written )/ psychosocial case presentation 20 H e a l t h M e d i c a l
Please no plagiarism Should be APA format 6th edition and 7th edition. you could just have the same paper you did but apa format should be 6th and 7th edition have two of the same paper.
This paper is based on the pt David carter
Please look at the sample papers I provided Again do not plagerize.
Paper Instructions:
Psychosocial Assessment (written)/ Psychosocial Case Presentation 20%
a. Introduction – 2 pts.
In the introduction provide an account of the patient and his/her illness from
his/her perspective. Briefly describe how he has dealt with the
diagnosis/treatment and how he has lived in the past/ present.
b. Complete a full biopsychosocial assessment including the mental status
assessment. (See chapter in Boyd, The Psychiatric Nursing Process. Describe
how the client lived in the past and present. Based on the client’s psychiatric
symptoms, how does this affect his/her functional ability? 5 pts.
c. Identify an appropriate assessment instrument in accordance with the patient’s
diagnosis and briefly describe its properties – e.g. CAGE, AIMS, SANS, SAPS,
Beck Depression Inventory – 2 pts.
d. Identify client’s DSM V diagnoses – describe the observed behaviors that meet
the DSM criteria. – 2 pts.
e. Write a care plan for the top two nursing diagnoses. – 4 pts.
f. Include six to ten references that are further explained below. 5 pts.
i. Etiology, S/S, manifestations, of the psychiatric diagnosis.
ii. Nursing interventions pertaining to nursing diagnoses.
iii. One meta-analysis pertaining to either nursing or psychiatric
diagnosis/treatment.
iv. State rationale for selecting each article, including a statement of how it
applies to patient’s diagnosis and/ or treatment. Briefly summarize each
article including a description of the purpose, sample, methods, findings,
implications for practice, and conclusions of the authors. Cite all
references in APA format.
David carter pt info:
Location: Patient room on a locked mental health unit
Time: 19:00 (2 hours after admission)
Report from the day shift nurse:
Situation: David Carter, a 28-year-old male, was admitted today after he became violent with his mother and threw a table at her when she asked him to take his medications. She then called the police, who brought him to the emergency room.
Background: David has a 10-year history of schizophrenia and has previously been stable on his medications. However, recently he has become more isolated, not going out and always sitting at his computer, and his mother reports that he has been posting some pretty weird updates online. Lately he has also been talking about his food being poisoned, so his mother suspects that he has stopped taking his medications, probably because he believes they are responsible for his weight gain. The current medications, which he has been taking for the last year, include olanzapine 10 mg and venlafaxine XR 75 mg daily. During his admission, he was alternately agitated and withdrawn, but he did answer questions, although at times inappropriately. He has paranoid delusions, believing that people are listening to his thoughts, and he has auditory hallucinations telling him that he should not eat the hospital food because it is poisoned. His speech is tangential with some evidence of neologisms, and it is difficult to carry on a conversation with him. He has refused a shower and has a disheveled, dirty appearance.
Assessment: I have finished most of the admission; I have taken his vital signs, recorded his history, and obtained the history of his present illness from his mother. All that is left is the mental status examination. He is in his room, and his mother just left. David refused to eat his dinner but did drink a few sips of water from a sealed water bottle. His vital signs, as follow, are stable: temperature, 37.2°C (99°F); heart rate, 90 beats/min; respiratory rate, 16 breaths/min; blood pressure, 134/84; and blood oxygen saturation, 96%. He appears tired. With a lot of coaxing, I did get him to take his medications.
Recommendation: Please complete a mental status examination, orient him to reality, offer food, and find ways to encourage him to eat it. Please also call the charge nurse with the report when you have completed your assessment.
A concept map of the pt was provided hope it helps
Any other things about the patient you can google to complete the paper or ask me any questions if you have any
should be 10 plus pages
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