Behavioral Health Care Plan

Student: Evelina Balzhyk Date: 9.12.2019

Course: NSG322CC Instructor: Dustin Gorsky

Clincial Site: Banner University Medical Center Phoenix Client Identifier: LT Age: 35

Reason for Admission:

LT was admitted on 8.29.2019 for suicidal ideation due to issues with family and not having housing.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

The patient was diagnosed with Borderline Personality Disorder (BPD) Clinical manifestations for Borderline Personality Disorder include
and PTSD.  Unstable relationships 
 Sleep disturbance
According to research, “The pathophysiology of borderline personality
 Depression
disorder is likely a combination of genetic predisposition combined with
 Fear of being alone
early childhood environmental factors and neurobiological dysfunction.”
 Attachment-related anxiety
(Chapman, 2019). Various factors in an individual’s life affect the
 Self-harm
formation of this disorder. Personality disorders involve a rigid and
 Extreme emotional swings
unhealthy pattern of thinking (Chapman, 2019). Recent studies have been
 Explosive anger (Chapman, 2019)
showing that the hormone oxytocin may contribute to Borderline
LM experienced unstable relationships, depression and explosive
Personality Disorder. In addition, “serotonin dysregulation reduced the anger.
sensitivity of the 5HT-1A receptor may contribute to borderline
personality disorder.” (Chapman, 2019). Patients with BPD have Clinical manifestations for PTSD
increased rates of learning disorders, ADHD, as well as neurocognitive  Flashbacks
deficits.  Nightmares
Risk factors pertaining to BPD include environmental factors such as:  Avoiding people, places

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

  Childhood maltreatment (physical, sexual, or neglect)  Being constantly on the lookout for threats
 Maternal separation  Depression, irritability
 Poor maternal attachment  Symptoms that last longer than a month (Bailey, 2016)
 Inappropriate family boundaries LM experienced irritability, avoiding people, and depression.
 Parental substance abuse
LT was also diagnosed with Post-Traumatic Stress Disorder.
Pathophysiology for PTSD is still unclear and “our current understanding
about the human pathophysiology governing the divergent paths
associated with extreme stress response is lacking” (Bailey, 2016).
Risk factors for PTSD include:
 Experiencing intense or long-lasting trauma
 Childhood abuse
 Mental health problems (anxiety, depression)
 Lacking good support system (Bailey, 2016)

Assessment Data
Subjective Data: Patient states “I had a plan to commit suicide, but did not attempt”. LT says that she had suicidal thoughts years ago as well.
One week ago, after taking a trip to Oregon to visit her family, the patient states she got into an argument which was the precursor to her suicide
ideation. The patient’s plan is to live in a ‘half-home’ after discharge, because she has no other support system.
VS: T : 36.8 C Labs: Diagnostics:
BP: 125/84 HDL 41 mg/dL (normal 50-59 mg/dL) LT had no diagnostic testing performed.
HR: 75 bpm LDL 101 mg/dL (normal <100 mg/dL)
RR: 18 bpm
O2 Sat: 96 on room air

Assessment: Orders/Safety Protocols:

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Mental Status Exam: Meet with psychiatrist
Appearance- patient had eye contact thoughout the whole interview. Q15 checks
Patient’s clothing was appropriate to weather and age, clean, without
Make sure patient is attending classes proovided by facility.
odor. Patient was showered, hair was clean and brushed. Posture was
relaxed, but patient was constantly stroking her hair. Patient’s gait is
normal, but she is obese.
Behavior- very engaged in conversation and a little anxious
Attitude- neutral. Negative attitude when speaking about family.
Level of Consciousness- alert and oriented x3, to person, place, time
Speech and Language – normal volume and speed, intonation with
appropriate emphasis. Language is understandable.
Mood- patient says she is a little anxious, but “feels good”
Affect- patient is neutral, congruent with situation and mood. Facial
expression is annoyed when speaking of her family.
Thought Process/Form - thought process is mostly linear, however,
patient goes into preseveration about her health complications (genetic
mutation)
Thought Content- patient is mostly focused on her health
complications and how she will go about coping with them. Patient says
she does not have suicidal thoughts at the moment.
Suicidality and Homicidality - patient states that she does not have
suicidal/homicidal thoughts at the moment and no hallucinations
Insight and Judgment- good judgment- patient is looking forward to
treatment, has a discharge plan, has goal of finding better housing
Good insight- patient says she will no longer abuse marijuana and will
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comply with medication regimen
Attention Span (observed/inquired)- patient and I talked for about 35
minutes, appropriate attention span
Memory -memory is intact; patient remembers childhood (long term),
and what what happened this week (short term)
Intellectual Functioning- general mental ability includes reasoning,
planning. Patient says she is a few classes from getting her degree (did
not specify what kind)

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 Medications
ALLERGIES:
Augmentin, Betadine, cherry, Doxycycline, Iodides, Red dye, Xyzal
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Bupropion 100 mg po qd Treatment of depression Seizures, suicidal thoughts, Assess mental
agitation, headache, status and mood
aggression, anxiety, changes, especially
delusions, depression, during initial few
hallucinations, hostility, months of therapy
insomnia, mania, panic, and during dose
paranoia, psychoses changes. Inform
HCP if severe signs
(Vallerand, 2017). of depression,
fatigue, weight
loss/gain, suicide
attempt or ideation
(Vallerand, 2017).
75 mg po qd Reduction of depression, dizziness, Assess patient for
Clopidogrel atherosclerosis in patients fatigue, headache, symptoms of stroke,
at risk for MI, acute epistaxis, cough, dyspnea, peripheral vascular
coronary syndrome eosinophilic pneumonia, disease, or MI
chest pain, edema, periodically during
hypertension therapy.
(Vallerand, 2017). Monitor patient for
signs of thrombotic
thrombocytic
purpura
(Vallerand, 2017).

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client- or family-focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Ineffective coping related to situational crisis as evidenced by suicide ideation.
This has been selected as the priority diagnosis because ineffective coping is a concern for physiological needs which is the first tier in
Maslow’s Hierarchy of Needs.
Patient will identify and Patient will identify and 1. If possible, assign a 1. to provide continuity of 1. Patient was assigned
demonstrate ability to use demonstrate ability to use consistent care provider to care and promote to care provider.
at least two healthy coping at least two healthy coping patient. development of therapeutic 2. Patient received an
behaviors. behaviors by the end of 2. Explain all treatments and relationship. explanation of all
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 the shift. procedures, and answer
patient’s questions.
3. Refer patient to
professional psychological
counseling.
(Phelps, Ralph, &
Taylor, 2017).
Secondary Nursing Diagnosis: Risk for suicide related to psychiatric disorder.
This has been selected as a diagnosis because risk for suicide is a concern for physiological needs which is the first tier in Maslow’s Hierarchy
of Needs.
Patient will voice Patient will voice 1. Help the patient set a
improvement in self- improvement in self-worth goal for obtaining long-
worth. by discharge. term psychiatric care.
2. Supervise the
administration of
prescribed medications. Be
aware of drug actions and 2. Medications may be
side effects. Make sure
patient does not hoard the verbal interventions.
medication.
3. Use a warm, caring,
nonjudgmental manner.
(Phelps, Ralph, &
Taylor, 2017).
2. To allay fear and allow treatments and got
patient to regain self- questions answered.
control. 3. Patient was referred
3. If patient’s maladaptive to professional
behavior has high crisis psychological
potential, formal counseling.
counseling helps ease
nurse’s frustration,
increases objectivity, and
fosters collaborative
approach to patient’s care.
(Phelps, Ralph, &
Taylor, 2017).
1. Ambivalence about 1. Patient set a goal for
psychiatric care or refusal obtaining long-term
to consult with a therapist psychiatric care.
marks the suicidal 2. Patient was supervised
patient’s lack of insight in administation of
and use of denial. prescribed medications.
3. Warm, caring,
appropriate alternative to nonjudgmental manner
was used with patient.
3. To show unconditional
positive regard.
(Phelps, Ralph, &
Taylor, 2017).
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Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socioeconomic
status, and cultural and spiritual preferences of the individual and focused on providing safe, evidence-based care for the achievement
of quality client outcomes.

References
Bailey, C. R., Cordell, E., Sobin, S. M., & Neumeister, A. (2016, March). Recent progress in understanding the pathophysiology of
post-traumatic stress disorder: implications for targeted pharmacological treatment. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629370/

Chapman, J. (2019, June 7). Borderline Personality Disorder. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430883/

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:
Wolters Kluwer.

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.