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    HA-RLE-WS # 3 Caday Sherish Millen

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    Sherish Millen Caday
    This case study describes a 54-year-old female mathematics teacher who is experiencing increasing memory loss and difficulty retaining information. A mental status examination found the client to be alert and oriented, with clear speech and logical thought processes, but an impaired ability to recall words after a delay. Tests scores suggest mild cognitive impairment. The client's brother had bipolar disorder and she reports disrupted sleep. No medical diagnoses or substance use issues were noted. Nursing diagnoses could include risk for acute confusion and deficient knowledge related to her symptoms.

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    HA-RLE-WS # 3 Caday Sherish Millen

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    Sherish Millen Caday
    109 views15 pages
    This case study describes a 54-year-old female mathematics teacher who is experiencing increasing memory loss and difficulty retaining information. A mental status examination found the client to be alert and oriented, with clear speech and logical thought processes, but an impaired ability to recall words after a delay. Tests scores suggest mild cognitive impairment. The client's brother had bipolar disorder and she reports disrupted sleep. No medical diagnoses or substance use issues were noted. Nursing diagnoses could include risk for acute confusion and deficient knowledge related to her symptoms.

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    This case study describes a 54-year-old female mathematics teacher who is experiencing increasing memory loss and difficulty retaining information. A mental status examination found the client to be alert and oriented, with clear speech and logical thought processes, but an impaired ability to recall words after a delay. Tests scores suggest mild cognitive impairment. The client's brother had bipolar disorder and she reports disrupted sleep. No medical diagnoses or substance use issues were noted. Nursing diagnoses could include risk for acute confusion and deficient knowledge related to her symptoms.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    109 views15 pages

    HA-RLE-WS # 3 Caday Sherish Millen

    Uploaded by

    Sherish Millen Caday
    This case study describes a 54-year-old female mathematics teacher who is experiencing increasing memory loss and difficulty retaining information. A mental status examination found the client to be alert and oriented, with clear speech and logical thought processes, but an impaired ability to recall words after a delay. Tests scores suggest mild cognitive impairment. The client's brother had bipolar disorder and she reports disrupted sleep. No medical diagnoses or substance use issues were noted. Nursing diagnoses could include risk for acute confusion and deficient knowledge related to her symptoms.

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    HA-RLE Worksheet # 3

    ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE

    Case Study:

    Read the following case study. Then work through the steps of analysing the case study
    data.

    1. First identify abnormal data and strengths in subjective and objective findings;
    2. Assemble cue clusters;
    3. Draw inferences;
    4. Make possible nursing diagnoses;
    5. Identify defining characteristics;
    6. Confirm or rule out the diagnoses; and
    7. Document your conclusions.

    Use the table below to collect subjective and objective data provided to guide you.
    Propose nursing diagnoses that are specific to the client in the case study. Identify
    collaborative problems, if any, for this client. Finally identify data, if any, which point
    toward a medical problem requiring a referral.
    Mrs. Susan Dy, a 54-year-old, 6th grade Mathematics teacher, comes to wellness
    screening and expresses concern that she has had difficulty recalling her students’
    names over the past semester. She also misplaces objects more frequently than in the
    past. Both her memory and misplacing things are getting worse. She has no history of
    stroke, meningitis, or head injury and no family history of Alzheimer’s. Her brother had
    bipolar disorder. She is able to perform activities of daily living but it is getting more
    difficult to grade math papers at night. She tries more easily than in the past. She
    awakens two times a night but is able to return to sleep within 30 minutes. She reports
    having good appetite and a daily well-formed bowel movement. She is active in her
    church community and walks 3 miles, four times a week. She enjoys quilting. Mrs.
    Susan has positive relationships with her husband and two daughters.

    Mental status – alert and oriented to person, place, day, and time. Clean and
    neat appearance. Has direct eye contact with pleasant cooperative disposition. Speech
    clear with moderate tone. Somewhat anxious over forgetting names and location of
    objects. Looking forward to retirement in 8 years. Able to name familiar objects in room.
    Expressed clear, realistic and logical thought processes about the past and future.
    Recalls breakfast and past dates of family member’s birthdays. Repeated four unrelated
    words after 5 minutes, one word after 10 minutes, unable to repeat any words after 12
    minutes. Explained the meaning of common proverbs, explained what she would do in
    an emergency situation in her classroom. Correctly drew the face of a clock. Scored 28
    in the Saint Louis University Mental Status (SLUMS) Examination.
    Note: Please secure consent before starting the interview to actual client….

    NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA


    QUESTIONS FINDINGS
    Biographical Data
    Name (use Code Name or Alyas) Cassie

    Gender Female

    Address, Phone Number General Santos City

    Date and Place of Birth n/a

    Nationality or Ethnicity Filipino

    Marital Status Married

    Religious or Spiritual Practices Roman Catholic

    Primary and Secondary Languages English and Filipino


    spoken, written, and read; Birth Language
    Educational Level College graduate

    Occupation and Working Status Mathematics Teacher

    Who lives with the client? Identify Husband, two daughters


    significant others
    Caregivers and support people for the n/a
    client

    Present History (Reasons for Seeking Health Care)


    What is your major health care or The client has a problem in retaining her
    concern? memory.

    Are you comfortable with seeking care n/a


    from this organization? Past Experiences
    good or not?

    History of Present Health Concern (use COLDSPA when appropriate)


    Character of symptom or condition? Memory loss

    Onset (when it begin; better? Worse? Estimated fifteen weeks ago


    Same?
    Location (where and does it radiate?) n/a

    Severity (on scale of 1-10?) n/a

    Pattern (what makes it better? Worse? n/a

    Associated factors (other associated n/a


    symptoms? Effect on leisure or
    exercise?)

    Past Health History


    Head injuries, meningitis, encephalitis, none
    stroke? Effects on health?
    Past medical diagnoses, surgeries none

    Past counselling services received? n/a


    Results?

    Headaches? Describe n/a

    Served in active duty in armed forces? n/a

    Breathing Difficulties? n/a

    Heart Palpitations? n/a


    Exposure to environmental toxins? n/a

    Family History
    Family history of mental health problems? Brother-Bipolar disorder

    Family history of psychiatric disorders, none


    dementia, brain tumors?

    Lifestyle and Health Practices


    Describe typical activities in a day  active in church community
     enjoys quilting.

    Energy level with ADLs? high


    Typical eating habits? Healthy eating habits

    Alcohol consumption? Type? Amount? none


    Frequency?

    Use the CAGE self-assessment tool to n/a


    detect at risk clients. ( Box 6-1 p.79)

    Use the AUDIT questionnaire to assess n/a


    alcohol related disorders. Calculate
    score. ( Assessment Tool 6-1 pp 93-94 in
    the textbook).

    Any use of recreational drugs (i.e. none


    marijuana, tranquilizers, barbiturates,
    cocaine, methamphetamines)?

    Sleep patterns Disrupted sleep

    Typical bowel elimination patterns Well-formed bowel movement

    Exercise patterns walks 3 miles, four times a week.

    Use of prescribed or OTC drugs n/a

    Religious practices and activities? Active in church community


    Role in family and community? teacher

    Relationship with others (family members, n/a


    coworkers, neighbors)

    Perception of self and relationship with n/a


    others?

    View of one’s future? Life goals? Looking forward for retirement in 8 years

    PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA


    *When time is limited, use the St. Louis Score: 28 (normal); high school education
    University Mental Status (SLUMS)
    examination (Assessment Tool 6-3 p. 95
    in the textbook). Report client’s SLUMS
    score and clients level of education.
    Otherwise complete observation below.
    Level of consciousness. Ask for name, The client is responsive and is able to
    address and phone number as answer the questions.
    appropriate. If no response:

    Call name louder

    Next shake gently

    If still no response, apply painful stimulus.


    Use the Glasgow Coma Scale (GCS)
    (see Assessment Tool 6-2 p. 93 in the
    textbook) for clients who are at high risk
    for rapid deterioration of consciousness.
    Note posture, gait and body movements. Has direct eye contact during the
    interview

    Observe behaviour and the clients affect. Alert, oriented to person, time, place and
    day

    Note dress, grooming and hygiene. Clean and neat appearance


    Observe facial expression. Anxious

    Observe speech Speech clear with moderate tone

    Note mood, feelings and expressions. The client shows a pleasant cooperative
    Use depression questionnaire (Box 6-2 p. disposition.
    81 in the textbook) if depression is
    suspected. Use the Geriatric Depression
    Scale (Box 32-2 p 797 in the textbook) for
    older adults.
    Note thought processes and perceptions. Expressed clear, realistic and logical
    thought processes about the past and
    future.

    Observe for any destructive or suicidal none


    tendencies.

    Observe the following cognitive abilities:


    ● Orientation to person, time and ● Orientation to person, time and
    place place ☑

    ● Concentration and alternatives ● Concentration and alternatives ☑

    ● Recent memory ● Recent memory ☑

    ● Remote memory ● Remote memory ☒

    ● Memory to learn new information ● Memory to learn new information

    ● Abstract reasoning ☑

    ● Judgment ● Abstract reasoning ☑

    ● Visual and constructional ability ● Judgment ☑

    ● Visual and constructional ability ☑

    Use the Alcohol Use Disorders n/a


    identification Test (AUDIT): Interview
    Version to interview a client for risk of
    alcohol abuse (Assessment Tool 6-1 p.
    93 in the textbook).
    Use the Confusion Assessment Method During the assessment, the client recalls
    (CAM) to assess for confusion (see breakfast and past dates of family
    Assessment Tool 6-4 p. 96 in the member’s birthdays. Repeated four
    textbook) unrelated words after 5 minutes,

    one word after 10 minutes, unable to


    repeat any words after 12 minutes.
    Use the modified SAD Persons Suicide n/a
    Risk tool to assess for suicide risk (see
    Assessment Guide 6-1 p. 83 in the
    textbook).
    Analysis
    Formulate nursing diagnoses 1. Risk for Acute confusion in related to
    fluctuation in sleep-wake cycle and
    metabolic abnormalities
    2. Deficient knowledge r/t lack of
    exposure and recall
    3. Impaired memory r/t neurological
    disturbances as evidenced by
    impaired problem solving/ decision-
    making and inability to recall or learn
    new information
    4. Disturbed sensory perception,
    specifically gustatory r/t psychological
    stress as evidenced by disturbed
    sleeping pattern
    5. Mild anxiety r/t stress as evidenced
    by restlessness, sleep disturbance

    Formulate collaborative problems

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