NURS 360 PMH Care Plan Student Nurse Reporting Form SN: Brandi Anastacio Pt!

: Se": Male 'rans&erred( No )ncome source: Supports sel& *$ doing +,ettering- and income &rom sister! Per c.art/ client is currentl$ appl$ing &or social securit$! ,egal Status: MH# SM iagnosis: Paranoid Sc.i0op.renia A"is l1 Paranoid Sc.i0op.renia 2Client-s criteria per medical c.art: Positi3e Auditor$ .allucinations &or 45mont. &or o3er 6 mont.s! Results in social6occupational d$s&unction! iagnosis 7as made 7.en .e 7as 89 $rs! old! He 7as pre3iousl$ .ospitali0ed in 5::5 and 5::6 &or sc.i0op.renia and complaints o& auditor$ .allucinations!;
Criterion A: Two or more symptoms, each present for a significant portion of time during a 1 month period Delusions, Hallucinations, Disorganized speech, grossly disorganized or catatonic behavior, Negative symptoms Criterion B: Social/occupational dysfunction Criterion C: Duration Continuous signs of distur!ance persist for at least " months Schi#ophrenia Su!types PARANOID T P! $reoccupation with one or more delusions or fre%uent auditory hallucinations &one of the following are present: disorgani#ed speech, disorgani#ed or catatonic !eha'ior, flat or inappropriate affect(

ate: ate o& Admission:

Age: #0 $rs!%old

A"is )))1 ia*etes Mellitus/ H$pertension A"is l<1 ,i3es alone/ unemplo$ed A"is <1 =AF 35%90 >una*le to assess in c.art/ per o*ser3ation1

>Admission: pro*a*l$ assessed at 85%30: =reatl$ in&luenced *$ .allucinations/ *ut since admission/ t.is .as decreased as an issue related to medical6t.erapeutic management! Client appears to *e reac.ing =AF le3el o& 35%90/ ma?or impairment in social6occupational roles1

@.at *roug.t patient to t.e .ospital( Client-s c.art states .e 7as e"periencing suicidal ideation related to increasing auditor$ .allucinations! Patient-s description o& illness6issues: A) .a3e a mental illness! )t-s di&&icult! )t started 7.en ) 7as $oung/ *ut t.is .as ne3er .appened *e&ore 7it. 3oices in m$ .ead! '.e 3oices are Bind o& liBe c.anting and t.e$ manipulate t.ings/ liBe t.e '<!C

Spiritualit$: Client states A)-m not religious!C Considerations r6t et.nicit$ or religion: Religion: Client states .e does not practice a religion/ *ut .e is open to *eing 3isited *$ a clerg$ or minister! Ethnicity: Client is Caucasian! Client states .e doesn-t .a3e an$ cultural pre&erences! @.en asBed 7.at .is et.nicit$ is/ .e stated +7.ite-! Patient-s Strengt.s: Per client: A) am independent!C Per D*ser3ation: Client acti3el$ participates in group acti3ities and is appropriate 7it. peers and sta&&! Per Sta&&: Client is pleasant 7it.in t.e milieu and approac.a*leE non%impulsi3e! Client is a*le to 3er*ali0e needs! Patient-s ,imitations: Per Client: A)-m &orget&ul!C Per D*ser3ation: Client-s a&&ect is *lunted and appears to *e e"periencing po3ert$ o& speec.! Per Sta&&: Alt.oug. client is a*le to per&orm A ,s/ .e reFuires &reFuent reminders to per&orm .$gienic sel&%care!
'otal Medication Drder Class 89.r dose Haldol 6mg 'a* PD HS 5mg I50H PRN #00mg B) 76meals Pra3astatin ,isinopril 90mg dail$ 90mg dail$ 5mg PD PRN F9. ,ipid ,o7ering Agent ACG )n.i*itor 90mg 90mg Client denies Client denies ro7siness/ Ben0odia0epine 89mg di&&icult$ in concentrating An"iet$
An"iet$M5H3 mg 8H3 times dail$ >up to 50 mg6da$1

Side G&&ects Client is e"periencing ro7siness/

'arget s$mptom: to reduce t.e &ollo7ing Ps$c.osis

0!#H# mg 8H3 times dail$! Patients 7it. se3ere s$mptoms ma$ reFuire up to 500 mg6da$ 5H8 mg6da$ in 5H8 di3ided doses >range 0!#H6 mg6da$1 #00 mg t7ice dail$E ma$ J *$ #00 mg at 7eeBl$ inter3als up to 8000 mg6da$ 50H80 mg once dail$ initiall$ >ma$ start 7it. 90 mg6da$ i& , , s.ould *e lo7ered *$ 4 9#K1E ma$ *e increased F 8H9 7B up to L0 mg6da$! H$pertensionM58!#H8# mg 8H3 times dail$/ ma$ *e J at 5H8 7B inter3als up to 5#0 mg 3 times dail$

Recommended ose Range

'$pical Antips$c.otic Anti% ParBinson-s6c.olinergic Anti%dia*etic

6mg

di&&icult$ in concentrating

Ben0tropine

8mg

Not currentl$ taBing

GPS

Met&ormin

5000 mg

Client denies

H$pergl$cemia

H$perlipidemia H$pertension

,ora0apam

AN)S ))): ,ist all conditions e3en i& t.e$ are not listed in multi%a"ial diagnoses or on c.art! 1. ia*etes Mellitus%treated 7it. oral anti%dia*etic/ Met&ormin

2. H$pertension%treated 7it. ,isinopril 3. H$perlipidemia%treated 7it. Pra3astatin BM): 8:!: Categor$: D3er7eig.t >Heig.t: 5O:cm @eig.t: :#!LBg1 Food P &luid intaBe: AdeFuate/ eats almost 500K o& all meals Bladder P *o7el status: Continent Sleep pattern: Client states/ a3erage o& 9%# .ours per nig.t! He also states t.at .e normall$ sleeps a&ter midnig.t! 'otal sleep689 .rs!: Per medical c.art/ O!# .ours! i&&icult$ &alling asleep Middle insomnia Garl$ morning a7aBening

Num*er o& .rs o& disruption: 8Q Naps: A&ternoon 'otal nap time: 8 .ours

,a* P studies
ate6Panels in 7.ic. all 3alues 7ere normal: Urinal$sis/ CBC 76microscop$ and Urine rug Screen: Ranuar$ 83/ 8059 ate6An$ a*normal la*s: ,a*s @N, ,a*s $ou 7ould e"pect *ut 7ere not ordered: ,F's and BUN6Creat!/ due to medication regimen =lucose readings " 89. &or all dia*etic pts!: =lucose: :0 mg6d, >@N,1 All drug screen &indings: Negati3e

rugs: Su*stance a*use or dependence: N6A/ Per medical c.art P client denies su*stance a*use!

MGN'A, S'A'US ASSGSSMGN':

Be.a3ior: Calm and appropriate 7it. sta&& and peers! Mood: Client states ANot so 7ell 7it. t.e 3oices!C A&&ect: Blunted Sensorium: QAuditor$ Hallucinations/ Client states A)t-s liBe c.anting/ *ut t.e$ .a3e Fuieted do7n a lot!C Client also states t.at t.e$ do not asB .im to .arm .imsel& or ot.ers! )mager$: is.e3eled/ unBempt Cognition: )n.i*ited 7it. po3ert$ o& t.oug.t )nterpersonal relations.ips: Mot.er and sister/ li3ing in C.icago! Client denies an$ close &riends or case manager! e3elopmental le3el: Erickson: Intimacy vs. Isolation! Client appears to *e e"periencing a &eud 7it. a*ilit$ to create interpersonal relations.ips related to side e&&ects o& .a3ing sc.i0op.renia and t.e *arriers it creates/ i!e! *lunt a&&ect/ po3ert$ o& t.oug.t and concrete t.oug.t process! '.is ma$ result in a c.allenge to create positi3e social relations.ips and t.us adapting more to7ards isolation! Moral/ ,egal and Gt.ical )mplications o& Care: Moralit$ includes t.e a*ilit$ to care &or t.e client 7it. complete sel&%a7areness and to pro3ide eFual Fualit$ care to eac. person/ 7it.out an$ preconcei3ed ?udgment or implications to7ard t.e client *ased on t.e client-s diagnosis or *acBground! ,egalit$ is t.e maintenance o& con&identialit$ and t.e client-s rig.ts at all times! Gt.ical care encompasses man$ t.ings liBe *ene&icence/ non%male&icence and autonom$! )t can *e displa$ed *$ maintaining t.e client-s dignit$/ colla*orating care &or sa&et$ o& t.e client and ensuring t.at t.e client is t.e center o& t.eir treatment plan! All o& t.ese t.ings can *ecome di&&icult in an$ aspect o& .ealt. care/ *ut especiall$ di&&icult in mental .ealt. 7.en sometimes it ma$ seem t.at t.e client cannot *e a 3ia*le decision maBer o& t.eir care and t.e client-s &amil$ ma$ come to taBe on t.e reigns! Also/ due to t.e stigma associated 7it. mental illnesses/ t.e nurse must *e 3er$ care&ul to not &all into t.is societal trap and compartmentali0e clients into 7.at t.e$ *elie3e a mental illness is!

Pro*lems )denti&ied in Hospital-s Master 'reatment Plan: 5! ia*etes Mellitus 8! Pre3enting Patient Falls 3! Sc.i0op.renia Current isc.arge Plan: Sc.i0op.renia/ treat 7it. Haldol 6mg F.s and Cogentin 5mg PRN B) ! Follo7 up 7it. CBC/ BMP/ &asting glucose/ lipid/ P GS=! Set up &ollo7 up 7it. ps$c.iatrist and colla*orate 7it. a case manager6social 7orBer! ia*etes Mellitus/ continue to manage 7it. diet and Met&ormin! H$pertension/ continue 7it. ,isinopril and d$slipidemia 7it. Pra3astatin! Client 7ill return .ome and 7ill 7orB 7it. case manager and &amil$ regarding possi*ilit$ o& mo3ing to C.icago 7it. mom and sister! Nursing interventions you performed this shift (Include safety and teaching!): Per&ormed t.erapeutic communication to esta*lis. a trusting relations.ip and *uild rapport! Assessed client-s mental status and per&ormed suicidal risB assessment! Reported &indings to primar$ nurse! Gncouraged client to participate in group acti3ities and to per&orm personal .$giene/ i!e! s.o7er/ oral care/ sBin care and laundr$! iscussed coping strategies and assisted client in iscussed goals prior to coming up 7it. a plan i& suicidal ideation recurs!

disc.arge and &or a&ter disc.arge/ reported to primar$ nurse! Pro3ided teac.ing regarding pre3ention o& &alls and to rise slo7l$ due to possi*le ort.ostatic .$potension related to medications! Pro3ided additional teac.ing regarding dia*etic diet and signs o& .$po6.$pergl$cemia! Also pro3ided teac.ing regarding s$mptoms o& GPS and t.e need to report signs and s$mptoms! : Client sitting alone at ta*le! Client appears calm 7it. appropriate a&&ect! Client states A) ?ust 7ant to *e normal liBe *e&ore!C A: 5 to 5 to esta*lis. rapport and assess mental status! Gngaged client in milieu t.erap$ 7it. group communit$ meeting/ recreational t.erap$ and cra&ts! R: Client participated *$ 3er*ali0ing goals in communit$ meeting/ pla$ing *asBet*all 7it. sta&& and maBing stain glass art in cra&ts! Client stated A)t .elps i& ) participate!C

Patient%centered Care Anal$sis PR)DR)')TG PA')GN' NGG S @.at are t.e patient-s 9 .ig.est needs6pro*lems( 5! P: Sa&et$ >G3idence Based Article Attac.ed1 G: <er*ali0ation o& suicidal ideation upon admission in relation to auditor$ .allucinations! S: Assess &or suicide risB/ plan and intent! Gsta*lis. rapport/ encourage client to e"press &eelings and contract &or sa&et$ at t.e start o& eac. s.i&t! Reassess as needed! 8! P: )solation G: Client sits disengaged in t.e milieu! Client 3er*ali0es t.e desire to participate! S: Use o& t.erapeutic communication tec.niFues to engage client in group and recreational t.erap$! 3! P: Coping sBills in reducing an"iet$ related to auditor$ .allucinations G: Client states +t.e sounds o& t.e '< can maBe t.e c.anting louder and t.e$ manipulate t.e '<-! S: G"plore coping sBills/ i!e! Fuiet area/ distraction and communication o& t.oug.ts and &eelings! 9! P: H$giene G: Client appears dis.e3eled/ unBempt and is malodorous 7it. greas$ .air! S: Remind client o& t.e importance o& .$giene/ especiall$ in relation to dia*etes/ and direct client to per&orm sel&%care *$ assisting client in o*taining supplies and guiding to &acilities 7it. sta&&!

Priority # 1 CARE PLAN Nursing Diagnosis: Risk for self-directed violence P: Safety E: Ver ali!ation of suicidal ideation u"on ad#ission related to auditory $allucinations% &: Assess for suicide risk' "lan and intent% Esta lis$ ra""ort' encourage client to e("ress feelings and contract for safety at eac$ s$ift% Reassess as needed% L) goal: Client will not harm himself during admission &) goal: Client will not harm himself !y the end of the shift
*ntervention + ,re-uency
)nter'iew the patient to assess potential for self*harm at the !eginning of each shift

t$e start of

&cientific Rationale

Evaluation

$eople who are suicidal remain am!i'alent a!out wanting to 5ith use of suicide ris- assessment, score of 2: no ris- Client end their li'es $atients may 'iew suicide as the only way to states 6) do not feel li-e hurting myself since the 'oices ha'e %uieted relie'e se'ere, persistent, or recurrent emotional pain ( down 7 +,ulanic- . /eyers, 0111, p 23"4

$ro'ide close patient super'ision !y maintaining o!ser'ation or awareness of the patient at all times, with random chec-s

The degree of super'ision is defined !y the degree of ris- ( +,ulanic- . /eyers, 0111, p 2334

$erformed 1:1 with client Client did not display an attempt to perform self*harm

De'elop a 'er!al or written contract stating that the patient will not act on The patient !enefits from tal-ing a!out suicide ideation with impulse to do self*harm 8e'iew and update the contract as needed or at Client 'er!ally contracted for safety for the duration of the shift trusted staff A written or 'er!al agreement esta!lishes least e'ery shift permission to discuss the su!9ect, ma-es a commitment not Client stated 6) will let staff -now if the 'oices are !ad enough for me to act on impulse, and defines a plan of action in case to want to hurt myself 7 impulse occurs ( +,ulanic- . /eyers, 0111, p 2334

:ncourage 'er!ali#ation of negati'e feelings within appropriate limits, periodically or at least e'ery two hours, assess for this need

Depressed patients need the opportunity to discuss negati'e thoughts and intentions to harm themsel'es ;er!ali#ation of Client reassessed periodically for thoughts of S) and increasing these feelings may lessen their intensity $atients also need auditory hallucinations resulting in negati'e thoughts Client denies to see that staff can tolerate discussion of suicide ideation ( thoughts of S) and any negati'e thoughts +,ulanic- . /eyers, 0111, p 2334

Reference Gulanick, M., & Myers, J. (2011). Nursing care lans! "iagn#ses in$er%en$i#ns, an" #u$c#&es. ('$( e" e".). )*! M#s+y

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