321 Care Plan for patient PDF

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TUSKEGEE UNIVERSITY DEPARTMENT OF NURSING NURSING CARE PLAN

Student Name: Taylor Bulls Facility: Bullock County Outpatient Activity Center Unit/Area: Mental Health Clinic Instructor: Ms. Macklin Course: NURS 321 Dates of Care: 11/16/18

Assessment Objective Data: DOB: 11/19/1976 Age: 42 Gender: Female Ethnicity: African American Language Spoken: English Marital Status: Married Children: 1 Allergies  Haldol Dec Medications:  Benztropine Mesylate, 1 mg, tab, PO, 2x a day  Abilify, 20 mg, tab, PO  Fluphenazine Dec, 25 mg/mL, oil, IJ  Depakote, 500 mg TCP, PO  Fluphenazine HCl, 5 mg, tab, PO

Medication Compliance:  Yes, client cannot self medicate  Mild adaptive Mental Status:  Appropriate  Euthymic

Nursing Diagnosis 1.) Disturbed Thought Process related to inability to evaluate reality as evidenced by flight of ideas and grandiose delusions. 2.) Disturbed Sensory Perception: Auditory related to biochemical imbalance, caused by schizophrenia as evidenced by hallucinations. 3.) Impaired Social Interaction related to impaired thought processes (delusions or hallucinations) as evidenced by observed use of unsuccessful social interactions behaviors.

Planning 1. S.D. will have realitybased thinking during my shift at 0830-1400. 2.) S.D. will learn ways to refrain from responding to hallucinations in 1 week. 3.) S.D. will attend structured group therapy 5-7 days a week.

Interventions Disturbed Thought Process 1a.) TUSN will provide antipsychotic medications as ordered and monitor effects 1b.) TUSN will look for the client’s strengths and abilities when providing nursing care. 1c.) TUSN will reinforce reality. Talk about what is really happening. 1d.) TUSN will not argue with the patient about delusional thoughts. Disturbed Sensory Perception: Auditory 2a.) TUSN will administer antipsychotic medications as ordered and monitor effects. 2b.) TUSN will access for hallucinations. Redirect patient back to reality. 2c.) TUSN will ask what the voices are telling the client to do. 2d.) TUSN will stay with

Rationale Disturbed Thought Process 1a.) It is the responsibility of nurses to access the client’s response to medications for the purpose of evaluating their effectiveness. (Halter & Varcarolis, pp. 76-79) 1b.) It is important to look for the client’s strengths and to acknowledge the normal parts of the person. (Halter & Varcarolis, pp. 117-) 1c.) Conversations about the simple realities of daily life focus the client’s attention away from disorganized thoughts and into the here and now. (Varcarolis, pp. 260-261) 1d.) Client’s do not recognize that they are having delusions, and arguments can force the client to focus on defending the false idea. Change the subject to realitybased topics. (Varcarolis, pp. 249-250) Disturbed Sensory Perception: Auditory/Visual 2a.) Antipsychotic medications

Evaluation 1.) Goal was met. The client managed to stay in reality. 2.) Goal was partially met. Client managed to not indulge the hallucinations, but still says she hears voices. 3.) Goal was met. Client demonstrates willingness and desire to socialize with others.

Subjective Data: Pain Level:  None, client stated that she was not in any pain No eye contact. Client looked pass you when talking. Clothes were clean and neat. Hygiene was good. Client participated in group therapy. Client would fidget in seat. Client would hold her head to the side

clients when they are starting to hallucinate, and direct them to tell the “voices they hear” to go away. Repeat often in a matter-of-fact manner. Impaired Social Interaction 3a.) TUSN will identify with the client what symptoms they may be feeling that cause her to become anxious around others. 3b.) TUSN will structure activities based on the client’s pace and abilities. 3c.) TUSN will encourage the client to use coping skills particularly conversational and assertiveness abilities. 3d.) TUSN will give praise or recognition for positive steps the client takes in increasing social skills.

decrease hallucinations. (Halter & Varcarolis, pp. 215221) 2b.) Assessment enables evaluation of the client's responses to hallucinations. (Halter & Varcarolis , pp. 204213) 2c.) Assess for command hallucinations that tell the client to harm self or others. (Halter & Varcarolis , pp. 212213) 2d.) Client can sometimes learn to push voices aside when given repeated instructions. Especially within the framework of a trusting relationship. (Halter & Varcarolis , pp. 212) Impaired Social Interaction 3a.) Identification of the symptoms of anxiety will help to decrease agitation and aggression of the client. (Varcarolis, pp. 132-133) 3b.) The client might be disinterested in activities that they may find overwhelming. This will then lead to an increased sense of failure. (Varcarolis, pp. 260-261) 3c.) This will help the client develop the fundamental skills in socializing. (Varcarolis, pp. 260-261)

3d.) Recognition and appreciation encourages the client to sustain and increase a specific social behavior. (Varcarolis, pp. 260-261)

Reference: 6 Schizophrenia Nursing Care Plans. (2018). Retrieved from https://nurseslabs.com/schizophrenia-nursing-care-plans/4/ Schizophrenia Care Plan Interventions For Nurses - NurseBuff - Page 2. (2018, March 28). Retrieved November 26, 2018, from https://www.nursebuff.com/schizophrenia-care-plan/2/ Varcarolis, E. M. (2017). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (3rd ed.). St. Louis, MO: Elsevier. Halter, M. J., & Varcarolis, E. M. (2014). Varcarolis foundations of psychiatric mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Elsevier/Saunders...