MENTAL HEALTH CLINICAL

©2018 Keith Rischer/www.KeithRN.com

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SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Karen West is a 26-year-old single female who was admitted to the mental health unit this morning (0200) for a possible

overdose of pills following a fight with Steve, her boyfriend of six months. Steve shared that Karen flew into a rage when

he suggested that she “slow down” on her drinking at a party last night. She stormed out after throwing a drink at him.

When he arrived home an hour later Karen was breathing, but unresponsive with an open bottle of unknown pills on the

floor. Steve called 911, and she brought to the emergency department (ED).

In the ED, Karen began to awaken and stated that she remembers getting angry at her boyfriend at the party and thinks

she may have thrown a drink in his face. When she gets that angry, “Everything goes black.” She feels embarrassed at

what she did but is more upset that her boyfriend turned out to be “like everybody else. People always let you down. He

will probably leave me now, won’t he?” She remembers she couldn’t calm down after she got home and just kept taking

more and more pills hoping that would help. She states, “I wasn’t trying to kill myself.” There is a recent superficial cut

on her left thigh that is 4 cm in length. She admits that her life is getting out of control again and agreed to admit herself

voluntarily to a behavioral health unit, so she doesn’t “do something crazy.”

Personal/Social History:
Karen describes herself as someone who never feels content. She can feel deliriously happy at one point and then sad or

angry ten minutes later. She tries to put on a happy face for others, but almost always feels anxious. Even when things are

going well, she states that she feels like she is a fraud. She admits that sometimes the only way to feel better is to cut

herself. She revealed “old” razor blade cuts (scarring) to her inner thighs. She frequently drinks and uses marijuana to

calm down.

She was hospitalized once in her freshman year of college for depression and “cutting.” She saw a therapist for a few

weeks and started on an antidepressant, but the therapist was “awful,” and the medication made her gain weight, so she

quit both.

What data from the histories are RELEVANT and have clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

RELEVANT Data from Social History: Clinical Significance:

Patient Care Begins:

  • Current VS:
  • P-Q-R-S-T Pain Assessment:
    T: 99.0 F/37.2 C (oral) Provoking/Palliative: Provoked by movement of leg

    P: 86 (regular)

  • Quality:
  • Dull

    R: 20 (regular) Region/Radiation: Left inner thigh

    BP: 130/82

  • Severity:
  • 2/10

    O2 sat: 98% room air

  • Timing:
  • Continuous

    © 2018 Keith Rischer/www.KeithRN.com

    What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?

    RELEVANT VS Data: Clinical Significance:

    What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
    (Reduction of Risk Potential/Health Promotion & Maintenance)

    RELEVANT Assessment Data: Clinical Significance:

    RELEVANT Mental Status Exam Data: Clinical Significance:

  • Current Assessment:
  • GENERAL

  • APPEARANCE:
  • Appears to be uncomfortable.

  • RESP:
  • Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort

  • CARDIAC:
  • Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal

    with palpation at radial/pedal/post-tibial landmarks, brisk cap refill

  • NEURO:
  • Alert & oriented to person, place, time, and situation (x4)

  • GI:
  • Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants

  • GU:
  • Voiding without difficulty, urine clear/yellow

  • SKIN:
  • Skin integrity intact except superficial 4 cm cut to left inner thigh. Multiple scars from previous

    self-harm cutting

  • Mental Status Examination:
  • APPEARANCE: Disheveled with no body odor; appears younger than stated age.

    MOTOR BEHAVIOR: Fidgeting in chair; wringing hands

  • SPEECH:
  • Clear with normal rate and rhythm

    MOOD/AFFECT: Reports feeling sad and remorseful for her behavior. Flat affect. Reports feeling anxiety

    level of 8 out of 10.

    THOUGHT PROCESS: Linear, logical

  • THOUGHT CONTENT:
  • Currently reality-based thinking. No evidence of delusional thinking when assessed.

    Some evidence of cognitive distortions

  • PERCEPTION:
  • Denies hallucinations

    INSIGHT/JUDGMENT: Insight fair – knows she needs some help now. Judgment: Fair to poor: Tends to think

    about using maladaptive coping skills

  • COGNITION:
  • Alert and orientated x4. Reports some memory issues around the events of previous night

    Short term memory intact when tested. Long-term memory grossly intact – able to give an

    accurate history

    INTERACTIONS: Reports “people always let you down” so she doesn’t trust people

    SUICIDAL/HOMICIDAL:

    Self-Harm

    Admits she could have died “by accident” from taking so many pills. Reports she thinks

    about ending it all but denies a suicide plan. Feels so anxious that she thinks about cutting

    herself while in the hospital to help herself calm down.

    © 2018 Keith Rischer/www.KeithRN.com

    Diagnostic Results:

  • BMP:
  • Sodium (135–145) Potassium (3.5–5) Glucose (70–110) Creatinine (0.6–1.2)

  • Current:
  • 138 4.8 99 1.0

  • Prior:
  • 140 4.5 88 1.1

  • CBC:
  • WBC (4.5-11) Neutrophil (42-72%) Hgb (12-16) Platelets (150-450)

    Current: 7.0 44 12.8 229

    Prior: 8.9 58 13.2 298

  • LFT:
  • Albumin (3.5–5.5 g/dL) Total Bili (0.1–1.0 mg/dL) ALT (8–20 U/L) AST (8–20 U/L)

    Current: 3.9 0.8 38 34

    Prior: 4.1 0.5 24 22

  • Misc:
  • ETOH level Acetaminophen Aspirin

    Current: 0.28 0.0 0.0

    Prior: n/a n/a n/a

    What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

    RELEVANT

    Diagnostic Data:

    Clinical Significance: TREND:

    Improve/Worsening/Stable:

    © 2018 Keith Rischer/www.KeithRN.com

    Part II: Put it All Together to THINK Like a Nurse!
    1. After interpreting relevant clinical data, what is the primary problem?

    (Management of Care/Physiologic Adaptation)

    Problem: Pathophysiology in OWN Words:

    Collaborative Care: Medical Management
    2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
    Care Provider Orders:

  • Rationale:
  • Expected Outcome:
  • Voluntary admission to

    behavioral health unit

    CIWA every shift or as

    indicated. Treat with Ativan

    for symptoms of withdrawal

    – score above 15

    Close Observations for

    positive suicide, self-harm or

    violence ideation and if

    patient is unable to contract

    for safety per unit protocol

    Milieu therapy

    Fluoxetine 20 mg PO in AM

    Topiramate 100 mg PO

    every 12 hours

    Olanzapine 2.5 mg PO every

    6 hours PRN acute agitation

    Lorazepam 1 mg PO every 4

    hours PRN for ETOH

    withdrawal symptoms

    © 2018 Keith Rischer/www.KeithRN.com

    Collaborative Care: Nursing
    3. What is the nursing PRIORITY and plan of care? (Management of Care)

  • Nursing PRIORITY:
  • Nursing Interventions: Rationale: Expected Outcome:

    4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?(Psychosocial Integrity)

  • Psychosocial Priorities:
  • Nursing Interventions: Rationale: Expected Outcome:

    5. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as
    a person? (Psychosocial Integrity/Basic Care and Comfort)

    1. RELEVANT Data from Present
    2. ProblemRow1:
    3. Clinical SignificanceRow1:
    4. RELEVANT Data from Social HistoryRow1:
    5. Clinical SignificanceRow1_2:
    6. Current VS:

    7. PQRST Pain Assessment:
    8. Provoked by movement of leg:
    9. P 86 regular:
    10. Quality:

    11. Dull:
    12. R 20 regular:
    13. Left inner thigh:
    14. BP 13082:
    15. Severity:

    16. 210:
    17. Timing:

    18. Continuous:
    19. RELEVANT VS DataRow1:
    20. Clinical SignificanceRow1_3:
    21. Current Assessment:

    22. Appears to be uncomfortable:
    23. RESP:
      CARDIAC:
      NEURO:

    24. Alert oriented to person place time and situation x4:
    25. GI:
      GU:

    26. Voiding without difficulty urine clearyellow:
    27. SKIN:
      Mental Status Examination:
      APPEARANCE:

    28. Fidgeting in chair wringing hands:
    29. SPEECH:

    30. Clear with normal rate and rhythm:
    31. MOODAFFECT:
    32. Linear logical:
    33. THOUGHT CONTENT:
      PERCEPTION:

    34. Denies hallucinations:
    35. INSIGHTJUDGMENT:
    36. COGNITION:

    37. SUICIDALHOMICIDAL SelfHarm:
    38. RELEVANT Assessment DataRow1:
    39. Clinical SignificanceRow1_4:
    40. RELEVANT Mental Status Exam DataRow1:
    41. Clinical SignificanceRow1_5:
    42. BMP:
      Current:
      Prior:
      CBC:

    43. Current_2:
    44. Prior_2:
    45. LFT:

    46. Current_3:
    47. Prior_3:
    48. Misc:

    49. Current_4:
    50. Prior_4:
    51. 22Row1:
    52. RELEVANT Diagnostic DataRow1:
    53. Clinical SignificanceRow1_6:
    54. TREND ImproveWorseningStableRow1:
    55. ProblemRow1:

    56. Pathophysiology in OWN WordsRow1:
    57. RationaleVoluntary admission to behavioral health unit CIWA every shift or as indicated Treat with Ativan for symptoms of withdrawal score above 15 Close Observations for positive suicide selfharm or violence ideation and if patient is unable to contract for safety per unit protocol Milieu therapy Fluoxetine 20 mg PO in AM Topiramate 100 mg PO every 12 hours Olanzapine 25 mg PO every 6 hours PRN acute agitation Lorazepam 1 mg PO every 4 hours PRN for ETOH withdrawal symptoms:
    58. Expected OutcomeVoluntary admission to behavioral health unit CIWA every shift or as indicated Treat with Ativan for symptoms of withdrawal score above 15 Close Observations for positive suicide selfharm or violence ideation and if patient is unable to contract for safety per unit protocol Milieu therapy Fluoxetine 20 mg PO in AM Topiramate 100 mg PO every 12 hours Olanzapine 25 mg PO every 6 hours PRN acute agitation Lorazepam 1 mg PO every 4 hours PRN for ETOH withdrawal symptoms:
    59. Nursing PRIORITY:
      Rationale:
      Expected Outcome:

    60. Nursing InterventionsRow1:
    61. undefined:
    62. Psychosocial Priorities:

    63. Nursing InterventionsRow1_2:
    64. RationaleRow1:
    65. Expected OutcomeRow1:
    66. Answer5:

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