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Monday Day 3



NURSING NOTES:

Date: 5/26-27

Shift: 11p-7a



Please refer to admission intake/history/physical regarding admission diagnosis/behavior.



Mr. John C. Williams is a 31-year-old male, self-admitted due to psychotic behavior. The patient appears completely unaware of behavior, and only relays what he has been told regarding events of the past few weeks. Mr. Williams is co-operative as far as he claims to remember.



During the first 24-hours, the patient has slept only a few short hours intermittently, and was often seen talking to himself, nervously pacing, and has been seen on several occasions, sitting with his back toward the wall banging his head.



When asked about this behavior by the nursing staff, Mr. Williams appears to be unaware or unwilling to admit that he has engaged in this behavior. When asked if he had noticed this behavior in the past, Mr. Williams adamantly denies.



The patient is forthcoming regarding past events in his life or current difficulties that he is aware of. The patient has refused all medications, stating that he has no need for pharmacotherapeutic agents; the patient has stated, "I just need to sleep, if I could just get some sleep, I'll be fine." It was noted by one of the night attendants that Mr. Williams claimed he had a nightmare and couldn't sleep.



Mr. Williams has not actively participated in-group sessions, nor does he appear to seek companionship with other patients. He seems to prefer to keep to himself.



During his second night approximately 11:22 p.m., this RN went to check on the patient's status, as he had been seen pacing the halls, stating that he was unable to sleep.



Mr. Williams became very startled and agitated stating, "Just don't touch me." At no time did this RN physically touch the patient, but attempted to coax him back to his room and offered sleep medication as ordered by Dr. Sajak. Mr. Williams refused. Mr. Williams did go back to his room eventually.



1:44 a.m. Mr. Williams was heard calling out. When this RN entered the room, Mr. Williams was not in his bed. He was on the floor, cradled in a modified fetal position, hands up as if to "ward off" perceived danger.



The patient was unresponsive to voice commands. When an attempt was made to coax the patient off of the floor, he became very agitated and aggressive. At this point, security was called in as back up.



It appeared to this RN that Mr. Williams was experiencing a psychotic episode. At this point, the security officer, Mike Collins and night attendant Matt Adams, attempted to talk to the patient. Mike placed his hand on Mr. Williams arm, at which point, Mr. Williams began to shrink from the officer and began to cry out as if in pain, stating, "No, don't touch me, please, don't touch me."



Mike explained to the patient that he had no intention of harming him in any way, to which the patient replied, "I won't tell, I promise, I promise, just please don't touch me." Mr. Williams appeared completely unaware of his surroundings.



The patient was then noted to be perspiring profusely as well as trembling, appearing to be in great fear. When Mike attempted to explain to the patient that medical staff was going to take his vital signs, the patient became very emotionally unstable, intermittently crying and aggressively pushing away staff.



Three staff members were needed to attempt vitals, which were obtained with great difficulty as the patient was pushing away staff members and crying out stating that he did not want to be touched.



Initial blood pressure was 180/150, pulse approximately 140, respiratory rate between 28 and 30. At this point, the patient was given Haldol 5 mg IM as ordered by Dr. Sajak. Dijana was called and soft wrist restraints were ordered as well as one on one staff member for Mr. Williams' safety.



Mike Collins of security physically placed the patient in the bed.



Approximately 20 minutes after Haldol injection, the patient seemed to recognize his surroundings and asked in a very quiet voice for a glass of water.



He then recognized that his hands were held in soft wrist restraints and after struggling for a few seconds, resigned to his situation. This RN noted that at this time, Mr. Williams began to cry, attempting to hide his face under the pillow and move his body in a curled position. When asked by this RN if he would like to talk, Mr. Williams stated, "There's anything to talk about, I take it I did it again."



When told that he did indeed have a psychotic episode, the patient refused to talk further saying that he didn't remember. Mike Collins of security stayed with the patient. He will file a separate incident report.



Sarah Hatcher RN



~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



SECURITY INCIDENT REPORT:



Patient name: John C. Williams

Date: 5/27

Time: 1:47 a.m.

Place: Patient room 17



Situation: I was called to the room of Mr. John C. Williams at 1:47 a.m. as the patient had become aggressive and unable to be controlled. After numerous attempts to coax the patient off of the floor, Haldol was given by the nursing staff, at which point, I was able to physically lift the patient to the bed.



I was asked by Dr. Sajak to sit with the patient for his protection and the protection of the staff. Soft wrist restraints were placed. The patient was unaware of my presence until I moved to turn on the night-light. He appeared terrified by my presence, as he had his wrists in soft restraints and was unable to defend himself, and the patient began to panic.



I explained to the patient who I was and what I was doing in his room. He appeared to be briefly unaware of his surroundings and did not respond to my voice, approximately a minute later, the patient asked for water, stating that his mouth was 'on fire.'



The patient also complained of back and leg pain and asked to be moved on his side. I removed the patient's restraints briefly in order to move him on his side. The patient pleaded with me to 'not put them back on,' stating that he 'wasn't crazy.' I told the patient that no one thought he was crazy, to which he responded, "I can see that you do, you don't have to lie to me."



At this point, the patient appeared to become very introspective, and was seen to be shaking. At first I believed this to be an agitated response to my refusal to let his wrist restraint off, but as I observed further, the patient's shoulders slumped in a defeated gesture and he was seen to be crying.



I attempted to rub the patient's shoulder in an attempt at comfort him, to which the patient allowed and attempted to raise his hand toward me, at which point, the restraint again, caused him much anguish.



I removed the right wrist restraint, as the patient seemed well aware of his surroundings and the restraint was causing the patient increased anxiety. The patient allowed me to hold his hand and asked that the rail on the bed be put down.



This I did due to the fact that the patient seemed well aware of his surroundings and had no physical disability for which a rail was needed. At this point, I moved my chair up toward the patient's bed, again, taking the patient's hand in a comforting gesture. The patient moved himself onto the edge of the bed, as far as the other wrist restraint allowed, seeking comfort.



I placed my arm around the patient's shoulders and I could feel him physically trembling a great deal. The patient cried for approximately an hour, after which, he thanked me profusely for staying with him.



Mike Collins

Security



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John had had a rather rough night but had managed to get enough sleep to get him through another day. He looked around to see Mike Collins sitting at his bedside.



"Morning, John," he said as he observed him waking.



John noticed right away that he was still in restraints. "Can I get up? I need to use the bathroom." His voice was hoarse and he looked utterly defeated.



Mike moved cautiously toward the bed and released the restraints. He held out his hand to help John up.



John wasn't quite sure why he had been restrained but he was sure he had gone off the deep end again. He also felt that heaviness in his head that told him that he had been drugged, so he figured it had to have been bad.



Coming back out of the bathroom he went directly to his dresser for his clothes. Mike watched him as he pulled out a pair of jeans, a polo shirt, socks and underwear and returned to take a shower.



~~~~~~~~~~~~~



As soon as he was allowed to leave the table, John took a walk outside immediately lighting up a cigarette. He soon found himself being escorted by Geneen.



"You really don't need to follow me around, I'm fine. I thought I'd take walk down to the stables before I have to go see Dr. Bowers." He explained sheepishly. "If that's okay?"



"It's my job to follow you around," she smiled. "You wouldn't want to get me into trouble now, would ya?" Geneen made a mental note of the fact that he remembered his appointment.



~~~~~~~~~~~~~



Dijana looked over the information sent to her by John's last therapist. There seemed to be a lot of information missing. No medical history, even though it had been noted that on two occasions, Ativan had been administered. There was no pre-session evaluation; no consent forms, nothing at all to indicate that John even gave his permission for any of the sessions to take place. She understood that his identity was being protected but this concerned her.



After attempting to contact Dr. Montgomery at her office to no avail, she decided this was important enough to left a message on her voice mail.



~~~~~~~~~~~~~~~~~~~~~~



Veronica checked her voice mail to find a rather interesting message. "Hello, my name is Dr. Sajak and I am reviewing some records sent to me by you on a 'John C. Williams' I have a few questions that I need to ask you and would appreciate it if you would contact me at 1-800-669-2426 ex: 416."



After dialing the number, Veronica sat on John's bed and waited for the line to connect.



"Hello, Dr. Sajak's office," came the reply.



"Yes, this is Dr. Veronica Montgomery returning your call in reference to John C. Williams." She was almost positive that it had to be about John since she didn't recognize the name. She had managed to learn from Kerry that he did not want to be contacted by anyone.



"Oh, yes, I have a few questions that I need to go over with you. Do you have a moment?" Dijana asked.



"Actually, I'm rather busy at the moment but I'm here in Chicago and could meet you for lunch, if that would fit your schedule. I also have something rather important for you as well." Veronica did not want to get caught by Abby or even Brandon for that matter until she knew a little more about what was going on.



"I can't get away for lunch but I could meet you for dinner," Dijana asked.



"Is it possible for me to come to your office?" Veronica questioned hoping that she could find out more about where John was and possibly see him.



"I'm afraid that's not possible," Dijana answered. She had her suspicions, about this woman and was concern for John's confidentiality.



They had finally agreed on a place to meet for dinner.



~~~~~~~~~~~~



John was greeted by Hannah and led to a bathroom. Hannah handed him a small specimen cup. "Here, Hon, I need for you to fill this for me." She smiled and opened the door.



John shook his head and gave a small laugh remembering how he had to do this in front of Mark. "Are you going to watch me," he snorted indignantly.



"Only if you want me too," she giggled. " Just set it on the counter when you're finished." She said as she walked away and headed for the linen closet down the hall.



Hannah then led John to an examining room where she handed him a gown. "Take off all your clothes and put this on, there's a sheet on the table, make yourself comfortable and I'm be back in a few minutes."



Shortly after sitting on the table, Hannah came in to take his vitals and draw some blood. Dr. Bowers joined them.



"Hello, John, I'm Dr. Bowers and I will be doing your exam." He began checking John's ears, nose, and throat. "I understand you have a few cracked ribs. You doing okay with that?" He checked the side of John's head examining the small scar.



"Yeah I'm fine." John yawned pulling his head away.



Dr. Bowers continued pressing, poking and prodding, asking questions right and left, does this hurt? Is this tender? Any back pain? Shortness of breath? Palpitations? Headaches? Difficulty with sleep? John answered him in short 'yes' and 'no' answers, getting more irritated by the minute.



Dr. Bowers checked his lungs, his heart, and his belly, marveled at the lovely scar on his abdomen for a moment. He didn't say anything of course, just asked matter-of-fact questions about the 'incident.'



"Okay, now hang your legs over the side of the table so I can test your reflexes."



John dutifully did as he was told, trying his best not to let his aggravation show, he tandem walked, did the finger-nose-finger test, followed the doctors finger with just his eyes…this was getting ridiculous.



"You mentioned low back pain earlier, have you had any problems with urination? Bowel function? Any problems walking? Pain or weakness in the legs?"



"No and no, yes sometimes, and yes." John answered thinking that he wasn't here to get anything physical fixed, he needed to get his head right.



"GI pain? Rectal bleeding? Urinary retention?"



"No, not that I know of... and no." John was about to fall asleep.



"Okay, now comes the fun part, John, lie on your left side for me, " Dr. Bowers donned a pair of latex gloves and squeezed out a glob of KY-Jelly onto his fingers.



His sleepiness dissipated rather quickly as the realization of what this guy was about to do sank in. "Uh, is this really necessary?" John asked.



"Now just relax." He placed a hand on John's shoulder. "Take a deep breath and blow out slowly...and again," he encouraged.



John tensed up as he felt the coolness of the lube touching his warm skin. He willed himself to relax and soon felt the fullness of Dr. Bowers' fingers inside of him. He could not help but think of Brandon but this was definitely not as comfortable as Brandon.



"Hey, ow!" John exclaimed feeling a sharp pain rip through his backside all the way through to his belly. His tender opening was in a spasm and the fact that he was tensing up didn't help.



“Ow, just uncomfortable or ow, that really hurts?" Dr. Bowers asked rooting around more.



“Ow, that really hurts!” John exclaimed holding his breath in pain.



Dr. Bowers continued his manipulations asking John a series of questions as he moved his fingers around trying to pinpoint exactly where the pain was coming from. "Have you had anal intercourse recently, John?" He asked.



John swallowed hard as he turned about 3 shades of red. He remembered being with Brandon. It had been a bit rough and had been his first time that it had actually drawn blood. He kicked himself for not remembering and thinking that this could happen after being still tender inside.



"Uhmm...last Wednesday," John confessed in between breaths, his eyes were tearing up from the pain and he couldn't breathe.



"Why is it, when the patient says ow, the doctor has to keep going…that fucking hurts! Jeezus." John exclaimed, his patience at an end, moving away from the doctor as fast as he could scoot over to the other side of the table.



Dr. Bowers removed his gloved hand and noted the bright red blood on his fingers, he held John’s backside making sure that John wasn’t having any diffuse rectal bleeding. He noted that his manipulations had caused a spasm in John’s anal area. He had unfortunately caused this during his examination. Dr. Bowers waited for John to calm himself somewhat. “You said you’d never had any rectal bleeding correct?” Dr. Bowers asked.



“Hannah?" Dr. Bowers asked for the nurse, who had been waiting outside the partially open door.



"Yes, Dr. Bowers?" Hannah answered.



"Can you step in here while I get a stool sample from Mr. Williams?"



"Hey, is that really necessary?" John asked, now his irritation gave way to a steady aching pain that became sharp when he moved. Dr. Bowers kept a strong hand on John's hip as Hanna held John's shoulders.



"Okay, take one more breath for me, I need to get a sample. This won't take but a second." Dr. Bowers decided to just go for it since John was not letting out the breath he held.



"John, you have to breathe or this won't work." Hanna encourages, watching John squeezing his eyes shut. John began to quietly rock.



"No please, don't...don't touch me." John tried to pull away but Dr. Bowers had the physical advantage and he held tightly to John's hip. John began to curl up into a ball.



"Come on John, relax." Dr Bowers was unaware of how John was reacting as he dug further, continuing his exam.



"Don't hurt me please, oh God please, stop." Suddenly as Dr. Bowers pressed into him, John managed to get his hips away as he scurried off the table, trying to 'protect his private areas.' He backed himself up into the corner of the room, slinking to the floor. He wrapped his arms around himself and rocked like a baby. "Please, just don't touch me, I'll do anything, please…"



"Call Dijana," Dr. Bowers ordered Hannah.



"John, it's okay, I'm not going to hurt you." Dr. Bowers positioned himself to administer a shot of Haldol.



With the help of an orderly, Dr. Bowers got John up off the floor and into a room. Hanna tucked a blanket around him and soon Dijana joined them.



"I had to sedate him," Dr. Bowers explained what happened as they sat together and filled out their incident report.



“I didn’t get the sample, and unfortunately, as soon as it’s feasible, we do need to get that. He is going to need to start on a stool softener definitely, and a few sitz baths a day wouldn't hurt. I'd highly recommend that he takes at least three to four per day. If he can stand to insert a suppository, it would help the spasms." Dr. Bowers handed his orders over to Dijana, after a full explanation of what had happened during the examination and his findings thus far. He felt sorry for John; he was obviously in pain and had had no idea that he was torn from his last partner.



"Thank you, Dr. Bowers and Hannah, please page me as soon as he wakes up." Dijana added.





To be continued...
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