Name: Thomas Sykes Gender: Male Age: 17 Marital Status: Single Weight: 240 pounds (108.86kg) Height: 5 ft 11 inches (71 inches) Occupation: High School Student Address: New York, USA Race: African American Religion: Baptist Allergies: None Known Immunizations: Up to date Major Support Name: Keisha Sykes, age 31 Relationship: Sister Phone: 577-666-7890 Attending Provider/Team: Susan Henretty, DNP, CRNP, PPCNP-BC Past Medical History: Significant for chronic obesity. History of Present Illness: Thomas was recently admitted to an inpatient psychiatric program for suicidal ideation. He has undergone group therapy, individual therapy, and is taking an SSRI antidepressant medication (escitalopram). Social History: Thomas lives with his sister, Keisha, and her 3-year-old son Torrey. Keisha has been Thomas’ legal guardian since their mother passed-away 10 years ago from complications associated with uncontrolled diabetes and obesity. Thomas’ father is not involved in his life. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Last year, Thomas was in his junior year of high school and had been planning to graduate with his classmates, so the move for Keisha’s work has been difficult for him. Thomas has not made friends at his new school and spends most of his time alone playing video games or watching television with Torrey. Primary Medical Diagnosis: Obesity and depression. Surgeries/Procedures & Dates: No previous surgeries. SBAR Report: Person providing report: Nurse completing the day shift Situation: 17-year-old male seen yesterday by his pediatric nurse practitioner (PNP) who determined that Thomas was a risk to himself and had him admitted for inpatient psychiatric evaluation. Background: Thomas Sykes is a 17-year-old male who lives in an inner-city apartment with his sister Keisha and Keisha’s 3-year-old son, Torrey. Thomas’ father is not involved in his life and his mother passed away about 10 years ago from complications associated with uncontrolled diabetes and obesity. Following his Mother’s death, Thomas moved in with Keisha, and she became his legal guardian. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant packaging batteries. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Thomas has been overweight for most of his life, but over the past year, he has gained 60 pounds and currently weighs 240 pounds. With a height of 5 feet, 11 inches, Thomas is obese, with a BMI of 33.5. Last year, Thomas was in his junior year of high school and had been planning to graduate with his classmates, so the move for Keisha’s work has been hard. Thomas has not made friends at his new school and spends most of his time alone playing video games or watching television with Torrey. He has also been skipping school up to three times a week and doesn’t want to leave the apartment. Yesterday, Thomas was seen by the PNP and completed the Columbia-Suicide Severity Rating Scale. He identified suicide intent with a specific plan. He was admitted late yesterday and put on suicidal precautions. He is at his first group therapy meeting right now. Assessment: Obesity and depression What other members of the care team should be considered important to achieving good care outcomes?
Name: Thomas Sykes
Gender: Male
Age: 17
Marital Status: Single
Weight: 240 pounds (108.86kg)
Height: 5 ft 11 inches (71 inches)
Occupation: High School Student
Address: New York, USA
Race: African American
Religion: Baptist
Allergies: None Known
Immunizations: Up to date
Major Support
Name: Keisha Sykes, age 31
Relationship: Sister
Phone: 577-666-7890
Attending Provider/Team: Susan Henretty, DNP, CRNP, PPCNP-BC
Past Medical History: Significant for chronic obesity.
History of Present Illness: Thomas was recently admitted to an inpatient psychiatric program for suicidal ideation. He has undergone group therapy, individual therapy, and is taking an SSRI antidepressant medication (escitalopram).
Social History: Thomas lives with his sister, Keisha, and her 3-year-old son Torrey. Keisha has been Thomas’ legal guardian since their mother passed-away 10 years ago from complications associated with uncontrolled diabetes and obesity. Thomas’ father is not involved in his life. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Last year, Thomas was in his junior year of high school and had been planning to graduate with his classmates, so the move for Keisha’s work has been difficult for him. Thomas has not made friends at his new school and spends most of his time alone playing video games or watching television with Torrey.
Primary Medical Diagnosis: Obesity and depression.
Surgeries/Procedures & Dates: No previous surgeries.
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SBAR Report: Person providing report: |
Nurse completing the day shift |
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Situation: |
17-year-old male seen yesterday by his pediatric nurse practitioner (PNP) who determined that Thomas was a risk to himself and had him admitted for inpatient psychiatric evaluation. |
|
Background: |
Thomas Sykes is a 17-year-old male who lives in an inner-city apartment with his sister Keisha and Keisha’s 3-year-old son, Torrey. Thomas’ father is not involved in his life and his mother passed away about 10 years ago from complications associated with uncontrolled diabetes and obesity. Following his Mother’s death, Thomas moved in with Keisha, and she became his legal guardian. About a year ago, Keisha, Thomas, and Torrey moved for Keisha’s new job in the local battery plant packaging batteries. Her shifts rotate between days and evenings, requiring Thomas to care for Torrey when Keisha has to work the evening shift. Thomas has been overweight for most of his life, but over the past year, he has gained 60 pounds and currently weighs 240 pounds. With a height of 5 feet, 11 inches, Thomas is obese, with a BMI of 33.5. Last year, Thomas was in his junior year of high school and had been planning to graduate with his classmates, so the move for Keisha’s work has been hard. Thomas has not made friends at his new school and spends most of his time alone playing video games or watching television with Torrey. He has also been skipping school up to three times a week and doesn’t want to leave the apartment. Yesterday, Thomas was seen by the PNP and completed the Columbia-Suicide Severity Rating Scale. He identified suicide intent with a specific plan. He was admitted late yesterday and put on suicidal precautions. He is at his first group therapy meeting right now. |
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Assessment: |
Obesity and depression |
What other members of the care team should be considered important to achieving good care outcomes?
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