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vSim ISBAR Activity Student WorksheetIntroduction(Your name, position (RN), unit you are working on)Mary Frometa Mental health unitSituationPatient’s name, age, specific reason for visitLi Na Chen is a 40-year-old Chinese female Reason for visit is Major Depressive Disorder BackgroundPatient’s primary diagnosis, date of admission, current orders of patientAdm Dx: Major Depressive DisorderDate of admission: 4/17/2020Orders- Laboratory tests: once every 12 hours, and then every day for 3 days Complete blood count Liver function tests (alanine aminotransferase[ALT], aspartate aminotransferase [AST], bilirubin [total and fractionated], alkaline phosphatase) AmmoniaProthrombin time with international normalized ratioGlucose Renal function studies (electrolytes, blood urea nitrogen, creatinine) Vital signs every 6 hours for the first 2 days until stable and then daily Encourage fluidsSuicide precautions; observation every 15 minutesUnit safety check protocolHamilton Depression Scale every other dayParticipation in unit milieuActivity: up and aboutDiet: regularMedications: Sertraline 75 mg orally every day at 09:00 for5 days, and then decrease to 50 mg. On hold until restarted by the attending psychiatrist
Venlafaxine 37.5 mg orally every day at 09:00for 5 days, and then increase to twice daily. On hold until restarted by the attending psychiatrist AssessmentCurrent pertinent assessment data using head to toe approach, pertinent diagnostics, vital signsThe pill bottles for her recently prescribed acetaminophen and ibuprofen accompanying her appear empty. Mrs. Chen claims to have been using the medications as prescribed by the community clinic. Her husband reports that she may have taken approximately 6000 mg of acetaminophen and 4800 mg of ibuprofen. Acetylcysteine 7000 mg in 200 mLof 5% dextrose in water was given in the ER, and she underwent a gastric lavage; many recognizable pills were identified in the contents. Her vital signs are being monitored; the results of her last set of vital signs, which were taken in the ER, are as follows: temperature, 37°C (98.6°F); heart rate, 100 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 110/70 mmHg. Blood for laboratory tests was obtained in the ER. The results are available in the chart. The acetaminophen level was 80 mcg/mL, and theibuprofen level was 150 mcg/mL. They also assessed her depression in the ER using the Hamilton Depression Scale. The result is in her chart.RecommendationAny orders or recommendations you may have for this patient Depression or hostility monitoring and precautionsMajor depressive disorder patient care Major depressive disorder patient careSuicide precautions Suicide risk assessment, ambulatory care Suicide risk assessment, ambulatory carePatient Education WorksheetName of medication, classificationMedication: Sertraline hydrochloride