Suicidal Ideation Story
The patient stated that when she was admitted, she was very depressed, sad, and irritated because of the situation of her family. She said her family is broken, the mother and father are in Mexico separated, and the brothers and sisters are living in different places with relatives, and she is the only one here with her aunt and uncle who is her guardian. The patient stated, “my parents do not care if I exist or not because none of them calls me to check on me and when I call, they do not pick my call.” The patient said, “I do not belong to this world because no one represents me in a school meeting or events. Every other child brings their parent and talks good about their parents, and I have nothing to show, nobody cares. The students bullied me because of that, and they talk badly about my family and me. This made me sadder and more depressed, and I started having suicidal thoughts, and cut my thigh once but never tried it again even though I still have the thought.
PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name: |
Week: 4 |
Dates of Care: 2 /4/2022 |
Demographics and Brief History
Patient Initials
M D
Sex
F
Age
1
3
Room
281
Admitting Date
2/12022
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Depression
.
Suicidal ideation without a plan
Attending physician/Treatment team:
Precautions:
Suicidal precaution
Primary Diagnosis:
Major depressive disorder, recurrent, severe without psychotic symptoms. Anxiety disorder unspecified F 41.9
Co-morbidities:
Suicidal ideation, depression, and anxiety
Allergies:
No known allergies
Code Status:
Full Code
Isolation: (type and reason)
There is no isolation
Admission Height:
60.98 in
Admission Weight:
40.801 kg (89.0 lbs.)
Arm Band Location (colors & reasons)
No arm-band
Past Medical History: (pertinent & how managed)
Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)
Physical Assessments and Interventions: (Include all pertinent data)
Vital signs:
Time
T
98.7
97
P
90
95
R
16
18
B/P
125/89
115/63
General Appearance
·
Grooming/Clothing
·
· Hygiene
·
· Posture
·
· Gait
·
· Obese/average or normal/ underweight
·
· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings
·
Activities of Daily Living
· Sleep/rest
·
· Diet
· Regular
· Eat 76% of her food
· Exercise/mobility
·
· Elimination
·
· Hygiene
·
GI
Diet:
Blood Glucose (time & date):
Last bowel movement (time & date):
Pertinent Labs/Test:
Assessments:
· Stool
·
· Bowel sounds
·
· Tenderness, distention
·
· Appetite, nausea, vomiting
·
Interventions:
Respiratory:
Assessments:
· Lung sounds
·
· Cough, sputum
·
· SOB
·
Interventions:
Neurosensory:
Alert & Orientated:
Follows commands:
Speech Comprehensible:
Pertinent Labs/Test:
Assessments:
· LOC
·
· Pupils
·
· Glascow Coma Scale
·
· Dizziness
·
· Headaches
·
· Tremors
·
· Tingling, weakness, paralysis, or numbness
·
Interventions:
Cardiovascular:
Pertinent Labs/Test:
Assessments
· Peripheral pulses
·
· Heart sounds (murmurs or bruits)
·
· Edema
·
· Chest pain, discomfort, palpitations
·
Interventions:
Musculoskeletal:
Activity:
Casts/Slings:
Assessments:
· Strength, weakness
·
· ROM
·
· Gait (documented under appearance)
· Pain
·
· Fractures, amputations, or transfers
·
Interventions:
Renal:
Pertinent Labs/Test:
Assessments:
· Bruit, thrill, location
·
· Urine-quality
·
· Burning with urination, hematuria
·
· Incontinent, continent, I & O
·
Interventions:
Skin:
Braden Score:
Pertinent Labs/Test:
Assessments
· Bruising, wounds, drains
·
· Turgor
·
· Surgical incisions
·
· Finger & toe nails
·
Interventions:
Pain:
Pain score:
Assessments/Interventions:
· Scale used
·
· Location, duration, intensity, character
·
· Exacerbation, relief
·
Interventions:
·
Gyn:
Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test:
Assessment
· Bleeding
·
· Discharge
·
Interventions:
Safety:
Bed Rails:
Bed alarms:
Fall risk:
Assistive Devices:
Interventions:
·
Advance Directives/Ethical considerations:
AD:
POA:
Lab Values
Results
Normal Lab Values
Significance to your patient (if applicable)
WBC
8.1
RBC
4.15
HGB
10.8
HCT
31.6
MCV
76
MCH
26
MCHC
34.2
Platelets
293
RDW
14.0
MPV
None
Glucose
100
BUN
14
Creatinine
0.5
Sodium
137
Potassium
3.5
Cloride
104
Calcium
9.9
Salicylate
None
Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)
Lab Value
Results
Normal Lab
Values
Significance to your patient (if applicable)
10 Panel Toxicology/Drug Screen: if available
Lab Value
Results
Normal Lab
Values
Significance to your patient (if applicable)
Utox
Negative
Urine
Negative
Blood Alcohol Level/Ethyl Serum Level: if available
Lab Value
Results
Normal Lab
Values
Significance to your patient (if applicable)
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Psycho/Social Assessment |
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· Level of education · · Occupation · · Race/Ethnic Background or Identification · · Religion/Spiritual Beliefs · · Communication needs: (verbal, nonverbal, barriers, languages) · · Special Talents/Interests/Skills · · Environment (home and community) · · Family Structure/History: |
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Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed) |
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Support System: |
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Stressors/Stress Management Practices: |
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Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article. |
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Discuss the current disease process: |
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Discuss the etiology of the patient’s illness: |
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Also note the complications that may occur with treatments and patient’s overall prognosis: |
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Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list: . References |
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Medications |
Classification |
Dose |
Route |
Freq |
Purpose/Mechanism of Action |
Significant Side Effects / Adverse Reactions | Nursing Implications |
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(Tylenol) Acetaminophen |
650 mg |
PO |
Q4H |
PRN |
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Al Hydrox/Mg Hydrox/Simethicone |
15 ml |
Q6H PRN |
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Magnesium Hydroxide |
Daily PRN |
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Escitalopram Oxalate |
5 mg |
Nightly |
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Nursing Process Section
Nursing Diagnosis
:
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.
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Priority |
Nursing Diagnosis |
Related to |
As Evidence By |
Rationale (reason for priority) |
| 2 | ||||
| 3 | ||||
| 4 |
Complete a table for the top two priorities listed in the table above. A minimum of 3 interventions are required for each nursing diagnosis, and one intervention must be an individual patient teaching and one must include a teaching for the patient’s family/caregivers (if applicable- i.e., patient is not homeless and/or has no family).
| Table for Nursing Diagnosis Number 1 | |||||||
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Assessment · Signs and symptoms relative to the nursing diagnosis, as evidence by · 2 objective · 2 subjective |
Patient Outcome
· SMART · Specific · Measurable · Attainable · Realistic · Timely |
Interventions/Implementations
· Includes interventions/ nursing actions directly relating to pt. outcomes · Specific in action, frequency and contain rationale · Minimum of 3 interventions appropriate to help pt./ family meet their outcomes |
Evaluation
· Includes all data that is listed as criteria in outcomes · Outcomes are determined to be met, partially met, or not met · If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set |
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| Table for Nursing Diagnosis Number 2 |
