SW 607 – Psychopathology Mental Status Exam Report Format (50 points total) Student Name Nadia Telfort Client Name Client/Patient-resident I. General Description Client is a 78-year-old Haitian Creole-speaking male with a history of diabetes, edema, hypertension and seizures. Client was treated for respiratory failure at an inpatient hospital facility. Client was transferred from the inpatient hospital facility to Miami Jewish Health Systems for inpatient short-term care rehabilitation. Client appears average height, slender and weighs approximately 178 lbs. Client has a clean-shaven head, facial stubble, and appears to be stated age. Client is dressed in a hospital gown, with normal grooming and hygiene. Client appears relaxed …show more content…
Client is fully aware that completion of the assigned therapy program is strongly encouraged to be released from skilled nursing with a low possibility for retention or return. He presented with mild cognitive impairment and respiratory failure. Client demonstrated an adequate understanding of his condition and treatment recommendations. Client identified his older sister, niece and daughter as primary caregivers and supporters in case of financial or medical emergency. Client noted older sister as most significantly attentive to his needs. A care plan meeting was scheduled to meet with members of his immediate support system. Client medication upkeep will be closely and frequently monitored as he is on serious life sustaining medicines which need to be administered in a timely manner. Frequent rounds to client room, and follow-up assessments will be conducted and documented to track progress of respiratory rehabilitation. Rehabilitation will include nutritional, recreational, basic breathing and exercise training, specialized care targeting acute care needs. Client is new to the older adult living community therefore care planning will also include and attend to acclimation to daily living at a skilled nursing
Long-term care (LTC) covers a wide range of clinical and social services for those who need assistance due to functional limitations. These limitations usually result from complications associated with age related chronic conditions, from disabilities related to birth defects, brain damage, or mental retardation in children; or from major illnesses or injuries suffered by adults (Shi L. & Singh D.A., 2011). LTC encompasses a variety of services including traditional clinical services, social services and housing. Unlike acute care, long-term care is much more complicated and has objectives that are much harder to measure. Acute care mainly focuses on returning patients to their previous functional level and is primarily provided by specialty providers. However, LTC mainly focuses on preventing the physical and mental deterioration of an individual and promoting social adjustments to suit the different stages of decline. In addition the providers of LTC are more diverse than those in acute care and is offered in both formal and informal settings, which include: hospitals, physicians, home care, adult day care, nursing home care, assisted living and even informal caregivers such as friends and family members. Long-term care services have been dominated by community based services, which include informal care (86%, about 10 to 11 million) and formal institutional care delivered in nursing facilities (14%, 1.6 million) (McCall, 2001). Of more than the 10 million Americans estimated to require LTC services, 58% are elderly and 42% are under the age of 65 (Shi L. & Singh D.A., 2011). The users of LTC are either frail elderly or disabled and because of the specific care needs of this population, the care varies based on an indiv...
Based on http://www.austincc.edu/adnlev1/rnsg1161online/clinical_homework_samples/Nursing_care_plan_sample.htm column one: nursing diagnosis; column two: the expected outcome and goal of what you would like to see from the patient after a specific time frame; column three: interventions; (column four: scientific rationale for each intervention)
There are six set standards of the nursing practice; assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ANA, 2010; pp. 9-10). Throughout a typical shift on the unit I work for, I have set tasks I am expected to complete in order to progress the patient’s care, and to keep the patient safe. I begin my shift by completing my initial assessment on my patient. During this time, I am getting to know my patient and assessing if there are any new issues that need my immediate intervention. From here, I am able to discuss appropriate goals for the day with my patient. This may come in the form of increasing mobility by walking around the unit, decreasing pain, or simply taking a bath. Next, I plan when and how these tasks will be able to be done, and coordinate care with the appropriate members of the team; such as, nursing assistants and physical therapists. Evaluating the patient after any intervention assists in discovering what works and what does not for the individual. “The nursing process in practice is not linear as often conceptualized, with a feedback loop from evaluation to assessment. Rather, it relies heavily on the bi-directional feedback loop...
Generally, in a LTC setting there is a director, assistant director, physician, pharmacist, nurses, medication aides, certified nursing assistants, case managers, social workers, and clergy. These individuals are tasked with providing a daily health plan for long-term care residents 24 hours a day, seven days a week. This group could consist of less or more healthcare associates which is conditional and determined by the goal plan; moreover, the intended outcome not solely geared towards physical rehabilitation. In modern society, rehabilitation is targeted to restore mind, body and soul thereby promoting the overall health of the patient, or
Nursing assistants work in many types of settings including nursing homes, hospice, mental health centers, assisted living residences, home care agencies, hospitals, rehabilitation and restorative care facilities (Sorrentuino & Remmert, 2012). There are many types of Long-term care centers. For this paper, I will focus on the long-term care centers often referred to as nursing homes. These LTCs are "licensed facilities that provide extended care for individuals who do not require the acute care provided in a hospital but who need more care than can be given at home" (U.S Department of Health And Human...
Assessment instruments are a critical component in psychological testing. Clinicians use psychological assessments as a process of testing individuals to generate a hypothesis about their behavior, personality, or capabilities. There are four primary types of psychological assessments including, clinical interviews, assessment of intellectual functioning, personality assessment, and behavioral assessments. In addition, other types of psychological testing can include, achievement, aptitude, neuropsychological, occupational, and specific clinical test that can measure current levels of depression or anxiety. For example, the assessment instrument called the Beck Depression Inventory (BDI), measures characteristic attitudes
...rcise, social activity, and proper nutrition are important in keeping the patient healthy as well. Any steps toward producing a calm, safe, and well-structured environment may help the patient. Helping the patient and the family with the legal aspects, supporting the family through care giving, and assisting with decisions about long-term care placement are also crucial to help the patient.
Most long-term care facilities have a nice, caring environment. Most facilities have exceptionally trained personnel caring for that family member’s needs and concerns. Being within the nursing field one notices the morale and the health of these forgotten individuals declining rapidly with no family bonds to connect to anymore. The nursing staff and facilities members, attempt to replace the bonds lost between resident and family. The bonds formed with staff and resident, are not equal to seeing a grandchild at holidays, and being included at that special family reunion. It is understandable some family units don t carry the tight connections other ily units share. Family support systems most require on admittance to semiprivate, busy nursing home settings are lost. Surroundings of this...
Therapeutic nurse-patient relationships lay the groundwork for successful care and rehabilitation of a patient in any setting. Whether the patient is in a nursing home, hospital, or receiving home care, a therapeutic nurse-patient relationship is vital to the care of the patient. A therapeutic nurse-patient relationship can be defined as a professional relationship between the nurse and the patient that, “focuses on the client, is goal directed, and has defined parameters” (Craven & Hirnle, 2009, p. 329).
The nursing profession consist of different workflow designs to provide the appropriate care to our patient population. “Nursing models of care are developed to identify and describe nursing care” (Finkelman, 2016). While providing care for our patients it is important to render the appropriate care delivery model according to the type of patients you are serving within the community. They are many different approaches to providing care to patients and the care model design. Some model may include some aspect of the other nursing model depending on the situation. Some of the different models include “total patient care, functional nursing, team nursing, primary nursing, contemporary model and care and service team
Simpson, C. (2007) ‘Mental Health part3: Assessment and Treatment of Depression’ British Journal of Healthcare assistants. pp 167-171.
... directed by the client’s changing status throughout the process. The nurse may collaborate with the client, family, significant others, and other members of the health care team in applying steps of the nursing process. The following standards shall be used by a registered nurse, using critical thinking and clinical judgment in applying the nursing process for each client under the registered nurses care: assessment, analysis and reporting, planning, implementation, and evaluation (“Ohio Board of Nursing,” 2008).
The Mental Status Exam will be very valuable because there are useful items to determine whether a client is presenting depression, psychotic break, mania or anything in between. It is focused in the present tense and it also focuses on appearance, mood, cognitive functioning, presentation (i.e. eye contact, affect, cognitive perceptions), and other things that are crucial in determining a person's suicidal/homicidal risk, and severity of impairment.
After the handover, I was asked by my mentor to attend to a patient who is bed ridden to have her personal care done with the assistance of one of the health care assistant staff. The patient was recently admitted to the ward and she looks sc...
In EOL decisions for aged, nurses who have previously developed a trusting relationship with the family gain a unique perspective that allows them to become aware of a clinical deterioration and this places nurses in a position to facilitate EOL decision-making (Adams, Bailey & Anderson,2011). Thou the individual competence, employer policies standards and conditions may vary the registered nurse’s scope of practice allows her to commence an EOL decision when a plan is already in place but restricts her to make a decision for the patient in the first place, she give the information and directions so that family or patient itself reaches the right decision (Leditshke, Crispin & Bestic, 2015; Tiffen, Corbridge & Slimmer,