MH Process Recording Assignment

docx

School

Tukkar School Of Nurisng , Belgaum *

*We aren’t endorsed by this school

Course

2092

Subject

Nursing

Date

Nov 24, 2024

Type

docx

Pages

Uploaded by GrandBookBeaver33

MH Process Recording Assignment University/ College Or School Nursing Name of the Professor December 4, 2023

MH Process Recording Assignment Client’s Initials: J.T. Date of Interaction: December 4, 2023 ASSESSMENT: Background Information: J.T. is a 26-year-old female with a history of depression, anxiety, and substance abuse. She presented to the unit due to worsening suicidal ideation and depression following the completion of a Partial Hospitalization Program (PHP) a week prior. Upon admission, she reported active suicidal ideation with a plan to overdose on heroin. J.T. has a known history of medication allergies to ketorolac, morphine, and nalbuphine. She is currently prescribed Effexor (venlafaxine), Xanax (alprazolam), and Seroquel (quetiapine). Medications: 1. Effexor (Venlafaxine): Dosage: 75mg, Frequency: Daily, Route: By mouth (PO), Indication: Major depression (Schneider et al., 2020). This medication works by Inhibiting the reuptake of serotonin and norepinephrine. Side effects: Common side effects include nausea, drowsiness, dizziness, dry mouth, constipation, loss of appetite, and raised blood pressure. Severe adverse effects include worsening mood, serotonin syndrome, blurred vision, seizures, trouble breathing, and easy bruising or bleeding. Assessment findings: The client appeared thin, potentially due to a side effect of loss of appetite.

2. Xanax (Alprazolam): Dosage: 1mg, Frequency: PRN, Route: By mouth (PO), Indication: Needed anxiety. It binds to GABA receptors in the brain (Schneider et al., 2020). Side effects: Common side effects include light-headedness, increased saliva production, drowsiness, and change in sex drive. Severe adverse effects include yellowing of the skin or eyes, trouble speaking, seizures, memory loss, and thoughts of suicide. Assessment findings: No observed effects as the patient reported not taking Xanax the night prior. 3. Seroquel (Quetiapine): Dosage: 0.5-1 tab, Frequency: PRN at bedtime, Route: By mouth (PO), Indication: Anxiety and depression as needed. It causes a rapid dissociation from D2 receptors in the brain (Schneider et al., 2020). Side effects: Common side effects include constipation, drowsiness, upset stomach, weight gain, and dry mouth. Severe adverse effects can include tremors, mood swings, restlessness, persistent nausea and vomiting, or abdominal pain. Assessment findings: No observed effects supporting this medication. Chart notes mention constipation, a side effect of Seroquel, and Effexor. Assess Myself: It was a challenging day at the unit, given the severity of J.T.'s condition. I approached the day with a focused mindset, recognizing the importance of empathy and active listening. The gravity of J.T.'s situation required a delicate balance of support and observation. As a student, I was prepared to learn from the experienced staff and contribute to J.T.'s care in any way possible.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

Assess Milieu: The unit had a mix of patients dealing with various mental health challenges. Some engaged in group activities and discussions, while others preferred solitude. J.T. appeared withdrawn, sitting quietly and avoiding interaction with other patients. The atmosphere was tense, with staff members actively involved in monitoring and supporting the diverse needs of the individuals on the unit. It was evident that creating a safe and supportive environment was crucial for J.T.'s well-being. DIAGNOSIS: Nursing Diagnosis: Risk for self-harm related to severe depression, active suicidal ideation, and substance abuse (Ernstmeyer & Christman, 2022). PLANNING:  Tentative Goal of the TC: J.T. will experience a reduction in suicidal ideation, actively engage in therapy, and adhere to medication regimen. The patient will identify at least three coping strategies for managing anxiety and depression (Ernstmeyer & Christman, 2022). By the end of the TC, J.T. will demonstrate an understanding of the importance of medication compliance and its role in her treatment plan.  By Completion of the TC, the Patient will: 1. Articulate factors contributing to worsening SI. 2. Identify and practice three coping strategies for managing anxiety and depression. 3. Verbalize understanding of the importance of medication compliance and potential side effects.

IMPLEMENTATION: Nurse Communication (or Student Nurse Communication) Patient Communication Analysis of Process Therapeutic Technique "Good afternoon. My name is Sarah, and I'm a nursing student working with the team here and would like toobserve and note some things from you” Nods, "Afternoon. My name is J.T.” I noted J.T.'s willingness to engage in conversation, acknowledging her recent challenges. Using a broad opening to initiate dialogue and establish rapport. “How are you feeling today?" “ Not great, honestly. It's been a tough week." She seemed depressed so I wanted to find out from her how she was feeling. Exploring “How long “2 days” Inquiring to know Exploring

have you been here?” whether she has experienced any progress during the duration of her “How did you sleep last night?” “Eh, okay. It can be loud out here until like midnight.” Accepts contract, eye contact indicates a willingness to engage. Beginning with general questions. “Do you usually have trouble falling asleep?” Not quite. I desire the option to have a cigarette to aid in my sleep, but they provide me with nicotine gum and patches instead. Kept switching topics to nicotine use. Exploring “Do you mind me asking what your diagnoses are?” “That’s fine, I have depression, PTSD, anxiety and borderline.” Accepts the question, and provides information. Information Gathering “Do you find that any one of those in particular gives you “Eh, I don’t know. They are kind of go together don’t they? When I get sad I J.T provides information, She once again brings Exploration (Exploring the severity of her diagnoses.)

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

the most trouble?” guess it’s everything playing together. But the drugs help, I drink too sometimes.” up indulging as a coping skill. “Recreational drugs?” “Yeah” Acknowledging Information seeking and clarification "I understand that. Substance use is prevalent among individuals dealing with PTSD and depression as it provides an escape. However, relying on drugs is not the optimal coping strategy, as they can potentially alter the chemistry of your brain." Silence I believe she was taken by surprise by my response and appeared unsure of how to react or what to say next. Educating the patient / giving information. "I appreciate you sharing that. I know "Just a lot of dark thoughts, you J.T. expressed difficulty Offering an open- ended question to

it's not easy. Can you tell me more about what's been on your mind lately?" know? It's hard to explain." articulating her thoughts, indicating the complexity of her emotions. encourage expression of feelings. "I'm here to listen and support you. Let's talk about the thoughts you mentioned. Can you describe them a bit more?" "It's like this weight on my chest, and I can't shake the feeling that things won't get better." J.T. used a metaphor to convey her emotional burden, providing insight into her feelings of hopelessness. Encouraging exploration of emotions through metaphors, allowing for deeper understanding. "I understand this is incredibly challenging. You mentioned a plan involving heroin. Can we discuss what led to that specific plan?" "It just seems like the only way to stop the pain. I don't know what else to do." J.T. expressed a sense of desperation and a lack of alternative coping mechanisms. Employing a focused question to address specific details of the suicidal plan. "I'm really sorry to hear you're feeling this way. Let's work together to ensure "I don't know if it'll help, but I'm willing to try anything at J.T. showed openness to collaboration, indicating a Collaboratively developing a safety plan to empower the patient and enhance

your safety. Can we create a safety plan with strategies for when these thoughts arise?" this point." potential for engagement in therapeutic interventions. coping skills. "In addition to our sessions, it might be beneficial to identify individuals in your support network. Who are some people you feel comfortable reaching out to during difficult times?" "I guess I have my sister and a close friend. They might understand." J.T. identified potential support, demonstrating a willingness to involve others in her care. Incorporating the patient's existing relationships into the support network for enhanced resilience. "Thank you for sharing that, J.T. It's crucial that we continue these conversations. If you ever need to talk, I'm here. Let's keep working "I appreciate that. It means more than you know." J.T. expressed gratitude, indicating a positive impact of the conversation on her emotional state. Concluding with reassurance and encouragement for ongoing communication.

Your preview ends here

Eager to read complete document? Join bartleby learn and gain access to the full version

Access to all documents
Unlimited textbook solutions
24/7 expert homework help

towards your well- being." EVALUATION: Strengths and Weaknesses of the Interaction: The interaction with J.T. had notable strengths and some identified areas for improvement. J.T. demonstrated a willingness to engage in conversation and shared her struggles openly. The use of open-ended questions allowed for exploration of her emotions, and she expressed gratitude for the support. However, there was a challenge in getting J.T. to articulate specific details about her suicidal plan, highlighting the complexity of her thoughts. Therefore, Further exploration into this area may be necessary to enhance the risk assessment and safety planning. However, the conversation maintained a nonjudgmental and empathetic tone, fostering a sense of trust. Outcomes of the Session: During the session, J.T. revealed a history of major depression exacerbated by the recent completion of a Partial Hospitalization Program (PHP). Her suicidal ideation was associated with feelings of hopelessness and a specific plan involving heroin. While J.T. acknowledged the lack of family support and occasional conflict with her mother, she expressed a desire for help to overcome her struggles. The session concluded with J.T. recognizing the need for improvement in her life, particularly to return to school and become a better version of herself. This acknowledgment signifies a potential for collaboration in her treatment and a glimpse of hope amid the challenges. References

Ernstmeyer, K., & Christman, E. (2022). Table 4.6, [Sample Nursing Interventions for Risk for Suicide]. Www.ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK590042/table/ch4planning.T.sample_nursing_interven tio/ Satinsky, E. N., Kimura, T., Kiang, M. V., Abebe, R., Cunningham, S., Lee, H., Lin, X., Liu, C. H., Rudan, I., Sen, S., Tomlinson, M., Yaver, M., & Tsai, A. C. (2021). Systematic review and meta- analysis of depression, anxiety, and suicidal ideation among Ph.D. students. Scientific Reports , 11 (1). https://doi.org/10.1038/s41598-021-93687-7 Schneider, R. A., Chen, S. Y., Lungu, A., & Grasso, J. R. (2020). Treating suicidal ideation in the context of depression. BMC Psychiatry , 20 (1). https://doi.org/10.1186/s12888-020-02894-5

MH Process Recording Assignment

Related Documents