Behavioral Health Care Plan

Student: Caitlyn Summers Date: 3/12/20

Course: NSG-322CC Instructor: Professor Ryan Mckenzie

Clincial Site: Banner Del Webb Medical Center Client Identifier: K.B. Age: 57

Reason for Admission: K.B was admitted dut to suicidal thoughts, contemplating suicide with a gesture to jump out of the car while his wife
was criving on a freeway. His wife drove straight E.D. where he was voluntarily admitted. K.B. also mentioned that he was hearing voices and
that it began 3 weeks prior to when he came in.

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

Depression – Observed:
Depression is a chronic mental disorder that alters a person’s mood, - Distant
thoughts, behavior and physical health. It causes constant feelings of - Isolated from others
sadness, hopelessness and a lack of interest in activities or socializing. It - Doesn’t socalize
can cause an adult who is struggling with depression to have a loss of - Very flat affect
appetite, sleeping problems, fatigue, memory difficulties and even Expected:
personality changes (Depression, 2018).
- Adhedonia (lack of enjoyment in activities)
- Withdrawing from loved ones and regular activites
Risk factors: Certain personality traits (those with low self-esteem), a - Irritabiility
person who has experienced a tramatic or stressful event like physical or - Restelessness
sexual abuse, blood relatives that have a history of depression, bipolar - Agitation
disorder, alcoholism, or suicide, LGBTQ community that may be in an - Weight loss of gain
unsupportive situation, abuse of alchol or recreational drugs, a chronic
illness and certain medications (blood pressure and sleeping medications)
(Depression, 2018).

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

 Assessment Data

Subjective Data: “I am having some chest pain that started this morning.”
VS: Taken at 8 am Labs: 2/12/20 Diagnostics: 2/12/20
T : 98.7 F Calcium: 8.7 Low (Normal: 8.8-10.4) CT head/brain w/o cont. –
BP: 165/94 These labs are abnormal due to a deficiency in - Preiventricular and subcortical white matter
calium, potential kidney problems or certain hypoattenuation are noted, likely related to chronic
HR: 87
drugs. ischemia small vessel disease
RR: 18
Creatinine: 1.66 High (Normal: 0.60-1.50) US retoperitoneal limited –
O2 Sat: 99%
If this lab value is high it is typically due to - Normal sized kidneys w/o hydrophrosis
Taken at 2 pm impaired kidney function or kidney disease.
T: 98.9 F eGFR (Non-African): 45 low (Normal low: 60)
BP: 166/94 This also occurs with kidneys that aren’t
HR: 85 functioning properly.
RR: 18 eGFR: (African): 52 Low (Normal low: 60)
O2 Sat: 99% This also occurs with kidneys that aren’t
functioning properly.
BUN/Creatining: 8 Low (Normal 10-28)
Again, this lab value is typically low when the
kidneys aren’t functioning properly.

Assessment: Orders/Safety Protocols:

PMH: - Regular Diet

Medical Hx: - Follow up OT (group/individual for social skills training)

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GERD & HTN - Suicide/ dnager to self

Psychiatric Hx: - BeH precautions (Q15 minute checks and unit restriction)
- Diagnosed bipolar in 2005
- Diagnosed TBI and early onset dementia 6 years ago
- Substance abuse Hx: began using cocaine when playing NFL,
multiple times a week (stated last used about a week ago)
- Admitted to Quail Run twice
Mental Status Exam -
Appearance (observed): Dressed appriopriately and well groomed
Behavior (observed): isolated himself, didn’t speak to anyone
Attitude (observed): calm, co-operative
Level of Consciousness (observed): Conscious and responsive
Orientation (inquired): Alert and orientated x 4
Speech and Language (observed): clear, non-garbled and easy to
understand
Mood (inquired): K.B.’s mood was congruent with behavior
Affect (observed): flat, shows no emotion
Thought Process/Form (observed/inquired): can carry a conversation
is ask questions, long gaps in between responses
Thought Content (observed/inquired): logical
Suicidality and Homicidality (inquired): 9/10 for depression & 7/10
for anxiety
Insight and Judgment (observed/inquired): Patient understands need
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for treatment
Attention Span (observed/inquired): attention span is appropriate
Memory (observed/inquired): short and long term memory is intact
Intellectual Functioning (observed/inquired): intact, carris logical
conversations

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 Medications
ALLERGIES: NKA

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing Considerations

Effect
Losartan 50 mg/1 PO 30 tablets Lowering of BP in
tab hypertensive patients.
Decreased progression of
diabetic nephropathy.
Decreased incidence of
stroke in patients with
hypertension and left
ventricular hypertrophy
(effect may be less in
black patients) (Vallerand,
Sanoski, & Deglin, 2017).
Dizziness, fatigue, Assess BP (lying, sitting,
headache, insomnia, standing) and pulse
weakness. Chest pain, frequently during initial
edema, hypotension. Nasal dose adjustment and
congestion. Hypoglycemia, periodically during
weight gain. Diarrhea, therapy. Assess patient for
abdominal pain, dyspepsia, signs of angioedema
nausea. Impaired renal (dyspnea, facial swelling).
function. Hyperkalemia. Monitor renal function.
Back pain, myalgia. May cause increased BUN
ANGIOEDEMA, fever and serum creatinine, AST,
(Vallerand, Sanoski, & ALT, and  serum bilirubin.
Deglin, 2017). May cause hyperkalemia.
May causes light decrease
in hemoglobin and
hematocrit (Vallerand,
Sanoski, & Deglin, 2017).

Hydralazine 50 mg/1 PO BID Moderate to severe Dizziness, drowsiness, -Administer with meals
tab hypertension (with a headache, tachycardia, -Emphasize the importance
diuretic) (Vallerand, angina, arrhythmias, of continuing to take this
Sanoski, & Deglin, 2017). edema, orthostatic medication, even if feeling
hypotension, diarrhea, well
nausea, vomiting, rash, -Patients should weigh
sodium retention, themselves twice a week
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 arthralgias, arthritis, and assess feet and ankles
peripheral neuropathy, for fluid retention
drug-induced lupus -Educate that it may cause
syndrome. drowsiness (Vallerand,
(Vallerand, Sanoski, & Sanoski, & Deglin, 2017).
Deglin, 2017).
Memantine 5mg/1 tab PO BID For moderate to severe Dizziness, fatigue, Assess cognitive function.
dementia/neurocognitive headache, sedation, Caution patient on
disorder associated with hypertension, rash, dizziness as a side effect.
alzheiner’s disease diarrhea, weight gain, Educate patient that
(Vallerand, Sanoski, & Urinary frequency, and improved cognitive
Deglin, 2017). anemia (Vallerand, functioning might take
Sanoski, & Deglin, 2017). months to start seeing
(Vallerand, Sanoski, &
Deglin, 2017).
Pantoprazole 40 mg/1 PO Daily Erosive esophagitis HA, C-diff, abdominal Assess patient routinely for
tab associated with GERD. pain, diarrhea, eructation,
epigastric or abdominal pain.
Binds to an enzyme in the flatulence, hyperglycemia,
Check labs frequently.
presence of acidic gastric hypomagnesemia, acute
pH, preventing the final interstitial nephritis, Monitor serum magnesium
transport of hydrogen ions vitamin b12 deficiency prior to administering.
to the gastric lumen (Vallerand, Sanoski, & Monitor bowel function.
(Vallerand, Sanoski, & Deglin, 2017). Teach patient to report signs
Deglin, 2017). and black
tarry stools (Vallerand,
Sanoski, & Deglin, 2017).

Melatonin 3 mg PO QBedtime Moderate to severe Dizziness, fatigue, Assess cognitive function

dementia/neurocognitive headache, sedation. (memory, attention,
disorder associated with Hypertension (Vallerand, reasoning, language, ability
Alzheimer’s Sanoski, & Deglin, 2017). to perform

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 Disease (Vallerand,
Sanoski, & Deglin, 2017).
Trazodone 200mg/2 PO Q bedtime Anti-depressant, increases
tab total sleep time, decreases
number and duration of
awakenings in depressed
patient, and decreases
REM sleep
Use: Sleep aid (Vallerand,
Sanoski, & Deglin, 2017).
Drowsiness, light-
headedness, tiredness,
dizziness, insomnia,
headache, agitation,
impaired memory and
speech, disorientation. CV:
Hypotension (including
orthostatic hypotension),
hypertension, syncope,
shortness of breath, chest
pain, tachycardia,
palpitations, bradycardia,
PVCs, ventricular
tachycardia (short episodes
of 3–4 beats). Special
Senses: Nasal and sinus
congestion, blurred vision,
eye irritation, sweating or
clamminess, tinnitus. GI:
Dry mouth, anorexia,
constipation, abdominal
distress, nausea, vomiting,
dysgeusia, flatulence,
diarrhea. Urogenital:
Hematuria, increased
frequency, delayed urine
flow, early or absent
menses, male priapism,
simple tasks) periodically
during therapy.
Lab Test Considerations:
May cause anemia
(Vallerand, Sanoski, &
Deglin, 2017).
Monitor pulse rate and
regularity before
administration if patient
has preexisting cardiac
disease.
Observe patient's level of
activity. If it appears to be
increasing toward
sleeplessness and agitation
with changes in reality
orientation, report to
physician for potential
change in dosage. Manic
episodes have been
reported.
Check patient for
symptoms of hypotension.
If orthostatic hypotension
is troublesome, suggest
measures to reduce danger
of falling and help patient
to tolerate the effects.
Discuss with physician;
reduction of dose or
discontinuation of the drug
may be prescribed.
Male patient should report
inappropriate or prolonged
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 ejaculation inhibition. penile erections.
Hematologic: Anemia. Be aware that overdose is
Musculoskeletal: Skeletal characterized by an
aches and pains, muscle extension of common
twitches. Skin: Skin adverse effects: Vomiting,
eruptions, rash, pruritus, lethargy, drowsiness, and
acne, photosensitivity exaggerated
(Vallerand, Sanoski, & anticholinergic effects.
Deglin, 2017). Seizures or arrhythmias are
unusual. (Vallerand,
Sanoski, & Deglin, 2017)

Bupropine 200 mg/2 PO Daily Treatment of depression Seizures, SUICIDAL Monitor patient for mood
tab and depression with THOUGHTS/BEHAVIOR, changes. Assess mental
seasonal affective disorder agitation, headache, status. Monitor hepatic and
(Vallerand, Sanoski, & aggression, anxiety, renal function. Administer
Deglin, 2017). delusions, depression, doses in equally spaced
hallucinations, hostility, time increments during the
insomnia, mania, panic, day to minimize seizure
paranoia, psychoses, dry risk (Vallerand, Sanoski, &
mouth, nausea, vomiting, Deglin, 2017).
change in appetite, weight
gain, weight loss,
photosensitivity,
hyperglycemia,
hypoglycemia, syndrome
of inappropriate ADH
secretion, and tremors
(Vallerand, Sanoski, &
Deglin, 2017).

Lithium 150 mg/1 PO Daily Treatment, maintanence SEIZURES, fatigue, Assess mental status

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 cap and prophylaxis of manic headache, impaired periodically. Monitor
episodes of bipolar I memory, ataxia, sedation, intake and output. Monitor
disorder (Vallerand, confusion, dizziness, for S/S of toxicity
Sanoski, & Deglin, 2017). drowsiness, psychomotor (including nausea,
retardation, restlessness, vomiting, diarrhea, slurred
stupor, aphasia, blurred speech, drowsiness, or
vision, dysarthria, tinnitus, twitching) (Vallerand,
ECG changes, arrhythmias, Sanoski, & Deglin, 2017).
edema, hypotension,
unmasking of Brugada
syndrome, abdominal pain,
anorexia, bloating,
diarrhea, nausea, dry
mouth, metallic taste,
polyuria, glycosuria,
nephrogenic diabetes
insipidus, renal toxicity,
acneiform eruption,
folliculitis, alopecia,
diminished sensation,
pruritus, hypothyroidism,
goiter, hyperglycemia,
hyperthyroidism,
hyponatremia,
leukocytosis, weight gain,
muscle weakness,
hyperirritability, rigidity,
and tremors.

Quetiapine 12.5 PO Qbedtime Management of psychotic Neuroleptic malignant Monitor mental status,
mg/0.5 tab and bipolar disorders, syndrome, seizures, assess for suicidal
antipsychotic, and pancreatitis, Stevens- tendencies, assess for rash,
management of agitation Johnson syndrome monitor for development
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Cholecalciferol 1,000 PO Daily
units/1 tab
Nursing Diagnoses and Plan of Care
Goal Expected Outcome
Client- or family-focused. Measurable, time-specific,
reasonable, and attainable.
Priority Nursing Diagnosis: Risk for injury related to depression as evidence by suicide attempt of trying to get out of a moving car on a
freeway.
This is the priority nursing diagnosis because it is related to his own safety and according to Maslow’s hierarchy, it is the priority after
physiological needs have been met.
The patient will remain While at Banner Del
safe and refrain from Webb, K.B. will remain
attempting suicide. free of any self harm and
suicidal thoughts will
decrease by the time of
discharge.
Indication: stabilize mood
(Vallerand, Sanoski, &
Deglin, 2017).
Treatment or prevention
of vitamin D deficiency
particularly bone
manifestation (Vallerand,
Sanoski, & Deglin, 2017).
Intervention(s)
Nursing or interprofessional Provide reason why intervention
interventions.
1. Assess the patients
enviroment to ensure
all hazards and
potential dangerous
items are removed.
2. Encourage the client
to talk about
feelings.
(Vallerand, Sanoski, & of neuroleptic malignant
Deglin, 2017). syndrome, monitor for
signs of pancreatitis
(Vallerand, Sanoski, &
Delgin, 2017).
Hypercalcemia, Assess for symptoms of
conjunctivitis, increased vitamin deficiency prior
liver enzymes, metallic and periodically during
taste, pancreatitis, bone and therapy. Assess for bone
muscle pain (Vallerand, and muscle pain. Observe
Sanoski, & Deglin, 2017). for hypocalcemia
(Vallerand, Sanoski, &
Deglin, 2017).
Rationale Evaluation
Was goal met? Revise the
is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
1. This will provide a 1. Met. The
safe enviroment, enviroment was
free from anything free from any
that may harm the dangerous items
client. that the patient
2. This encourages the could harm
client to deal with themselves with.
their emotions and 2. Not met. The
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 3. The nurse will express them in a patient did not
educate the wife and way that will be express any
family on four ways effective. personal feelings
to recognize levels 3. Preparing the that day and
of impending self family on ways to stayed quiet.
harm that may be catch early on when 3. Not met. The
committed by the a patient could family has not
patient. potentially inflict yet been
(Phelps, Ralph, & Taylor, self harm could educated on the
2017). prevent it from four ways to
happening. recognize levels
of impending
(Phelps, Ralph, & Taylor, self harm.
2017). (Phelps, Ralph, &
Taylor, 2017).

Secondary Nursing Diagnosis: Ineffective coping related to depression as evidence by attempted suicide of trying to get out of a moving car on
a free way to end his life.
This is the secondary nursing diagnosis because the patient exhibited ineffective coping techniquemwhen he attemptted suicide. This is also a
safety priority as well and needs to be prevented in the future by teaching better ways to cope.
K.B. will be able to
1. Asses patients
The patient will be able to identify and show at least 1. Assessing the 1. Met. The patient
two different effective mood coping patients mood
show effective coping admitted to his way
coping strategies while abilities and past coping helps to
strategies. of coping with his
staying at Banner Del coping techniques determine what emotions was not
Webb. that were used. their level of effective for him.
2. Have one on one cooperation will 2. Not met. The
therapy with the be. patient has not had
patient every other 2. This will allow the frequent one on
day with a patient to build a one therapy, but
therapist. relationship with would benefit
3. Have the patient one person and be greatly from it
identify and write able to open up since he doesn’t
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 down 3 alternative about their participate in group
ways to cope when emotions and how therapy.
they are they are feeling . 3. Partially met. The
experiencing 3. Having the patient patient was able to
feelings of write three useful identify one way to
depression. ways of coping cope with his
(Phelps, Ralph, & Taylor, will allow the depression which
2017). patient to refer was to watch
back to it to remind football which he
themselves. used to play.
(Phelps, Ralph, & Taylor, (Phelps, Ralph, &
2017). Taylor, 2017).
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

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Depression (major depressive disorder). (2018, February 3). Retrieved from https://www.mayoclinic.org/diseases-

conditions/depression/symptoms-causes/syc-20356007

Phelps, L. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD: Lippincott, Williams &

Wilkins/Wolters Kluwer.

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

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