Therapeutic Communication
Student’s Name: Client’s Initials: M.P.
Date of Interaction: 27 October 2015 Therapeutic Communication #3
ASSESSMENT:
· Background Information: M.P. is a 54yo separated Caucasian woman who was encouraged to go to ABH after sharing with her day group that she possibly overdosed the day before on one of her home medications. She has a history of major depressive disorder which has left her out of work for several years and recently she has developed suicidal ideations in the past several months.
· Medications
1. Aripiprazole (Abilify), 15mg tab PO nightly—for psychosis
Side effects: dizziness, weakness, nausea, vomiting, fatigue, excess saliva, choking or trouble swallowing, blurred vision, headache, anxiety, weight gain, sleep problems, constipation
2. Diphenhydramine (Benadryl), 50mg cap PO nightly—for insomnia
Side effects: sedation, fatigue, dizziness, disturbed coordination, constipation, dry mucus membranes, blurred vision, tremor, anorexia, nausea
3. Fluoxetine (Prozac), 5mg tab PO nightly—for depression
Side effects: nausea, constipation, headache, anxiety, insomnia, drowsiness, dizziness, heart palpitations, weight changes, cold symptoms, dry mouth, impotence
4. Lithium, 300mg cap PO QID—for mood stability
Side effects: tremors, increased thirst, increased urination, diarrhea, vomiting, weight gain, impaired memory, poor concentration, drowsiness, weakness
5. Oxybutynin (Ditropan), 5mg tab PO BID—for bladder spasm
Side effects: dry mouth, blurred vision, constipation, diarrhea, nausea, dizziness, weakness, headache, insomnia
6. Propanolol (Inderal), 10mg tab PO BID—for tremors
Side effects: dizziness, fatigue, nausea, vomiting, stomach pain, vision changes, insomnia
· Assess myself: While I had prepared to present my teaching project that day, I was eager to help the nurses and spend time with patients. It was my last week on Montgomery unit, so between my teaching project and interacting with patients on the unit, I was eager to have a productive day.
· Assess milieu : There were 12 patients on the unit that day. Many of the patients were spending time with each other in the day room, laughing and chatting as they painted each other’s nails. Because of MP’s fluctuating SI and recent attempts to hide plastic utensils in her room, the nurse asked if I would sit with MP while she ate dinner.
DIAGNOSIS:
Nursing diagnosis: Risk for self-directed violence, ineffective individual coping, anxiety, hopelessness, social isolation
PLANNING:
· Describe a tentative goal of the TC: I want the patient to openly discuss her recurrent suicidal ideations and contemplate stressors. Hopefully I can also direct her to focus on the positives in her life, like her family and her possibilities.
· By completion of the TC, the patient will:
1. Discuss her desire to die.
2. Recognize possible stressors leading to SI.
3. Focus on the positives and motivations in her life.
