Mental Health Case Linda Waterfall

Mental Health Case: Linda Waterfall

Mental Health Case: Linda Waterfall

Documentation Assignments

1.       1. Document your findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment.

Pt is experiencing increased anxiety and reports SOB related to cardiac/respiratory distress

2.       2. Document your findings related to the focused assessment of Ms. Waterfall’s signs and symptoms of acute anxiety. Include her responses to your assessment.

Pt is showing distress, concern, worrisome, anxiety, restless nights related to past traumatic experience regarding her mothers death from complications from surgery. Pt is in need of her “medicine bag” that was left at home, this is of high importance to her religious beliefs- Surgery can not begin w/o pt’s “medicine bag”. Pt has low support system as all family lives far away. Pt but does have a cousin, Alice, who accompanied her to the hospital.

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

Upon entering the room the scene was obversed to maintain safety, washed hands and pt was identified using full name and DOB. Pt was asked for consent on her cousin being in the room during any qestions, pt agreed and became very upset to the thought of her fanily member leaving her. Pt was reassured the she was not going to be alone. Pt V.S were assessed and all w/in normal range. Pt was asked if she is have anychest pain or trouble breathing; Pt reports no pain but she feels like she is going to die and she can’t catch her breathe . Beathing exercises were tought and educated properly.  It was explained that she is safe here. Pt was offered the pre-op medication of Loraxap 2 mg-pt refused medication. Pt continues to stay anxious as she has stated that she left her “medicine bag” at home, this is of high importance and w/in her religion.