RN PROGRAM

PSYCHIATRIC NURSING CLINICAL CARE PLAN #_____

Attachment #4 Psych Care Plan Document

Student Name: Joanne Smith Patient Initials: ZH Age: 38 y.o. Height: 65 Weight: IN KG 127.3 Kg

Clinical Date: 6/18/10 Clinical Site: VAMC

 DIAGNOSTIC AND STATISICAL MANUAL OF

MENTAL DISORDERS

Axis I: PRIMARY PSYCHIATRIC DIAGNOSES

EXCLUDING MENTAL RETARDATION AND PERSONALITY DISORDERS Major Depressive Disorder; Generalized Anxiety Disorder Axis II: MENTAL RETARDATION, PERSONALITY DISORDERS Deferred Axis III: MEDICAL CONDITIONS Diabetes Type I; hysterectomy five years ago.

 Axis IV: PSYCHOSOCIAL AND ENVIRONMENTAL

PROBLEMS
Poor support system; marital discord.

Axis V: Current GAF: (Overall psychological

functioning - if available) 50 PAST MEDICAL/PSYCHIATRIC HISTORY: Patient has Diabetes Mellitus Type I; hysterectomy five years ago; treated as an outpatient for major depression and suicide attempt two years ago.

 FAMILY HISTORY: Patients mother and aunt have a history of depression; father

has a history of Diabetes and was abused as a child. States she has an ok relationship with her mother, but is estranged from her father. She states that her father drank a lot and physically and emotionally abused her. She is married with two grown children who live out of state; she does not have grandchildren. States that her relationship with her husband is strained. of achievement of developmental tasks):

STAGE OF DEVELOPMENT (Include developmental theorist and behaviors indicative

Theorist: Erikson. What is the stage that the client is in, based on age, and what should he/she be accomplishing? E.g., Erikson. Generativity v. Stagnation. Being creative and productive, planning for future generations. E.g., Evidence: Is he/she accomplishing the tasks of this stage? Why or why not?

Patient is not meeting this life task. She wants to die and feels hopeless and helpless. She isolates herself; states she has no interests, has stopped attending church, and avoids her best friend. Does not feel she has anything to look forward to.

SPIRITUAL BELIEFS: Patient believes in God but is conflicted since she wants to die. CULTURAL BELIEFS: Believes that the man is the head of the household. Her family
is important to her.

ASSESSMENT (Please be specific)

General Assessment and Motor Behavior: (Hygiene and Grooming; Appropriate Dress; Posture; Eye Contact; Unusual Movements or Mannerisms; Speech) Patient is dressed in jeans, t-shirt, and black tennis shoes. Her posture is slumped, no direct eye contact. She constantly taps her foot when talking and occasionally pats her right knee with her right hand. Speech is slow, volume low. Mood and Affect: (Expressed Emotions; Facial Expressions) Patient states that she is depressed and wants to die. Her affect is blunted, congruent to verbal expressions. She frowns frequently and occasionally cries when discussing her feelings. Thought Process and Content: (Content: what the client is thinking; Process: how the client is thinking; Clarity of Ideas; Self-harm or Suicidal Urges) Patient states that she wants to die. She thinks that she has wasted her life and states that she has nothing to look forward to. No delusional statements.

Sensorium and Intellectual Processes: (Orientation; Confusion; Memory; Abnormal Sensory Experiences or Misperceptions; Concentration; Abstract Thinking Abilities) Patient is oriented to date, time, place, and situation. She is not confused. Memory is intact. This was assessed by asking her when she was married and what she ate for breakfast. She denies having any hallucinations. She demonstrated difficulty concentrating by having to ask me to repeat questions. Abstract thinking intact: She was able to interpret the proverb, People in glass houses shouldnt throw stones. Judgment and Insight: (Judgment: interpretation of the environment; Decisionmaking Ability; Insight: understanding ones own part in his/her current situation) Patient states that she is hospitalized because she is depressed and feels like she wants to die; insight is poor since she is unable to verbalize her feelings. Judgment is poor, as she has tried to commit suicide in the past. She states that she has contributed to the current situation by threatening to her husband that she was going to kill herself. She also stated that she had stopped taking her antidepressant medication three weeks ago.

Self-Concept: (Personal View of Self; Description of Physical Self; Personal Qualities or Attributes) She does not believe that she is a worthwhile person, even though she states that she has raised two good children. She feels that she is overweight and ugly. She cannot verbalize any strengths at this time. Roles and Relationships: (Current roles; Satisfaction with Roles; Success at Roles; Significant Relationships; Support Systems) Her two children live out of state, and she is not able to see them often. States that she and her husband fight a lot. Her only support system is a best friend and her church, although she reports that she has stopped going to church and at times avoids her best friend. Physiologic and Self-Care Issues: (Eating Habits; Sleep Patterns; Health Problems; Compliance with Medications; Ability to Perform ADLs) She states that she eats approximately 50% of her meals and eats three times a day while in the hospital, but that she tends to overeat when she is home. She is compliant with taking her medications. She admits that she is not careful with managing her diabetes. She reports that she sleeps 5-6 hours per night and has frequent awakenings. She is able to independently perform ADLs.

MEDICATIONS Please include trade & generic name, dosage, action, reason your patient is receiving this medication, major side effects, and nursing implications. PLEASE NOTE THAT YOU WILL BE DOING THREE PSYCHIATRIC DRUGS (OR RELATED) IF NONE, THESE WILL BE CHOSEN BY YOUR INSTRUCTOR.

Drug Action Acts as an Trade Name antagonist of Seroquel dopamine and serotonin to Generic Name decrease Quetiapine manifestations Dose of psychoses, 600 mg depression, or Frequency: acute mania. at bedtime Route Patient taking for psychosis. P.O.

Is Dose Appropriate ? Yes PTs Weight IN KG 127.3 Kg

Adverse Reactions The most common side effects include dizziness and weight gain. Other side effects can include sedation, extrapyramidal symptoms, tardive dyskinesia, palpitations,

Nursing Implications It is important to monitor the patients mental status for mood, orientation, and behavior. Also, assess for suicidal tendencies, weight, and blood pressure

LAB DATA & DIAGNOSTIC EVALUATION Include date LAB Ordered Hemoglobin A1C Client Values 8.1% H Normal Values 4.8-5.6 % Indication for Diseases / Illness The most common reason for an elevated Hemoglobin A1C is diabetes mellitus, in which the relative lack of physiologically active insulin results in an increased blood glucose level and can lead to acidosis and a comatose state.

LAB Ordered Cholesterol, Total Triglycerides HDL Cholesterol

Client Values 160 171 H 39 L

Normal Values 100-169 mg/dL 0-149 mg/dL >39 mg/dL

Indication for Diseases / Illness Many clinical conditions can cause an increase in serum cholesterol levels also can cause increased in triglyceride levels. Patients with nephritic syndrome, pancreatic dysfunction, diabetes, toxemia pregnancy, and hypothyroidism have elevated triglyceride levels. Low levels of HDL can indicate an increased incidence of CHD (congenital heart disease). Low levels can be due to genetics and some change in lifestyle factors can increase HDL.

PSYCHIATRIC MANAGEMENT NOTE IF PATIENT DOES NOT HAVE A PSYCHIATRIC DX, OR ONLY HAS ONE, YOUR INSTRUCTOR WILL CHOOSE THESE FOR YOU.
PSYCHIATRIC DIAGNOSIS PRIMARY (The Axis diagnosis, not the nursing diagnosis.) Major Depressive Disorder Define WHAT IS IT? Major Depressive disorder is SECONDARY (The Axis diagnosis, not the nursing diagnosis.) Generalized Anxiety Disorder WHAT IS IT?

(Give your reference.) Etiology What may have caused or contributed to the illness in this patient? Loss of friend, mother and aunt have been diagnosed with depression, abuse, death of family member, etc.

(Give your reference.) She and husband fight a lot, etc.

Pathophysiology Psychological and physiological causes.

Include physiological (for instance, neurotransmitters) and psychological factors; E.g., degree of depression is comparable with the persons sense of helplessness and hopelessness (Videbeck, 2011), etc.

Clinical Manifestations (textbook)

Usually involves 2 or more weeks of sad mood or lack of interest in activities, have low Self-esteem, changes in weight, sleep, energy, concentration, and decision-making (Videbeck, 2011), etc.

Actual Manifestations

What do you see? Patient expresses feelings of hopelessness and helplessness and states that she wants to die. She has gained 30 pounds in the last three months.

PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS

List all nursing diagnosis relevant to patient condition & based on assessment. It is not necessary to include the related to or as evidenced by for this list.

EXAMPLES

1. 2. 3. 4. 5.

Risk for suicide. Ineffective individual coping. Altered thought processes. Low self-esteem. Social isolation.

NURSING DIAGNOSIS (NANDA APPROVED) Risk for suicide related to feelings of helplessness and feelings of low self worth as evidenced by expression that she wants to die and past suicide attempt.

EXPECTED OUTCOME (Measurable Goal)

NURSING INTERVENTIONS (What do you plan to do?) THREE interventions for short term AND long term.

RATIONALE (Why are you doing this?) (Must give references.)

EVALUATION (Be specific!)

Short term: The patient will be free from harm for the remainder of the shift. Long term: The patient will be able to identify three positive aspects about herself by discharge.

1) Initiate a no self-harm contract, and monitor the patient frequently. 2) Spend time with the patient. 3) Encourage the patient to focus on strengths and accomplishments. + three interventions/rationales for long term goal.

1) A contract gets
the subject out in the open and places some of the responsibility for the clients safety with the client (Townsend, 2008, p. 119). 2) Spending time with the patient provides a feeling of safety and conveys that you believe the patient is a worthwhile person (Townsend, 2008). 3) This will minimize negative ruminations about the past and perceived failures Videbeck, 2011).

SHORT TERM: WHAT DID YOU SEE? E.g., Patient was free harm throughout the shift on (day you were there). LONG TERM: WHAT WOULD YOU HOPE TO SEE? E.g., Patient stated that she is a good mother, a loyal friend, and an honest person.

References (APA format) (APA format double spaced, second line indented. See APA manual or the MCI Resource & Style Guide for Paper Writing)

Videbeck, S.L. (2008). Psychiatric-mental health nursing

(5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.