NURS 360

Capstone Project
PMH Care Plan
Student Nurse Reporting Form
SN: Meagan Kubo
Pt.: Sex: M

Date: 9/9/15
Age: 23

Date of Admission: 9/8/15

Transferred? ___No __X_Yes: (Reason/Date) From Pali Momi ED d/t +SI/HI/AH on

9/8/15
Income source: None, steals from others
Legal Status: MH4

Expiration Date: 9/10/15 @ 1158

DSM Diagnosis: Substance induced psychotic disorder

I Presence of prominent hallucinations or delusions.
II Hallucinations and/or delusions develop during, or within one month of, intoxication
or withdrawal from a substance or medication known to cause psychotic symptoms.
III Psychotic symptoms are not actually part of another psychotic disorder (such as
schizophrenia , schizophreniform disorder , schizoaffective disorder ) that is not
substance induced. For instance, if the psychotic symptoms began prior to substance or
medication use, then another psychotic disorder is likely.
IV Psychotic symptoms do not only occur during delirium .
V

What brought patient to the hospital?

23-year-old Japanese male presents as direct admission from Pali Momi with both SI &
HI and meth intoxication Both SI & HI occur in context of meth use. Denies premeditated thoughts. Denies any specific person he wishes to harm or kill. No
consequences of killing someone else d/t comment, It wont matter if I kill someone
because I will be dead.

Patients description of illness/issues:

Patient states he was smoking meth on 9/8/15 and started to hear voices. Voices were
telling him his neighbor was stealing his things, so he had a plan to hurt them by
burning their house down. After burning their house down, the voices told him to kill
himself. Instead of going through with the plan, he decided to go to Pali Momi ER to get
help.

Spirituality: Christian
Considerations r/t ethnicity or religion: Japanese
Patients Strengths: Good at reading
Patients Limitations: No job, no income, homeless, no support system

Medications:
Order: : Abilify 10mg by mouth HS
Drug class: Atypical antipsychotic
Pts target sx: no SI, HI, or AH
Total 24h dose: 10 mg
Recommended range: 10-15 mg
daily
: L M H Max
Current Side effects: none
Order: Tylenol 650 mg Q4H PRN
Drug class: Antipyretic
Pts target sx: decreased pain or fever
Total 24h dose: none
Recommended range: 325-650 mg Q6H, not to exceed
3000mg/day
: L M H Max
Current Side effects: none
Order: Benadryl 25 mg cap/inj TID PRN
Drug class: Antihistamine
Pts target sx: no EPS
Total 24h dose: none
Recommended range: 25-50 mg Q4H, not to exceed
400 mg/day
: L M H Max
Current Side effects: none

Order: Haldol inj/tab 5mg Q4H PRN

Drug class: Typical antipsychotic
Total 24h dose: none
Recommended range: 0.5-5 mg TID
Current Side effects: none

Pts target sx: no SI, HI, AH

: L M H Max

Order: Lorazepam tab 1mg Q2H PRN, syrg 2mg Q4H PRN
Drug class: Benzodiazepam
Pts target sx: decreased agitation
Total 24h dose: none
Recommended range: 1-3 mg
TID
: L M H Max
Current Side effects: none

AXIS III: List all conditions even if they are not listed in multi-axial diagnoses or
on chart. (Particularly note any unstable conditions & all non-medication
interventions.)
1. Meth induced psychosis
2. None
3. None
4. Job loss, lack of adequate support system, inadequate finances
5. GAF=30

BMI: 21.3

: Category: Healthy weight

(Height: 170.2 cm Weight: 136 lbs)

Food & fluid intake: 100% breakfast (2 sandwiches, 4 juice box)

Bladder & bowel status: Continent, last BM 9/9/15
Sleep pattern: Consistent with awakenings in the middle of the
night

Total sleep/24 hrs: 12.75 hrs

(Circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning

awakening
Number of hrs of disruption: 1.25hrs

Naps: When? After meals

Total nap time: 1-2 hrs/day

Lab & studies

Date/Panels in which all values were normal: 9/8/15 Chemistry and CBC within
normal limits
Date/Any abnormal labs: None
Labs you would expect but were not ordered: HBA1C, fasting BS, lipid profile
Glucose readings x 24h for all diabetic pts.: No diabetes
All drug screen findings: Positive UDS for meth
MENTAL STATUS ASSESSMENT:
Behavior: Apathetic, withdrawn, negative, detached, avoids eye contact
Affect: Flat, blunted, expressionless, irritable, inappropriate, restricted
Sensorium: Alert and oriented to person, place, time, and situation, poor judgment, fair
insight of illness.
Imagery: Auditory hallucinations
Cognition: Alert, poor judgment, fair insight, short term memory intact, able to read,
able to follow directions, poverty of speech
Interpersonal relationships: No family or friends
Developmental level: (Assets & barriers): GED from youth challenge, visual learner:
easiest way to learn is from pictures, video tape, written handouts, audio tape. Able to
follow simple commands, but lacks social interactions.

Drugs: Substance abuse or dependence: (Include nicotine & any alcohol &
drugs. List by drug: Last date of use/Current acute intoxication or withdrawal

signs and symptoms when SN caring for pt./Used how long/Route/Usual

amount/Negative consequences)
Drug class
Methamphetamin

Acute intox Length

or withdrawal of Time
Route
Use
sx?
Used
9/7/15 Withdrawal- 16 years Injectable
Last

increased

Usual

Negative

amt.

Consequences

Unable

or smoking to

appetite,

specify,

sleepiness

states a

Positive SI and
HI while using
meth

lot

Problems Identified In Hospitals Master Treatment Plan:

1. History of meth, benzo, and amphetamine
2. Previous OD on meth as a teenager
3. Addiction to meth
4. Hallucinations
5. Homelessness
Current Discharge Plan:
Patient to sign MH5, call outpatient MD to discuss alternative medication options, meet
with SW to review treatment programs or shelters.
Nursing interventions you performed this shift (Include safety and teaching!):
Explored pt view of admission to hospital with response of patient believes he needs to
be there to stay out of trouble. Reviewed medication compliance of Abilify with patient
with response that he understood importance of continuing medication and not stopping
abruptly. Discussed plan after hospital with patient and responded he wants help and
doesnt want to go back to the streets where he will continue to abuse meth. Talked
about positives of hospital stay and patient responded of having the opportunity to go to
treatment facility. Discussed patients feelings of going to a treatment center and patient
verbalized he is ready to go and make a change because he will end up killing someone
if he goes back to the streets.
Patient-centered Care Analysis
PRIORITIZED PATIENT NEEDS

What are the patients 4 highest needs/problems?

(Use your best nursing judgment! It will be different than the master treatment
plan.) P=Problem, E= Evidence, S= Solution.
1. P: Danger to self
E: Positive SI, TM-33 score of 4=moderate risk, verbal explanation
S: Cognitive behavioral therapy, AAP/TAP medications, 12 step program,
therapeutic communication, treatment facility, not living on the streets

2. P: Danger to others
E: Positive HI, verbal explanation
S: Cognitive behavioral therapy, AAP/TAP medications, therapeutic
communication, treatment facility, not living on the streets

3. P: Hearing voices
E: Positive AH, verbal explanation
S: Cognitive behavioral therapy, AAP/TAP medications, dialectical behavior
therapy, treatment facility

4. P: No medication compliance
E: No income, doesnt understand importance, verbal explanation
S: Cognitive behavioral therapy, medication education, finding a job, not living
on the streets

Priority # _1__
CARE PLAN
Nursing Diagnosis: Risk for self-mutilation r/t meth induced psychosis AEB positive SI, suicide plan, substance abuse
P: Danger to self
E: Positive SI, TM-33 score of 4=moderate risk, verbal explanation
S: Cognitive behavioral therapy, AAP/TAP medications, 12 step program, therapeutic communication, treatment facility,
not living on the streets

LT goal: Patient will enter treatment facility and participate in his recovery.
ST goal: Patient will verbalize any feelings of self-harm and notify staff immediately.
Scientific Rationale
(In complete sentences!)
Evaluation
(Reference in APA format, including page
number)
Interview the patient to assess
Suicidal gestures are acts of self-harm Patient verbalized positive SI with plan on the
potential for self-harm. Ask the
that typically are not considered lethal. streets, but currently does not have feeling of
following: Have you ever felt like
Suicidal attempts are potentially lethal
hurting self. Denies previous suicide attempt, but
hurting yourself? Have you ever
actions. Development of a plan and the has a history of OD on meth. Patient states he
attempted suicide? Do you currently ability to carry it out greatly increase the feels no control over self when using meth.
feel like killing yourself? Do you have risk for suicidal attempt. The more lethal
a plan to kill yourself? What is your
the plan r the more detailed and specific
plan? What means do you have to
the plan, the more serious the risk for
carry out your plan? Do you trust
suicide. Patients with strong suicidal
yourself to maintain control over your
feelings may feel their sense of control
thoughts, feelings, and impulses?
slipping away or they may feel
themselves surrender or give up trying to
control suicidal feelings.
Intervention & Frequency

Assess for risk factors that may

increase the potential for a suicide
attempt: History of suicidal attempts by
self or by important others, suicidal
statements, unexplained euphoria or
energy, giving away personal
possessions, male gender,
hallucinations, delusions.

It is a myth that suicide occurs without Patient is a male that has history of previous
forewarning. It is also a myth that there is history of meth OD. Positive auditory hallucinations
a typical type of person who commits
that tell him to hurt self and others. Denies of
suicide. The potential for suicide exists in unexplained energy or euphoria.
all people. The patient may make threats
about suicide or talk idealistically about
release from his or her life. Patients may
be responding to internal cues that
compel them to hurt themselves with
little or no warning. Men commit suicide
three times more often than women,
whereas women attempt suicide 2-3
times more often than men.
Provide a safe environment.
Suicide precautions are used to prevent Patient states that the hospital is the only area
the patient from acting on sudden self- where he feels safe. He denies of any thoughts to
destructive impulses. These measures hurt himself or others. Verbalizes he still has
include removing potentially harmful
voices, but is able to control them while in the
objects and maintaining visual contact hospital.
with the patient at all times.
Teach verbalization of negative feelings Depressed patients need the opportunity Patient able to verbalize negative feelings of what
within appropriate limits.
to discuss negative thoughts and
the voices in his head tell him. Patient verbalized
intentions to harm themselves.
positive SI and HI while on the streets, which
Verbalization of these feelings may
brought him to the ER. Patient denies of any
lessen their intensity. Patients also need negative feelings at this time.
to see that staff can tolerate discussion
of suicidal ideation.

Priority # _2__
CARE PLAN
Nursing Diagnosis: Risk for violence: Other directed r/t positive homicidal ideation AEB plan to hurt others, paranoid
thoughts, impaired perception of reality while using meth
P: Danger to others
E: positive HI, verbal explanation
S: Cognitive behavioral therapy, AAP/TAP medications, therapeutic communication, treatment facility, not living on the
streets

LT goal: Patient will seek treatment to learn different approaches to handle situations without resorting to violence.
ST goal: Patient will verbalize his plan to staff of how he will hurt others.
Intervention & Frequency
Assess cognitive factors that may
contribute to development of violent
behaviors, including the following:
psychotic or delusional thought
patterns, impairment in judgment,
decreased ability to solve problems,
alteration in sensory and perceptual
capacities.

Scientific Rationale
(In complete sentences!)
Evaluation
(Reference in APA format, including page
number)
Factors may indicate decline in cognitive Patient states the voices in his head tell him to hurt
condition. The patient may become
himself and others. Patient has poor judgment,
overresponsive to environmental stimuli, impulsive, suspicious, assaultive, and blames
leading to agitation and combativeness. others for his bad behavior.
The patient may have poor impulse
behavior control. Decreased attention
span and memory loss can contribute to
the personas inability to respond to
environmental stimuli.

Teach measures such as reorientation, Sensory stimulation needs to be

Patient is able to be redirected and follows a
reduced stimuli, and consistent
reduced. Frequent reorientation to ones consistent schedule while in the hospital. Stimuli
schedules.
environment increased ones ability to
reduced by dark lighting and quiet environment.

trust others. Consistency in schedules

and the physical environment promotes
orientation and reduces anxiety.
Speak in slow, clear, soothing tones.
Attention to technique helps avoid
Spoke to patient in a clear soft tone. Approached
Make comments brief and to the point. communication conflicts. The patient
patient in a non-aggressive nature and used
Repeat as needed.
may have declines in short term memory therapeutic communication. Conversation was to
that require frequent repetition of new
the point and used open-ended questions.
information.
Evaluate impact of medication regimen Antipsychotics may cause EPS ,
on behaviors in terms of contribution to manifested as restlessness.
agitation.

Patient has only been on medication for one day.

No side effects observed at this time. Patient did
not exhibit any EPS.

Priority # _3__
CARE PLAN
Nursing Diagnosis: Powerlessness r/t auditory hallucinations AEB hearing voices to hurt self and others
P: Hearing voices
E: Positive AH, verbal explanation
S: Cognitive behavioral therapy, AAP/TAP medications, dialectical behavior therapy, treatment facility
LT goal: Patient will seek treatment to help how to control the voices with appropriate therapies.
ST goal: Patient will verbalize to staff what the voices are telling him to do.
Intervention & Frequency

Scientific Rationale
(In complete sentences!)

Evaluation

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(Reference in APA format, including page

number)
Assess the patients decisionmaking
energy level and ability.

Powerlessness is not the same as the

inability to make a decision. It is the
feeling that one has lost the implicit
power for self-governance. Energy
conservation will help reduce or relieve
fatigue so the patient will be better able
to use available energy for appropriate
decision making.

Patient able to make appropriate decisions

regarding his hospital stay. Patient alert and able to
make needs known. Patient verbalized wanting to
get treatment for meth addiction.

Teach the patient acceptable

Verbalizing these feelings may diminish
opportunities for expressing feelings of or diffuse the patients sense of
anger, anxiety, and powerlessness.
powerlessness. The care provider may
need to make a special effort to maintain
a careful sense of timing and
compassion to alleviate the patients
feeling of loneliness or abandonment.
Offer continuity of a support network.
Encourage personal control by offering
continuity in staffing and sustained
involvement of significant others.

Patient able to express feelings of hospital stay and

his current situation. Patient expresses
hopelessness and frustration with meth addiction.
States he feels powerlessness when using meth.

Support the patients sense of

autonomy by involving the patient in
decision making, by giving and
accepting information, and by assisting
the patient with controlling the
environment as appropriate.

Patient was able to verbalize concerns or his

expectation of hospital stay with his health care
professional. He was able to work with the health
care professional to set goals for himself when
discharged from the hospital.

The ultimate decision-making authority

lies within the patient. However, the goal
of the health care professional is to
assist patients in identifying and
verbalizing their references in making
authentic choices.

Provided patient with information of treatment

facilities. Encouraged patient to seek for help if he
had any questions about hospital, medications, or
treatment facilities.

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Priority # _4__
CARE PLAN
Nursing Diagnosis: Non-compliance with treatment program r/t financial problems AEB no income, no job, homeless, no
transportation.
P: Non medication compliance
E: No income, homeless, lack of knowledge, verbal explanation
S: Cognitive behavioral therapy, medication education, finding a job, not living on the streets
LT goal: Patient will continue to take prescribed medications even when feeling better.
ST goal: Patient will verbalize reasoning for prescribed medication and importance.
Intervention & Frequency
Plan for small, steady improvements.

Support the patients growing

awareness of substance abuse
behaviors.

Scientific Rationale
(In complete sentences!)
Evaluation
(Reference in APA format, including page
number)
It is realistic to expect patients to refrain Patient aware that meth abstinence will be a life
from alcohol and drugs one say at a tie. long process and will not be cured immediately.
However, recovery from substance
Patient aware of steps he needs to take to help
abuse is marked by relapse.
guide his way to the path of recovery.
Positive support may encourage the
patient to work toward greater
understanding of his or her own
behavior. Keep in mind that insight is

Patient has fair insight regarding meth addiction

and what it has done to his life. Patient states he
has insight regarding illness, but feels
powerlessness when using the drug and makes

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Teach the patient how to learn to

identify difficult feelings.

Assess the patients use of denial,

rationalization, and blame to sustain
his or her habit.

only the first step toward recovery and

that insight without action is
meaningless.
Articulating thoughts and feelings
sometimes helps discharge emotions.

bad judgment. Encouraged patient of positive

decision of wanting treatment and not going back
to the streets.
Encouraged patient to verbalize feelings of his
addiction. Patient stated he feels his life is now
unmanageable and feels powerless to the drug.

Substance users have an enormous

capacity to explain the behaviors they
use to support substance use,
Rationalization and denial may obstruct
a patients ability to be honest with care
providers.

Patient currently not using meth while in the

hospital and states his thoughts are more clear.
Patient states when he uses meth, his thoughts are
cloudy, makes bad decisions, and blames
others for everything.

Scholarly Journal Article review, Source and Implications:

Assessment Tool(s): TM-33 completed, score: 4 = moderate risk for suicide/self harm

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