Sharon Cole Documentation _ Mental Health Case: Sharon Cole | Complete Solutions (Graded A)
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Course
Nursing
Institution
Nursing
Mental Health Case: Sharon Cole
Documentation Assignments
1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute
agitation. Include her responses to your assessment.
The findings related to Sharon Cole’s s/s of acute agitation are that she has...
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Mental Health Case: Sharon Cole
Documentation Assignments
1. Document your findings related to the focused assessment of Mrs. Cole’s signs and symptoms of acute
agitation. Include her responses to your assessment.
The findings related to Sharon Cole’s s/s of acute agitation are that she has bipolar disorder type 1. She has
stopped her medication, which has caused an imbalance in her behavior and she is experiencing a manic
episode. She is known for stopping her medication and the last time she had a manic episode was 2 years ago.
Her husband noted that she has not been sleeping well or eating well for the past 2 weeks.
2. Document all interventions made to manage Mrs. Cole’s acute agitation through medication administration.
Include her responses to the medication administered.
The interventions for Sharon Cole’s management of acute agitation with medication was successful. She was
experiencing panic when stating she can’t think with all the racing thoughts or that fact that the nurse is forcing
her to stay in the hospital and she can’t get any of her work done. Her responses were that she would take any
medication because the nurse was pretty.
3. Referring to your feedback log, document all nursing care provided and Mrs. Cole’s response to this care.
0:00 You checked scene safety. It was correct to check
scene safety in order to maintain your own safety.
0:06 You introduced yourself.
0:29 You washed your hands.
0:35 You identified the patient.
0:50 You asked if the patient had any known allergies.
1:09 You supported the patient about safety.
2:01 You asked the patient: Can you tell me where we are?
2:15 The patient said: Last night seems like a dream. I don't
think I was even there. You answered: What seemed to
lead up to you going to the bar? You used the
therapeutic technique of placing the event in time.
2:48 You asked the patient: Can you tell me what a desired
, outcome of treatment would be for you?
3:25 The patient said: Look, I need to get out of here. The
whole thing is going to fall apart. I can't get to
Washington. Don't you people care about all the
soldiers who are going to die without my help? Nobody
can see it, but I can! They are going to waste all the
money on the wrong things! I have to get out of here.
Allen can drive there. This thing on my leg is in the
way. You answered: Mrs. Cole, I am your nurse today
and I am here to help you. You just had surgery. Please
stay in the bed. You used the therapeutic technique of
presenting reality.
3:36 You supported the patient about rest and healing.
3:46 You supported the patient about racing thoughts.
4:02 You educated about discharge.
4:48 You asked the patient: Do you have any pain?
5:07 The patient said: And you, because of you I can't do
my work. You keep me downtown all the time in this
bed. You answered: Mrs. Cole, I'll be glad to sit with
you and talk awhile. You used the therapeutic
technique of offering self.
5:11 You asked the patient: How would you rate your pain,
on a scale of 0 to 10? The patient said: I don't have any
pain.
5:22 You asked the patient: Can you tell me a little bit more
about what's going on with you today? It was
appropriate to ask the patient what was going on with
her to get an understanding of this.
5:42 The patient said: There's too much work to be done. I
can't do it here and you can't make me stay here. I'm
going to call the police and have you arrested. You are
keeping me prisoner. I'm leaving now. You answered:
You are in the hospital for treatment. Please stay in the
bed. You used the therapeutic technique of giving
information.
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