psychiatric soap note

psychiatric  soap note

Discussion questions

Discussion Questions:

1. Because the patient’s reported hallucinations are not persecutory, as a clinician, what medications would you start with?

2. What treatments (pharmacological and non-pharmacological) are most effective for patients with extensive trauma history?

3. What symptoms could be co-occurring in relation to PTSD vs schizophrenia for this patient?

4. Define Schizophrenia and the symptoms related to schizophrenia?

Must have 2-3 reference for each questions listed above

mental health


Rasmussen University – Mental Health Care Plan

A. Patient identifiers:

Age: Gender: Ht: Wt. Code Status:

Isolation:

Development Stage (Erikson): Give the stage and rationale for your evaluation

Health Status

Date of admission:

Activity level: Diet:

Fall risk (indicate reason)

Client’s description of health status

Allergies: (include type of reaction)

Reason for admission:

Past medical history that relates to admission:

Socio-cultural Orientation

Cultural and Ethnic Background with current practices:

Socialization:

Family system: (Support system)

Spiritual:

Occupation: (across the lifespan)

Patterns of living: (define past and current)

Barriers to independent living:

Healthcare systems elements (continued) ALLERGIES:

Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.

DEFINE 1: What the medications Mechanism of Action AND 2: Why the patient is taking the medication?

Medication Classification Dosage Rationale Possible negative outcomes

Psychiatric Diagnosis and DSM 5 Diagnostic Criteria

History of Present Psychiatric Illness

(Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services)

CON
CEPT MAP

Pathophysiology – (to the cellular level)

Medical Diagnosis

Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)

Complications

Treatment (Medical, medications, intervention and supportive)

Risk Factors (chemical, environmental, psychological, physiological and genetic)

Nursing Diagnosis

Problem statement: (NANDA)

Related to: (What is happening in the body to cause the issue?)

Manifested by: (Specific symptoms)

General Appearance

Presenting Appearance (nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)
Basic Grooming and Hygiene (clean, disheveled and whether it is appropriate attire for the weather)

Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),
posture (slouched, erect),
any noticeable mannerisms or gestures

Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise)

Manner and Approach

Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)

Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing).
Coping and stress tolerance.

Speech (normal rate and volume, pressured, slow, loud, quiet, impoverished)

Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling)

Receptive Language (normal, able to comprehend questions,

Orientation, Alertness, and Thought Process

Recall and Memory (recalls recent and past events in their personal history).
Recalls three words (e.g., Cadillac, zebra, and purple)
Orientation (person, place, time, presidents, your name)

Alertness (sleepy, alert, dull and uninterested, highly distractible)
Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)

Concentration and Attention (naming the days of the week or months of the year in reverse order, spelling the word “world”, their own last name, or the ABC's backwards)

Thought Processes (loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).
Values and belief system

Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)

Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

Mood and Affect

Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry).
Affect or how they felt at a given moment (comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation.

Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)

Response to Failure on Test Items (unaware, frustrated, anxious, obsessed, unaffected)
Impulsivity (poor, effected by substance use)
Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)

Lab

Range

Value

Reason Obtained

Risk Assessment:

Suicidal and Homicidal Ideation

(ideation but no plan or intent, clear/unclear plan but no intent) Self-Injurious Behavior (cutting, burning) Hypersexual, Elopement, Non-adherence to treatment

Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program

Teaching Assessment and Client / Family Education:

(Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles

NRS DX:

Problem Statement:

R/T: (What is the cause of the symptom?)

Manifested by: (specific symptoms)

Short term goal: Create a SMART goal that relates to hospital stay.

Long term goal: Create a SMART goal that is appropriate for discharge.

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)

Was it met or not met there is no partially met.

References:

week 7

Our Struggle for Freedom, Civil Liberties And Political Equality

Discussion

Required Resources

Read/review the following resources for this activity:

· Textbook: Chapter 15, 16

· Lesson: Read this Week's Lesson which is located in the Modules tab.

· Initial Post: minimum of 2 scholarly sources (must include your textbook for one of the sources). Follow-Up Post: minimum of 1 scholarly source for your Follow-Up Post.

· Your Initial Post and your Follow-Up Post must be based on the same Option that you chose in order to receive credit for both posts. 

Initial Post Instructions

For the initial post, respond to one of the following options, and label the beginning of your post indicating either Option 1 or Option 2:

·
Option 1: The Equal Rights Amendment was first proposed almost a century ago and has still not been added to the United States Constitution. It is supposed to guarantee equal legal rights for all American citizens regardless of sex. It was first introduced to Congress by Alice Paul, leader of women's suffrage movement in 1923. Compare/contrast the Equal Rights Amendment with the Fourteenth Amendment. Did they deal with separate concepts? Explain your answer.

·
Option 2: The Bill of Rights is not only included with the United States Constitution but also state constitutions. All states have provisions in their constitutions that protect individual rights. Go online and look up your state constitution concerning amendments that are included in the Bill of Rights. How does your state constitution protect your individual rights?

Be sure to make connections between your ideas and conclusions and the research, concepts, terms, and theory we are discussing this week.

Writing Requirements

· Minimum of 2 posts (1 initial & 1 follow-up)

· Minimum of 2 sources cited (assigned readings/online lessons and an outside source) for your Initial Post, and 1 scholarly source for your Follow-Up Post.

· APA format for in-text citations and list of references

· Ebook:
https://bookshelf.vitalsource.com/reader/books/9780135246849/pageid/11

· The Struggle for Democracy, 2018 Elections and Updates Edition

· Or
manuela.ng13@gmail.com

· PWD: Bryanthierry@09

·

fundamentals M 5

Concept Map: Respiratory Process

Top of Form

Bottom of Form

Module 05 Content

1.

Top of Form

Complete the
ATI Systems Disorder template for your assigned respiratory topic. Every box on the template must be completed, a citation is needed for every box, and your reference list must be included (APA). 

MAT m6 diss

 

Initial Post: Toddlers have behavioral characteristics that often present challenging situations for parents and/or caregivers.

Describe challenges parents and/or caregivers would encounter with these specific characteristics.

  • Temperament
  • Nutritional Barriers
  • Hygiene,
  • Activity
  • Sleep

demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting

The purpose of this assessment is to demonstrate your understanding of and ability to analyze a root cause of a specific safety concern in a health care setting. You will create a plan to improve the safety of patients related to the concern of medication administration safety based on the results of your analysis, using the literature and professional best practices as well as the existing resources at your chosen health care setting to provide a rationale for your plan.

Use the Root-Cause Analysis and Improvement Plan [DOCX] Download Root-Cause Analysis and Improvement Plan [DOCX]template to help you to stay organized and concise. This will guide you step-by-step through the root cause analysis process.

Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score.

  • Analyze the root cause of a specific patient safety issue in an organization.
  • Apply evidence-based and best-practice strategies to address the safety issue.
  • Create a feasible, evidence-based safety improvement plan to address a specific patient safety issue.
  • Identify organizational resources that could be leveraged to improve your plan.
  • Communicate in writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Anemia

Create a discussion about anemia related to right sided colon cancer, What patient education would you provide for a patient recently diagnosed? what recommendations would you give him?  400 words and at least 2 scholarly references not older than 5 years. 

DIscussion asignment

 

Discuss the safety and effectiveness of alternative and complementary medicine for the treatment of specific

illnesses such as cancer, diabetes, and hypertension.  Share your opinions about holistic and allopathic care.

Would have any conflicts or concerns supporting a patient who chooses holistic or allopathic medicine?

500 words