SOAP Note for Crisis Intervention and Safety Planning for the Adult/Geriatric Patient

 

SOAP Note for Crisis Intervention and Safety Planning for the Adult/Geriatric Patient

Patient Name: [Patient’s Name]
Date: [Date]
Provider: [PMHNP Provider’s Name]
Facility: [Facility Name]

S: Subjective

– Chief Complaint: “I feel very anxious and overwhelmed.”
– History of Present Illness: The patient is a 75-year-old male with a history of depression and generalized anxiety disorder who was admitted due to increased agitation and panic episodes over the past week. He reports feeling restless, unable to concentrate, and has had difficulty sleeping. The patient denies suicidal thoughts but expresses feelings of hopelessness.
– Past Medical History: – Depression
– Generalized Anxiety Disorder
– Hypertension

– Medications: – Sertraline 50 mg daily
– Lisinopril 10 mg daily

– Allergies: No known drug allergies.

O: Objective

– Mental Status Exam:- Alert and oriented x3.
– Mood: Anxious; Affect: Labile.
– Thought Process: Logical but preoccupied with worries.

– Vital Signs: – BP: 130/80 mmHg
– HR: 78 bpm
– Temp: 98.6°F

– Physical Exam: No acute distress; no neurological deficits; cardiac and respiratory exams within normal limits.

A: Assessment

– Diagnosis:- Generalized Anxiety Disorder (GAD)
– Adjustment disorder with anxiety due to recent life changes (loss of spouse)

– The patient’s agitation is likely exacerbated by situational stressors and requires immediate intervention to ensure safety and stability.

P: Plan

1. Medication Management:

– Prescribe: Lorazepam (Ativan) 1 mg PO as needed (PRN) for anxiety/agitation.
– Instructions for Nursing Staff:- Administer Lorazepam 1 mg PO PRN for anxiety/agitation every 6 hours, if the patient reports significant distress or exhibits agitation.
– Monitor the patient’s response to medication, including sedation levels, mood stability, and any adverse effects every hour for the first four hours post-administration.

2. Standing Orders:

– This medication can be listed as a standing order for the nursing staff, but the staff must notify the PMHNP provider before giving it to assess need and verify dose appropriateness.

3. Visual Assessment:

– Yes, I would want to visually assess the patient before having medications administered to evaluate current agitation levels and overall mental status.

4. Monitoring Post-Medication:

– Monitor vital signs every hour for the first four hours after administration.
– Assess for sedation levels using a sedation scale (e.g., Ramsey Sedation Scale).
– Record patient’s self-reported anxiety levels before and after medication.

5. Documentation Required:

– Document the administration of Lorazepam including time, dose, route, and patient’s response.
– Document changes in vital signs, sedation levels, and mental status assessment every hour for four hours post-medication.
– Continue to document daily assessments of anxiety levels and overall mental health status.

6. Consideration of Chemical Restraints:

– The use of Lorazepam in this context would not be considered a chemical restraint as it is being administered therapeutically to manage acute anxiety symptoms rather than to control behavior or restrict freedom. The intent is to alleviate distress and facilitate a safer environment for the patient.

Follow-Up

– Schedule follow-up within one week to re-evaluate the treatment plan, adjust medications if necessary, and monitor the patient’s overall mental state and coping mechanisms in response to recent life stressors.

[Signature of PMHNP Provider]
[Contact Information]

This SOAP note outlines a comprehensive approach to managing a geriatric patient experiencing anxiety, including medication management, monitoring protocols, documentation requirements, and considerations regarding the ethical use of medications in a crisis intervention setting.