[Top Rated] - The sloppy copy needs to be done based on this example. The patient is a man with schizophrenia, schizoaffective disorder, seizure disorder and TBI. He is a

The sloppy copy needs to be done based on this example. The patient is a man with schizophrenia, schizoaffective disorder, seizure disorder and TBI. He is a danger to self and danger to others. He throws himself off beds and into walls to hurt himself, or randomly attacks staff. He also is constantly in restraints and seclusion because he feels safer and because of his behavior. I used FA Davis Nursing Consult the app for my resource.

This is instructor feedback for the patient profile, plus what I have for partially completed profile.

“describe path, define dx, and cite?”

“GCS and Morse Fall Scale can be assessed by looking at your patient. No hands on skills required. You must take time to look at your patient rather than rely on charts that are someone else’s interpretation of what is going on. “

She wants the sloppy copy to be from maslows, from a mental health standpoint.

CONCEPT MAP – PATIENT PROFILE

ADMISSION INFORMATION	Student Name: Dana Priest
Date of Care: 2/25/25	Patient Initials: CEM	Age: 31	Growth and Development Stage Young adult:	Gender: M	Admission Date: 1/12/2018
Reason for care needed: DTS/DTO	Secondary Medical Diagnoses: TBI
Surgical Hx: Broken femur repaair	Isolation (type & reason): None
Primary Medical Dx (describe pathophysiology, define the diagnosis, cite reference): Schizoaffective disorder, schizophrenia and seizure disorder List all signs and symptoms (subjective/objective data) possible with diagnosis – Highlight those your patient exhibits : Hallucinations , delusions, depression, bizarre behavior , manic moods, personal care management , disorganized thoughts.
History of present illness: Patient has auditory and visual hallucinations, can become aggressive very suddenly and has become a danger to self and others who trigger psychosis. Currently a 2:1 because he threw himself off of his bed and broke his arm intentionally.
ADVANCE DIRECTIVES
Living Will: Refused	Power of Attorney: Refused	Do not resuscitate (DNR) order: Refused
LABORATORY DATA:	Reason why it pertains to patient. Indicate with an “L” if low or “H” if high. (Change Norms so it is consistent for your facility’s lab data)
Test	Norms	Current Value Date	Test	Norms	Current Value Date	Test	Norms	Current Value Date
Na	135-145	141	WBC	4-11.5	10.18	T3
K	3.5-5.5	4.0	RBC	3.9-5.5	4.88	T4
Cl	98-110	108	Hgb	11.5-16.5	15.7	TSH
CO2	22-30	25	Hct	35-49	47.9	PT
BUN	7-25	8	MCV	80-98	98.2	INR
Creatinine	0.4-1.4	0.94	MCH	27-34	32.1	HbA1c
Glucose	75-110	97	MCHC	32-36	32.7	OTHER
Ca	8.0 -10.5	WNL	Neuts	40-75	68.9
Globulin	2.0-4.5		Lymphs	14-46	20.90
Albumin	3.5-5.0	3.4	Monos	4-13	8.8
Bilirubin	0.2-1.5	0.7	Eos	0-7	1.0
GFR	>59.00		Baso	0-3	0.5
Describe how lab value being high or low relates to patient diagnosis: When the numbers are either too high or too low, it can be symptomatic of a disease, or the cause of a disease. The exact arrangement of values can be linked to specific conditions.
DIAGNOSTIC TESTS
Chest X-ray: None	EKG: normal	Other abnormal reports:
Other:	Other:	Other:
Describe how diagnostic test relates to patient diagnosis: Much in the way of blood tests, these can indicate or pinpoint a specific condition.
ALLERGIES/PAIN
Allergies: NKDA	When was the last pain medication given? None given
Where is the pain? No pain	How much pain is the patient in on a scale from 0-10? 0
TREATMENTS
Treatments: Patient is being supervised with 2:1 monitors. What are the treatments for? DTS/DTO
Support services: 2:1 monitors
Consultations:physical therapy, dietary and psychiatry
DIET/FLUIDS
Type of Diet: HH	Rationale: to meet patient needs	Restrictions: None	Gag reflex intact: Yes	Appetite: Poor
Intake (% each meal)	Breakfast: <50%	Lunch: : <50%	Dinner: : <50%
What types of foods are included in this diet and what foods should be avoided? No restrictions.
Fluid Intake in mL: (Oral & IV) Not monitored	Highlight the problems experienced by your patient below:
	Problems: None (Swallowing, Chewing, Dentures)	Needs assistance with feeding: None
	Nausea or Vomiting: None	Overhydrated or Dehydrated: None
Tube Feedings: None Type and Rate: None	Belching: None	Other:
Is the patient’s intake greater than output? Not monitored Calculate: Not monitored
INTRAVENOUS FLUIDS (IV Therapy Record)	IV lines: WDL Location: Not mentioned
Type and Rate: Not mentioned	IV dressing dry: yes	Edema: No	Redness: No	Other:
ELIMINATION	Foley/Condom catheter: Not monitored
Last bowel movement and characteristics of stool: Not monitored
Characteristics of urine: Not monitored	24-hour Urine Output: Not monitored
Highlight the problems experienced by your patient below:
Bowel: constipation, diarrhea, flatus, incontinence, belching: continent, not monitored
Urinary: hesitancy, frequency, burning, incontinence, odor: continent, not monitored
Other:
ACTIVITY
Ability to walk (gait): Independent	Type of activity orders: None	Use of assistive devices (cane, walker, crutches, prosthesis): None
Bed modifications: None	Weakness: None	Trouble sleeping: None
VITAL SIGNS:
BP: Refuse	Pulse: Ref	O2 Sat: Ref	Respirations: 16	Temperature: Ref	Weight: Ref	Height: Ref

Other Assessments Learned throughout program that applies to patient?

Glasgow Coma Scale Nott monitored

Braden Scale 23

Morse Fall Scale 0

Other (specify) Nott monitored

Other Assessment or Treatment Information not included above:

None tsken

7/4/2022 TH Page 1 of 1

Sloppy Copy- Pre-conference –Carry in Pockets at all times!

Reason For Needing Health Care: Medical

Diagnosis/Surgical Procedure:

Key Assessments:

Key Problem # I don’t know how this fits

with the problems.

Key Problem # Key Problem #

Key Problem #