Mental Health Case: Sandra Littlefield

Mental Health Case: Sandra Littlefield

Documentation Assignments

• Document your findings related to the focused assessment of Ms. Littlefield’s coping strategies. Include her responses

to your assessment. Ms. Littlefield resorted to anger and saying mean things. She did not have any healthy coping strategies developed. She had a history of self harm and attempted suicide.

• Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided Ms.

Littlefield. Include her response to the teaching. Ms. Littlefield was not eager to learn other coping strategies and was continuously focused on medication. She was not receptive to breathing or relaxation techniques. I offered education regarding other methods such as support groups, heat or cold packs, and exercises. She was receptive to going to the library with me to check out a book and understood that saying mean things and being angry was unacceptable. She was also receptive to learning some exercises to strengthen her back.

• Referring to your feedback log, document all nursing care provided and Ms. Littlefield’s response to this care.

0:06You introduced yourself.

0:31You washed your hands.

0:37You identified the patient.

0:52You asked if the patient had any known allergies.

1:00You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with her to get an understanding of this.1:20The patient said: I am in so much pain. You are a nurse. Don't you know

how to tell when someone is hurting?\nYou answered: Why don't you try

some deep breathing exercises to calm down? \nYou used the nontherapeutic technique of giving advice.1:23You asked the patient: Over the past year, when did you feel your best? It was appropriate to ask the patient about when she felt her best.1:42The patient said: There's no reason for me to be here anymore. No one

cares about me at all.\nYou answered: Are you saying you feel

hopeless? \nYou used the therapeutic technique of translating to feelings.1:42You asked the patient: Do you have any pain?1:57The patient said: I'm finished. I'm done with you and your worthless

medicine. Guard, take me back now!\nYou answered: What you really

mean is that you are mad I did not give you more pain medicine. \nYou used the nontherapeutic technique of interpreting.2:00You asked the patient: How would you rate your pain, on a scale of 0 to

10? The patient said: It changes but is always high. Now it is 8 to 9!

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2:12You asked the patient: On a scale of 0 to 10, how would you rate your

level of distress? The patient said: I don't know. 10?

2:22You asked the patient: Where is your pain located?2:43The patient said: You are trying to kill me with the pain. Just let me die; I

can't live like this!\nYou answered: It seems like you are very frustrated.

\nYou used the therapeutic technique of making observations.2:44You asked the patient: What other pain management strategies have you

used other than medications? The patient said: No. Let's stick with the

meds. It was correct to ask if the patient was using any pain management strategies other than medication.2:54You asked the patient: How many meals do you eat each day? The patient

said: I usually eat three meals a day.

2:59You asked the patient: Have you had any changes in your appetite over

the past month? The patient said: My appetite has been about the same.

3:07You asked the patient: Have you lost or gained weight over the past

month? The patient said: No, I am about the same weight.

3:12You asked the patient: Tell me about any changes you have had in your

sleep over the past few weeks? The patient said: It isn't easy to sleep in

this place.3:21You asked the patient: Do you have any trouble falling asleep? The patient

said: No, not usually.

3:26You asked the patient: Do you nap during the day? If so, how often and for

how long? The patient said: I sleep a lot because there isn't much to do

here.3:34You asked the patient: Do you have nightmares or vivid dreams on a

regular basis? The patient said: No, not usually.

3:40You asked the patient: Approximately how many hours of sleep do you get

each night? The patient said: I sleep about 7 hours a night.

3:47You asked the patient: Do you have energy to do the normal activities necessary to get through the day?4:10The patient said: You think I'm a horrible person because I'm in jail. You

are no better than I am.\nYou answered: Are you feeling that no one

understands how you feel? \nYou used the therapeutic technique of translating to feelings.4:11You asked the patient: Do you have energy to do the activities that give

you enjoyment? The patient said: I have plenty of energy when I am not in

pain.4:20You asked the patient: I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care. These are questions I ask all of the patients I see.May I ask you these questions?From vSim for Nursing | Mental Health. ©Wolters Kluwer. This study source was downloaded by 100000808701186 from CourseHero.com on 05-04-2021 21:18:11 GMT -05:00

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4:48The patient said: Just because you are in love with the guards, you prance

around like you own this place and you do not!\nYou answered: Ms.

Littlefield, you need to lower your voice now. I am here to help you. \nYou used the therapeutic technique of giving information.4:50You asked the patient: Please tell me what today's date is. The patient

said: It is the 25th.

4:55You asked the patient: Have you lost interest in activities that you once enjoyed?5:13The patient said: I know you have some stronger pain medicine. You gave some to another patient, and she wasn't even in pain like me.\nYou

answered: We are here together today to talk about you. \nYou used the

therapeutic technique of giving information.5:14You asked the patient: Can you name the last five American presidents

starting with Barack Obama and going back? The patient said: Barack

Obama, George W. Bush, Bill Clinton, George H. W. Bush, Ronald Reagan.5:30You asked the patient: Do you have any thoughts or wishes to harm or kill

yourself? The patient said: If they don't help with my pain, I will.

5:40You asked the patient: Have you ever tried to harm or kill yourself? The

patient said: I slit my wrists in the past but nobody really cared.

5:48You asked the patient: Do you have any thoughts or wishes to harm or kill

yourself? The patient said: If they don't help with my pain, I will.

5:56You asked the patient: Have you ever tried to harm or kill somebody else?

The patient said: Yes, that police officer but he deserved it.

6:03You asked the patient: Can you tell me what a desired outcome of treatment would be for you?6:23The patient said: Everyone is against me. You, the other nurses, the provider—you all hate me. The only one who likes me is that cute

guard.\nYou answered: You feel that people hate you? \nYou used the

therapeutic technique of restating.6:24You asked the patient: How do you understand your problems?6:44The patient said: The other nurse is nicer than you. She is better looking

and has newer clothes too.\nYou answered: The next time you feel

frustrated, what are things you can do to handle it appropriately? \nYou used the therapeutic technique of formulating a plan of action.6:45You asked the patient: Are you frightened of anything?7:03The patient said: You look so nice today. And you smell good. What

perfume are you wearing?\nYou answered: Are you uncomfortable when

you talk about your feelings about being here? \nYou used the therapeutic technique of making observations.

7:03You supported the patient about suicide attempts.

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7:11You supported the patient about pain medication.

7:22You supported the patient about relaxation techniques.

7:35You educated about strategies for pain management. It was correct to

educate the patient about pain management strategies other than medication.

8:01You educated about coping strategies.

8:47You educated about medications.

9:20You assessed the respiration.

9:29You checked the pulse oximetry.

9:46You checked the radial pulse.

10:0

1 You measured the blood pressure.

10:1

7 You measured the temperature.

10:3

2 You observed the appearance.

10:5

You assessed the attention.

10:5

5 You observed the motor activity.

11:0

3 You assessed the speech.

11:0

8 You assessed the thought processes.

11:1

6 You auscultated the lung sounds.

11:2

8 You auscultated the heart sounds.

13:0

7 You submitted the Mental Status Examination form. Some of your assessment answers were incorrect.Regarding the indicator "3. Mood.Indicate mood": You should have indicated "Angry."Regarding the indicator "6. Thought content. Indications of": You should have indicated "Worries," "Frustrations," and "Hopelessness or helplessness."Regarding the indicator "8. Thought process. Indicate thought process": You should have indicated "Goal directed."Regarding the indicator "11. Orientation and cognitive functions. Insight.": You should have indicated "Partial."

13:2

8 You called the provider.From vSim for Nursing | Mental Health. ©Wolters Kluwer. This study source was downloaded by 100000808701186 from CourseHero.com on 05-04-2021 21:18:11 GMT -05:00

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