Behavioral Health Care Plan

Student: Nicole Kretkowski Date: 1/26/19

Course: NSG-322CC Instructor: Dustin Gorsky

Clincial Site: Banner University Behavioral Health Unit Client Identifier: NM Age: 24

Reason for Admission: Suicide attempt. An excessive intak of BP medications and antipsychotic medications. (40 tablets of lisinopril and 20
tablets of prothenazine)

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

Schizoeffective disorder Generalized Anxiety Disorder
Generalized Anxiety Disorder -Persistent worrying/anxiety about situations that are out of
Patho: Excessive ongoing anxiety and worry that are difficult to control proportion
and interfere with everyday activities. A person may develop this as a -Overthinking plans and solutions to all possible worst-case
child or as an adult. Generalized anxiety disorder can improve with outcomes
psychotherapy, medications, coping skills, and relaxation skills.
-Difficulty trying to let go of worry
Risk factors: Personality (a person whose temperament is timid, negatice
or avoids anything dangerous may be more prone to this disorder than -Inability to relax
others), genetics, or certain experiences that occurred in one’s life. -Difficulty concentrating
PTSD -Muscle tension or aches
Patho: PTSD is a mental health condition that is triggered by a terrifying PTSD
event (either witnessing it or experiencing it). People who go through
traumatic events may have diffulty adjusting or coping. Symptoms may -Intrusive memories
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
include flashbacks, nightmares, and severe anxiety. Uncontrollable -Avoidance
thoughts about the specific event commonly occur in an idividual who has -Easily being startled or frightened
PTSD.
-Negative thoughts about oneself, or other people
Risk factors: Experiencing intense or long-lasting trauma, having
experienced trauma earlier in life such as childhood or sexual abuse, -Memory problems
having a job that increases the risk of being exposed to traumatic events -Difficulty maintaining close relationships
(military personnel and first responders), and having blood relatives with
mental health problems are all factors that can make one more likely to ADHD
develop PTSD. The most common events leading to the development of -Hyperactive-impulsive behavior
PTSD include sexual violence, physical abuse, physical assault, an
accident, being treatened with a weapon, or combat exposure -Inattention

ADHD -Talks too much

Patho: A chronic condition that affects children and often continues into -Fidgets with or taps his or her hands or feet/squirms in the seat
adulthood. A person who has ADHD can have difficult sustaining -Easily distracted
attention, hyperactivity, and impulsive behavior. Children can also have
-Trouble paying attention
poor performance in school and have a hard time with relationships.
Symptoms sometimes lessen with age but some individuals never Borderline Personality Disorder
completely outgrow ADHD symptoms. Treatment will not cure ADHD, -Intense fear of abandonment
but it can help dramatically. Treatment includes medications and
behavioral interventions. The exact cause of ADHD is not clear. However, -Rapid changes in self-identity and self-image
factors involved in the development include genetics, environment, and -Periods of stress-related paranoia
central nervous system development.
-Impulsive or risky behavior (gambling, reckless driving, spending
Risk factors: Blood relatives, exposure to environmental toxins, maternal sprees, binge eating, or drug abuse.
drug use (alcohol or smoking during pregnancy), or premature birth.
Sugar is a possible suspect in causing hyperactivity, but there is no -Ongoing feelings of emptiness
reliable proof. -Inappropriate, intense anger (losing temper)
Borderline Personality Disorder Client Manifestations
Patho: A mental health disorder that impacts one’s way of thinking and - Difficulty trying to let go of worry
feeling about themselves. This can cause problems in functioning in
-Inability to relax
everyday life and usually includes a pattern or unstable intense
relationships, distorted self-image, and extreme emotions and -Intrusive memories
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impulsiveness. A person with this disorder will usually have an intense -Negative thoughts about oneself, or other people
fear of abandonment or instability and may have difficulty tolerating -Hyperactive-impulsive behavior
being alone. This disorder usually begins by early adulthood and seems to
be worse in young adulthood. -Inattention
Risk factors: Hereditary predisposition or a stressful childhood (Mayo -Talks too much
Clinic, n.d.). -Fidgets with or taps his or her hands or feet/squirms in the seat
-Easily distracted
-Trouble paying attention
-Impulsive or risky behavior (gambling, reckless driving, spending
sprees, binge eating, or drug abuse.

Assessment Data
Subjective Data: NM states she took BP medications as a suicide attempt.

VS: T : 36.8 C Labs: 1/24/19 at 08:30 Diagnostics:

BP: 162/100 CBC 1/9/19 at 14:45
HR: 83 bpm WBC: 10.0 K/MM3 -Chest PA + Lat
RR: 20 RBC: 4.86 M/MM3 1/15/19 15:55

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HGB: 13.0 g/dL -Chest Single View Portable
HCT: 41.0 %
Platelets: 268 K/MM3
Chem General
Glucose: 97 mg/dL
BUN: 14.1 mg/dL
Creatine: 0.67 mg/dL
BUN/Creat Ratio: 21
Sodium: 135 mmol/L
Potassium: 4.6 mmol/L
Chlorid: 99 mool/L
CO2: 13
Magnesium: 1.8 mg/dL
Calcium: 9.5 mg/dL
Liver Enzymes
AST: 21 U/L
ALT: 27 U/L
Bilirubin: 0.2 mg/dL
*Labs within normal range.

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Assessment: Orders/Safety Protocols:

Mental Status Exam: - Full code

Appearance - Regular diet

Eye contact is present while communicating, darts around at times. - Vital signs
Apparel is appropriate to the occasion, wearing jeans with fashionable - Belt precations: Danger to self
holes in them and a white jacket. Female patient who wears men’s
clothing. Hair is short, clean, and brushed. Client is showered, - Activity as tolerated
fingernails are maintained and not dirty, and patient wears no make-up.
Three tattoos are noted- (Three green dots on the right between thumb
and index finger. Client’s age agrees with overall look. Size is
appropriate for age.
Behavior
Shakes hands and feet while communicating. Gait pattern is normal.
Psycho-motor agitation is noted. Patient rocks in chair and is fidgeting.
Attitude
Positive attitude about other people. Low-self esteem when talking
about self. States she can easily give advice to others but hard for her to
take own advice.
Level of Consciousness
Alert and responsive to questions.
Orientation
Alert and oriented x3- can identify who she is, where she is, and what
time it is. Is aware of conversation going on and answers questions
appropriately.

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Speech and Language
Words come tumbling out with pressured speech. Volume is high
pitched. Flow of speech is rapid.
Mood
Patient appears anxious as evidenced by fidgeting and rapid speech.
When asked her mood she states she is happy that nursing students are
here visiting and talking with her.
Affect
Bright, outward expression of happiness. Congruent with situation and
mood. No random bursts of anger are noted.
Thought Process/Form
No disturbances noted with logical thought process. No rumination,
loosening associations, neoligisms, or clang associations are noted.
Thought Content
Auditory, command, olfactory, and gustatory hallucinations are noted.
Patient explains that she hears demonic voices telling her to kill her
family or self. Smells burning like a fire or heavy smoke and can taske
heavy smoke. Delusions are noted. Patient thinks men are out to get her.
Gets along better with women. Wants to fight men if they make her feel
uncomfortable.
Suicidality and Homicidality
No current suicidal/homicidal thoughts are noted. Patient denies when
asked. Patient states this is the last SA and she is moving on with her
life.

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Insight and Judgment
Emotional and fair insight focus as evidenced by knowing what her
illness entails but not fully aware of limitations or consequences of
actions. Judgement is fair as evidenced by inabilty to set goals for
discharge. Patient states she wants to “smoke a cig” when asked about
current goals. Patient then focuses back to coping skills she can identify
to help with discharge such as deep breathing.
Attention Span
Attention is 7/10. Patient appears to switch subjects or gaze out the
window.
Memory
Long term memory is intact. Poor short-term memory. Not able to recall
any three words (Ball, tree, flag). Not able to count backwards by serial
7’s. Recalls the month and year.
Intellectual Functioning
Fair. Patient needs further assistance with making decisions and setting
out goals for her future.

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 Medications
ALLERGIES:
Abilify, Clozaril, Zyprexa, Seroquel, Cogentin
*Used for all medications: Vallerand, Sanoski, & Deglin, 2017).
Name Dose Route Frequency Indication/Therapeutic
Effect
Haloperidol (Haldol) 5 mg PO Q Bedtime -Alters the effects of dopamine
in the CNS. Also has
choinergic and alpha-
adrenergic blocking activity.
-Used for acute and psychotic
disorders including
schizophrenia, manic stages,
and drug-induced psychoses.
-Useful in managing aggressive
patients .
Adverse Effects Nursing
Considerations
-Seizures, agranulocytosis, -Assess mental status
neuroleptic malignant syndrome, prior to and periodically
constipation, dry mouth, blurred during therapy.
vision, extrapyramidal reactions. -Assess positive
(hallucination,
delusions) and negative
(social isolation)
symptoms of
schizophrenia.
-Monitor BP (sitting,
standing, lying down)
and pulse prior to and
frequently during the
period of dose
adjustment. May cause
QT interval changes on
ECG.
-Observe patient
carefully when
administering the
medication, to ensure
that it is actualy taken
and not hoarded.
-Monitor for
developnment of
neuroleptic malignant
syndrome- fever,
respiratory distress,
tachycardia, seizures,
diaphoresis,
hypertension or
hypotension, pallor,
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Nicotine 21 mg Transdermal Daily -Provides a source of nicotine
during controlled withdrawal
from cigarette smoking.
-Used for adjunct therapy (with
behavior modification) in the
management of nicotine
withdrawal patients desiring to
give up cigarette smoking.
Diphenhydramine 50 mg IM PRN -Antagonizes the effecgt of
(Benadryl) agitation histamine at H1-receptor sites;
does not bind to or inactivate
histamine. Significant CNS
depressant and anticholinergic
properties.
-Used for relief of allergic
symptoms caused by histamine
-Headache, insomnia, abnormal
dreams, dizziness, drowsiness,
nasopharyngeal irritation,
sneezing, increased appetite, oral
injury, trandermal burning at the
patch site, erythema, pruritus,
and dysmenorrhea.
-Drowsiness, dizziness,
headache, paradoxical
excitation, blurred vision
tinnitus, hypotension, nausea,
anorexia, dry mouth, dysuria,
photosensitivity, urinary
retention, thickened bronchial
tiredness, severe muscle
stiffness, loss of bladder
control.
-Monitor CBC with
differential and liver
function tests
periodically during
therapy.
-Prior to therapy, assess
smoking history
(number of packs per
day, smoking patterns,
nicotine content of
preferred brand, degree
to in which patients
inhale smoke).
-Assess patient for
symptoms of smoking
wwithdrawal during
nicotine replacement
therapy.
-Monitor for toxicity
and overdose: nausea,
vomiting, diarrhea,
increased salivation
abdominal pain,
headahce, dizziness,
auditory and visual
disturbances, weakness,
dyspnea, hypotension,
and irregular pulse.
-Determine why the
medication was ordered
and assess symptoms
that apply to the
individual patient.
-Assess for urticaria
and for ptency or
airway.
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 release including: anaphylaxis,
seasonal and perennial allergic
rhinitis, allergic dermatoses.
-Used to prevent motion
sickness and a mild nighttime
sedation.
Hydroxyzine 25 mg PO Q6H PRN -Acts as a CNS depressant at
anxiety the subcortical level of the
CNS. Has anticholinergic,
antihistamine, and antiemetics
properties. Blocks histamine 1
receptors.
-Used for treatment of anxiety.
Preoperative sedation.
Antiemetic. Antipruritic. (may
be combined with other
opioids).
Ondansetron (Zotran) 4 mg PO Q6H, PRN T3-receptor sites (selective
nausea and antagonist) located in the vagal
vomitting nerve terminals and the
secretions, wheezing, and chest
tightness.
-Drowsiness, agitation, ataxia,
dizziness, heache, weakness,
wheezing, dry mouth, urinary
retention, pain at IM site, chest
tightness, constipation, nausea,
abscesses at IM sitees.
-Sedation, dry mouth, transient
increases in liver
aminotransferases and bilirubin,
-May decrease skin
response to allergy
tests.
-Assess sleep patterns.
-Assess degree or nasal
stuffiness, rhinorhea,
and sneezing.
-Caution patients to
avoid OTC cough and
cold products while
breast feeding or to
children less than 4 yrs.
-Assess patient for
profound sedation and
provide safety
precautions as indicated
(side rails up, bed in
low position, call light
within reach,
supervision of
ambulation and
transfer).
-Older adults are more
sensitive to CNS and
anticholinergic effects.
-Assess mental status.
-May cause false-
negative skin test using
allergen extracts.
Discontinue the drug at
least 72 hrs before test.
-Assess degree of
vomiting/nausea.
-Assess degree of
itching and character of
involved skin.
-Monitor fluid and
electrolyte status.
Diarrhea, which may
cause fluid and
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 chemoreceptor trigger zone in
the CNS
-Prevents nausea and vomiting
associated with cancer
chemotherapy and anesthesia.
Lorazepam 2 mg=1 mL IM PRN -Most potent of the available
agitation benzodiazepines.
-Effects are mediated by the
inhibitory neurotransmitter
GABA. Action sites: thalamic,
hypothalamic,, and limbic
levels of the CNS.
-Used for the management of
anxiety disorders and for short-
term relief of symptoms of
anxiety. Also used for
preanesthetic medication to
produce sedation and the
reduce anxiety and recall of
events related to day or surgery.
-Also used for management of
status epilepticus.
hypersensitivity reactions,
diarrhea, headache.
-Anterograde amnesia,
drowsiness, sedation, dizziness,
weakness, disorientation, sleep
disturbance, hallucinations,
hypertension or hypotension,
blurred vision, diplopia,
decreased hearing, abdominal
discomfort, and anorexia.
electrolyte imbalance is
a potential adverse
effect of this drug.
-Have equipment for
maintaining patent
airway immediately
available before starting
IV administration.
-Supervise ambulation
of older adult patients
for at least 8 hours after
injection to prevent
falling and injury.
-Assess CBC and liver
function tests
periodically for patients
on long-term therapy.
-Inform the client not to
self-medicate with OTC
drugs and seek
physician guidance.
-Drug should be
gradually decreased.
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Goal
Client- or family-focused.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for suicide related to life-threatening situation as evidenced by attempting to overdose.
-Patient will be able to
focus on positive ways to
cope in order to maintain
the quality of life.
Nursing Diagnoses and Plan of Care
Expected Outcome
Measurable, time-specific,
reasonable, and attainable.
- Identifies healthy ways
to deal with and express
anxiety within two weeks.
- Identifies positive
coping strategies within
two weeks.
- Demonstrates ability to
manage suicidal impulses
within two weeks.
- Discloses posession of
and surrenders harmful
objects within two weeks.
-Identifies available
community resources and
support systems within
two weeks.
Intervention(s)
Nursing or interprofessional
interventions.
- Assess suicide risk and
protective factors using
approved risk assessment
scale/tool.
- Discuss benefits and
values of psychotherapy
treatment.
- Encourage constructive
expression of fears,
anxieties, and anger.
- Establish trusting
therapeutic relationship
Rationale
Provide reason why
intervention is
indicated/therapeutic.
Provide references.
-To identify patient’s
safety in regards to
harming self.
-Each patient needs
communication
interventions tailored to the identifies positive
patient’s situation.
-To reduce anxiety.
-To stimulate
nonthreatening two-way
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
-Goal is ongoing.
Patient continues to
have outbreaks due to
anxiety and yells at
staff. Needs to be able to
respond to anxiety in a
healthier manner.
-Goal is met. Patient
coping strategies such as
deep breathing, listening
to music, and drawing.
-Goal is ongoing.
Patient states she is not
suicidal but needs to
continue to be stable
unil discharge and
throughout.
-Goal is met. Patient
does not carry any
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Secondary Nursing Diagnosis:
Ineffective coping related to inadequate opportunity to prepare for stressors as evidenced by risk-taking behavior.
-Patient will be able to
form a valid appraisal of
stressors and use available
resources to help cope.
-Patient will express
understanding of the
relationship between
emotional state and
behavior within two
weeks.
-Patient will become
actively involved in
planning own care.
-Patient will accept
responsibility for behavior
within two weeks.
-Patient will identify
effective and ineffective
coping techniques within
two weeks.
-Patient will use available
support systems, such as
family, friends, and
using nonjudgemental conversation (Phelps,
approach. Ralph & Taylor, 2017).
-Spend consistent, -An open environment will
uninterrupted time with help the patient ventilate
the patient. Encourage intense emotion. Through
open expression of discussion, you can help
feelings. the patient understand the
personal meaning attached
to recent events and foster
a realistic assessment of
the situation.
-Help the patient recognize
and accept responsibility
-Developing a sense of
for own actions.
responsibility is necessary
Discourage the patient
before change can occur.
from unfairly placing
blame on others.
harmful objects and
does not attempt to harm
self.
-Goal is met. Patient
identifies community
resources such as
“Cheers” group that she
will attend outside of the
hospital.
-Goal is ongoing. Patient
is working on expressing
understanding of inner
emotions related to
behaviors.
-Goal is met. Patient is
actively involved in
planning care as evidenced
by using adequate
resources such as group
therapy, communicating
with health care
professionals, and using
deep breathing techniques.
-Goal is met. Patient
accepts responsibility for
behavior and states she
will not try to kill self
again.
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 psychotherapist, to
develop and maintain
effective coping skills
within two weeks.
-Help the patient analyze
the current situation and
evaluate the effectiveness
of coping strategies.
-Praise the patient for
identifying and using
effective coping
techniques.
-Goal is ongoing. Patient
identifies effective coping
-To foster an objective
techniques but needs more
outlook.
time identifying
ineffective coping
strategies.
-Goal is met. Patient uses
-To reinforce appropriate available support systems.
behavior. She relies on her sister,
(Phelps, Ralph & Taylor, friends, and support
2017). groups to help cope.

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.
Phelps, L., Ralph, S., & Taylor, C. (2017). Spark’s & Taylor’s Nursing Diagnosis Reference Manual (10th ed.). Riverwood, IL:

Wolters Kluwer. ISBN: 9781496347817

Mayo Clinic. (n.d.). Retrieved from https://www.mayoclinic.org/

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s Drug Guide for Nurses (15th ed.). Philadelphia, PA: F:A. Davis Company.

ISBN: 9780803657052

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