After reviewing the information available to you,

After reviewing the information available to you, you knock on Anna’s door. She invites you to enter and as you open the door, you notice a strong odor of urine emitting from the one bedroom studio. Anna is sitting in a reclining chair surrounded by piles of newspaper. Looking around, you note that Anna saves empty cereal boxes and plastic bottles. These items are collected in large laundry bags that crowd the perimeter of her home. You also notice boxes of Christmas decorations piled to the ceiling. You enter the apartment via a small path that leads to Anna’s chair. You take a seat on a milk crate. “Hi Ms. Paint, I am the visiting nurse. Dr. Chidester asked me to stop by to see if you need any help with your new medication and leg wound”. You observe that Anna is tearful, eyes cast down and has slow movements as she crosses her legs and adjusts her hair. She is unkempt, her clothes are soiled and you note a foul body odor. She has a rolling walker beside her. Both legs look edematous. Though she is tearful, she shows little emotional expression on her face. She states, “I wish you told me you were coming, I would have cleaned up.” She continues, “I don’t think I need a nurse. I am taking care of this scratch on my leg just fine”. You note the dressing on her RLE is wet with clear drainage and poorly secured with scotch tape. You respond, “I can understand how my visit may have come as a surprise. Perhaps I can check your blood pressure and we can take it from there?”. She starts giggling and her giggles turn into a robust laugh. With a large, slow, grin she says, “Come on over! I don’t bite!” Anna allows you to take her vitals. As you place the cuff of the sphygmomanometer over her left arm, she begins to shake. “Ok, do this quick! You are making me so nervous”. She says this as she smiles. While you listen to her Apical pulse she says, don’t talk too loud, my neighbor keeps an ear close to the wall to listen to my thoughts. Vital Signs: T 99.1F, RR16, HR 112, BP 162/64, Pain 0/10 Anna allows you to redress her wound according to the orders you were provided. The wound is clean, edges intact, wound bed 100% granulation tissue, drainage clear. You educate Anna on Hydrochlorothiazide and the possible side effects. Identify the findings that require the most immediate follow-up and place them in order of priority below starting with the MOST important: What additional information would you want to know from Ana? Call Anna’s primary care provider to discuss observations and seek a referral for an emergency visiting mental health professional. You contact Dr. Chidester, Anna’s primary care provider, and discuss your findings. You express concern for Anna’s safety, her inability to care for herself, her behavior and her environment. You recommend a referral to the Visiting Mental Health Service Agency that provides acute level mental health support in the home. Dr. Chidester agrees and sends the referral. You say to Anna, “Anna, I see that you are working very hard to care for yourself and that it is becoming increasingly difficult since you injured your leg. I am here to support your independence and make sure the wound heals and your blood pressure improves. I notice you become anxious when I approach you and you are struggling to control how you feel. I believe you would benefit from the support of a mental health provider. Would you agree with an in-home evaluation? They can come tomorrow?”. Anna states, “As long as they don’t lock me up like my mother did”. She agrees to the visit. Within 24hrs a Psychiatric Nurse Practitioner (PNP) arrives at the apartment. You agree to accompany him to the visit to support Anna. The PNP asks Anna, “Tell me about why you think I am here today.” Anna starts to tremble, “Because that witch reported me! She is jealous of my apartment and wants everything I own!”. She points to the wall of the apartment next to her. She continues, “Please don’t ask me anything else. My heart feels like it is jumping out of my chest”. You move a newspaper off the milk crate to sit down and she screams, “Don’t touch my stuff! Please stop! I organize everything for a reason!”. During the visit with the PNP, Anna speaks to her experience as a child. “They took me away from my mother when I was 4. She wasn’t right in the head and would lock me in a room and forget to feed me. I lived on and off with relatives… some good, some bad…for so long I just wanted to disappear.” The PNP enters into the medical record several new diagnoses of Generalized Anxiety Disorder, Depression and Obsessive Compulsive Disorder. He orders Sertraline (Zoloft) 50mg po QD. Identify the behaviors that are consistent with Generalized Anxiety. How do they support the PNP’s diagnosis? Identify the nursing interventions that are of greatest priority. List them in order of priority beginning with MOST important.

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