her to the hospital after she started getting violent at home. she was initially in 4 point restraint until she fell asleep.
support systems outside of hospital: she moved to New York 10 years ago, her mother stayed in Chicago, her father passed away 6 years ago. She thinks that loose of support system caused the break down. She stated it was hard to build new relationships and find new friends when she moved to New York. She stated her husband and 3 older children will be helping her take care of the baby.
social history/ support system: Patient lives at home with husband, 3 teenage children and a new born daughter. She works in nursing home as nursing assistant. And rebuild her network of friends that she lost after she moved.
medication history: Haldol 5 mg po at bedtime, Liquid Lithium 300 mg/5ml, 5ml po TID
discharge planning: patient was discharged on 11/26/08. She was going back home and her family will be helping her.
Nursing notes: Patient A&O X 3 . Calm, cooperative and sleepy. Mood- neutral. Denies desire to hurt self and others.. Patient compliant with medications. Appearance- hair is not combed clothes is dirty. Attended group activity on 11/25 but didn’t communicate a lot on 11/26, stated she is very sleepy. Ambulates at lib. Diet-normal. Safe and therapeutic environment maintained.
AXIS I-Primary psychiatric diagnosis
AXIS I- postpartum depression
AXIS II- Secondary psychiatric diagnosis
AXIS II- none


EXPECTED BEHAVIORS
ACTUAL BEHAVIORS
Appearance – lack of grooming. Appears tired
Appearance- hair is not combed, close is dirty, sitting with her eyes closed.
Motor behavior-slow, muscle weakness.
Motor behavior- passive, appears sleepy and complaints of muscle weakness
Mood- sad, fearful, euphoric, neutral, hopeless, adhendonia, angry, and irritable, frustrated
Mood- neutral

Affect-blunted or flat, withdrawn, anxious, negative
Affect- flat, indifferent.

Speech- slow speech, tone – normal, soft,
Speech- slow, soft

Perception-guilt, fear, hurt
Perception- fear of taking care of a baby by her self.
Thought content-negative thoughts, denial, unrealistic.
Thought content- denial.
Thought process- pessimistic
Thought process: illogical


Sensorium- normal

Sensorium- normal


Insight/ Judgment- relevant and appropriate
Insight/Judgment- poor understanding of cause of depression. Stated she was got depressed because she was thinking too much

Interpersonal behaviors-withdrawal,

Interpersonal behaviors- cooperative, calm
Hx. Suicide attempts/assaults- suicidal ideation, suicidal plan, suicidal method
Hx. Hurt self but stated that had no intentions to kill self. Threw her self at walls and doors causing bruising and abrasions on right arm and bilateral legs

NUTRITION WORKSHEET
NUR 203
1. Patient’s age – 39 years old , Gender-Female

2. Height - 5’7” , Weight 225 lb.

3. Ideal body weight for a person of this age, sex, and height( from the textbook)

35.2

4. Compare the patient’s actual weight to the ideal body weight and draw a conclusion- Patient is obese
Guide for BMI Evaluation-
The normal BMI for female with patient’s measurements is 20-25.
31-40- moderately to severely obese.
5. Identify any stressors that the patient has that might impact on the patient’s nutritional needs.
Recent birth of a child “has to eat for two”
Patient is an African American female
Patient stated she likes eating and she eats when she is sad
Medications: one of the side effects of Haldol is dry mouth. Lithium has a side effect of nausea/vomiting, dyseusia (taste distortion) salty taste, swollen lips, dental caries.


Medical history-psychosis, bipolar, depression recent child birth (2.5 month prior to admission.
Several studies have found weight to be linked with depression. Some patients experience weight loss, some may experience weight gain.
While researchers have found a connection between depression and weight gain, they have not been able to determine the direction of the connection .In other words, they have not been able to demonstrate that excess weight causes depression or that depression causes excess weight. Several theories , however, could support either direction. For example, depression could lead to excess weight because of overeating-using food as a comforting tool and because of less physical activity- feeling very tired and having no energy. On other hand , being obese could lead to depression. There is a stigma attached to being obese, which is often accompanied by of negative and hurtful comments.
Child birth can lead to weight gain. In many cultures it’s tought that the mother has to eat twice as much in order to have nutrients for the child to develp.
Psychosis can cause violent behavior and increased activity which requires more energy.
6. What adaptations does the patient exhibit indicating a nutritional problem (actual or potential)?
Patient’s BMI indicates that she is moderately obese
It can cause heart disease hypertension and increases chances of diabetes. Lab results indicate blood glucose level within a normal range, patient’s blood pressure was within a normal range on admission. Cholesterol level was not checked during this hospitalization. Although she doesn’t have diabetes and hypertension now, she has increased chance of getting it in the future.
7. How many calories is the patient receiving in a 24 hour period-
Calories count was not performed.

8. What type of hospital diet is your patient on, and what is provided on that diet?(Use nutritional manual)

Patient is on –normal diet. Patient had a lot of carbohydrates, fats and proteins during thanks giving lunch. She needs a decrease in caloric intake and low fat diet in order to loose weight. Eating fruits instead of juice and eating vegetables will benefit nutritional status by providing a low calorie snack as well as a lot of vitamins. Increasing amount of fiber in the diet will be beneficial as well. It will prevent constipation and help loose weight. Using Food Guide Pyramid will help balance diet for patients personal nutritional needs.
I f your patient is on a nutritional supplement, list 3 important ingredients that will help your patient- None
Evaluate patient’s actual % of intake.
100% of her meal. Plus frequent snacks
List specific nursing interventions including teaching to assist your patient to meet nutritional needs
Oral care is very important in nutrition. Lack of hygiene can cause taste disturbance. Due to side effects of medications patient is taking, she might have dry mouth, which will effect appetite.
Supplementing some foods for healthier alternative will help reduce weight. For example whole wheat bread will be healthier alternative to white bread. Fat free or 1% fat milk can also help reduce weight
Exercise help not only reduce weight, but will prevent heart disease as well. Developing muscles will increase metabolic rate.
DEVELOPMENTAL WORKSHEET
Nursing 203
1. Patient’s age and gender- Age-39 , Gender- F
2. Erickson’s stage for age of patient(theory)
Adulthood
3. Central tasks of #2
Generativity vs stagnation
4. Behaviors that indicate negative resolution of this Developmental phase (from Psych text). Self-indulgence, self concern, lack of interest and commitments
5. Developmental level at which your patient is functioning and adaptations which support the developmental level.
Adolescence: identity vs. role confusion. Plans to actualize self. Wants to go to college and become an LPN. Feeling of confusion and indecisiveness. Avoidance of life style commitments.
6. SPECIFIC nursing interventions to prevent regression/ to maintain present level of function( at least 5)
- Use therapeutic communication techniques. Show empathy and real concern
- Advise the patient to comply with meds and group therapy during and after discharge
-Encourage the patient to be actively involved in planning her social life outside the hospital
-Encourage the patient to explore her feelings about her family
# Priority – 1

Nursing Problem Statement:
Risk for violence self directed related to disturbed thought process secondary to psychosis.
Short term goal: patient will not hurt self while in my care

Long term goal : patient will not have another violent outbreak for 10 years as evidence by patients report.

NSG. INTERVATIONS(in priority order)
RATIONALE
EVALUATION
1.Put 4 point restrain during violent outbreak

2. administer Haldol 5 mg po at bedtime

3.Administer Liquid Lithium 300 mg/5ml, 5ml po TID

4. Remain calm

5. do not approach a violent individual alone

6.reduse noise

7 . remove individual from situation if environment is contributing aggressive behavior

1. 4 point restraint is not allowing patient hurt self, restraining patient when patient is not violent will limit freedom and is unnecessary.

2. Haldol is a dopaminergic blocker and an antipsychotic.

3. Lithium is an antimanic medication, given to treat manic episodes of bipolar disorder. During manic episodes patient can harm self. Perception of own abilities might be distorted during such episodes, which can lead to self harm

4. patient can feel when others are anxious and might become more anxious. This can lead to more violent outbreaks.

5. presence of three or four staff members will be enough to reassure the individual that you will not let him or her lose control.

6. quite environment reduces agitation.

7 anxiety can be contagious and can lead to violence

1 patient didn’t have violent outbreaks while in my care. She was put in 4 point restrain during first day of hospitalization. After being restrained for a few hours she fell asleep and restraints were removed. Patient bruised arm and both legs before restraints were used. Skin break down was minimum.

2. patient didn’t have psychotic episodes after she started taking Haldol. Medication caused some side effects such as dry mouth, drowsiness, insomnia, headache, weakness. Patient understood the need to take them and said that these medication helps her.

3. patient stated she is taking this medication because it helps her. she did however say she doesn’t get manic. She just gets sad and starts hitting walls when she thinks too much. Patient had muscle weakness which is be a side effect of this medication.

4. patient remained calm while in my care. She stated she is not anxious and is happy she can go home.

5. patient didn’t have violent outbreaks while in my care.

6. patient didn’t have TV in her room. although she was shearing room with others, her roommates were sitting in front of a nurses station. Patient was able to stay in her room by herself. She remained calm while in my care.

7. patient went to her room when another patient started shouting. She was aware of her own level of agitation and knew that hearing others scream will get make her more anxious and agitated. She wanted to stay calm so she would go home.

# Priority – 2
Risk for Impaired parenting related to interruption of bounding process secondary to postpartum depression.
Short term goal: patient will acknowledge a problem with parenting skills
Long term goal: patient will not neglect or abuse her new born daughter as evidence by patient’s husband’s report.
Nsg. Interventions ( in priority order)

RATIONALE
EVALUATION
1. Establish rapport

2. provide information about age-related developmental needs.

3.teach relaxation techniques

4.Assess support system.

5. allow to express feelings about infant and provide an atmosphere of acceptance

6.encourage parent to meet basic self-needs

1. It is a process of establishing good will and trust.

2. athough patient already has 3 children, there is a 14 year gap between this child and the second youngest. patient was also helped to raise her three children by her mother. She is raising this child without strong support system she had before. If parent doesn’t know what is normal for a child, the parent may have unrealistic expectation for him or her.

3.relaxaton techniques help prevent psychotic episodes and depression which effects child-parent relationships.

4.Family and friends can help take care of the child as well as help to cope with depression.

5. it is normal for a parent to have negative feelings about a child, underlying feelings must be recognized.

6.it is exhausting to care for a child. A parent who is not meeting his or her own needs of rest, nutrition, and hygiene will ne ineffective in carring for the child

1. rapport was established, patient felt comfortable talking to me.

2. patient is aware of developmental mile stones, however she needed more information on age-specific care. After information was provided, she was able to explain why child needs to be bathed frequently and fed every 2 hours. She stated that because of increased rate of fluid exchange, infants have to consume liquids more often then adults.

3. Patient stated she will try guided imagery at home, said she is too sleepy to do it in the hospital

4. Patient stated she was helped by her parents to raise children in the past, however she is now living away from her mother. She stated that her husband and older children will be helping her raise the youngest child.

5. Patient didn’t want to talk about problems she encountered with this infant. She said that she loves her daughter and that children are fun and cute. She stated this is the first time she is raising a child without help of her parents.

6. Patient stated she will try to relax more. She said she will try to sleep more as well.

#Priority – 3

Sleep deprivation related to frequent awakening secondary to depression ans a new born child.
Short term goal :Patient will report sleeping at least 7 hours without waking up while in my care
Long term goal: patient will report an optimal balance of rest and activity a year after discharge.
Nursing interventions
Rationale
Evaluation

1. Reduce noise at night

2. Limit caffeine intake

3. limit day time napping

4. increase physical activity (not prior to bedtime)

5. bedtime routines

6. set a relaxing routine to prepare for sleep (e.g., herbal tea, warm bath)

7. limit alcohol intake

1. Noise interrupts sleep

2. Caffeine is a stimulant and will keep patient awake, interrupting sleep cycle

3. Day time napping can disrupt sleep cycle.

4. Physical activity prior to sleep will over excite patient and will not allow for proper sleep, physical activity during the day however can improve sleep.

5. Bed time routine helps regulate sleep cycle.

6. Relaxation prior to sleep allows falling asleep easier.

7. Alcohol intake can cause nightmares and frequent awakening

1. Patient stated that it is usually quiet at night in the hospital, only sometimes she can hear other patients talking. At home she can not sleep all night because the child wakes her up at least once a night

2. Patient didn’t drink beverages containing caffeine during hospitalization. She stated she will not drink caffeine containing beverages after discharge.

3. Patient was very sleepy due to lack of sleep and side effects of medications. She fell asleep in front of nursing station, however was unable to stay asleep for ore then 10 minutes. She didn’t nap after that.

4. Patient was helping prepare tables for thanks giving lunch and was walking around the unit. She was more awake after helping set tables.

5. Patient stated she was going to sleep at the same time during hospitalization. She stated she will try to keep the same schedule after discharge. She reported understanding that reading, watching TV and other activities should not be performed in bed. She stated that she will sleep in bed and if she cannot fall asleep, she will get up and try again later.

6. Patient stated she will try to take baths after discharge.

7. Patient stated she will not drink alcohol until her daughter is at least one year old and can