Sharon_Cole_Documentation - 1 2 3 4 5 6 Sharon Cole Documentation Sharon Cole exhibited pressured speech When asked questions she exhibited agitation in

Sharon_Cole_Documentation - 1 2 3 4 5 6 Sharon Cole...

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Sharon Cole Documentation 1. Sharon Cole exhibited pressured speech. When asked questions she exhibited agitation in her composure and tone of voice. She expressed thoughts of self harm and a desire to leave. Sharon Cole was redirectable when she expressed agitated thoughts and behaviors. 2. The patient was provided Lorazepam for agitation. The medication was successful in reducing the patient’s agitation level. The patient also had a continuous infusion and PCA pump of Fentanyl. This could reduce any pain she had from surgery which would in turn reduce her agitation. 3. The patient's vital signs were taken and were as follows: Blood pressure was at 155/90, strong and regular pulse of 104 bpm, respiration rate of 24, and a temperature of 37.2. The patient’s IV and surgical site were inspected for complications and none were found. Questions were asked pertaining to the patient’s mental status. The patient had pressured speech, flight of ideas, and tangential speech. Patient was agitated with the questions. The patient was redirectable. The patient was provided therapeutic communication and support. The lights were dimmed to provide a low stimulus environment and the patient appreciated it. The patient was educated about condition and treatment. The patient did not provide confirmation of understanding. 4. The lights were dimmed to provide a low stimulus environment and the patient was accepting of this. The patient agreed to stay in bed which would help limit her activity and distractibility. A 1:1 was provided to monitor the patient and ensure a low stimulus environment continues. 5. The patient expressed an interest to get up. The patient was directed to stay in bed, her reasons for being in the hospital, and I would be willing to speak with her while she was in bed. The patient expressed a disinterest in sleep. The patient was educated on the importance of sleep and the goals for sleep. The patient made sexual remarks about a

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