Psychiatric Mental

Health Capstone
Project
Amy Boyd
NURS 360
Psychiatric Mental
Health Nursing

Identifying data:

Sixteen year old Caucasian male

10th grade of high school
Lives with mother / financially dependent [Financial status]
Tricare insurance (Mom in Navy)
Multi-diagnoses : dual diagnosis of ADHD & Aspergers Disorder (ASD)

Reason for admission

Psychiatric evaluation after client reported having +SI/HI after being transferred to a
detention home by the court
In need of a safe, locked residential facility while waiting for court-ordered facility
placement [Legal Status]

History

Sexual assault in 3rd degree in 2013 when client was 14 and touched a boy who was
8 or 9 at the time
Terroristic threatening in 1st degree

DSM Diagnoses:

Axis I: ADHD - combined type, Aspergers Disorder (ASD),

sexual abuse of a child (perpetuation)

Axis II: Mild mental retardation, pervasive learning disabilities

Axis III: Obesity & dyslipidemia

Axis IV: Involvement with legal system; problems in peer

relationships; parents divorced & minimal contact with father
[Legal status: MH5a in chart but not complete. Awaiting courtordered tx facility as mentioned]

Axis V: GAF of 40, serious symptoms & impairment

Patients Description of Problem

1.

I am sure you know what its like to have emotional

problems like me.

2.

Sorry, I am just so indecisive today!!

3.

I have a low IQ

4.

Yeah, just some family problems. I just feel guilty cause I

am not grown up for my mom.

Strengths

Limitations

Behaviorally
Social and cognitive
cooperative with 1:1
impairment
interaction with staff

Sexual precautions
Accepts redirection

Medications:
1.

Order: Concerta (methylphenidate) 72 mg PO daily

Drug Class: Psychostimulant (PS)
Pts target sx: inattention, hyperactivity, impulsivity

2.

Order: Aripiprazole (Abilify) 2 mg PO daily

Drug Class: Atypical Antipsychotic (AAP)
Pts target sx: Irritability & depressed mood
Current side effects: (Suspected) weight gain, dyslipidemia

3.

Order: Guanfacine (Intuniv) 1 mg PO BID

Drug Class: Antihypertensive (Indication: Tx of ADHD)
Pts target sx: Distractibility & intrusiveness

4.

Order: Sertraline (Zoloft) tab 100 mg PO daily

Drug Class: Antidepressant (SSRI)
Pts target sx: crying, guilty feelings, decreased motivation

Labs
8/6/15: Normal labs:
-Cholesterol:189
-Triglycerides: 109
-Hematology panel: all normal
-Thyroid panel: all normal
-Glucose: 89
8/6/15: Abnormal labs:
-HDL Cholesterol: 37 (low)
-LDL cholesterol: 130 (high)
-Non-HDL cholesterol: 152 (high)

Axis III
Obesity (HT: 59, Wt: 239 lb 8.5 oz., BMI: 35.36 k/m2)
Teach/encourage patient about importance
of eating a healthy diet & exercising regularly

Dyslipidemia
Teach patient about importance of eating a
healthy diet & exercising regularly

MSE:
Behavior:
Erratic as evidenced by:
Cooperative / friendly when interacting with me 1:1
Pacing when indecisive about where to go
Impulsive when intruding on peers
Affect:

Labile
Inappropriate

MSE, cont.
Sensorium:
Alert and oriented to person, place, time, and situation
Poor attention span
Imagery:
Patient denies any hallucinations, delusions, flashbacks, etc
Cognition:
Recent memory & remote memory intact
Poor concentration
Low intelligence
Unable to count cards in head
Unable to assess ability of abstraction of proverbs

MSE, cont.
Interpersonal relationships:
Difficulty with social interactions/interacting in a socially acceptable
manner
Needs redirection to maintain interpersonal boundaries
Observed client only interacting with peers much younger than him
or staff who were assigned to interact with/observe client 1:1.

Developmental level (assets & barriers):

Erikson: Industry vs. inferiority -> Unable to gain self-confidence so
unable to progress

D/C Plan

/ Assessment Tools

Transferred on 9/13/15 to
court-ordered tx facility in
PA called Cove PREP
Treatment Facility for
Adolescent Sexual
Offenders.

TM33
Coppersmith selfesteem inventory

DSM criteria comparison

Criterion 1 - ADHD - Inattention

Often has difficulty sustaining attention in tasks or play activities as

evidenced by jumping from showing me how to play one card game to the
next

Often avoids, dislikes, or is reluctant to engage in tasks that require

sustained mental effort as evidenced by irritated mood when staff
suggested to attend group therapy and hesitating to participate

DSM criteria comparison, cont.

Criterion 2 - ADHD - Hyperactivity

Often leaves seat in classroom or in other situations in which remaining seated is
expected as evidenced by standing up and asking staff if could leave goal-setting
meeting early a couple times

Often has difficulty playing or engaging in leisure activities quietly as evidenced by

shouting loudly while watching TV and playing Jenga even after being asked by staff
to quiet down

Is often on the go as evidenced by pacing back and forth up and down hallway
Criterion 2 - ADHD - Impulsivity

Often interrupts or intrudes on others as evidenced by standing in front of the TV

while another boy was trying to watch it and remaining there even after that boy
asked him to move

PRIORITIES*
Self or other directed violence
At risk for suicide
ST: NOT HARM SELF / SEEK OUT STAFF IF SELF-HARM
THOUGHTS OCCUR**W/I 2 WEEKS

LT: SAME BUT **DURING HOSPITALIZATION

 Ineffective Coping

ST: VERBALIZE UNDERSTANDING OF INEFFECTIVE

COPING STRATEGIES*W/I ONE MONTH
LT: UTILIZE ONE SOCIALLY ACCEPTED COPING
STRATEGY**BY D/C

Impaired social interaction

ST: ATTEMPT TO INTERACT WITH PEERS USING SOCIALLY

APPROPRIATE BEHAVIORS IN PRESENCE OF TRUYSED
CAREGIVER**W/I ONE MONTH
LT: IDENTIFY 3 INAPPROPRIATE/APPROPRIATE SOCIAL
INTERACTIONS**BY D/C

Care Plan
Nursing Diagnosis: Risk for self-directed or other-directed violence related to impulsivity
Problem:

Risk for other-directed violence

Evidence:

Admitted for homicidal ideation

History of sexual assault in the 3rd degree

Charge of terroristic threatening in the 1st degree

Continues to have sexual urges that he is concerned about (per H&P)

Client stated he has too much sexual deviants (per H&P)

Client was transferred to another facility that is specifically for adolescent sexual offenders

Impulsivity as evidenced by intruding on others.

Solution:

Frequently observe clients behavior

Be available to stay with the client when tension rises

Encourage verbalization of thoughts/feelings for ventilation of emotion

Teach client ways to redirect violent behaviors.

LT goal: Client will not harm self or others & client will seek staff out any time if thoughts of harming self or others should occur
during hospitalization.
ST goal: Client will not harm self or others & client will seek staff out any time if thoughts of harming self or others should occur
within two weeks.

References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th
Ed.). Arlington, VA: American Psychiatric Association.

Fortinash, K. & Worret, P. (2012). Psychiatric Mental Health Nursing (5th ed.). St. Louis, MO: Elsevier.

Townsend, M (2015). Psychiatric nursing: assessment, care plans, and medications (9th ed.).
Philadelphia, PA: F.A. Davis Company.