Nurses Notes

Significant AMSIT data, relevant interview information, therapeutic interventions Day 1 Day

Pt. appears stated age of 50. He is thin, Phillipino-American male dressed in blue jeans and a blue t-shirt wearing blue socks. He is well groomed and gave obvious attention to hair. lient has neither increased or decreased ps!chomotor activit!. He generall! sits in a laid back posture with his hands together. "he client maintains good e!e contact. He is compliant and cooperative with the e#aminer. His speech is clear with an average rate, and a low tone. "he client$s mood is mildl! depressed as indicated b! a sad look on his face. His affect is appropriate earl! in the interview. %n the topic of suicidal thoughts he looks sad and uncomfortable. After the first &0 mins his affect changes to a more positive tone. 'ensorium is clear. He is correctl! oriented to month, da!, !ear, and his current situation. He remembers the ( of ( objects at the end of our (0 min conversation. He demonstrates ade)uate memor! as demonstrated b! his report of past events. He was not asked to do calculations. He demonstrates concentration b! maintaining the conversation. lient$s primar! language is *nglish. He was able to estimate the population of 'an Antonio at about &.5 million. His intellectual function is average to above average. He has a bachelor$s in computer science. lient$s thinking is coherent, logical, and goal directed. He doesn$t demonstrate blocking or flight of thoughts. His thoughts include negative feelings about his thoughts of suicide and negative feelings about the +stigma of a mental diagnosis,. -enies hallucinations. -enies delusions. He Acknowledges pas suicidal ideations but presentl! denies. lient demonstrates good judgment in response to what to do with a bab! on the doorstep. He seems to have insight into his bipolar disorder and is read! to seek effective treatment and

lients mood toda! is between euth!mic and mild! elated. He said her got +the best sleep he$s had in a long time,. He remembered our conversation from the other da!. . had also re)uested two more positive things about himself toda!. He said that he felt in control and calm. He seems a little more distracted toda!, but this could be due to having the interview held in the "/ room. *!e contact was less present toda!, and was directed at the "/ or looking down, however his affect is good and appropriate. Theraputic0 "oda! we focused on resources, teaching, and getting a plan of action for dealing with stressors and his 1ipolar disorder. . told the client about A 1ipolar support group that he could research online. www.dbsalliance.org . . encouraged him to at least look at the website and ma!be tr! finding a forum or discussion to get involved with if meeting in a group made him too an#ious. He had let me know that he likes to e#ercise regularl!. . discussed the importance or regular e#ercise and the positive effects it can have on managing stress. .n addition to thinking about two positive things about himself dail! . challenged him to write them down before he goes to sleep each night. "his would reinforce a more positive frame of mind. He also made a verbal contract that if he ever had suicidal thoughts again that he would seek help through his personal ps!chiatrist or at a hospital. . also told him that he could call the suicide hotline. . reinforced also that he is in control of his 1ipolar disorder and that his 1ipolar is not in control of him. "hat seemed to reall! get through to him. He verbali2ed interest in continuation of learning about his disorder and about his medication.

information. Theraputic0 3e discussed the importance of taking his medication consistentl!. He seemed to understand. 4pon further e#ploration of what brought him in he said the reason he was tr!ing to stop taking his medication is because he didn$t want the +stigma, of having a mental diagnosis. . reframed this negative thought b! letting him know that a mental diagnosis is no different than a medical diagnosis in that it is no respecter of person$s and that it re)uires proper treatment. He said that wasn$t getting the proper amount of sleep at home due to his wife$s snoring. . let him know the importance of sleep especiall! when it comes to the bodies stress response. He said that he was going to tr! sleeping in an upstairs room to get more sleep. He also said that his job was a source of stress in his life. 4pon further e#ploration he said that this was a new job with a lot more people to interact with, and he related to +being alone in a crowd of people,. . asked him to think of 5 positive traits about himself. He said that he was funn! and smart. . encouraged him to use those positive thoughts to replace negative thoughts that he would think of when interacting with new people.

Teaching provided! The importance of sleep, maintaining an effective medicinal regimen, the importance of e"ercise, dealing with stress in a healthy manner, #oining a support group, learning more a$out his diagnosis, handling the stress of meeting new people, and $eing in control of his diagnosis%

&valuation of effectiveness of teaching 'provide data(! )lient ver$ali*ed and understood teaching% He was especiall! interested in www.dbsalliance.org he said that he wanted to take a more active role in keeping his condition in check for himself and for his

famil!. He said that when he learned 1ipolar disorder was hereditar! that he also taught his children the importance of sharing their feelings, and to watch out for the signs and s!mptoms of bipolar. "his teaching was affective because he was able to give some signs and s!mptoms of 1ipolar disorder, and he had a basic grasp that it was related to chemical imbalances in the brain.
Summary of report to staff+instructor! Pt came in with 1ipolar disorder and suicidal ideation. "his was a result of the client cutting his medication dosage b! half because he +thought this was something he could get over6didn$t need help with,. 1eing admitted to the hospital was an e!e opener and he now understands the importance of maintaining his therapeutic regimen. "his includes dail! e#ercise, sleep, stress management, and a need for information related to 1ipolar. 3ith the therapeutic interventions done and the P" back to his normal dosage he is on the right track. &valuation of effectiveness of your communication 'provide data(! ,t was a$le to ver$ali*e signs and symptoms of $ipolar disorder ,t was a$le to come up with a way to get $etter sleep at night ,t was a$le to reframe the social stigma of his condition to a more positive regard of a medical diagnosis

-ther learning e"periences to support achievement of course o$#ectives! Day 1! Practice nursing in a caring, nonjudgmental, nondiscriminatory manner. It is not only important to practice this

objective, but I learned that it is important to show it. You have to reword questions so they dont sound so judgmental. For example instead o as!ing "why# as! "how is it that$# ,or "can you clari y this a little more or me#.
Day ! I as!ed the client about his culture and how it related to his situation. %e said that the phillipino culture is much li!e

the %ispanic culture in that mental&physical health issues are something that arent tal!ed about and can be construed as a sign o wea!ness. 'ypically the male is the head o the house this view is part o the reason or his caregiver role strain. 'his relates to the course objective o applying support according to culture.
.eferences!

/arcarolis, *li2abeth. Psychiatric Nursing Care Planning. 7th. 't. 8ouis0 'aunders *lsevier, 50&&. Print.