TC Psych-Clinical

April 18, 2012 Mental Health Care Plan

Department of Nursing Nursing 3462 (Psychiatric Mental Health Nursing) Nursing Care Plan

Student: T C Patient Initial: T. D .

Date: Feb. 13, 2012 Instructor: Dr. Kim

Axis I Diagnosis: Mood Disorder not otherwise specified, Bipolar disorder 2, Substance Induced Mood Disorder w/o psychotic feat., cocaine abuse. AXIS II: Deferred Axis III: Diabetes Mellitus 2, axilla. abcess, degenerative disk disease, fibromyalgia, chronic back pain, hysterectomy Axis IV: Moderate Axis V: Global Assessment of Function = 35

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April 18, 2012 Mental Health Care Plan

Assessment (10 pts.) (Subjective and Objective).

(5) Identify sources of data, chart, interview, observation, etc. (5) Include bio-psycho-social-spiritual components and diagnosis.

General History and Data T.D. is a 41 y/o Caucasian female with history of bipolar disorder who presented to UNC-ED for depression and suicidal ideation seeking voluntary admission to psychiatric unit. During assessment interview client stated; Ive experienced severe depression lately and I seriously thought about killing myself. Im not happy with myself or the decisions Ive made in the past. I had no energy, and I couldnt concentrate. So I stopped taking my meds. I recently left my husband and kids for 3 weeks, because I felt hopeless and I honestly felt I was better off dead. My family would be better off w/o me. I just felt like killing myself. While I was away from home I was getting high, using crackcocaine. The cocaine kept me from being so depressed, but it didnt really help. My mind started to race, I couldnt sleep, and all I cared about was getting high and using more cocaine. I know I need help, I want help and I want to get better. Client was anhedonic regarding her 3 children, and expressed guilt for feeling this way. Client also has a history of polysubstance abuse, including Intra-venous Drug Abuse. T.D attempted to commit suicide at the age of 15 by taking an overdose of pills, resulting in hospitalization and stomach pump (Shapiro, 2012). She admits that she thought of walking in front of a moving bus short after arriving here at UNC. (Shapiro, 2012) At the age of 10-15 and again at 18, client was repeatedly raped by her biological older brother. She acknowledges that this has been very difficult to deal with and the experience still haunts her. She claims that her 2nd older brother is partially responsible for introducing her to hard drugs (i.e heroin, meth, and cocaine and crack cocaine). She endorses, during episodes of depression and mania she is increasingly angry, irritable, and ready to fight (Shapiro, 2012). She has been hospitalized on 4 different occasions for her mental illness (Shapiro, 2012). Mrs. T.D is currently on Depakote, Abilify, and Trazadone to help with her mental illness. Her meds were recently changed when admitted to unit after knowledge of non compliance with previous prescribed therapy. She feels that the regimen wasnt working, meds werent doing any good, whats the point of taking them? She reports feeling better after 8 days on the unit and she says she ready to go home and embrace her family. She feels shes ready to make a change and be more actively involved in her family life. She also expressed a desire be more spiritually connected with God. Stating Even through all the BS I have experienced in my life, I know God has some kind of plan for me. 12/14/09 De Gagne

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April 18, 2012 Mental Health Care Plan

She says that her husband has been very supportive to her and she expresses her gratitude. She knows her family will be her motivation (husband & kids), because no matter what, theyve loved me unconditionally. Ms. T.D has no real social life, she says that she has no true friends because she says friends and family are just too much of a disappoinment and will hurt you the most. So she stays to herself and immediate family. She did say that she has one friend in particular that she talks to from time to time. She hasnt spoken to her lately, in fear of what the friend might think of her, because of her recent poor judgment. She expressed that she needed to contact her when she got out of here. T.D also stated that she, also keeps in contact with her father and talks to him more often than any other family member besides immediate. She is estranged from mother and older brother. She stated that she simply didnt want anything to do with them. As for her middle brother, she talks to him as well. But she said that maybe it isnt in her best interest anymore until he seeks help and rehab himself. Client says when she gets upset, overwhelmed and stressed. She claims that her husband has the most success at calming her down and snapping her back into reality. Client is aware that mental illness/drug dependence does run in the family. Her maternal uncle suffered from bipolar mood d/o, depression, and substance abuse. He tried several attempts of suicide, he succeeded at his last attempt in 2006. (Shapiro, 2012). T.D has been marrried x 10 yrs and lives in Cameron County, SC with her husband and 3 children; 13girl, 9-girl, and 4-boy. T.D has only up to eighth grade education, she dropped out of school in the 9th grade (Shapiro, 2012). She wans to go back to school, so she can receive her GED. Client denies use of ETOH. She does smoke a pack of cigarettes per day, and is currently unemployed due to her many medical ailments. She reports being sexually active with husband. When experiencing manic episodes she does engage in multple sexual relations with other men (Shapiro, 2012). She did say that it is hard finding real pleasure in intimacy, because she feels that she is obligated to do such things (as if having sex was a chore. Upon observation; T.D is well groomed , appropriately dressed in clean clothes jeans and tee shirt. Her hygiene is appropriate. Clients hair is neatly pulled back in a pony tail. Maintains remarkable eye contact. Behavior is calm, cooperative, friendly (smiled and laughed throughout interview), and maintains good posture (sitting up straight in chair). Speech is normal. Rate, tone, volume, and articulation are clear, fluent and understandable. Overall, the patient seemed in a good mood. Patient had full rage affect that had euthymic congruancy (Shapiro, 2012).

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April 18, 2012 Mental Health Care Plan

T.D has good attention, concentration and intact memory. Knowledge of information is appropiate for age and education. T.D is coherent and goal directed. She knows that she has to make some changes in her life in order to better herself. When talking with her it seems she wants to set goals and reach them.

Analysis (10 pts.)

(10) Logical statement that reflects accumulated data.

Nursing Diagnosis (PES Format) (10 pts.)

Problem Etiology Signs & Symptoms

T.D has multiple risk factors of suicide and progression of mental illness, including; recent active suicide ideations with a plan, previous suicide attempts, family history of mental illness, suicide and suicidal behaviors, poor insight/judgment, recent substance abuse with a history of dependence, history of sexual abuse, feelings of hopelessness/depression, behaviors of agitation/aggression/impulsiveness, previous psychiatric diagnoses, and signs/symptoms of major depressive episodes (Shapiro, 2012). Furthermore, these risk factors put my client at an increased risk of suicide and further worsening of psychiatric condition (Shapiro, 2012). These factors outweigh her protective factors of willingness and motivation for treatment, and her limited family/social support. T.D. has experienced a number of unfortunate events in her lifetime, including: being raped by her eldest brother, dropping out of 9th grade, getting introduced to several serious drugs by other older brother, and becoming a single teenage mother. These circumstances have caused T. D. to use (become dependent) IV heroin/crack-cocaine/opioid pain killers, to be non-compliant with medical conditions/treatment, to engage in multiple sexual indiscretions with various partners, and to implement addictive behaviors to substance and personal relationships. T.Ds coping strategies have had a negative impact, and have not been ineffective to her mental illness because they further exacerbate depressive state into manic condition; promoting increased risk of danger to well being. (1.) Risk for self directed harm r/t suicide ideation and previous plan prior AEB suicide attempts and feelings of hopelessness/depression. -Stated that my family would be better off if I were dead, Ive caused so much pain to them. -Client stated that she thought about and planned to walk in front of a moving bus. -At age 15, client overdosed on pills, in which she had to be hospitalized for. (2.) Ineffective coping r/t situational crisis AEB substance induced mood disorder (manic behavior), poor judgment/insight, and lack of emotional instability impeding adaptive behavior. -Raped at 10-15 year of age by older brother. -Admits to use of Cocaine, Heroin, and Meth to cope when in depressed state, resulting in manic behavior.

(4) Clearly stated using current accepted NANDA format (3) Diagnosis is supported by assessment data. (3) Reflects clients current need for intervention-prioritize.

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April 18, 2012 Mental Health Care Plan

Expected Outcomes / Planning (Make goal safe, measurable and realistic) (15 pts.)
(6) At least one long term and one short term for each diagnosis (3) Statement must identify client as subject of action verb (3) Goal is based on assessment data and diagnosis (3) Goal is stated in measurable timeframes

-Non-Compliant with treatment. -Engages in sexual indiscretions with multiple partners, due to emotional instability. -addictive behavior -reports feelings of hopelessness - Dropped out of high school in the 9th grade. (#1.) Short term goal: T.D. will verbalize compliance to seek out staff, when feeling an urge to harm self within 24-48 hrs of admission. (Varcarolis, 2010, p. 483). Long term goal: Upon discharge, client will state she wants to live and will refrain from harming self after discharge (Varcarolis, 2010, p. 483).

(#2.) Short term goal: T. B. will identify at least two drug free coping strategies she can use when experiencing depression within 24-72 hrs of admission. (Varcarolis, 2010, pp. 342-43) Long term goal: Continue to verbalize cues or situations that pose increased risk of drug use by discharge. (Varcarolis, 2010, p. 342). #1- Risk for self directed harm (ST1) Create a safe enviorment. Take away objects that can cause potential harm to patient. Providing a safe enviornment while patient is suicidal is important because self directed harm is percieved as the only way out in an intolerable situatios. Client safety is a top nursing priority. (Varcarolis, 2010, p. 484). (ST2) Encourage patient to avoid decisions during time of crisis, until alternatives can be considered. During crisis situations, people are unable to think clearly or evaluate their options (Varcarolis, 2010, p. 484). (ST3) Encourage patient to talk about feelings (anger, disappointments). Gives patient alternative ways of dealing with overwhelming emotions and gaining a sense of control over life (Varcarolis, 2010, p. 491).

Implementation (Start with action word and write rationale for each) (15 pts.)
(2) At least 3 interventions per goal. (2) Reflects dynamics of the family system (2) Describe action toward goal achievement (2) Based on nursing diagnosis (2) Paired with scientific rational (3) Incorporates collaboration/consultation with multidisciplinary team members (2) Includes appropriate community resource.

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(LT1) Ask client directly Have you thought about harming yourself in any way? If so, What/How do you plan to do? Do you have a means to carry out plan? The suicide risk is greatly increased if the client has developed a plan and particularly, if means exist for client to execute plan (Townsend, 2010, p. 132) (LT2) Formulate a short term (3-6 months) verbal or written contract with patient, that she will not harm self during stay on unit and after discharge. A contract gets the subject out in the open, and places some responsibility for the clients safety. An attitude that the client is worthwhile is conveyed (Townsend, 2010). Encourage feelings of honesty and assist with what gives the client joy/happiness. This helps client identify symbols of hope in her life and gives motivation to live, through exploration and discussion (Townsend, 2010, p. 135). (LT3) Spend time with patient (most important intervention). Provides a feeling of safety and security, while sending message of; I want to spend time with you, because I think you are a worthwhile person. (Townsend, 2010, p. 132) #2- Ineffective coping (ST1) Assess patients non effective coping behaviors that result in negative emotions and substance abuse. Getting patient to identify triggers of emotional distress will help identify areas to target for teaching and planning strategies that are more effective for self enhancing behaviors (Varcarolis, 2010, p. 491). (ST2) Assess and identify clients current social support and resources. Will aide in assuring patient has positive and effective support when dealing with triggers of negative coping. Encourages patient to share honest feelings and help with redirection. Helps to increase compliance with treatment when patient knows they have someone to confide in and they dont have to go through struggle alone (Varcarolis, 2010, p. 492). (ST3) Give positive feedback when patient applies new and effective responses to difficult trigger situations. Valdates patients ositive steps toward growth andchange. (Varcarolis, 2010, p. 345)

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April 18, 2012 Mental Health Care Plan

(LT1) Role-play with patient adaptive coping strategies patient can use when situations that lead to negative coping and drug use. Not all new coping strategies are effective (Nurse and patient work together to find what works and what doesnt work for the patienttheres more than one way to cope effectively) (Varcarolis, 2010, p. 491). (LT2) Assess patients strengths and positive coping skills (i.e creative outlets etc.). This helps build and plan alternatives to self-defeating behaviors (Varcarolis, 2010, p. 491). (LT3) Inform client of additional resources for support (i.e support groups-drugs,incest, rape, bipolar). Will provide client with an outlet to talk to others that have experienced whats she has gone through.Gives patient opportunity to build positive coping relationhips with others who are motivated to change circumstances (Fontaine, 2009, p. 226) (LT4) Continue to work with patient on the following areas: a) Personal/relationship issues. b) Social issues (family abuse). c) Feelings of self-worth. These ares of human life need to find healing so that growth and healing can take place. (Varcarolis, 2010, p. 345)

Evaluation (Tell if goal was met and tell what should be done with goal) (10 pts.)
(10) State how you would evaluate if the care plan was successful (or achievable)

#1. Short term goal met. T.D has not further expressed suicidal thoughts, she actively communicates to nurses and other patients on unit with no apparent depression and manic characteristics. States that she knows she has a purpose in life. Long term goal met. Client has expressed that she actively wants to be there for her husband and kids, they are her motivation to live. #2. Short term goal met. Client has assisted with plan to have husband help oversee that she stays in compliance with treatment and takes meds properly. Client has agreed to be open to communication. Patients states she will inform husband when she has difficulty with mood and emotions. She will continue to be more active around house, and get involved in childrens life outside of home. While on unit husband and SW from residing county helped with initiating enrolling patient in school to get her GED. Long term goal NOT met completely. Knows that she need to refrain from relationships that inhibit effectiveness of treatment. States she would like to join a support group she thinks it would help her increase her chances of staying motivated and help with her frame of mind . This will give her something to do outside of family and keep her motivated/sober. Hasnt been set up with a contact. Will follow up after discharge to give more information. Continue with follow up.

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April 18, 2012 Mental Health Care Plan

References: Fontaine, K. L. (2009). Mental Health Nursing. In K. L. Fontaine, Mental Health Nursing (p. 226). Saddle River, NY: Julie Levin Alexander. Shapiro, A. (2012, April 6). History and Physical Notes. Chapel Hill, NC: UNC Webcis. Townsend, M. C. (2010). Nursing Diagnosis in Psychiatric Nursing. In M. C. Townsend, Alterations in Psychosocial Adaptations (pp. 132, 135, 345). Philadelphia: F.A. Davis. Varcarolis, E. R.-M. (2010). Manual of Pyschiatric Nursing Care Plans; 4th Edition (pp. 342-23, 483-84, 491-92). Philadelphia: W B Saunders.

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April 18, 2012 Mental Health Care Plan

RATIONALE WITH CITATIONS: 10 Points (2) One for each intervention. (3) Is related to or describes interventions. (3) Illustrates understanding of pathophysiology specific to client (2) Include references with page of citations REFERENCE LIST: 10 Points (10) Reference list reflects APA format and reflects current practices. COMMUNICATION SKILLS: 10 Points (10) Written product is legible, concise, using full sentences and correct grammar.

Successful (80%): _____________ TOTAL POINTS: COMMENTS:

Unsuccessful: ____________

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