Todd Shumway

DAR

Diagnosis: Cannabis Abuse, Aggressive Behavior LOS: Day 3 Age: 17

D: Quote: “I when scrap the guy who when mob me, I had to.”

Pertinent Positives: Patient reported his intention and need to scrap the guy who beat up him

weeks earlier. Patient reported a decline in his grades from A’s and B’s to C’s and D’s. Patient

made comments and jokes about smoking marijuana during therapy sessions such as “This looks

like a dab”, or “Its like smoking one joint”. Patient reported stress after recent breakup with

girlfriend and poor relationship with mother aeb “my girlfriend cheated on me”, and “my mom

talks to me like, ay fucka go back to your room”. Patient showed affect of irritability and

annoyance with other patient on unit aeb raising his voice to the other patient when he

commented about hating Hawaiian culture.

Pertinent Negatives: Alert and Oriented X3. Patient had good hygiene, clean and neat

appearance, participated/attended in all activities, and was cooperative with staff.

A: Assessed mental status 1:1, Encouraged participation in group activities. TM48 score is 8,

indicating moderate risk precautions. TM33 is 0, indicating no precautions. Discussed patients

feelings of anger with girlfriend, mom, and bullies. Reinforced education on DBT therapy in

thinking about happy places. Discussed patients adjustment to acute unit. Discussed patients loss

of both grandparents and future plans. Discussed patients sleeping patterns.

R: Patient reported no Hx of suicidal ideation. Patient reported physical aggression and anger

towards various people in his life. Patient reported that he will practice and try to focus on happy

places when feeling stressed and angry. Patient reported restless sleep due to nurses constant

Todd Shumway

interruption. Patient reported a future and plan in working for Matson. Patient described how

hard it has been to lose grandparents and how he copes with that loss by doing the things he

loves such as diving, fishing, sailing, and smoking weed.

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Nursing Plan: Continue to assess patients use of coping skills during times of stress and anger.

Continue to provide education on coping skills. Continue to encourage patient participation.

Monitor patient for safety. Track sleep and promote for restful environment. Continue

Interventions.