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Mrs.Smith (Implementation (least restrictive, safe, and monitored…
Mrs.Smith
Implementation
least restrictive, safe, and monitored environment to promote continuous observation
Closely monitor patient during the use of potential weapons (scissors, razors)
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Involve patient in treatment planning and self-care management. Ensure that patient is taking medications as prescribed
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Check mouth to ensure all medications have been swallowed and patient is not holding medications in jaws
observe, record, and report any changes in mood or behavior that may significantly increase suicide risk and document results of regular surveillance checks
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Encourage sleep with frequent rest periods throughout the day because the lack of sleep can increase symptoms of mania.
Assess suicidal ideation, allow patient to express feelings.
Administer medications Zoloft, Lithium, and consult with the physician about Depakote. The patient has an order for Depakote and she has an allergy so withhold medications and consult physician and pharmacy
Soft restraints (allow for bathroom breaks, assess the patient to ensure if restraints are still needed)
continuously monitored, plastic utensils only, no cords, no shoe strings, patient cannot have anything that can be used for self-harm, no visitors are allowed depending on the state of the patient’s condition
when taking lithium, lithium levels should be taken to avoid lithium toxicity. The IV should be assessed to ensure the patient is getting the fluids because the patient is NPO
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NG tube on continuous suction that she keeps trying to remove, so the nurse should check the placement of the tube checking regularly by aspirating gastric contents and checking PH levels
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When the patient is taking medications raise the head of the bed to prevent aspiration and hospital-acquired pneumonia
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Ensure the cleaning of the wound is sterile to prevent infection and monitor the site of the wound for signs of infection
Monitor IV site for bleeding, redness, and patency
Monitor the color and amount of urine, because she yanks out her Foley
Cast care to lower left leg is important, because the cast cannot do its job without proper routine care
Check the skin color, intactness of the skin, and circulation in areas restraints are in use
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Monitor wound for drainage, color, and odor.
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Assessment
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She reported a recent decreased need for sleep, euphoric mood, and racing thoughts.
poor hygiene, restless, agitated, depressed, anxious, and distracted.
Pt. stated, “I was on the floor, my husband was trying to hurt me, so I jumped.” “I wanted to hurt myself, and I wanted to hurt my husband.”
Pt. suffered multiple comminuted fractures of her left ankle and penetrating laceration to the abdomen requiring surgery.
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Pt is a post op patient with a high risk of post surgical complications (bleeding, hemorrhage, infection, dehiscence, etc)
Pt is in restraints with not much room to move, this may affect or enhance postoperative complications
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Pt has abdomen wound, covered with dressing
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Evaluation
pain is reduced because patient takes all pain medication as directed is able to verbalize a decrease in pain level using the pain scale
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risk of infection is reduced due to adequate mouth care, proper catheter care, and sterile dressing changes
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other complications are minimized due to adequate cast care and checking wrists for circulation, bruising, etc
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