Nursing Assignment Acers
NURS 6670 Week 9 Assignment
NURS 6670 Week 9 Assignment
A 63 year-old male Caucasian, homeless ,with no jobs , retired from the military, has been diagnosed with Schizophrenia and PTSD.
CC: He states, “During the night, I hear voices in my head, constantly yelling and telling me to do things like jumping my window. I see shadows dancing across the wall and .
Lately whenever somebody comes near me, I fear for my life and my heart rate starts to increase and I start getting paranoid.”
The patient is experiencing the symptoms of hallucinations and voices from his Schizophrenia which is also causing his anxiety to occur and become paranoid around people.
Medication: Buspirone 10mg PO Daily for anxiety.
Olanzapine 10mg PO Daily for his Schizophrenia
Informed consent explained and signed by patient
Pt is alert and oriented x4,
Denies any street drug taken
Denies any alcohol use
Denies any allergy to medications or food
No side effects of any taken medications presently
Sleeps Pattern :Not sleeping well during the night or day, paces around in her room sometimes reading.
Food she stated she cannot eat well now Has gain 1 lb. after her last visit with her psychiatrist Is not pregnant Very compliance with taken medications taken
No suicidal ideations Hearing of voices or seeing any images Sees her regular therapist weekly Goes for individual therapy Family therapy SI/HI/AVH.
Clinical Impression: Based on the diagnostic criteria in APA (2013) Diagnosed: Schizoaffective disorder (ICD-10: F25.9),
Psychopharmacology of the patient’s symptoms cause a significant impairment in function or agitation, irritable treatment is based on patients’ signs and symptoms presented, client cannot sleep always on the edge ,easily irritated ,dissociate herself from friends and family and has decrease in her appetite.
Medication Management :Increase buspirone 15mg PO Daily continue to for month.
Olanzapine 15mg po for a month .
Decreases all active activities before bedtime ,getting her family involve especially.
Sees her regular therapist weekly Goes for individual therapy Family therapy monthly Family and client educated about her illness to watch for any suicidal ideations .
Advise given to husband not arguing with client. Read or dim lights or noise around her sleeping room Patient to see her PCP for regular checkup and labs Return for evaluation in a month time.
In 3–4 pages, write a treatment plan for your client in which you do the following:
• Describe the HPI and clinical impression for the client.
• Recommend psychopharmacologic treatments and describe specific and therapeutic endpoints for your psychopharmacologic agent. (This should relate to HPI and clinical impression.)
• Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
• Identify medical management needs, including primary care needs, specific to this client.
• Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
• Recommend a plan for follow-up intensity and frequency and collaboration with other providers.