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PATIENT

48 year-old Caucasian Male

No religious preference, no related considerations pertaining

to ethnicity.

Received In ED Suicidal Ideations

No income source. Quest Insurance.

MH-4 Legal Status with exp. date of 01/15/16

Patient appeared to be personable, open to discuss some of

his current situation and problems.

Not completely forthcoming: is withholding some information.

Denies illicit drug use despite lab results indicating this. Loose
associations.

DSM DIAGNOSIS
I

ALCOHOL USE DISORDER --SCHIZOAFFECTIVE -- BIPOLAR -DEPRESSION

II

None

III

HEP C

IV

HOMELESS, NO TRANSPORTATION, UNEMPLOYED, NO

SOCIAL OR FAMILY SUPPORT

GAF 10 SERIOUS ATTEMPTS IN THE PAST TO HARM SELF.

MEDICATION

Haloperidol(Haldol)

Quetiapine (Seroquel)

Trazodone (Trazodil)

Thiamine (Betaxin), vitamin B1

Diazepam (Valium)

BMI:
Category:
Height:
Weight:

22.9
Normal.
5'9"/175.26cm
155lbs./70.3 kg

Food & fluid intake: No diet restrictions.

Patient currently eating steady diet.

Bladder & bowel status:

Last BM previous evening.

Sleep pattern:

Stays up late usually, sleeps in late

sometimes, no complaints of difficulty
sleeping.

Total sleep/24 hrs:

7.5 hours

Hypersomnia/Difficulty falling asleep/Middle

insomnia/Early morning awakening.

None.

Number of hrs of disruption:

None reported.

Naps:

None.

Total nap time:

No naps taken during clinical day.

AXIS III

HEP C

Nursing Interventions:
Educate patient on risks of alcohol abuse in combination
with Hepatitis C. Encourage patient to seek treatment
and medical compliance.

LAB & STUDIES

Date/Panels in which all values were normal: No normal date
available. Lab test on 1-12-16 methadone and barbiturate's
negative
Date/Any abnormal labs: 1-12-16
Labs you would expect but were not ordered: liver function
test, albumin, h + h
Glucose readings x 24h for all diabetic pts.

All drug screen findings: 1-12-16 positive for oxycodone,

opiates, benzos and alcohol 0.33

MENTAL STATUS ASSESSMENT

Behavior:
Grooming and level of hygiene lacking. Some gross motor shaking of
extremities, interacts and answers questions, makes eye contact.
Affect:

Displays full range of emotion, appropriate responses to questions.

Sensorium: Oriented to person place and time.

Imagery:

No flashbacks from trauma, no nightmares.

Cognition:

Some impairment noted, unable to name most recent presidents.

Interpersonal
relationships: Isolated from family, no significant personal relationship, gives last
roommate as only contact. Patients symptoms compared to DSM criteria.
Developmental
level:

(Assets & barriers) able to maintain conversation, some looseness of association

noted as evidenced by believing others conversation are regarding him.

Drugs: Substance abuse or dependence: (Include nicotine & any alcohol & drugs. List by
drug: Last date of use/Current acute intoxication or withdrawal signs and symptoms
when SN caring for pt./Used how long/Route/Usual amount/Negative consequences)

PROBLEMS IDENTIFIED IN HOSPITALS

MASTER TREATMENT PLAN
1.

Suicidal ideations

2.

Depression

3.

Chronic alcoholism, illicit drug use

4.

Homelessness

5.

Non-complaint with antipsychotic medication

CURRENT DISCHARGE PLAN:

Preparation planning for placement at Kalihi Palama, follow up
with case worker, primary care provider.

CAREPLANS
Three priorities:
Safety
Injury prevention
Alcohol withdrawal management

CAREPLAN -- SAFETY

Prevention of self harm.

Frequent rounding every 15 minutes
Random checks

Establish therapeutic relationship to learn reasons why

patient may want to harm himself.

Implement contract for safety with patient.

CAREPLAN INJURY PREVENTION

Follow CIWA protocol and monitor for signs and symptoms.

Provide safety for possible seizures:

Padded bedrails
Lowest bed position

Administer Thiamine as ordered to prevent complications.

CAREPLAN -- ALCOHOL WITHDRAWAL

MANAGEMENT

Monitor and manage anxiety levels.

Administer anti-anxiety medications.

Provide consultation for referral to detox.

REFERENCE
Gulanick, M., & Myers, J.L. (2014). Nursing care plans:
Diagnoses, interventions, & outcomes. (8th ed.). St. Louis, MO:
Moby.