BATOMIR examples

[Scenario1]

Miss, X was diagnosed with Bipolar 1.

She was on EL with Her husband at the start of the shift, and returned at approx.1600hrs. Dressed in her stained jacket and long pants. Appeared unkempt and slightly malodourous Mood described as “good”. Objectively, mood appears euthymic with reactive affect. However, her low profile was observed at 17400hrs. had 1:1 brief interaction. Stated she wants to discharge as soon as possible. Speech was normal rate and rhythm. Thought contents and process appear reality based. Memory appeared intact. She was able to remember her future plan after discharge, talked with writer last time. Stated, she wants to travel to Hamilton with her husband. Denied AH/VH. Denied any other concerns. Accepted nocte meds with nil issues. At 2030hrs, observed dried vomit on her room floor. Cleaned with spill kit with RN. Miss, X stated, I vomited and it has been for 3-4days. Her room was disorganised. Assisted and encouraged to keep the room tidy, and she agreed.

Stated BM x1 today.

NZEWS - 0

@ Current risk:

-        No imminent risks noted during this shift.

@ Task for next shift

-        As per RC : aim for discharge Wed (Date)

-        BD obs

-        PRN Lorazepam reduced, please do not increase Lorazepam dose (Risk of paradoxical agitation/confusion with increasing doses)

 

 

[Scenario 2]

Mr, X. is diagnosed with schizophrenia. During the shift, he mainly stayed in his room, was Isolative and had poor self-care. Appears dishevelled and malodourous. Mood appears euthymic with blunt affect. Thought contents appear delusional themes. He stated, he is busy communicating with supernatural beings in his room. Denied any SI/SH. Accepted regular meds. Unable to recall when he last opened his bowels. But denied abdominal pain/discomfort.
NZEWS – 1 due to HR 112.
@ Current risk: 
- At risk of poor self-care
- Social isolative 
- Poor sleep hygiene
@ Task for next shift
- Daily obs

 

 

[Scenario 3]

 

Miss, X is diagnosed with dysthymic disorder and borderline personality disorder.
She was dressed in a grey hoodie and pants. She appears well-kempt. During 1:1 interaction, her speech is soft and low. Speech rate and rhythm appear normal. Objectively, her mood appears anxious with congruent affect. Thought contents and process appear logical and linear during the conversation. Memory appears intact. Insight and judgment appear intact. She had EL (Escort leave) with her mom at 1700hrs. After coming back from EL, she asked for PRN meds Lorazepam 1mg, and given with setting effect. Denied any risk for SI/SH. She stated, that when she feels this risk, she will inform the RN. Stated, that she will reach out to her support system when she is in the community. She is aware of the crisis hotline numbers as well when she needs additional support. Observed E+D well. Accepted nocte meds with nil issue. Nil other concerns were voiced. Stated BM x1 today. 
NZEWS-1 due to BP 107/71, asymptomatic.
@ Current risk: 
- No imminent risks noted during this shift.
@ Task for next shift
- Phone assessment with WINZ on the (date) at loan. SW (social worker) will support.
- As per RC, BULE 30mins 1x per shift and EL up to 6hrs with her mum. 

 

 

 

Labile
Euthymic with Congruement/reactive affect with underleying anxiety
Fidgety
Volatile
Dysregulation