Preface: This place and space is used for sharing the rough drafts of a slip-fiction novel I am currently working on. All rights reserved, comments and feed back welcome.
Meet Michelle. A twelve-year-old girl who experiences visual and auditory hallucinations after experiencing a set a traumas. How she sees herself, compared to how others see her.
Day Two: Left
Nurse’s Progress Report
Date of Exam: 5/30/2016
Time of exam: 2:02:45 PM
Patient Name: Michelle Joy Williams
Patient Number: 1000010649803
Nurse: Mawi Ersamo
Status of Patient
Michelle has been asleep for 25 hours. No indication of awakening has been observed.
Dr. Wong reports that Michelle was admitted due to having auditory and visual hallucinations as well as refusing to move from fetal position.
1 mg Xanax has been administered intravenously every eight hours. Drug effect seems to have unfurled her from the fetal position and patient is now resting in a regular sleeping position. Due to lack of physical conscious response, an IV was introduced at 5:05:36 PM on 5/29/2016 due to concerns of dehydration.
Additional Signs or Possible Side Effects:
Due to patient’s unresponsiveness, no side effects are observed at this time.
Patient is still unresponsive. A slight smile has been observed in her sleep, so she looks peaceful; however, due to unresponsiveness, it is assumed that the current trauma is still having a significant impact upon Michelle’s mental health at this time.
Michelle remains unresponsive. A call light has been placed within her reach and observations continue once per hour to note any changes.
Resting blood pressure is 120/80. Resting pulse rate is 80. Respiratory rate is 16 per minute. Temperature is 98.56 degrees F. Weight is unknown as this time, but expected to be between 90-100 lbs. (40-45 kg).
The following nursing interventions were performed:
Medication was administered to Michelle intravenously. Symptoms, and possible side effects were monitored and recorded as appropriate. Response to medication is as follows: Michell’s response to Xanax resulted in no response, other than the first response observed, which was that Michelle was able to go from the fetal position to a more traditional resting position.
Level of Care
Michelle needs to continue inpatient care until consciousness is observed and further evaluated. Michelle could not benefit from an out patient care due to lack of responsiveness.
Short Term Goals: Michelle will go from being unresponsive and sleeping to becoming conscious and begin to interact with the staff around her.
– Dr. Wong will monitor Michelle every 24 hours and make recommendations in regard to medication.
– Staff will continue to monitor Michelle every hour.
– Staff will continue to follow, monitor, and report medication administration.
– Staff will engage in conversation to encourage a conscious state.
It is recommended that the intervention and short term goals for this problem be continued since more time is needed to meet these goals and resolve this problem.
Mawi Erasmo, RN
Electronically signed by:
Mawi Erasmo, RN
On: 5/30/2016 2:22:36 PM