Mental Health Case: Linda Waterfall Feedback Log & Score 85%
Mental Health Case: Linda Waterfall
Documentation Assignments
1. Document your
... [Show More] findings related to the focused assessments of Ms. Waterfall’s signs and symptoms of respiratory and/or cardiac distress. Include her responses to your assessment.
• Ms. Waterfalls respiration was assessed, 24 breaths per minute and breathing equally was reported. I also checked her pulse ox which was 100%. Her pulse was at 110 beats per minute with her blood pressure at 150/80 mmHg. Throughout these initial assessments she kept insisting that her heart was racing and that he could not stay still. She was asked if she had any breathing issues and her response was that she feels like she is going to die, that she cannot catch her breath that it feels like a heart attack. When I asked about her pain, patient stated that she is going to die anyhow. When I auscultated her heart, she stated that she was very nervous. The results of auscultation was that she had normal heart sounds.
2. Document your findings related to the focused assessment of Ms. Waterfall’s signs and symptoms of acute anxiety. Include her responses to your assessment.
0:52 You asked the patient: Is it OK for your cousin to be here, while we talk? It was correct to let the patient give her consent for letting her cousin be a part of the interview.
1:07 The patient said: Alice! Don't leave me! Nurse, she said she wanted some coffee.\nYou answered: Mrs. Waterfall, I will stay with you if Alice wants to get some coffee. \nYou used the therapeutic technique of offering self.
2:44 You asked the patient: Do you have any difficulty with your breathing?
3:06 The patient said: I feel like I'm going to die. I can't catch my breath, and I feel like I'm having a heart attack.\nYou answered: You are safe here. I'm going to sit with you while we take several deep breaths together. \nYou used the therapeutic technique of offering self, using simple direct words. A patient with panic-level anxiety should never be left alone.
4:54 You asked the patient: Can you tell me a little bit more about what's going on with you today? It was appropriate to ask the patient what was going on with her to get an understanding of this.
5:16 The patient said: I had a horrible morning! I could not find my bag, then I broke a glass, and I could not get in touch with my father. My life is falling apart!\nYou answered: You must be feeling as if everything is out of your control. \nYou used the therapeutic technique of translating to feelings.
5:17 You asked the patient: Over the past year, when did you feel your best? It was appropriate to ask the patient about when she felt her best.
5:35 The patient said: You are trying to kill me by making me go through this surgery without it. All of you are out to get me. You want me to die!\nYou answered: Ms. Waterfall, I am your nurse and I'm here to help you. \nYou used the therapeutic technique of giving information.
5:37 You asked the patient: Do you have any difficulty with your breathing? The patient said: Yes. I feel I can't breathe.
5:43 You asked the patient: Do you have chest pain? The patient said: No, I don't have chest pain.
5:49 You asked the patient: Do you have any pain? The patient said: No.
5:54 You asked the patient: On a scale of 0 to 10, how would you rate your level of distress?
6:10 The patient said: I can't think straight until I find my medicine bundle.\nYou answered: This medicine bundle means a great deal to you. \nYou used the therapeutic technique of reflection.
6:44 You asked the patient: Tell me about any changes you have had in your sleep over the past few weeks? The patient said: When I am anxious I have a hard time sleeping. Recently this has been the case.
7:10 You asked the patient: Do you have any trouble falling asleep? The patient said: Sometimes I have trouble falling asleep when my thoughts are racing.
7:43 You asked the patient: Do you have energy to do the normal activities necessary to get through the day? The patient said: Yes, I have no trouble with energy once I get up in the morning.
8:15 You asked the patient: I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care. These are questions I ask all of the patients I see. May I ask you these questions?
8:44 The patient said: All of this talking, it's just a waste of time.\nYou answered: Do you feel that no one understands your feelings? \nYou used the therapeutic technique of verbalizing the implied.
9:35 You asked the patient: Can you tell me where we are? The patient said: Yes, I am in the hospital, but I don't know if I want to stay. I can't have the surgery without my medicine bundle to protect me. It is very important to me.
10:58 You asked the patient: Can you tell me what a desired outcome of treatment would be for you?
11:09 The patient said: Do you think I should have this surgery?\nYou answered: Do you think you should? \nYou used the therapeutic technique of giving reflection. This response encourages the patient to make decisions independently.
11:10 You asked the patient: How do you understand your problems?
11:38 The patient said: There was so much going on this morning. I was trying to get my things together and waiting on Alice. I can't believe I left it at home.\nYou answered: Go back over your morning. What led up to Alice arriving at your home? \nYou used the therapeutic technique of placing the event in time or sequence.
11:49 You asked the patient: Do you find that you worry more than others?
12:04 The patient said: Without my medicine bundle, I won't make it.\nYou answered: Are you feeling hopeless? \nYou used the therapeutic technique of translating to feelings.
12:05 You asked the patient: Are you frightened of anything?
12:17 The patient said: I'm not sure what to do.\nYou answered: Go on. \nYou used the therapeutic technique of offering general leads.
3. Referring to your feedback log, document all nursing care provided and Ms. Waterfall’s response to this care.
1:08 You asked if the patient had any known allergies.
1:15 You performed medication reconciliation.
1:35 You assessed the respiration.
1:44 You checked the pulse oximetry.
2:03 You measured the blood pressure.
2:19 You measured the temperature.
2:35 You auscultated the lung sounds.
3:09 You auscultated the heart sounds.
3:25 You checked the patient's skin.
3:45 You observed the appearance.
3:54 You assessed the attention.
4:01 You observed the motor activity.
4:06 You assessed the speech.
4:14 You assessed the thought processes.
4:25 You assessed the patients IV.
4:41 You asked the patient: What is your full name? The patient said: My name is Linda Waterfall.
4:47 You asked the patient: Have you taken your medication? The patient said: I don't have any prescribed medications.
5:37 You asked the patient: Do you have any difficulty with your breathing? The patient said: Yes. I feel I can't breathe.
5:43 You asked the patient: Do you have chest pain? The patient said: No, I don't have chest pain.
5:49 You asked the patient: Do you have any pain? The patient said: No.
5:54 You asked the patient: On a scale of 0 to 10, how would you rate your level of distress?
6:10 The patient said: I can't think straight until I find my medicine bundle.\nYou answered: This medicine bundle means a great deal to you. \nYou used the therapeutic technique of reflection.
6:10 You asked the patient: Have you had any changes in your appetite over the past month? The patient said: My appetite has been about the same.
6:17 You asked the patient: Do you get hungry? The patient said: Yes.
6:21 You asked the patient: How many meals do you eat each day? The patient said: I usually eat three meals a day.
6:26 You asked the patient: Do you eat between meals? The patient said: Sometimes I have a snack.
6:30 You asked the patient: Have you been eating much less or much more over the past few weeks? The patient said: No, not really.
6:37 You asked the patient: Have you lost or gained weight over the past month? The patient said: No, I am about the same weight.
7:03 You asked the patient: Do you nap during the day? If so, how often and for how long? The patient said: No, not usually.
7:10 You asked the patient: Do you have any trouble falling asleep? The patient said: Sometimes I have trouble falling asleep when my thoughts are racing.
7:18 You asked the patient: Do you wake up in the early hours of the morning and have trouble returning to sleep? The patient said: No, not usually.
7:25 You asked the patient: Do you have nightmares or vivid dreams on a regular basis? The patient said: No, not usually.
7:37 You asked the patient: Approximately how many hours of sleep do you get each night? The patient said: I sleep about 7 hours a night.
7:43 You asked the patient: Do you have energy to do the normal activities necessary to get through the day? The patient said: Yes, I have no trouble with energy once I get up in the morning.
7:53 You asked the patient: Do you have energy to do the activities that give you enjoyment? The patient said: I do have energy to do my hobbies and other activities that I enjoy.
8:15 You asked the patient: I would like to ask you a series of questions about how you are feeling to help me better understand how together we can start to plan your care. These are questions I ask all of the patients I see. May I ask you these questions?
8:44 The patient said: All of this talking, it's just a waste of time.\nYou answered: Do you feel that no one understands your feelings? \nYou used the therapeutic technique of verbalizing the implied.
8:47 You asked the patient: Do you feel alert to answer questions? The patient said: Yes, I am.
9:29 You asked the patient: Please tell me your name. The patient said: My name is Linda Waterfall.
9:35 You asked the patient: Can you tell me where we are? The patient said: Yes, I am in the hospital, but I don't know if I want to stay. I can't have the surgery without my medicine bundle to protect me. It is very important to me.
9:49 You asked the patient: Please tell me what today's date is. The patient said: It is the 19th.
10:00 You asked the patient: Have you lost interest in activities that you once enjoyed? The patient said: No, not really.
10:06 You asked the patient: Name an activity that you enjoy. The patient said: I like listening to music. It helps to calm me.
10:13 You asked the patient: Can you name the last five American presidents starting with Barack Obama and going back? The patient said: Barack Obama, George W. Bush.... I don't know. I am anxious and can't think.
10:27 You asked the patient: Can you tell me what you ate for breakfast? The patient said: I did not eat this morning because of surgery.
10:34 You asked the patient: Do you have any thoughts or wishes to harm or kill yourself? The patient said: No.
10:39 You asked the patient: Have you ever tried to harm or kill yourself? The patient said: No.
10:45 You asked the patient: Do you think it would be better if you were not alive? The patient said: No.
10:48 You asked the patient: Do you have any thoughts or wishes to harm anybody else? The patient said: No.
10:53 You asked the patient: Have you ever tried to harm or kill somebody else? The patient said: No.
11:40 You asked the patient: Do you ever see or hear things that other people do not? The patient said: No, I do not.
12:19 You supported the patient about religious beliefs.
12:25 You supported the patient about treatment.
12:35 You supported the patient about medicine bundle.
12:46 You supported the patient about family far away.
12:54 You supported the patient in taking deep breaths.
13:08 You supported the patient's cousin about family relations.
13:19 You educated about discharge plans. You should do this after contacting the provider.
13:40 You educated about possibilities and advocated for the patient.
14:26 You called the provider.
4. Document all interventions associated with the management of Ms. Waterfall’s anxiety as they are included into her plan of care. Include interventions especially focused on her spiritual and cultural needs, as well as those demonstrating nursing advocacy.
• Her breathing and heart rate were assessed and although the results of such actions produced normal vitals, she still insisted that she had trouble breathing and that her heart was racing. Before she came in, it was indicated that she wanted her tribal healers to accompany her before she scheduled her appointment. She was not able to do that so she went ahead and took the available appointment. This resulted her having her anxiety spike up. She also kept stating about her medicine bag. Consideration for her would be to provide assistance in obtaining her medicine bag. If surgery is not urgent perhaps she can reschedule her appointment until she is able to gather her tribal leaders to accompany her to her appointment.
5. Document your handoff report in the SBAR format to communicate Ms. Waterfall’s future needs.
Linda Waterfall is a 48-year-old patient of Dr. Samuels. She is scheduled for a left mastectomy this morning at around 08:30. Ms. Waterfall is of native American decent who was recently diagnosed with an aggressive form of breast cancer and is in need of surgery. She came into the surgical floor with much anxiety about her situation. She stated that her mother had died in surgery which further complicates her situation. Vitals were all normal although her blood pressure was elevated at 150/80 mmHg. An intravenous (IV) dextrose 5% lactated Ringer’s. It’s infusing at 80 mL/h through an 18-gauge catheter in her right forearm is currently running. Recommendation for Ms. Waterfall would be to educate her on techniques to reduce her anxiety level. Also assistance with obtaining her medicine bag to ease her worries and getting her tribal leaders to come to the hospital to help her make her decision about the current situation is recommended.
Show All
Study Tips
Information about earning
Selling tips
Copyright
Information
About us
Subjects
Need Support?
We are available 24/7
FAQ
Contact us
Legal
Privacy Statement
Terms of Use
Subscribe to Newsletter
Subscribe to Newsletter
submit
Latest Blogs
UNISA - University Of South Af...
7 Effective Note-Making Tips F...
How To Give A Good Presentatio... [Show Less]