Reflective Journal
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School
Galen College of Nursing *
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Course
4405
Subject
Health Science
Date
Dec 6, 2023
Type
Pages
4
Uploaded by CommodoreRavenMaster128
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Reflective Journal
Robert Pagniozzi
12/02/2023
0423 NSG 3450 - 01D01 Nsg Prac-Mental Hlth
Courtney Gamble
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Patient Assessment Narrative
Today, I felt my greatest accomplishment was being able to successfully communicate
with my patient as well as perform a mental status exam. During my assessment, I had to
determine my patient’s mental status by asking different questions as well as focusing on my
patient’s body language and demeanor. The patient is a fifty-year-old male who presented to the
brook with depression, psychosis, suicidal ideation, & methamphetamine dependence. The
patient has a past medical history of alcohol abuse, depressive disorder, drug-seeking behaviors,
hepatitis c, heroin dependence, hypertension, methamphetamine abuse, opioid dependence,
PTSD, and recurrent major depressive episodes. The patient also stated that they killed Osama
bin Ladin as well as stated that they served. After reading into his chart we were able to see that
he was a coast guard who was medically discharged due to using drugs while serving. This
patient correlates with my clinical focus since we are learning about how to perform a mental
status exam as well as different techniques for therapeutic communication, such as giving broad
openings to allow the patient to take the initiative in introducing the topic.
Nursing process
Based upon my clinical experience after assessing the patient, I was able to diagnose the
patient with ineffective coping R/T depression and a history of trauma as evidenced by
“self-medicating” with substances and planning suicide. The patient stated that they do think
about killing themselves and that he self-medicates not to feel everything going on in his life.
One policy that we have in place is suicide precautions. These are continuous interventions
aimed at providing a safe environment for patients identified as exhibiting suicidal behavior or
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ideations. A few interventions for this patient would be to evaluate and educate the coping skills
of the patient. Educate and assess triggers, stressors, signs, and symptoms of depression. As well
as educate and encourage health maintenance with self-care.
Clinical Experience
Today in clinical I was able to do a mental status exam which was challenging but was a
great lesson to learn from. In our theory class, we have been going over how to communicate
with a patient when asking if the person is suicidal or has attempted suicide. This can be a very
touchy subject and it is important to think before asking a question and let the patient guide the
conversation while communicating therapeutically. Going onto the floor I did not know what to
expect and was a little anxious, but after sitting down with the patient I felt more comfortable
and I would say the patient felt comfortable as well.
Communication & Diversity
While talking with the patient I was able to identify a few different therapeutic
communication techniques that I used. The first thing I did was offer myself by telling the patient
I will sit with you for a while, and when we finish talking, I will come back and see how you are
doing. This tends to help build a nurse-patient relationship and build trust. I also used broad
openings, which allows the patient to take the initiative in introducing the topic, such as asking
the patient “What are you thinking about?”. During times I also used silence because my patient
was pressured to speak. The patient was telling me his entire life story without me even having to
ask questions which was great because he was taking the initiative in guiding the conversation.
The patient is a thirty-six-year-old male who is homeless and grew up in a drug-induced
environment. Nurses should be aware of the situation of drug dependence and that the patient has
been around different drugs his entire life.
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Personal Growth
Today I was able to continue improving my communication skills as well as improving
my performance on a mental status exam. After this experience, I learned that in my future
nursing practice sometimes staying quiet and letting the patient just express everything to you is
the best way to gather information while asking questions as well. In the future, with this
information I have received I will be able to effectively communicate with my patient better by
letting the patient guide the conversation if they feel they can. Also being able to determine the
best diagnosis and interventions that would best suit the person.