University Of Texas The Patient Management Process Case Study

Instructions FOR PATIENT MANAGEMENT PAPER

You will develop a case study (no more than 8 pages no less than 6 pages excluding title and reference page(s) on a topic that will fuse nurse practitioner management. References for this paper must be recent (within the past 5 years).

Purpose: The purpose of this paper is to promote scholarly thought and writing. Writing this paper will increase your critical thinking skills, writing abilities, and will encourage you to incorporate published evidenced based literature in your practice. This paper will allow you to examine the patient management process based on a real person you have had the privilege of interacting with in the clinical setting.

Topic: The topic comes from an actual patient observation. Choose the patient and topic. Caution, since you may see the patient only once, be sure to get complete information from the chart, such as lab values, treatments, medications, etc.

Section I: Introduction

Objective	Points
One or two paragraphs identify the purpose/objective of the paper include an introduction of the patient and describe the diagnosis	5

Section II: Review Treatment Guidelines/ Present Evidence

Objective	Points
An Introduction is presented which discusses how the Guideline / evidence was obtained	5
2 to 3 paragraphs discussing the nature of the problem/diagnosis use of a literature search used to discuss the problem/diagnosis	20
One paragraph discussing the literature related to the management of the patient	5
Identify measurable and realistic short and long term goals fort this patient problem. Review appropriate medication intervention Report possible side effects of medication Discuss patient teaching related to the diagnosis Discuss any referrals this patient may need Report any assessment tools used to assess the patient	25
Plan addressed all of the following areas: social, ethical, legal, economic, spiritual or cultural influences.	10

Criteria	Points
Review teaching needs for the patient & family with the diagnosis presented. Provide a rationale for each of the teaching needs	15

Criteria	Points
In summation/closing paragraph discuss how this paper and treatment will guide your practice when evaluating a patient with the final diagnosis	5

Criteria	Points
Follow APA Guidelines for the whole paper	10
Provide a title page
Pages are numbered
APA format for Refrences
Minimum of 5 Citations No Spelling errors/grammar errors

You must Achieve > 80% to pass

Total Points = 100

ELEMENT FOR CASE STUDY. TAKEN FROM PATIENT CHART

Information Obtained From: Client , Record Referral Source: Other

Chief Complaint: Suicide Ideation, Voices that Patient cannot longer control

History of Present Illness

CJ is a 38 year old Hispanic female that was brought to our attention because of suicide ideation and plan to strangle self. The patient is currently in day 2 recovery. She has no medical Hx and has Psychiatric Hx of Unspecified Psychosis. She has NKDA, and lab were all negatives.

At the time of the present visit, the patient was sitting outside on a chair in the day room. To the question what brings you in she responded; “suicide” How often does that happen? “Often”. Are you on court orders for treatment?” yes, I am on medication and medications does not seem to help well”. Do you hear voices? ” yes, more when I am off medications”. How often do you hear voices when you are on medication?” once every two weeks only”. Do you have a plan to kill yourself?” Yes because life is too hard”. Any plan to kill any other person? “No, Cymbalta is not working”. Have you ever try Zoloft? “yes Zoloft was pretty good, it works for me, I have been on Cymbalta for 3 months and the suicide thoughts are the same, the suicide thought are getting worse and I cannot longer block them”. do you have any children?” Yes I have a 15 year old and I have not seen him in a while, heis with his dad”.

Psychiatric Review of Symptoms :

Depression, Mania, Psychosis, Anxiety Depression: DeniesSymptoms

Anxiety: Restlessness Mania: Denies Symptoms

Psychosis: Auditory Hallucinations Medications: Yes

Current Medications:

BENZTROPINE MESYLATE, 1 MG TABLET, ORAL, 1 Tablet Twice a Day, Start

Date: 10/02/2020

CYMBALTA(DULOXETINE HYDROCHLORIDE),60MG”CAPSULE, DELAYED

RELEASE”, ORAL, 1 Capsule Daily, Start Date: 10/02/2020

MILK OF MAGNESIA, 400 MG/5 ML SUSPENSION, ORAL, 30 Milliliter Every 6

Hours, As Needed, Start Date: 10/02/2020

IBUPROFEN, 200 MG TABLET, ORAL, 2 Tablet Every 6 Hours, As Needed, Start Date: 10/02/2020

NICOTINE, 21 MG/24 HR “PATCH, EXTENDED RELEASE”, TRANSDERMAL, 1 Patch

Once a Day, As Needed, Start Date: 10/02/2020 MAALOXADVANCED(ALUMINUMHYDROXIDE-MAGNESIUM

HYDROXIDE-SIMETHICONE), ORAL, 30 Milliliter Every 4 Hours, As Needed, Start Date: 10/02/2020

PEPTO-BISMOL(BISMUTHSUBSAUCYLATE), 262 MGTABLET, ORAL, 2Tablet

Every 4 Hours, As Needed, Start Date: 10/02/2020

TRAZODONE HYDROCHLORIDE, 100 MG TABLET, ORAL, 1 Tablet At Bedtime, As

Needed, Start Date: 10/02/2020

HYDROXYZINE PAMOATE, 25 MG CAPSULE, ORAL, 1 Capsule Threelimes a Day, As Needed, Start Date: 10/02/2020

Histories

Past Psychiatric History (previous hospitalizations, med trials, outpatient treatment, court ordered treatment, suicide attempts, etc):

IP: multiple admits. Last admit x 5 months ago

OP: LFC

SA: Slit wrists 10 years ago with intention of dying; sought medical care s/p attempt

TBI/SZ/LOC: Denies

Was this information reviewed and/or updated?: Yes

Medical History: Denies

Surgeries: Denies

Allergy: NKDA

At Risk for Pregnancy: Yes

Social Hx

From Tucson. Divorced. Has 3 children (although psychsocial states 5). Dropped out of HS in 9th grade. No GED. Denies h/o trauma/abuse. Denies legal issues.

Substance Use History: Denies current illicit substance abuse; endorses remote h/o of opioid abuse but states she has been sober x 4 years. Declines to provide details. Denies ETOH use. Opportunistic use of nicotine (vaping).

Development: Unknown

Review of Systems

System Reviewed: Constitutional Constitutional: Denies Problem

Mental Status Exam

Most Recent Vitals:

Date: 10/03/2020 Time:08:28AM

Blood Pressure: 115/67 mmHg

Heart Rate: 87 bpm Respiration Rate: 16 bpm Temperature: 97.2 Fahrenheit Oxygen Saturation: 98 %

Appearance: Chronological Age, Normal Weight

Attitude: Accessible, Cooperative, Good Eye Contact, Relates Well Muscle Strength/Tone:NormaI

Gait/Station: Steady

Speech: Clear Articulation, Regular in Rate and Rhythm Language: Appropriate Use of Language, English Speaking

Orientation: Fully Oriented.

Affect: Dysphoric, Flattened, Labile

Mood: Depressed

Productivity: Spontaneous Associations:

Goal Directed

Abstract Thinking: Adequate Abstracting Ability Thought Content: Delusions, Illusions

Thought Content Comments: Reported Unspecified voices that she cannot longer blocked as use to do in the past.

Hallucinations reported: No

Suicide ideation reported: Yes Explain:

“I want to end my life because life is too hard”

Homicide ideation reported : No

Estimated Intellectual Functioning: Average Fund of Knowledge: Age Appropriate Memory: NoMemory Impairment Concentration: Adequate

Insight: Moderately Impaired Judgment: Adequate

Pbysical Exam

General: No Distress Neuro: WNL, Gait Normal

Pulm: No Use of Accessory Muscles, Unlabored Derm: WNL

Extremities: No Gross Deformity, Moves Extremities Equally, Normal Range of Motion Back: WNL

Risk Assessment

Estimated Suicide Risk Levels: High ( Schizoaffective disorder, Suicide ideation, worsening Psychotic symptoms as evidenced by the voices she cannot longer block.)

Estimated Violence Risk Level: Moderate

Comment: (Schizoaffective disorder, Suicide ideation, worsening Psychotic symptoms as evidenced by the voices she cannot longer block.)

Estimated Victimization Risk Level: Low Access to Firearms: No

Static Risk Factors: Divorced, Single, Hx of Suicide Attempts, Role of Significant Other Dynamic Risk Factors: Suicide Ideation, Anhedonia, Psychotic Symptoms

Protective Factors: Living with Someone, Social Support

Formulation/DiagnosticSummary(MedicalDecisionMaking):

C J is a 38 year old Hispanic female that was brought to our attention because of suicide ideation and plan to strangle self. The patient is currently in day 2 recovery. She has no medical Hx and has Psychiatric Hx of Unspecified Psychosis. She has NKDA, and lab were all negatives.

Pt is depressed, withdrawn and reported that her antidepressantis not working, express desire to switch from Cymbalta to Zoloft which she indicated has worked in the pass. Pt has symptoms consistent with depression; hopeless. poor sleep hygiene,isolative and has lack of interest in thing that use to be interested in and suicidal. Pt will benefit from addition time to stabilized on antidepressant

10/01/2020 Mental disorder, not otherwise specified

10/02/2020 Mental disorder, not otherwise specified 10/02/2020 Suicidat ideation

10/02/2020 Anxiety 10/02/2020 Suicidal ideations

10/02/2020 Unspecified anxiety disorder

10/02/2020 Unspecified psychosis not due to a substance or known physiological condition

10/02/2020 Schizoaffective disorder

Plan/Recommendations:

Reassess tomorrow Discontinue Cymbalta,

start Zoloft 50 mg PO Q am ( depression)

Will participate in group therapy as appropriate

CM please collaborate with outpatient team on dispo

Referral To: Primary Care Physician

Discussion with Individual: Prognosis, Treatment Options, Importance of Compliance, Risk Factor Reduction, Patient Family Education, Risk, Benefits, Side Effects, At Risk for Becoming Pregnant, Importance of Follow Up, Obtaining Additional Crisis Svcs, After Hours Crisis Resource, Crisis Prevention Plan

Return to Clinic/Crisis Center: 1 Week

Justification for Continued Hospitalization: Patient Remains Suicidal, Patient Remains Psychotic

Inpatient Only – Criteria for Discharge: Individual Will Not Have Suicidal Thoughts or Have Risk of Self-Harm, Individual Will Not Have Homicidal Thoughts or Have Risk of Harming Others, Individual’s Psychotic Symptoms Will Have Improved Sufficientlly to Independently Provide Self-Care and Respond Appropriately to Others

Inpatient Only – Estimated Length of Stay: 3 Days