SIM DEREK Essay

Submitted By Athena-Flores
Words: 954
Pages: 4

NUR 1520 CLINICAL SIMULATION CARE PLAN CLIENT ________Derek________________
Clinical background
20-year-old male, disheveled unshaven body odor, reports that someone was following him, he is very frightened with rapid speech, vague and states that someone is listening to him or her as they speak. Anxious and suspicious and highly agitated and he begins to start tapping his foot and muttering threatening statements. A few weeks prior to his final exam in chemistry he had placed sheets over his windows and locked his door and wedged his dresser under the doorknob so no in could get in. He stated that Taliban soldiers were lurking around the dormitory and following him thinking they were going to kill him. Derek has had difficulty functioning for the past 6 months and his symptoms have worsened over the last week. He is anxious and is having trouble with his thoughts and he is also isolating himself from others as he believes that he is being followed.
STUDENT____Athena Flores_______________ Date _______June 25, 2015______________

Pertinent psychopathology
Schizophrenia is known that the brain chemistry, structure and activity are different in a person with schizophrenia. It occurs when multiple inherited abnormalities combine with no genetic factors altering the structures of the brain affecting the brains neurotransmitter systems and or injuring the brain directly. There are genetic factors that come into play as well as a dopamine theory factor that is related to a neurobiological factor. Also brain structure abnormalities seem to play a role in the disruption of the brain. There are also psychological a d environmental factors that play a role as well for example prenatal stressors and environmental stressors like the tap water that we drink can have a solvent that will affect our brain chemistry.

Signs and symptoms, objective and subjective data
Unshaven, disheveled, body odor, said someone was following him, very frightened, rapid speech, states that someone is listening to their conversation, anxious, paranoid, suspicious, highly agitated, tapping of his foot, muttering threatening statements, hallucinations, isolating himself, delusions

Medications Why is this client on these meds? Classifications, Expected and Adverse effect, Client teaching

Seroquel an atypical medication 25mg PO TID titrate upward 25 on days 2 and 3 as tolerated until it reaches a larger dose of 100mg PO TID on day four. Antipsychotic medication with side effects of drowsiness, dizziness, flulike symptoms, palpitations, somnolence, agitation, dry mouth, weight gain, and orthostatic hypotension. Rare effects are dystonic reactions, seizures, and leukopenia. Teach patient to asses the relationship of anxious symptoms for med administration.
Xanax 2mg PRN Q3-4 h PRN Benzodiazepine for anxiety, side effects include drowsiness, dizziness, feeling tired or irritable, blurred vision, headache, memory problems, trouble concentrating, insomnia, swelling of hands and feet, muscle weakness. Teach patient no to stop abruptly has to be titrated. Must check vitals regularly and have a regular diet

Data analysis
State that thoughts are less intense and less frequent with aid of medications and nursing interventions by the end of the week. Nursing Diagnosis 1
Disturbed thought process related to overwhelming stressful life events as evidence by inappropriate thinking

Nursing actions utilize safety measures to protect patients or others

Attempt to understand the significance of these beliefs to the patient at the time of their presentation

Do not argue with the patients beliefs

Do not touch the patient use gestures carefully

Rationales During the acute phase, patient’s delusional thinking might dictate to them that they might have to hurt others to be safe.

Important clues to underlying fears and issues can found…