Question

Richard is a 25 y.o. male patient who is being admitted to the inpatient mental health unit. He has a diagnosis of Bipolar 1 disorder. He has no history of physical or medical illnesses. During the admission assessment, Richard indicates that when he was 21 y.o., he was treated for bipolar 1 as an outpatient in the hospital clinic. He indicates was prescribed Carbamazepine but stopped taking it about 1 year ago. He told the nurse he has recently moved to the city as a mechanic, lives with a close relative temporarily. He does not have any friends in the city. About 3 weeks ago he had a surge of energy, was working 14-hour days and was up at night for days. During the interaction Richard often talked about his past depression and suicidality. Over the past month he has lost 15 lbs., has difficulty eating and has no appetite. He does not have the”…energy to get out of bed..” and has missed 4 days of work in the past week. He acknowledges having thoughts of ending his life by “driving off the road”. However, he says he is uncertain and afraid that if he takes his own life he will go to hell. You are the nurse assigned to provide care to Richard.

What might you document regarding your assessment based on the above information? (from a nursing perspective)

Answer 1

As a nurse a comprehensive care is an important part.nimurse should record all the patient related aspect for the future reference and treatment purposes.

In this case patient admitted with bipolar disorder and while taking history nurse is getting more information about the patient.from that nurse understands patient harms serious mental issues in the past .so it's important document all the findings uwe notice .

Nurse can use the format SOAP method to document the details just as follows.

Subjective.in the subjective session we can entae all the details that patient has informed including past treatment for bipolar depression and also related suicidal thoughts. Also we can enter his details including weight loss decrease appetite previous medication and also minimal contacts with frnds.

Objective _here we can enter patient current staus including vitals signs patient behaviour patient approach to staff and other concerns of patient.do physical examination and enter details.

A_assessment. Based on history we can find out the main problem and we can get to know patient condition like sever mental stress with bipolar disorder.

R recommndation_in this part we can document based on history assessment what we plan to do for the patient including safety measure to prevent suicide,administer medication support the pat6 to prevent social isolation such things what we are going to do for the patient can be documented.