Doc Assignment (S.L).docx - Mental Health Case Sandra Littlefield Documentation Assignments 1 Document your findings related to the focused assessment

Doc Assignment (S.L).docx - Mental Health Case Sandra...

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Mental Health Case: Sandra Littlefield Documentation Assignments 1. Document your findings related to the focused assessment of Ms. Littlefield’s coping strategies. Include her responses to your assessment. Upon entering the room patient was asked to tell me more about what is going on with her today. Patient stated she was having 10/10 back pain and wanted stronger medication for relief. S.L was informed that I would not be able to administer more medications due to the schedule of administration. The patient was asked a series of questions related to her mental status. It was found that she has suicidal ideation, has a Hx of being sexually abused, intense feelings of abandonement, an inclincation to engage in risky behaviors, and a tendency towards anger, sarcasm, and bitterness. 2. Document all patient teaching regarding coping strategies and cognitive restructuring techniques provided Ms. Littlefield. Include her response to the teaching. S.L was educated on the medications she was prescribed for her pain, Ibuprofen and Acetaminophen. She was also educated on resources such as community support groups, regular appointments with her therapist, exercises she can do while in jail, and the benefits of using the jail libray to relieve stress. S.L was also educated on other forms of pain management that don’t require pain killers. She stated that she did not think they would help, but she was receptive to listening.

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