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Schizophrenia Documentation FOR MENTAL HEALTH
Mental Health Nursing (NU 309)
Herzing University
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Focused Exam: Schizophrenia Results | Turned In
NU309 - Mental Health Nursing - May 2021, (2021_summer_c16_term)__nu309km
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Documentation / Electronic Health Record
Nursing Admitting Note
Student Documentation Model Documentation
Chief Complaint
Patient complains hearing loud harsh voices. Patient is currently diagnosed with schizophrenia and reported quitting medications due to financial problems.
Eric Ford is a 28-year-old African American man who was br to the ER by his mother for acute auditory hallucinations and paranoia.
History of Present Illness
Patient experiences different types of voices. such as female and male. Patient also reported that sometimes the voices shouts at him or sing in choir. Patient stated that being alone triggers the voices. Patient copes with the voices by playing a musical instrument or music.
Eric Ford has a history of chronic paranoid schizophrenia, on age 23. Three previous hospitalizations with the most recent years ago. History significant for a suicide attempt by overdo age 25, requiring ICU admission. Patient has not been sleep eating well. His mother reports that he ran out of medication days ago and is concerned for his safety.
He denies suicidal intent and states that he sometimes listen music to avoid paying attention to the voices. Denies homici ideation. Does not initiate conversation. Presence of + audito command hallucinations. Appears to be limited in ability to complete activities of daily living, disheveled with soiled clot
Allergies
Medication- NKA Food- NKA Latex- NKA Seasonal- NKA
NKA / NKDA
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
Care Plan
Program Competency Progress
Reflections
Flowsheets Documentation
Suppor t
Student Documentation Model Documentation
Past Medical History
Patient was diagnosed with schizophrenia at the age of 23, five years ago. Patient reports difficulties in falling asleep. Patient denies any suicidal and homicidal thoughts. Patient reports three previous hospitalizations related to his diagnosis.
Schizophrenia, since age 23
Past Surgical History
No past surgical history.
No previous surgeries
Medication History
Patient is taking risperdal for schizophrenia and trazodone for insomnia. Patient reports that he stopped taking the risperdal and can't remember when was the last dose.
Risperdal 2 mg P. b.i. For Psychotic Symptoms Trazodone 25 mg P. Q HS for Insomnia
Family History
No family history of schizophrenia
No known history of family mental illness
Social History
- Patient reports not feeling safe outside
- Patient goes to college
- Patient smokes one pack of cigarrete everyday
- Patient drinks beers once in a while
- Patient denies illicit drugs
Occupation and Education: Employed as a stocker at a groc store. Patient completed high school, currently in college stu Audio Engineering. Reports missing school and work for the week.
Marital Status: Unmarried, no children-states he is in a monogamous relationship with girlfriend
Substance Use: Smokes cigarettes, 1 ppd since age 16. Consumes 1-2 alcoholic drinks per week. No illicit drug use.
Review of Relevant Systems
-Patient reports loss of appetite -Patient denies shortness of breath -Patient denies any changes in bowel movements
- Patient denies any tremors or involuntary movements
- Patient denies any oral problems
- Patient denies any neurological problems.
GENERAL: Poor Hygiene noted. No evidence of distinguishi marks, scars, tattoos. Wearing soiled clothing. Negative for f chills, night sweats. Reports difficulty falling asleep, mid-nig awakening.
RESPIRATORY: Negative for shortness of breath, cough, wheezing.
CARDIOVASCULAR: Negative for chest pain, palpitations, e
GASTROINTESTINAL: Denies nausea, denies vomiting, constipation, diarrhea. Positive for diminished appetite in pa week.
NEUROLOGICAL: Negative for weakness, frequent headach dizziness, falls, or changes in coordination. + perceptual disturbances including auditory hallucinations and paranoid delusions.
INTEGUMENTARY: Skin, pink, warm, intact. Negative for cha hair, or nails. Negative for rashes, pigmentation changes, pru or easy bruising.
MUSCULOSKELETAL: Negative for recent injuries, joint pain erythema, or edema of joints.
Mental Status Note
Student Documentation Model Documentation
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Schizophrenia Documentation FOR MENTAL HEALTH
Course: Mental Health Nursing (NU 309)
University: Herzing University
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