Mental Health Assessment

458 Words2 Pages
My assessment took place on two separate occasions in the community setting. The first patient R.J. is a 76 year old male diagnosed with hypertension, diabetes type II, and hyperlipidemia. The SPICES assessment reviled that R.J. needed further assessment of his sleeping patterns and arthralgia. The second patient M.T. is an 80 year old male diagnosed with diabetes type II and dyslipidemia. M.T. needed a further assessment of his sleeping patterns and he also uses a cane to ambulate when he leaves the house. R.J. indicated that he has issues sleeping through the night; to assess his quality of sleep and his sleep pattern I used the Pittsburgh Sleep Quality Index (PSQI). This tool measured R.J.’s sleep habits over the past month. His total global PSQI score was 5 indicating that he is a poor sleeper. During the assessment R.J. stated that it takes him fifteen to twenty minutes to fall asleep and on some days he wakes up about twice to urinate. R.J. also mentioned that he takes long naps during the day. The following interventions were discussed: no caffeine before bedtime, avoid eating or drinking at least 3 hours before bedtime, and to limit his day…show more content…
like R.J. was having difficulties sleeping throughout the night due to nocturia. I also used the PSQI tool to assess M.T.’s quality of sleep and his sleep pattern. M.T.’s total global PSQI score was 5, qualifying him as a poor sleeper. M.T. does not drink alcohol, smoke, or drink caffeine. On most days he goes to bed around 9:30 or 10:00 p.m., taking up to 30 minutes to fall asleep, and he wakes up at 7:00 a.m. everyday. On days when he cannot fall asleep, M.T. drinks chamomile tea. Similar to R.J. he takes naps during the day in his recliner. In an attempt to immediately improve his sleep M.T. and I discussed the following interventions: avoid drinking tea right before going to bed (no drinks 3 to 4 hours before bed), limiting his daytime naps to less than two hours, and avoid falling asleep in his
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