Therapeutic Communication Assignment NSG 350 Mental Health Clinical

Therapeutic Communication Assignment NSG 350 Mental Health Clinical Adam Padilla Stratford University THERAPEUTIC COMMUNICATION DATA FORM Student's Name Adam Padilla Client's Initials T.E. Date of Interaction 1/25/2019 ASSESSMENT: • Background information of client (age, sex, marital status, admission hx, etc.) from chart: T.E. A 29-year old Caucasian male was admitted to 3A on 01/17/2019 at 1230 as a TDO with the admitting complaint of Suicidal Ideation with a plan and Homicidal Ideation. Diet: Regular, No pork-derived and shell-derived products. Allergies: Benadryl, pork and shellfish products. Upon admission, patient is selectively mute and would respond by head and hand gestures only. Per report, patient called 911 this morning, stating he was suicidal with a plan to walk into traffic, but will not act on it. Patient also had HI, stating he had thoughts of harming others "on a global level". Merrifield CSB was called and issued a TDO. Per report, patient has a history of substance abuse (alcohol, Marijuana and Methamphetamines), last alcoholic intake was on 01/15/2019, last drug use was in December 2018. At approximately 1830, writer was able to briefly speak with writer, presents with pressured speech. Patient stated, "I just want to get back to my son. He's 2-years old, living with his grandma and grandpa.". Patient stated he collects disability for income. Denies HI/AVH. Admits to still feeling suicidal with no plan, contracted to safety • Psych meds: (list all psych related medications that the pt is prescribed, list the dosage, route, class, indication for use, and the top 3 side effects) o HydrOXYzine (Vistaril) capsule Q4H, PRN for anxiety Classification-Antianxiety Use: Anxiety Side Effects: dizziness, drowsiness, blurred vision o Haloperidol (Haldol) 5mg, oral Q4H, PRN Classification: Antipsychotic Use: Schizophrenia Side Effect: nausea, vomiting, diarrhea o Benztropine (Cogentin) 1 mg, oral Q4H; PRN; Classification-Antiparkinsonian Use: tremors, dsystonia/EPS Side Effects: skin rash, fast/irregular/pounding heartbeat, fever o Olanzapine (Zyprexa) 10 mg, injection (IM) Q4H, PRN Classification: Antipsychotics Use: Schizophrenia Side Effects: headache, weight gain (teenagers), speech/memory problems o QUEtiapine (SEROquel) 100 mg tablet PRN, Classification: Antipsychotic Use: Insomnia Side Effects: mood/behavior changes, constipation, dizziness o Ziprasidone (Geodon) 80 mg, oral, PRN, Classification: Antipsychotic Use: severe agitation Side Effects: unusual tiredness, dizziness, upset stomach