NURS 360

Capstone Project
PMH Care Plan
Student Nurse Reporting Form
SN: Amy Boyd
Pt.: Sex: M

Date: 10/10/2015
Age: 16

Date of Admission: 6/22/2015

Transferred? ___No X Yes: (Reason/Date) 6/22/2015; Per H&P, patient was having suicidal/homicidal
thoughts when transitioned to detention home by court. Admitted to residential program of FTC for courtordered evaluation
Income source: Financially dependent upon mother; Tricare medical insurance (Mother in Navy)
Legal Status: MH5 found in paper chart not completed
Expiration Date: N/A
DSM Diagnosis:
I: ADHD-combined type; Aspergers Disorder (ASD), Sexual abuse of children (perpetuation)
II: Mild mental retardation, Pervasive learning disabilities
III: Obesity and dyslipidemia (metabolic syndrome secondary to ariplprazole (Abilify) use per research)
IV: Involvement with the legal system; Problems in peer relationships, Parents divorced and minimal
contact with father
V: GAF: 40, serious symptoms & impairment
What brought patient to the hospital?
Court-ordered evaluation for suicidal and homicidal thoughts after being transferred to DH (detention
home) living situation by court.

Patients description of illness/issues: I

Although I was unable to formulate a description from the client per say due to the distractibility of the
client, I believe these four quotes give us an idea of the clients understanding of illness/issues:
1.
2.
3.
4.

I am sure you know what its like to have emotional problems like me.
Sorry, I am just so indecisive today!!
I have a low IQ.
Yeah, just some family problems. I just feel guilty cause I am not grown up for my mom.

Spirituality: Although stated unknown on face sheet of clients chart regarding religion, client wrote
Catholic Jewish on a handout that asked him his religion.
Considerations r/t ethnicity or religion Client unable to identify higher power.
Patients Strengths: Behaviorally cooperative with 1:1 interaction with staff; accepts redirection
Patients Limitations: Social and cognitive impairment; on sexual precautions
Medications:
1. Order: Methylphenidate TR24 (time released) 72 mg PO daily
Drug Class: Psychostimulant (PS)
Pts target sx: inattention, hyperactivity, impulsivity
Total 24h dose: 72 mg/24h
Recommended range: 18mg/day-54 mg/day
L M H Max: Max is 54 mg/day according to drug book
Current side effects: N/A
2.

Order: Aripiprazole (Abilify) 2 mg PO daily

Drug Class: Atypical Antipsychotic (AAP)
Pts target sx: Irritability
Total 24h dose: 2 mg/24h
Recommended range: 2 mg/day-15 mg/day
L M H Max: Low
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
Total 24h dose: 2 mg/24h
Recommended range: 1 mg/day-4 mg/day
L M H Max: Low
Current side effects: N/A

4.

Order: Sertraline (Zoloft) tab 100 mg PO daily

Drug Class: Antidepressant (SSRI)
Pts target sx: crying, guilty feelings, decreased motivation
Total 24h dose: 100 mg/24h
Recommended range: 50 mg/day-200 mg/day
L M H Max: Moderate
Current side effects: Possibly emotional lability

5.

Order: Benzocaine-menthol (Cepacol) 15-3.6 mg lozenge 1 loz. PO Q2H PRN

Drug Class: Analgesic/Antitussive Combination
Pts target sx: N/A
Total 24h dose: N/A
Recommended range: N/A
L M H Max: N/A
Current side effects: N/A

7.

Order: Loperamide 2 mg PO QID PRN - Diarrhea

Drug Class: Antidiarrheals
Pts target sx: Not aware of experiencing any symptoms during clinical day
Total 24h dose: N/A
Recommended range: 2 mg/day-8 mg/day
L M H Max: Low
Current side effects: N/A

8.

Order: Acetaminophen (Tylenol) 650 mg PO Q6H PRN pain/fever

Drug Class: Antipyretic
Pts target sx: N/A
Total 24h dose: N/A
Recommended range: 325 mg/day-3 g/day
L M H Max: N/A
Current side effects: N/A

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. Obesity-teach patient about healthy diet and regular exercise.
2. Dyslipidemia- teach patient about healthy diet and regular exercise
BMI: 35.36 kg/m2

Category: Obese

(Height: 5 9 Weight: 239 lbs 8.5 oz.)

Food & fluid intake: WNL

Bladder & bowel status: WNL
Sleep pattern: WNL

Total sleep/24 hrs: 8 hours/24 hrs

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

Number of hrs of disruption: 0

Naps: When? No

Total nap time: N/A

Lab & studies:

Date/Panels in which all values were normal:
8/6/15: Normal labs:
-Cholesterol:189
-Triglycerides: 109
-Hematology panel: all normal
-Thyroid panel: all normal
-Glucose: 89
Date/Any abnormal labs:
8/6/15: Abnormal labs:
-HDL Cholesterol: 37 (low)
-LDL cholesterol: 130 (high)
-Non-HDL cholesterol: 152 (high)
Labs you would expect but were not ordered: N/A
Glucose readings x 24h for all diabetic pts. N/A

All drug screen findings: N/A

MENTAL STATUS ASSESSMENT:
Behavior: Erratic as evidenced by:

Cooperative when interacting with me 1:1

Friendly when playing games
Pacing when indecisive about whether to go to group therapy in end room or not
Irritable when couldnt decide where to go

Impulsive when being intrusive on peer

Dramatic as evidenced by outbursts about not being able to find his paper sword and about his
cat dying (per nurse when asked why he was crying while talking to staff when I returned from
lunch)

Affect: Labile as evidenced by fluctuating from:

Sad when crying with head on table

Anxious when pacing in hallways stating he is so indecisive
Cheerful when petting dog during pet therapy
Calm when showing me how to play card games

Indifferent when sitting in Sun room upon my return to unit

Inappropriate when laughed about terrorist charge

Sensorium: Client is oriented to time, place, person, and circumstances. However, clients attention
spam is minimal.
Imagery: No description of hallucinations, delusions, flashbacks, etc.
Cognition: Clients recent memory intact as evidenced by talking about recent events during
hospitalization including making a paper sword the say before and showing a peer how to make one.
Clients remote memory intact as evidenced by talking about what a fight that had happened during the
previous school year. Client has poor concentration, low intelligence, and is unable to count cards. Unable
to assess capacity for abstract thought by asking client to try to interpret a proverb.

Interpersonal relationships: Difficulty with social interactions and interacting in a socially acceptable
manner. Needs redirection to maintain interpersonal boundaries. Only observed client interacting with
peers much younger than him or staff/me who were assigned to interact with/observe client 1:1.

Developmental level: (Assets & barriers): Per chart, clients cognitive function was deemed to be within
the third or fourth grade range, so this would Eriksons Industry vs. Inferiority stage of development
(Townsend 2015). In this stage, one is expected to achieve a sense of self-confidence through recognition
from peers, acquaintances, and significant others (Townsend 2015). Because of my clients mental
barriers, he has not been able to receive this type of feedback, and therefore, unable to advance to the
Identity vs. role confusion stage where he should be developmentally where he would use all the
previously-mastered tasks to create a secure sense of self (Townsend 2015). This has caused the client
to have low self-esteem and the problems with interpersonal relationships as mentioned above.

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)
N/A
Drug class

Last
Use

Acute intox or
withdrawal sx?

Length of
Time
Used

Rout

Usual

Negative

amt.

Consequences

Problems Identified In Hospitals Master Treatment Plan:

No problems identified in Hospitals Master Treatment Plan as of 9/12/15.
Current Discharge Plan: Transferred on 9/13/15 to court-ordered treatment facility in Pennsylvania
called Cove PREP Treatment Facility for Adolescent Sexual Offenders. Its for lower cognitively
functioning youth to address sexual behavioral problems.

Nursing interventions you performed this shift (Include safety and teaching!): Ensured clients
safety by ensuring surrounding were free of potentially harmful objects, established rapport, engaged in
1:1 interaction, assessed mental status, attempted to explore thoughts/feelings, encouraged to verbalize
thoughts/feelings, encouraged participation in group therapy, performed TM33 & CSEI assessments,
taught client about anger management strategies to improve coping ability, explained behavioral contract
to client, redirected client from disruptive behaviors with recreational activities
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.

P: Risk for other-directed violence

E: Per H&P, patient was admitted to FTC for psychiatric evaluation for homicidal ideations along
with SI when transferred to detention home. Client has a history of sexual assault in the 3 rd
degree from 2013 when pt was 14 and touched a boy who was 8 or 9 at the time and still has
sexual urges that he is concerned about. He has a charge of terrorist threatening in the 1st
degree & was being chased by a kid and chased the kid back with a knife. Although pt stated he
never intended to hurt the kid and was just trying to scare him away per H&P, other-directed
(sexual abuse) is definitely my main concern because client stated he has too much sexual
deviants per H&P and client was transferred to another facility that is specifically for adolescent
sexual offenders. Furthermore, client is impulsive as evidenced by intruding on others.
S. Frequently observe clients behavior, encourage verbalization of thoughts/feelings for
ventilation of emotion, be available to stay with the client when tension rises, and teach client
ways to redirect violent behaviors.
P: Suicidal ideation
E: Although scored at low risk on the TM33 and even denied suicidal ideation on admission per
H&P, patient was admitted to FTC for psychiatric evaluation after having suicidal ideation when
transferred to detention home. Also, per H&P, patient put a knife to his throat and threatened to
kill himself.
S: Perform TM33 assessment every shift per agency protocol, create a safe environment for
patient, one-to-one observation or Q15 minute checks by staff, & develop/explain short-term
behavioral
P: Ineffective coping
E: Low self esteem evidenced by scoring in the very low self-esteem on the Coppersmith SelfEsteem Inventory (CSEI), inability to meet [age appropriate] role expectations as evidenced by
developmental level being incongruent with age, poor concentration and hyperactivity as
evidenced by (see DSM criteria comparison), impulsivity as evidenced by intruding on others,
irritability as evidenced by pacing though halls, and emotional outbursts.
S: Make environment safe, redirect disruptive behaviors, encourage discussion of angry feelings,
and teach client about effective coping strategies.
P: Impaired social interaction
E: Client was isolative to self and did not initiate interactions with others; client only conversed
with me or staff member who was assigned to be one-on-one with him that shift; client did not
attend larger group therapy sessions and was placed with the small keiki group for therapy
sessions that included only one or two other boys who were a lot younger than him; when I did
witness any interaction with peers his age, it was dysfunctional, such as arguing with peers about
playing video games and being intrusive by standing in front of the TV when a peer was trying to
watch it and not moving when asked to move
S: Observe client behaviors/responses from others and provide positive reinforcement for
interaction efforts, establish rapport/develop therapeutic nurse-patient relationship, encourage
group therapy attendance and participation; acknowledge clients absence from group therapies,
and teach appropriate interaction techniques by being a positive role model.

Priority # 1 : CARE PLAN

Nursing Diagnosis: Risk for self-directed or other-directed violence related to impulsivity (At risk for behaviors in which an individual demonstrates that he or she
can be physically, emotionally, and/or sexually harmful [either to self or others] (NANDA-I, 2012, p. 447-448] (Townsend, 2015, p. 20).
P: Risk for other-directed violence
E: Per H&P, patient was admitted to FTC for psychiatric evaluation for homicidal ideations along with SI when transferred to detention home. Client has a history
of sexual assault in the 3rd degree from 2013 when pt was 14 and touched a boy who was 8 or 9 at the time and still has sexual urges that he is concerned about.
He has a charge of terrorist threatening in the 1st degree & was being chased by a kid and chased the kid back with a knife. Although pt stated he never intended
to hurt the kid and was just trying to scare him away per H&P, other-directed (sexual abuse) is definitely my main concern because client stated he has too much
sexual deviants per H&P and client was transferred to another facility that is specifically for adolescent sexual offenders. Furthermore, client is impulsive as
evidenced by intruding on others.
S: Frequently observe clients behavior, encourage verbalization of thoughts/feelings for ventilation of emotion, be available to stay with the client when tension
rises, and 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 stay in residential program
at FTC.
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 the first two weeks I am
assigned at FTC
Scientific Rationale
Intervention & Frequency
(In complete sentences!)
Evaluation
(Reference in APA format, including page number)
Observe the clients behavior frequently.
Frequency: Continuous one-to-one observation is
possible, but if not, Q15 minutes w/ random checks
Encourage client to verbalize feelings in daily oneto-one conversations.

Client at high risk for violence require close

observation to prevent harm to self or others
(Townsend, 2015, p. 30).

Client remained free of self-directed and other directed harm.

Continue to evaluate.

This allows client to ventilate emotions and receive

encouragement and reinforcement from staff
(Fortinash & Worret, 2012, p. 412).

Client stated understanding of the importance of verbalizing

feelings and verbalized some feelings he was experiencing, such
as feeling indecisive, guilty, and sad.

The presence of a trusted individual provides a

feeling of security (Townsend, 2015, p. 31).

Client behaviorally cooperative during 1:1 interaction and

accepted redirection when tensions began to rise as evidenced
by pacing.

Anxiety and tension can be relieved safely with

benefit to the client in this manner (Townsend, 2015,
p. 31).

Client demonstrated understanding of the list of healthy things he

can do when feeling angry that my classmates and I presented to
some of the clients in FTC for our psychoeducational group.

Frequency: at least once each shift

Be available to stay with client as anxiety level and
tensions begin to rise.
Frequency: as needed

Teach client to redirect violent behavior with physical

or other outlets to release tension.
Frequency: as needed

Priority # 2
CARE PLAN
Nursing Diagnosis: Risk for suicide related to (history of) suicidal ideation and (history of) threat to kill self
P: Suicidal ideation
E: Although scored at low risk on the TM33 and even denied suicidal ideation on admission per H&P, patient was admitted to FTC for psychiatric
evaluation after having suicidal ideation when transferred to detention home. Also, per H&P, patient put a knife to his throat and threatened to kill
himself.
S: perform TM33 assessment every shift per agency protocol, create a safe environment for patient, one-to-one observation or Q15 minute checks
by staff, & develop/explain short-term behavioral
LT goal: Client will not harm self & client & will seek staff out any time if thoughts of harming self should occur during stay in residential program at
FTC
ST goal: Client will not harm self & client will seek staff out any time if thoughts of harming self should occur within the first two weeks I am
assigned at FTC.
Intervention & Frequency
Perform a TM33 suicide/self-harm assessment.
This includes securing promise from client that he
or she will seek out a staff member or support
person if thoughts of suicide emerge.
Frequency: each shift or per agency protocol.
Create a safe environment for the client by
removing all potentially harmful objects from the
clients access (sharp objects, straps, belts, ties,
glass items.)
Frequency: throughout each shift
Maintain close observation of client. Depending
on level of suicide precaution, provide one-to-one
contact, constant visual observation, or 15-minute
checks.
Frequency:
Develop and explain short-term verbal behavioral
contract with the client that includes not harming
self for a specific amount of time.
Frequency: Every time contract expires.

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including page
number)
Suicidal clients are often very ambivalent about
their feelings. Discussion of feelings with a
trusted individual may provide assistance before
the client experiences a crisis situation
(Townsend, 2015, p. 138).
Client safety is a nursing priority (Townsend,
2015, p. 137).

Evaluation
Client was cooperative when performed TM33, and he scored
at a low risk. He agreed to inform staff if thoughts of suicide
emerge.
Client remained safe throughout shift.

Close observation is necessary to ensure that

client does not harm self in any way (Townsend,
2015, p. 138).

Client remained free of self-directed and other directed harm.

Behaviorally cooperative during one-to-one interaction.

Discussion of suicidal feelings with a trusted

individual provides some relief to the client. A
contract gets the subject out in the open and
places from of the responsibility for the clients
safety. An attitude of acceptance of the client as a
worthwhile individual is convey (Townsend, 2015,
p. 138).

Client stated understanding of behavioral contract. Client

agreed not to harm self and remained free of self-harm during
clinical days.

Priority # 3
CARE PLAN
Nursing Diagnosis: Ineffective coping related to maturational/situational crisis, inadequate coping strategies and low self-esteem as evidenced by
inability to meet [age appropriate] role expectations, poor concentration, and hyperactivity (evidenced by excessive motor activity, easily distracted,
short attention span).
P: Ineffective coping
E: Low self esteem evidenced by scoring in the very low self-esteem on the Coppersmith Self-Esteem Inventory (CSEI), inability to meet [age
appropriate] role expectations as evidenced by developmental level being incongruent with age, poor concentration and hyperactivity as evidenced
by (see DSM criteria comparison), impulsivity as evidenced by intruding on others, irritability as evidenced by pacing though halls, and emotional
outbursts.
S: Make environment safe, redirect disruptive behaviors, encourage discussion of angry feelings, and teach client about effective coping
strategies.
LT goal: By discharge, client will identify, develop, and use one socially acceptable coping skill.
ST goal: Within one month, client will verbalize understanding of ineffective coping strategies.
Scientific Rationale
Intervention & Frequency
(In complete sentences!)
Evaluation
(Reference in APA format, including page
number)
If client is hyperactive, make environment safe
Client safety is a nursing priority (Townsend,
Client remained free of injury throughout clinical days.
for continuous large muscle movement.
2015, p. 36).
Frequency: as needed
Redirect disruptive behavior with recreational
activities.
Frequency: as needed

This channels excess energy and prevents

escalation (Fortinash & Worret, 2012, p.408).

Encourage discussion of angry feelings and

help client to identify true object of the hostility.
Frequency: as needed

Dealing with the feelings honestly and directly

will discourage displacement of the anger onto
other (Townsend, 2015, p. 37).

Teach anger management techniques.

This is done to lessen the patients feelings of

powerlessness and to prevent future
escalation (Fortinash & Worret, 2012, p.408).

Frequency: at least once per shift or as

needed

Engaged in recreational activities with the client, such as

playing card games, chess, and Jenga. Client
demonstrated emotional and behavior control within his
capacity.
Client expressed his feelings safely without acting out
aggressively toward the self or others.
Client demonstrated understanding of the list of healthy
things he can do when feeling angry that my classmates
and I presented to some of the clients in FTC for our
psychoeducational group.

Priority # 4
CARE PLAN
Nursing Diagnosis: Impaired social interaction related to socially and developmentally inappropriate behavior as evidenced by not initiating interactions with
others, lack of eye contact, discomfort in social situations, use of unsuccessful social interaction behaviors, and dysfunctional interaction with others.
P: Impaired social interaction
E: Client was isolative to self and did not initiate interactions with others; client only conversed with me or staff member who was assigned to be one-on-one with
him that shift; client did not attend larger group therapy sessions and was placed with the small keiki group for therapy sessions that included only one or two
other boys who were a lot younger than him; when I did witness any interaction with peers his age, it was dysfunctional, such as arguing with peers about playing
video games and being intrusive by standing in front of the TV when a peer was trying to watch it and not moving when asked to move
S: Observe client behaviors/responses from others and provide positive reinforcement for interaction efforts, establish rapport/develop therapeutic nurse-patient
relationship, encourage group therapy attendance and participation; acknowledge clients absence from group therapies, and teach appropriate interaction
techniques by being a positive role model.
LT goal: By discharge, client will verbalize three interaction behaviors that are appropriate and three that which are inappropriate.
ST goal: Client will attempt to interact with peers within same age group using developmentally appropriate behaviors in the presence of trusted caregiver within
one month.
Scientific Rationale
Intervention & Frequency
(In complete sentences!)
Evaluation
(Reference in APA format, including page number)
Observe client behaviors and the responses he or
she elicits from others and provide positive
reinforcement for interaction efforts.
Frequency: throughout each shift

Positive reinforcement encourages repetition of

desirable behaviors (Townsend, 2015, p. 248).

Client did not initiate interactions with peers of same age group.
When client interacted with peers closer to developmental level, I
provided positive feedback by smiling and engaging in
conversation.

Develop a therapeutic nurse-client relationship

through frequent, brief contacts and an accepting
attitude.
Frequency: throughout each shift.
Encourage attendance in group activities and offer
to attend with client.
Frequency: At least once per shift

Your presence, acceptance, ad conveyance of

positive regard enhance the clients feelings of selfworth (Townsend, 2015, p. 144).

Able to establish rapport and a therapeutic nurse-client

relationship during clinical days.

The presence of a trusted individual provides

emotional security for the client (Townsend, 2015,
p. 144).

Act as a role model for client through appropriate

interactions with client and others

It is through these group interactions that the client

will learns socially acceptable behavior [..]
(Townsend, 2015, p. 35).

Encouraged client to participate in small group therapy.

Acknowledged clients absence from group therapy. With
encouragement, client spent some time painting with OT art
therapy group during one of the clinical days.
Client appeared to make better eye contact as interactions
became more frequent. Continue to evaluate.

Frequency: during every interaction with client

References for Care plans:

Townsend, M (2015). Psychiatric Nursing: assessment, care plans, and medications (9th ed.). F.A. Davis Company: Philadelphia, PA.
Fortinash, K. & Worret, P. (2012). Psychiatric Mental Health Nursing (5th ed.). Elsevier: St. Louis, MO.
Assessment Tool(s): TM33 Suicide/self harm assessment tool (Low risk) & Coppersmith self-esteem assessment (very low self-esteem)