Sharon Cole Documentation Mental Health Case Sharon Cole Documentation Assignments

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Sharon Cole Documentation;Mental Health

Case: Sharon Cole Documentation Assignments

Mental Health Case: Sharon Cole

Documentation Assignments

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.

The findings related to Sharon Cole’s s/s of acute agitation are that she has bipolar disorder type 1. She has stopped her medication, which has caused an imbalance in her behavior and she is experiencing a manic episode. She is known for stopping her medication and the last time she had a manic episode was 2 years ago. Her husband noted that she has not been sleeping well or eating well for the past 2 weeks.

2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration. Include her responses to the medication administered.

The interventions for Sharon Cole’s management of acute agitation with medication was successful. She was experiencing panic when stating she can’t think with all the racing thoughts or that fact that the nurse is forcing her to stay in the hospital and she can’t get any of her work done. Her responses were that she would take any medication because the nurse was pretty.

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

0:00	You checked scene safety. It was correct to check scene safety in order to maintain your own safety.
0:06	You introduced yourself.
0:29	You washed your hands.
0:35	You identified the patient.
0:50	You asked if the patient had any known allergies.
1:09	You supported the patient about safety.
2:01	You asked the patient: Can you tell me where we are?
2:15	The patient said: Last night seems like a dream. I don't think I was even there. You answered: What seemed to lead up to you going to the bar? You used the therapeutic technique of placing the event in time.

2:48

You asked the patient: Can you tell me what a desired outcome of treatment would be for you?

3:25

The patient said: Look, I need to get out of here. The whole thing is going to fall apart. I can't get to Washington. Don't you people care about all the soldiers who are going to die without my help? Nobody can see it, but I can! They are going to waste all the money on the wrong things! I have to get out of here. Allen can drive there. This thing on my leg is in the way. You answered: Mrs. Cole, I am your nurse today and I am here to help you. You just had surgery. Please stay in the bed. You used the therapeutic technique of presenting reality.

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