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Ms. Smith (DIAGNOSIS (Nursing Diagnosis (Risk for Injury r/t attempt of…
Ms. Smith
DIAGNOSIS
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Nursing Diagnosis
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Risk for Violence: Self-directed or Other Directed r/t combative actions during ED admission and attempt to harm self and husband with scissors
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Disturbed Sleep Pattern r/t racing thoughts, restless behavior, and agitated mood
INTERVENTIONS
Medical orders:
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Sterile dressing change to abdomen once a shift (normal saline, 4x4's, ABD dressing, secure with tape)
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Soft wrist restraints r/t continuous removal of foley catheter, IV line, & NG tube
Nursing Interventions:
Blood work for Lithium 900 mg, monitor for toxicity
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Monitor patient's foley catheter, IV line, and NG tube
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51 year old female
Bipolar Disorder
Feeling suicidal, depressed and scared.
"I was on the floor, my husband was trying to hurt me, so I jumped.
:warning: EMERGENCY ROOM :warning: Multiple comminuted fractures of her left ankle and penetrating laceration to the abdomen requiring surgery
ASSESSMENT
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Admission to ED
Alert and oriented, combative
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Judgment
Poor impulse control, maladaptive
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Assess cast for dirt, skin cyanosis, or drainage
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Monitor wound site for signs of infection : abnormal drainage, swelling, pain and heat
"I wanted to hurt myself, and I wanted to hurt my husband."
She reported that her ex husband had been abusive to her through the years, and he recently threatened to kill her.
Reported decreased need for sleep, euphoric mood, and racing thoughts
12 psych admissions, most recent was 2 years ago. Reports 1 past suicide attempt 6 years ago.
Past hospitalizations: decreased need for sleep, euphoria, bizarre behavior, racing thoughts, paranoia and increased activity
PLANNING
Due to Ms. Smith's assessment and diagnosis, a plan must be made in order to provide the best care possible.
Gather 4x4 gauze, ABD pad, securment tape and noraml saline for dressing change
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Plan interventions to avoid numerous trips in order to give her plenty of rest. Limit interruptions.
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EVALUATION
Evaluate medical orders and nursing interventions affect on patient care. If patient is not showing positive sings to interventions, new interventions must be planned.
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Cast care was/not not preformed. Limb does/does not have drainage, pain, or dirt.
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NG tube placement, patency, and care outcomes
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IV insertion site: infection, plebitis, infiltration, patent
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