Attachment #4 Psych Care Plan

Document

RN PROGRAM

PSYCHIATRIC NURSING CLINICAL CARE PLAN WITHIN PAPER

Student Name: NAME Clinical Date: Yada Yada

Patient Initials: Your Pts. Initials Clinical Site: PAPER

Age: 30

Height: 5’ 4”

Weight: 65.91kg

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: 30 year old female was living in Chesapeake, VA when she was diagnosed with
Sarcoidosis and depressive anxiety disorder. She has been feeling down for many years. She has anhedonia (lack of interest in normal
activities), lack of energy, increased appetite, with significant weight gain over the past several months. Client denied HI and
CLIENTSD or Mania. Client is unsure if experiencing SI. Denise PI. Client is non-compliant with medications and visiting a therapist.
She wants to stay in the house and doesn’t want to interact with any outside persons of either gender. Depression since she was 23
after a miscarriage. First hospitalization was for SI and blacking out at She had in hospital psychiatric treatment 2003. Client hasn’t
attempted suicide; however, the thoughts come and go. In mid-2006, She had thoughts of killing her new born son by drowning or
suffocating him. She states that she has tried all sorts of medications but none of them work or cause severe side effects. Client denies
any substance abuse and only mild use of marijuana as a teen. Client admits to drinking alcohol socially.

FAMILY HISTORY: Client grew up in a broken family and lived with mother and step-father and one half- sisters, that was killed in
a hit and run; she has other siblings that are much older than her on her father’s side of the family and doesn’t either of them very
much, and she reports being on better terms with other people from work more so than her own family. Client stated that she was
distant with her father during her childhood. Mother was warmer and states being quite active as a child. Client has two sons who
currently live at home with her in Nashville. Client reports some significant family history of psychiatric issues. Maternal grandmother
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, she filed for a divorce, and does not work. Client did raise her daughter and she is
moved out of the home and married. Client is creative when not depressed. She enjoys art and sports.

SPIRITUAL BELIEFS: Client does believe in God however, is questioning her beliefs 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 a hospital gown. Client stated that her husband will be bringing her, her own clothes later on today.
Client was wearing brown moccasin style slippers. Client was sitting back in her chair, lounging most of the morning and reading a
book. Client made eye contact when being talked to. She spoke clear and concise was able to follow and understand 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 “Generally, much better”. Her affect: mood-coherent. Thoughts
are logical and coherent. Client is in a good mood, denies any depression today. She 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)

Client is thinking clearly and able to answer questions logically. She was able to clearly explain the process of her profession of being
a Labor and Delivery Nurse. 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, time and situation. She did not seem confused. She was able to tell me about her family and
sons. She had discussed her military affiliation as a wife and a nurse for Naval Hospital Portsmouth and her favorite football team; the
Auburn Tigers. Abstract thinking was intact by patient’s ability to teach others how crochet.

Judgment and Insight: (Judgment: interpretation of the environment; Decision-making Ability; Insight: understanding one’s own
part in his/her current situation)
Client understood she was only one of two females on the ward. She has companionship with the one other female that she bunks
with. She understands that the time she was spending there is necessary for her well being. Client made decisions to become friends
with other members of the ward and by stating that she wants to move into the same town as her sister once she 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)

Client stated she was unclear of her feelings with her separation and divorce from her husband. She is looking forward to being
discharged so she can get a good job and improve her well-being. She stated that she knows she had problems but she wants to fix
them. She was happy to talk about her career in nursing. She also loves to watch sports, especially football.

Roles and Relationships: (Current roles; Satisfaction with Roles; Success at Roles; Significant Relationships; Support Systems)

Client has 2 years of college and also received an associate’s degree from Broome Community College She has worked as an L&D
nurse since 2004. She was married 10 years and separated from her husband in 2010, and soon to be divorced

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/she eat? Sleep?)

Client admitted to sleeping “like a baby” last night. She thinks the food she is eating here is “edible”. She explained to me that her
current health problems are depression and Sarcoidosis. Client admits to taking medications in the morning, as directed. They do help
the patient’s mood and to help her feel better emotionally but not working for the Sarcoidosis. Client is fully able to perform ADL’s.
 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 Reactions Nursing Implications
Appropriate?
Zoloft Antidepressant; Dizziness, Monitor appetite and
Inhibits neurological Yes drowsiness, fatigue, nutritional intake,
Generic Name uptake of serotonin in headache, insomnia, weight weekly.
the CNS, thus CLIENTs Weight tremors.
sertraline Monitor mood changes,
potentiating the 65.91kg
Dose activity of serotonin. assess for suicidal
tendencies, OCD, panic
50 mg tab/ day Client is taking to attacks, symptoms of
help with depression. social anxiety disorder
Frequency
(Deglin, 2009)
Take one tab in
morning.

Route

oral

Trade Name Drug Action Is Dose Adverse Reactions Nursing Implications

Appropriate?
Klonopin Anticonvulsant; due Behavioral changes, Assess degree and
to presynaptic Yes drowsiness, fatigue, manifestations of
Generic Name inhibition. Prevents slurred speech, anxiety and mental
seizures. Client is
clonazepam taking medication to CLIENTs Weight ataxia and sedation. status.
reduce recurrent
Dose suicidal thoughts. 65.91kg Assess Client for
drowsiness, clumsiness
0.5 mg tab and unsteadiness.
Frequency Complete a CBC and
Three times a LFT while on
day medication.
Route (Deglin, 2009)
Oral
 LAB DATA & DIAGNOSTIC EVALUATION

Include date

LAB Ordered Client Normal Values Indication for Diseases / Illness

Values

None ordered at this

time.

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 it?) Major depressive disorder is described
as two or more weeks of a sad mood or
lack of interest in life activities with
symptoms. (noted within)
Borderline personality disorder is
characterized by a pervasive pattern of
unstable interpersonal relationships,
self-imaging, and affect as well as
marked impulsivity.

Etiology (What Client being recently diagnosed with She was distant from her father and
may have caused or Sarcoidosis. She is also going through a other siblings during childhood. She
contributed to the divorced. also suffered through the demise of her
illness in this half-sister
patient?

Pathophysiology The influence of stress and adverse life The report of disturbed early
(Include both events. Depression has a high rate of relationships with their parents that
physiological and Comorbidity with other psychiatric often begins at 18-30 months of age.
psychological disturbances. Sometimes from sexual abuse, physical
possible causes per or verbal abuse or parental alcoholism.
your resource.) It is three times more common in
woman then men. Due to self-
mutilation. This is a cry for help, an

Clinical Lack of sleep or inadequate sleep,
Manifestations changes in weight, anhedonia, lack of
(textbook) energy, inability to concentrate, focus
or make decisions, worthlessness or
guilt, and hopelessness, helplessness,
powerlessness or suicidal ideations.
Clinical Client has become depressed since the
Manifestations birth of her stillborn son in 2003. Client
has no other support at home with her
(Actual – based on and her children. She is currently
your observations undergoing a divorced and has no
and history) family in the area.
(Videbeck, 2011)
expression of anger, helplessness, or a
form of self punishment.
Feelings of emptiness and boredom,
frequent displays of inappropriate
anger, impulsiveness with money,
makes impulsive major life changes
(divorce, career changes), binge eating,
or shoplifting, intolerance of being
alone, recurrent acts of crisis such as
the potential for overdosing, or self-
injury.
Client’s mood has changed since she
has been admitted. She is now more
stable and happy. Client came in
depressed, has a history of suicide
thoughts. Client has had thoughts of
drowning or suffocating her youngest
son, yet loves and adores him dearly
and with her eldest son.
 PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS

1. Anxiety related to threat or perceived threat to physical and emotional integrity AEB pt stating she has
threats to her health and safety.

2. Ineffective coping related to inadequate psychological resources, poor self-esteem and situational crises
AEB pt stating she is unhappy with herself.

3. Deficient knowledge related to emotional state affecting learning.

4. Interrupted Family Process related to impulsive major life changes (divorce, career changes)

5. Self care deficit related to lack of concern

6. Risk for powerlessness related to chronic illness

 NURSING CARE PLAN

Student Name: Your Name 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/ “expected outcome” measurable goal per nursing diagnosis
stated in terms of client achievement - “the client will…”). List at least 3 specific nursing actions (interventions) for
each nursing diagnosis and give the scientific rationale for selecting the action you will use to work toward that goal.

NURSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOME
(What do you plan to do?) (Why are you
(NANDA (Measurable doing this?)
APPROVED) Goal)
1. Anxiety STG: Client 1. Assess patient’s level of 1. Mild anxiety Short Term: Patient only
related anxiety level will anxiety. enhances the had one serve anxiety
to not be rated patient’s awareness attack during shift, goal
threat above moderate 2. Determine how patient and ability to was not meet, but the
or anxiety the copes with anxiety. identify and solve patient had a very
perceive entire shift. 3. Acknowledge awareness of problems. Moderate therapeutic day and was
d threat patient’s anxiety. anxiety limits able to control the
to LTG: Teach client awareness of majority of her anxious
physical coping strategies environmental threats that she usually
and for anxiety by stimuli. Problem perceives.
emotion the time she is 1. Instruct patient on deep solving can occur
al discharged. breathing and relaxation but may be more
integrity techniques to remain calm. difficult, and patient
Vacarolis, E. M. (2006). Long Term: Ongoing
AEB pt may need help.
stating Severe anxiety
2. Suggest that the patient
she has decreases patient’s
keep a log of episodes of
threats ability to integrate
anxiety.
information and
to her
3. Assist patient in recognizing solve problems.
health
symptoms of increasing With panic the
and patient is unable to
anxiety; explore alternatives
safety. to use to prevent the anxiety follow directions.
from immobilizing her. Hyperactivity,
agitation, and
immobilization may
be observed
Vacarolis, E. M. (2006). Vacarolis, E. M.
(2006).

2. This can be done

by interviewing the
patient. This
 NURSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OUTCOME

2. Ineffective STG: By the end 1. Assess for presence of defining 1. Behavioral and Short Term: By the end of
coping related of shift the patient characteristics. physiological the shift the client was able
to inadequate will be able to responses to stress to identify two strengths:
psychological identify some of 2. Assess specific stressors. can be varied and her family and friends; and
resources, poor her strengths and 3. Instruct in need for adequate provide clues to the one weakness: her
self-esteem weakness. rest and balanced diet. level of coping excessive worrying.
and situational difficulty Vacarolis, E.
crises AEB pt M. (2006).
stating she is LTG: Client will Long Term: Ongoing
unhappy with 1. Provide outlets that foster 2. Accurate appraisal
utilize her feelings of personal achievement
herself. can facilitate
strengths and set and self-esteem. development of
aside her weakens
appropriate coping
and utilize coping 2. Assess decision-making and
strategies. Because a
strategies to cope problem-solving abilities.
patient has an altered
with her anxiety
3. Assist in development of health status does
and properly.
alternative support system. not mean the coping
difficulties she
Vacarolis, E. M. (2006). exhibits are only
issue, if at all, related
to that Vacarolis, E.
M. (2006).

3. These facilitate
coping strengths.
Inadequate diet and
fatigue can
themselves be
stressors. Vacarolis,
E. M. (2006).

1. Opportunities to
role play or rehearse
appropriate actions
can increase
confidence for
behavior in actual
situation. Vacarolis, E.
M. (2006).

2. Patients may feel

that the threat is
greater than their
resources to handle it
and feel a loss of
control over solving
the threat or problem.
Vacarolis, E. M.
(2006).

3. Relationships with
persons with common
interests and goals
can be beneficial
Vacarolis, E. M.
(2006).
 URSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS OUTCOME

3. Deficient Short Term: By 1. Determine cultural influences 1. Providing a Short Term: Client was able
knowledge the end of the shift on health teaching. climate of acceptance to recognize that she
related to will client will be allows patients to be utilized more information in
emotional state able to recognize 2. Provide physical comfort for themselves and to a quiet and therapeutic
affecting her learning level the learner. hold their own beliefs environment. She was open
learning. so she can process 3. Explore attitudes and feelings as appropriate. to discussing freeing and
issues about changes. stressors in a group
appropriately. 2. This allows patient environment too.
to concentrate on
what is being
1. Provide information using discussed or
Long Term: Before various mediums. demonstrated. Long Term: Ongoing
the client is According to Maslow’s
discharged home 2. Include significant others theory, basic
she will be able to whenever possible. physiological needs
identify her 3. Explore attitudes and feelings must be addressed
stressor in the about changes. before patient
environment. education.
4. Allow client to identify what is
most important to her. 3. This assists the
nurse in
understanding how
Vacarolis, E. M. (2006). learner may respond
to the information
and possibly how
successful the patient
may be with the
expected changes.

1. Different people
take in information in
different ways. Match
the learning style
with the educational
approach.

2. This encourages
ongoing support for
patient.

3. This assists the

nurse in
understanding how
learner may respond
to the information
and possibly how
successful the patient
may be with the
expected changes.

4. This clarifies
learner expectations
and helps the nurse
match the
information to be
presented to the
individual’s needs.
Patients may want to
focus only on self-
care techniques that
facilitate discharge
from the hospital or
enhance survival at
home, but are less
interested in specifics
of the disease
process.

Vacarolis, E. M.
(2006).