Attachment #4 Psych Care Plan

Document

RN PROGRAM

PSYCHIATRIC NURSING CLINICAL CARE PLAN #3

Student Name: Clinical Date:

Patient Initials: Your Pts. Initials Clinical Site: VAMC

Age: 58

Height: 5’9

Weight: (kg) UNK

PYSCHIATRIC DIAGNOSIS (Include DSM-IV-TR and definition):

Axis I- Major depressive disorder with psychotic features.

Axis II- Borderline personality traits.

Axis III- Status post surgery for acoustic neuroma with residual left sided hearing loss and facial muscle
weakness. Obesity, DM 2 and HLD.

Axis IV- Chronic mental illness, poor coping skills, poor primary support.

Axis V- 35

PAST MEDICAL/PSYCHIATRIC HISTORY: 58 year old obese male was living in Hampton, VA when
he told to come in by his therapist to get his meds regulated since he feels he has not been doing well. He
has been feeling down for many years. He has anhedonia (lack of interest in normal activities), lack of
energy, decreased appetite, with loss of 7 lbs. VH and AH not discussed by patient. Denied HI and PTSD
or Mania. Client is unsure if experiencing SI. Denise PI. Client is not finding relief by visiting his
therapist 1-2 times a week. He wants to stay in his room and doesn’t want to interact with other male
patients here. Depression since he was 18. First hospitalization was for SI and hearing voices. God was to
heal him upon discharge. He has had psychiatric treatment since 1996. Client had 2 suicide attempts in
1996 and 1998, by overdosing on medications. In 1996, He chased after his daughter with a butter knife
and another occasion he tried to strangle his daughter. The third incident is when he “went after people”
Client reports that the voices he has been hearing stopped briefly in 1978 but resumed again in 1996. The
most recent commandment the voices gave was that the pt needed to offer his dog as an atoning sacrifice
for his sins. Pt received ECT at EVMS in 1997 for treatment of his depression. He states that he has tried
all sorts of medications but can’t remember what he has taken besides desvenlafaxine. Client denies any
substance abuse or use of illicit drugs. Client admits to drinking alcohol very rarely.
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FAMILY HISTORY: Client grew up with mother and father and two sisters; he doesn’t speak to one
sister very much, and he reports being on better terms with the other. Client stated that he was distant with
his father during his childhood. Mother was warmer and pt reports being shy as a child. Client has a one
daughter who has left home and married, which is a source of the sadness. No family history of
psychiatric issues. Sister had depression.

STAGE OF DEVELOPMENT (Include developmental theorist)

Theorist: (Include the theorist, stage, and what the patient should be accomplishing at this stage.)
Erik Erickson: Generatively vs, Stagnation: At this stage the individual should be creative and productive;
establishing the next generation.

Evidence: Due to patient’s depressive state, he is not productive, and does not work. Pt did raise
his daughter and she has moved out of the home and married. Client is creative when not depressed. He
enjoys art and sports.

SPIRITUAL BELIEFS: Pt did not want to discuss at this time.

CULTURAL BELIEFS: Did not discuss with patient.

ASSESSMENT

(Please be specific)

General Assessment and Motor Behavior: (Hygiene and Grooming; Appropriate Dress;

Posture; Eye Contact; Unusual Movements or Mannerisms; Speech. Be specific.) Client was clean and
wearing his own clothes. Client stated that he will be getting his own clothes later on today. Client was
wearing black slip in shoes. Client was sitting back in his wheeled chair, lounging most of the morning
and reading the newspaper. Client made eye contact when being talked to. He sometimes squints his left
eye when he speaks. He spoke clearly and was able to comprehend questions appropriately.

Mood and Affect: (Expressed Emotions; Mood: Labile, depressed, anxious, paranoid); Facial
Expressions: blunted, flat, inappropriate) Facial Expressions: were smiling and happy. Client admitted
mood as “very good overall”. His affect is mood-coherent. Thoughts are logical and coherent. He affirms
auditory and visual hallucinations during admission, but not today. Client is in a good mood, denies any
depression today. He was very inviting to conversation.

Thought Process and Content: (Content: what the client is thinking; Process: how the client is thinking;
Clarity of Ideas; Self-harm or Suicidal Urges) Pt is thinking clearly and able to answer questions
coherently. He was able to clearly explain the process of his profession of being an infantry man in the US
ARMY. No self-harm or suicidal urges noted. No delusions are present.

Sensorium and Intellectual Processes: (Orientation; Confusion; Memory; Abnormal Sensory

Experiences or Misperceptions; Concentration; Abstract Thinking Abilities. Include how you assessed.)
Client was orientated to person, place and time. He did not seem confused. He was able to tell me about
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his family and daughter. He had discussed his military career as an Infantry man and his favorite football
team; the Indianapolis Colts. Abstract thinking was intact by Client’s ability to teach others weapon
familiarization

Judgment and Insight: (Judgment: interpretation of the environment; Decision-making Ability; Insight:
understanding one’s own part in his/his current situation) He has companionship with the one other male
that he bunks with. He understands that the time he was spending there is necessary for his well being.
Client made decisions to become friends with other members of the ward and by stating that he wants to
move into the same town as his sister (Great bridge) once he is discharged. This showed that the patient’s
insight was better since admission.

Self-Concept: (Personal View of Self; Description of Physical Self; personal qualities or attributes) Pt
stated he was unhappy with his separation and divorce from his wife. He also was unhappy his daughter
had moved away. Though, he was happy his daughter was happily married. He is looking forward to
being discharged so he can get a good job and improve his well-being. He stated that he knows he had
problems but he wants to fix them. He loves to watch sports, especially college football.

Roles and Relationships: (Current roles; Satisfaction with Roles; Success at Roles; Significant
Relationships; Support Systems) Client has a 2 years of college and also received an associate’s degree
for foreign affairs. He worked as a weapons instructor for the Navy and the Army from 1980-1992. He
was married 20 years and separated from his wife in 2002, and divorced in 2003. He has one daughter
who has left home and married, which is a source of sadness. Client was Army infantry from 1974-1978,
with no history of combat. He was honorably discharge.

Physiologic and Self-Care Issues: (Eating Habits; Sleep Patterns; Health Problems; Compliance with
Medications; Ability to Perform ADLs) (Describe in detail; e.g., how many meals per day? How much
does he/he eat? Sleep?) Client admitted to sleeping “like a baby” last night. He thinks the food he is
eating here is “OK”. He explained to me that his current health problems are depression and “he hears
voices sometimes”. Client admits to taking medications in the morning, as directed. They do help the
patient’s mood and to help his feel better. Client is able to perform ADL’s with minimal assistance.

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 MEDICATIONS

Please include trade & generic name, dosage, action, reason your
patient is receiving this medication, major side effects, and nursing
implications.
Trade Name Drug Action Is Dose Adverse Nursing
Appropriat Reactions Implications
Augmentin The action of this e?
medication is to: Adverse reactions nursing
Generic Name Bind to bacterial Yes related to the use implications to
cell walls, causing of this medication keep in mind are
amoxicillin/clavula PTs as follows:
nate Dose cell death; are as follows:
Weight Assess for
spectrum of Seizures (High infection (vital
500 mg/ 125 mg amoxicillin is UNK Doses), signs; appearance
daily broader than Pseudomembranou of wound, sputum,
penicillin. s Colitis, diarrhea, urine, and stool;
Frequency Clavulanate hepatic WBC) at
resists action of dysfunction, beginning of and
bid throughout
beta-lactamase, nausea, vomiting,
therapy ((Deglin,
Route an enzyme vaginal 2009).
produced by candidiasis,
Oral bacteria that is rashes, urticaria, Obtain a history
capable of blood dyscrasias, before initiating
inactivating some ALLERGIC therapy to
penicillins (Deglin, REACTIONS determine
previous use of
2009). INCLUDING
and reactions to
ANAPHYLAXIS AND penicillin’s or
SERUM SICKNESS, cephalosporins.
The pt is taking and superinfection Persons with a
(Deglin, 2009). negative history
this medication to
of penicillin
treat pharyngitis. sensitivity may
still have an
The pt is allergic response
experiencing no (Deglin, 2009)
adverse reactions
related to the use Observe for signs
and symptoms of
of this medication. anaphylaxis (rash,
pruritus, laryngeal
edema,
wheezing). Notify
the physician or
other health care
professional
immediately if
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 these occur
(Deglin, 2009)

Monitor bowel
function.
Diarrhea,
abdominal
cramping, fever,
and bloody stools
should be
reported to health
care professional
promptly as a sign
of
pseudomembrano
us colitis. May
begin up to
several weeks
following
cessation of
therapy (Deglin,
2009)

Trade Name Drug Action Is Dose Adverse Nursing

Appropriat Reactions Implications
Zoloft This drug acts as e?
a sedative and to Adverse reactions Nursing
Generic Name decrease anxiety Yes related to the use implications while
and seizures of this drug are as using this drug
Lorazepam PTs Weight follows: are as follows:
(Deglin, 2009)
Dizziness, Assess degree
Dose UNK drowsiness, and manifestation
lethargy, hangover, of anxiety (Deglin,
1 mg every 30
The pt is receiving mental depression, 2009)
minutes to an blurred vision,
hour as needed this medication as
respiratory Caution pt to
for anxiety and needed for depression, apnea, avoid taking
agitation. anxiety or cardiac arrest, alcohol or other
agitation. diarrhea, nausea, central nervous
Frequency vomiting, physical depressants
and psychological (Deglin, 2009)
Take one tab in dependence
morning. (Deglin, 2009) Implement fall
. precautions
Route (Deglin, 2009)

IV

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Trade Name Drug Action Is Dose Adverse Nursing
Appropriat Reactions Implications
Ativan Anticonvulsant; e?
due to Behavioral Assess degree
Generic Name presynaptic Yes changes, and
clonazepam inhibition. drowsiness, manifestations of
Prevents seizures. PTs Weight fatigue, slurred anxiety and
Dose Pt is taking UNK speech, ataxia and mental status.
medication to sedation.
0.5 mg tab reduce recurrent Assess pt for
suicidal behavior. drowsiness,
Frequency clumsiness and
unsteadiness.
Three times a day
Complete a CBC
Route
and LFT while on
Oral medication.

(Deglin, 2009)

LAB DATA & DIAGNOSTIC EVALUATION

Include date

LAB Ordered Client Normal Values Indication for Diseases / Illness

Values

Basic Metabolic
Panel
(BMP) The Basic Metabolic Panel (BMP) is a frequently ordered
136 37-145 mmol/L panel of tests that gives your doctor important information
Sodium 6.5 3.3-4.6 mmol/L
Potassium 103 about the current status of your kidneys, blood sugar, and
Chloride
98-107 mmol/L
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Carbon dioxide 27.7 22-30 mmol/L electrolyte and acid/base balance. Abnormal results, and
Anion gap 151 70-99 mg/dL especially combinations of abnormal results, can indicate
Glucose 212
Blood Urea 9-20 mg/dL a problem that needs to be addressed.( Lab Tests Online,
Nitrogen (BUN) 21.6 2010)
Creatinine 9.8
BUN/creatinine 3
0.7-1.3 mg/dL
ratio 2 >60 mL/min/1.73
GFRAA 10.0 >60 mL/min/1.73
GRFNA 12.4 8.4-10.2
Calcium 1.3
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Phosphorus 2.5-2.5
Magnesium 1.6-2.3

LAB Ordered Client Normal Values Indication for Diseases / Illness

Values

PSYCHIATRIC MANAGEMENT

PSYCHIATRIC PRIMARY SECONDARY

DIAGNOSIS
(The Axis I or II – not your nursing (The Axis I or II – not your nursing
diagnosis) diagnosis)
Major depressive disorder
Borderline personality disorder

Define (what is Major depressive disorder is Borderline personality disorder is

it?) described as two or more weeks
of a sad mood or lack of interest
in life activities with at least four
other symptoms. (Listed below).
characterized by a pervasive
pattern of unstable interpersonal
relationships, self-imaging, and
affect as well as marked
impulsivity.

Etiology (What Client’s daughter had moved from He was distant from his father and
may have home recently and got married. one sister during childhood. He
caused or He is also divorced. also was shy as a child.
contributed to
the illness in this
patient?

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Pathophysiology The influence of stress and The report of disturbed early
(Include both adverse life events. Depression relationships with their parents
physiological and has a high rate of comorbidity that often begins at 18-30 months
psychological with other psychiatric of age. Sometimes from sexual
possible causes disturbances. abuse, physical or verbal abuse or
per your parental alcoholism. It is three
resource.) times more common in woman
then men. Due to self-mutilation.
This is a cry for help, an
expression of anger, helplessness,
or a form of self punishment.

Clinical Lack of sleep or inadequate sleep, Feelings of emptiness and

Manifestations changes in weight, anhedonia,
(textbook) lack of energy, inability to
concentrate, focus or make
decisions, worthlessness or guilt,
and hopelessness, helplessness or
suicidal ideation.
Clinical Pt has become depressed since
Manifestations his only daughter has moved from
home and been married. Pt has no
(Actual – based other support at home with his.
on your He is divorced and has a sister in
observations and the area.
history)
boredom, frequent displays of
inappropriate anger,
impulsiveness with money,
substance abuse, sexual
relationships, binge eating, or
shoplifting, intolerance of being
alone, recurrent acts of crisis
such as wrist cutting,
overdosing, or self-injury.
Pt’s mood has changed since he
has been admitted. He is now
more stable and happy. Pt came
in depressed, has a history of self
mutilation, and suicide attempts.
Pt has chased his daughter with a
knife, yet loves and misses her.

(Videbeck, 2011).

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS

List all nursing diagnosis relevant to patient condition & based on assessment (It is not necessary to
include the “related to” or “As manifested by.”

1. Risk for self and other directed violence

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 2. Disturbed Sensory Perceptions: auditory

3. Social Isolation

4. Hopelessness

5. Risk for suicide

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 NURSING CARE PLAN

Student Name: _Your Name Here___________ Date: ____Yada yada_______________ Class: _NUR 267_____

Patient Initials: Your Pts. Initials

A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest
priority first. Be sure to include “related to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least
one short term goal and one long term goal per nursing diagnosis stated in terms of client achievement - “the client will…”). List at least 3
specific nursing actions (interventions) for each short term and long term goal for each nursing diagnosis, and give the scientific rationale for
each intervention for selecting the action you will use to work toward that goal. Evaluate the short term goal and what you would expect, or
hope, to see for the long-term goal.

NURSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOME
(What do you plan to do?) (Why are you doing
(NANDA APPROVED) (Measurable Goal) this?)

Provide references
for each rationale.

Risk for self and STG: 1a.) Provide a safe environment 1a.) Client safety is a STG met;
other directed for the client. A) keep an eye out priority. Many
violence Pt will be safe and for any signs of aggression common items may Client was safe and free
free of self – be used in a self- from self-inflicted harm by
related to inflicted harm by 2a.) Continually assess the destructive manner. the end of the shift. The
end of shift. client’s potential for suicide. A) environment was well
Client’s past watch for signs of depression, 2a.) Depressed maintained, pt did not show
history of LTG: mood changes, any type of clients may have a signs of potential suicide.
suicide and attitude with other clients potential for suicide Though, pt mood had
violence. Client will be able
to express anger that may or may not changed to becoming more
3a.) Observe the client closely, be expressed and positive from the time of
or hostility especially after any dramatic
outwardly in a safe that may change with admission, pt stated he felt
behavioral changes. time. better and his medications
manner by the
time of discharge. 1b.) Encourage the client to were helping his.
3a.) Must be aware of

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 (Vacarolis, 2006). ventilate feelings in whatever
way is comfortable, verbal or
non-verbal.
2b.) Avoid asking the client many
questions, especially questions
that require only brief answers.
3b.) Teach the client about the
problem-solving process: explore
possible options, examine the
consequences of each
alternative, and evaluate results.
(Vacarolis, 2006).
NURSING EXPECTED NURSING INTERVENTIONS
DIAGNOSIS OUTCOME
1. Disturbed STG: 1a.) Ensure that the environment
Sensory is quite, calm, and non-
Client will
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the clients activities LTGs still ongoing:
at all times when
there is a risk for Client was to be discharge
injury to themselves later on that day. Pt was
or others. able to admit he was upset
upon admission. He was
1b.) Expressing open in expressing how he
feelings may help was feeling that day.
relieve despair,
hopelessness and so
forth.
2b.) Asking questions
and requiring only
brief answers may
discourage the client
from expressing
feelings.
3b.) The client may
be unaware of a
systematic method
for solving problems.
Successful use of the
problem- solving
process facilitates the
client’s confidence in
the use of coping
skills.
(Vacarolis, 2006).
RATIONALE EVALUATION
1a.) These qualities STGs were met by pt
help to avoid environment was kept calm
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 Perceptio demonstrate distracting. visual/auditory and quite. Therapeutic
ns: improved overload. touch was used at
auditory response to stimuli 2a.) Provide touch in a caring appropriate times. Client
related to by the end of shift. way. 2a.) Touch enhances worked with others on a
altered perception of self and puzzle before lunch time
LTG: 3a.) Encourage intellectual body boundaries, as
sensory activity such as word games, showing improved response
perceptio well as commutates to stimuli.
Client will be able discussion of current events, and caring.
n as to identify and storytelling.
evidence LTGs were still ongoing.
control external 1b.) Provides Client
by factors that 1b.) Help the client to identify
with normalcy and Client talked about what
hearing environmental and/or developmental
contribute to connection to others caused his disorders and
voices. factors, which increase risk for low self-
sensory esteem. and the world and what he can do to change
disturbances by stimulates remaining the negativity in his life.
the time of 2b.) Help the client to identify the cognitive abilities. Client wants to change and
discharge. resources and social support network start fresh. Client has a
available to him or his at this time. 2b.) Identification is positive outlook.
(Vacarolis, 2006). the early stage of the
3b.) Help the client to identify what has
problem solving
helped maintain positive self-esteem thus
process.
far.
3b.) Social support can
(Vacarolis, 2006).
give more positive
outcomes and structure to
the client’s life. Identifying
what works empowers the
client and encourages
positive outcomes.

NURSING EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

2. Social STG: 1a.) Spending time one-on-one 1a.) This helps to STGs was met by helping
Isolation with the client. understand what the client the patient talk about his
as The client will is saying and communicate daughter and how he
evidence express concern 2a.) Encourage the client to that understanding to the misses his. He stated

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 by pt for another by the participate in group activities. client. that he wanted to go live
stating end of the shift. near his once he is
3a.) Promoting client’s ability to 2a.) Group activities
he discharged.
LTG: safe expression of feelings and provide social support and
doesn’t
emotions. help the client to identify LTGs are still ongoing. Pt
want to The client will alternative ways to problem
leave his was being discharged
verbalize greater 1b.) Educate male clients about self- solve.
room or later on today. He stated
satisfaction and esteem differences between genders, and
talk to 3a.) This encourages he needed his daughter.
importance with encourage exploration.
the male the patient to show
relationships by 2b.) Encourage the client to verbalize
patients feelings and concern
the time of thoughts and feelings about the current
for others.
discharge. situation, individually or in groups.
1b.) Males tend to have
(Vacarolis, 2006). 3b.) Encourage the client to identify and
lower self-esteem than
maintain supportive relationships outside
males no matter what
the hospital.
domain is measured.
(Vacarolis, 2006). 2b.) Allowing the client to
clarify thoughts and
feelings promotes self
acceptance.

3b.) The client may fear

rejection from others in his
life and may need
encouragement to contact
others.

(Vacarolis,
2006).

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 References

Deglin, J.H.,&Vallerand, A.H. (2009). Davis’s drug guide for nurses (11th ed.). Philadelphia,

Pennsylvania: F.A. Davis Company.

Vacarolis, E. M. (2006). Manual of Psychiatric nursing:Diagnoses, Clinical Tools, and

Psychopharmacology (3rd edition ed.). St. Louis, Missouri: Saunders Elsevier.

Videbeck, S.L. (2011). Psychiatric-mental health nursing (5th ed.). Baltimore, Maryland: Wolters

Kluwer, Lippincott Williams &Wilkins

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