<정신간호학실습> Mental Health Case. Sharon Cole Documentation Assignments

소개글

<정신간호학실습> Mental Health Case. Sharon Cole Documentation Assignments 입니다.

목차

1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute agitation. Include her responses to your assessment.
2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered.
3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care
4. Document all interventions associated with the management of Mrs. Cole’s environment. Include her responses to the attempts to decrease environmental stimuli.
5. Document all interventions associated with boundary and limit setting directed toward managing Mrs. Cole’s manic behavior.
6. Document your handoff report in the SBAR format to communicate Mrs. Cole’s future needs.

본문내용

1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute agitation. Include her responses to your assessment.
간호문제
- 초조한 모습을 보인다.
근거
- 처음 병실을 들어갔을 때 침대 레일을 잡고 있었으며 이곳을 당장 나가야한다고 하였다.
- 처치를 하거나 의사소통을 할 때 계속 바쁘고 빨리 가야하며 시간이 없다고 말하였다.
간호진다
- 불안

<중 략>

2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered.
- 대상자는 통증 조절을 위해 Fentanyl PCA pump를 가지고 있지만 IV라인이 뱀을 떠오르게 한다며 떼어내겠다고 말하며 거부하고 있다.
- 계속 불안정한 모습을 보여서 처방대로 Lorazepam 2mg을 경구 투여하였다.

참고 자료

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