Problem:
The patient is a 31-year-old male who was referred from med/psych. He apparently was highly intoxicated, agitated, and confused. He was drinking heavily and tested positive for cannabis and cocaine, both of which he denies having a problem with. He says he can't remember if he made a suicide attempt or not but that he thinks he may have been talking of suicide, and his brother ended up tackling him. The patient also thinks he has post-traumatic stress disorder due to witnessing two murders. The patient says he gets flashbacks and nightmares, startles easily, is vigilance, and can't remember details of the trauma. He reports that for the past two years, he has been drinking a fifth and endorses tolerance and reduced social interaction due to legal charges. . Patient reportedly found his girlfriend dead recently from a drug overdose, he says he thinks she is alive, but the family apparently said she had died. Patient reported many symptoms of depression: tearfulness, feeling sad. Irritable, poor sleep, and stomach distress making it hard to keep food down, less motivation, confidence, and pleasure. He says he has been having non-specified suicidal thoughts for years. He denies any past attempts and can't say if he was trying to kill himself on the night of his admission, but his brother tackled him. Nursing Diagnosis: Risk for Suicide related to major depressive disorder and reported non-specified suicidal thoughts as evidenced by the patient's reported feelings of sadness, tearfulness, irritability, poor sleep, stomach distress, decreased motivation, confidence, and pleasure, and the incident where his brother had to tackle him due to a potential suicide attempt Patient Goals (include a minimum of one long term and two short term measurable goals per nursing diagnosis) Goals should be measurable, time-limited and realistic -SMART) The patient is a 31-year-old male who was referred from med/psych. He apparently was highly intoxicated, agitated, and confused. He was drinking heavily and tested positive for cannabis and cocaine, both of which he denies having a problem with. He says he can't remember if he made a suicide attempt or not but that he thinks he may have been talking of suicide, and his brother ended up tackling him. The patient also thinks he has post-traumatic stress disorder due to witnessing two murders. The patient says he gets flashbacks and nightmares, startles easily, is vigilance, and can't remember details of the trauma. He reports that for the past two years, he has been drinking a fifth and endorses tolerance and reduced social interaction due to legal charges. . Patient reportedly found his girlfriend dead recently from a drug overdose, he says he thinks she is alive, but the family apparently said she had died. Patient reported many symptoms of depression: tearfulness, feeling sad. Irritable, poor sleep, and stomach distress making it hard to keep food down, less motivation, confidence, and pleasure. He says he has been having non-specified suicidal thoughts for years. He denies any past attempts and can't say if he was trying to kill himself on the night of his admission, but his brother tackled him. Nursing Diagnosis: Risk for Suicide related to major depressive disorder and reported non-specified suicidal thoughts as evidenced by the patient's reported feelings of sadness, tearfulness, irritability, poor sleep, stomach distress, decreased motivation, confidence, and pleasure, and the incident where his brother had to tackle him due to a potential suicide attempt Patient Goals (include a minimum of one long term and two short term measurable goals per nursing diagnosis) Goals should be measurable, time-limited and realistic -SMART)