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Original Question

Mrs. Rogers, a 76 year-old-women, Recently widowed, was brought to a mental health center by her daughter, Sarah, for assessment and treatment the nurse assigned to walk inclines, is the first person to talk with Mrs. Rogers. Mrs. Rogers Tell the nurse that she “feels nervous all of the time and cannot stop crying”. she looks distraught and fatigued, her posture is stooped, her face is tear stained, she isn’t wearing make up, and her hair is uncombed. Sara states that nine months ago, Mrs. Rogers moved from another state to live with Sara after Sara’s father died. Mrs. Rogers, Who asked to be called Nell, is hesitant to tell the nurse what is bothering her period the nurse ask her. some specific questions together initial data. Nell speaks in soft voice, with frequent sighing. she answers briefly, with the few words, and she does not initiate any conversation. She keeps her eyes averted to the floor. Nell respond to the quiet, calm manner and sensitivity to how she is feeling. Nell sighs once again, But this time is in her seat, sets more upright, relax her shoulders, and begins to look directly at the nurses. she is still tearful, sad, and breathing rapidly. The nurses posture is a register to mirror Nell’s. Nell tells the nurse That she started feeling nervous a few weeks ago. A Isis intervention approach will be used in working with Nell. Somethings stressful happened recently, and nail has been distressed since that event. Crisis occur in all individuals at one time or another and does not necessarily indicate a psychopathology. Nell Confide that her daughter has decided to return to work. Sarah told nail about three weeks ago that next week she begins work. Nell sees her heart begins to pound, she has trouble breathing, her stomach hurts, and she noticed heavy precipitation under arms whenever she thinks about the possibility of her daughter being away all day. Nell is experiencing a situational crisis. A crisis that is participated buy a significant, external source or even is called a situation of crisis. The event is often on dissipated. Some examples include job change job loss, owns at office of Eden exchange in financial status or death of a loved one. The Death Nell’s spouse was a situational crisis for her than that a cur, and Nell is still grieving. Upon Gental questioning from the nurse, Nell express worry about how she’s going to manage been her daughter returns to work she feels too tired to fix anything to eat for herself, she has trouble sleeping, additionally, no things that she does not know how old she will call if she gets into trouble. Nell Tell the nurse that she feels like she cannot think straight or concentrate and wouldn’t know what to do if she was alone and the telephone ring, someone came to the door, or she had a plumbing problem. Nails is that prior to moving in with her daughter, she was quite capable of solving household problems, talking with strangers and maintaining a healthy, competent appeared in certain lifestyle. ” When I went to live with my daughter, she told me that I have to work hard all of my life and that I should take it easy now. So, she does all of the cooking cleaning and laundry I don’t have to do a thing. I would gotten used to being able to read, take walks, and a quarter chat whenever I want to. I had actually forgotten how to do many of the household chores that I used to do, I’m afraid I will have to start doing them again and won’t know how”. Exploring a little further, you learned that in the Nell is reluctant to talk with her about her feelings and concerns. Nell Say is that her daughter has been so thoughtful that she doesn’t want to seem ungrateful. Nell also does not want to burden Sarah with her problem. Nell. adds. ” In the past Sara and I have been able to talk about everything. It’s been a burden on me not to be able to tell her how I feel.” Nell Says she feels relieved having told you about her problem, and goes on to say, “maybe you can tell Sara how I feel.” Further assessment of an all reveals that she has trouble felling asleep, and after falling asleep, her sleep is restless with frequent nightmares. Nail report that during the day she picks at her meals. She doesn’t drink or smoke but it does have 2 cups of coffee each morning. Knowing that the elderly and people in crisis are at risk for suicide, you ask Nell about thoughts of suicide. Nell denies even remotely thinking about herself, saying “I’ am religious women. going to church and belief in the lord are important to me. I wouldn’t think of doing anything like that”. Nails has friends at church but has been reluctant to tell them about a recent feelings. The nurse tells Sara about Nell’s fear . Sara feels sad that her mother did not come to her directly. Sarah and Nell then have a loving conversation in which they both talk through some of their concern. together, Nell, Sara, and she and the nurse establish a goal for Nell. The established goal is that Nell will experience less anxiety about Sara’s return to work. At the end of your session with Nell, she says she feels so “much better”. before Nell and Sara leave, an appointment schedule in three days. Nell has agreed to learn deep breathing and progressive muscle relaxation. Three days later, Nella returns, she is neatly dressed, Her hair is combed, and she is wearing make up. She eagerly tells the nurse that she and Sara made a list of household chores, and “I made dinner last night!” Nell also volunteers “I’m still having trouble falling asleep, but I’m sleeping better and not having nightmares . Nell’s anxiety level is obviously lower. The nurse teach Nell deep breathing at progressive muscle relaxation . she demonstrate these techniques quickly and competently after a brief explanation and demonstration from the nurse. Nell says that she will use these techniques whenever she begins to feel worried or afraid. Nail prepare to leave and thanks for the help. even though Nell is less anxious, some issues seem unresolved to the nurse .the nurse believe that Nell would benefit from further discussion about grief and her inability to talk with her daughter. Nell’s Spirits are high and she doesn’t think she needs to see the nurse anymore. She plans to go to a widow/widower support group that the nurse mention to her. “I can meet some new people share what has helped me and me,maybe even learned some things.” Need a SOAP note on this?

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