A 16-year-old female is admitted to the acute mental health unit for observation and therapy. The nurse documents patient findings in the medical record.
A 16-year-old female is admitted to the acute mental health unit for observation and therapy. The nurse documents patient findings in the medical record.
Nurses’ Notes:
1100: Alert and oriented x 3. States she cut herself last night as she has done many times before and
doesn’t understand why she was admitted. Says she has been very depressed and was “planning to
take her mother’s antianxiety pills to help ease the emotional pain.” Recognizes that her parents love her and are very supportive but has no other support system. Thinks her boyfriend broke up with her because she is too fat. Has increased her binge eating and purging. Height = 68 in; weight = 108 lb. Left upper thigh dressing from cutting intact with old bloody drainage. Vital signs stable.
Hint: At this point in the clinical Judgment Process, you are NOT expected to interpret or analyze what is causing the patient’s findings or what nursing care is required at this point. Just think about the findings and answer the following questions:
2. Answer each of the following questions in one sentence:
· What information is important and matters most?
_____________________________________________________________________________________
· Why is the lack of support system information important also?
_____________________________________________________________________________________
· What information is important regarding her eating habits and height and weight?
____________________________________________________________________________________
· How is the information about her height and weight related to her breakup?
_____________________________________________________________________________________
· What additional data would you want to gather?
_____________________________________________________________________________________
3. Check if the findings are Expected or Not Expected
Patient Findings
Normal/Usual or Expected findings
Abnormal or Not Expected (Relevant Requiring Follow-up)
Alert and Oriented
Cuts herself
Depressed and planning to take medication
Parents loving and supportive
No other support system
Broke up with boyfriend due to client being too fat
Increased binging and purging
Underweight
Dressing with small amount of dry old bloody drainage.
Vital signs stable