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Report from charge nurse: Situation: Li Na Chen is a 40-year—old female who presented to the emergency
department (ED) accompanied by her partner, who reported that upon return home today, he found her crying on
the bathroom floor surrounded by several empty pill bottles, and he called 911. He reported that she tol… Show more

Based on the scenario above pill out this form 

Date Student Nam              vSim Li Na Chen Part 1 

Initials:

 

Age:

 

M/F:

 

Diagnosis:

 

 

Allergies:

Precautions:

 

 

Consults Needed:

Critical Labs: 

 

 

 

Why is your patient in the hospital, per patient and per EMR (include history of present mental illness):

 

 

 

 

 

 

 

BioPsychoSocial History:  Include Medical Health History/Co-morbities/coping skills/strengths/education (learning difficulties)/work/social history/relationships/Hx of abuse or trauma/Legal history/substance/addiction history:

 

 

 

 

 

 

 

 

 

 

Part 1 Admission

Alerts:

What are you on alert for with this patient? (signs & symptoms)

1.

 

2.

 

3.

Complications

List Complications that may occur related to dx, procedure, medications, and comorbidities:

1.

 

2.

 

3.

 

 

 

Assessments:

What Assessments will be used to focus on this patient? (How will I identify the above signs & symptoms?)

 

1.

 

2.

 

3.

 

Delegation:

What aspects of patient care can be delegated and who can do it?

 

 

1.

 

2.

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychopathology:

Axis I Diagnosis:  ________________________________________________________

Directions:  Present “textbook” picture; compare your client.  Include psychodynamics, etiology, description of signs and symptoms, treatment and prognosis.  How does your client compare with what the textbook says about the diagnostic label given to your client? 

 

TEXTBOOK DESCRIPTION (CITE SOURCE)

YOUR CLIENT

Etiology & Psychodynamics:

 

 

 

 

 

 

 

 

 

 

Signs and Symptoms:

 

 

 

 

 

Treatment:

(Medications, Therapy, Other)

 

 

 

 

 

 

Prognosis:

(Will it get better, stay the same, or get worse? Give your rationale for your prognosis)

 

 

 

 Style Reference:_  ____________________________

_____________________________________

 

Etiology & Psychodynamics:

 

 

 

 

 

 

 

 

 

 

Signs and Symptoms:

 

 

 

 

 

Treatment:

 

 

 

 

 

 

 

Prognosis:

 

SCIENCE
HEALTH SCIENCE
NURSING

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