Psychiatric Interview Reflection

On 12/13/17 I met family and staff for a team meeting with Ms. Perez. Ms. Perez has not been making much progress in her recovery. She continues to have poor motivation. She has become extremely needful. She is constantly on her call light or yelling out to staff. She wants someone in her room all the time. A recent psychiatric evaluation has been done and her medications have been changed. The abdominal wound continues to decrease in size. Ms. Perez has been very demanding on her husband. There was a very frank discussion with her and the family about what her goals are. She states she wants to go home. The treatment team outlined for her what she needs to do in order to get home and be able to take care of herself. She has agreed

to give greater effort and consistency. Her husband has agreed to stop doing tasks for her that she should and can do for herself. Jacob Perez their son and her MDPOA said he will participate more in the day to day activity. Jacob Perez reports that his Mother had poor motivation before the accident; she has a history of depression and trying to get everyone to do things for her.

I spoke with MSW Amy on 12/181/17 to confirm he wound appointment. I was told that on 12/17/17 Ms. Perez became very agitated and confused. Lab work showed her ammonium levels were extremely high. She was transferred to Covenant hospital.

WORK STATUS

N/A

ASSESSMENT

Ms. Perez seems to have given up and has not made much progress in her goal to go home. She again has agreed to try harder. It is questionable if she will ever be discharged.

PLAN/RECOMMENDATIONS

1. Contact Ms. Perez every four weeks to obtain an update on progress and address any concerns she may have. Visit Ms. Perez to continue to encourage and support her participation in her rehab program.

2. Attend care conference with Chesaning Care Center when made.

3. Attend the appointment with Dr. Wolohan January 2018 when made. Clarify if there will be any needed surgery on the bilateral ankle fractures.

4. Attend the wound appointment with Dr. Malik in January 2018 when made. Address the abdominal wound and the current treatment plan for the right arm and leg cellulitis.