Care Plan - Client care plan on a mental health unit PDF

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Client care plan on a mental health unit ...

Description

CLIENT CARE PLAN Name: Date: Room: Client Initials: CLUSTERED DATA

 poor communication patterns (ignoring questions, one word answers, bizarre responses)  decreased use of social support (lack of interest in CMHA meetings, lack of interest in socializing outside of hospital)  difficulty organizing information (cognitive impairment)  inability to meet basic needs  poor self-care  sleep pattern disturbance  poor concentration  lack of goal-directed behaviour

NURSING DIAGNOSIS (Client Problem)

Ineffective coping r/t disturbance in communication patterns, inadequate level of confidence in ability to cope, inadequate perception of control, inadequate social supports as manifested by poor communication skills, inability to seek help from others, poor concentration, decreased use of social support, difficulty organizing information, inability to meet basic needs, and lack of adequate self-care skills

EXPECTED CLIENT OUTCOME (Dated Goal)

Patient will identify 3 coping mechanisms that he will utilize during periods of distress by the end of shift (2100) Patient will use effective coping strategies throughout stay in hospital and after discharge Patient will report increase in psychological comfort after 3 days Patient will seek help from health care professionals as appropriate and when required throughout hospital stay and after discharge

NURSING INTERVENTIONS

Patient identified 3 coping mechanisms that he will utilize in times of distress: going for a walk, taking a nap,  identify current factors that impact listening to music by patients coping abilities the end of my shift. Patient was noted to  use verbal and non-verbal be listening to music therapeutic communication approaches during shift to help including empathy, active listening, and reduce the confrontation to encourage patient to occurrence of the express emotions and how they impact voices he was his coping abilities hearing. Patient agreed to seek help  collaborate with the client to identify in the future when strengths and weaknesses with coping required. abilities  observe for contributing factors of ineffective coping such as poor selfconcept, grief, lack of problem solving, lack of social support, recent changes in life situations etc.

 encourage client to describe previous stressors and the coping mechanisms used  assist the client to set realistic goals and identify personal skills and knowledge  offer instruction regarding alternative coping strategies

 lack of coping skills  inability to ask for

DATED EVALUATION OF GOALS

 explain importance of seeking healthcare when required and reassure

CLUSTERED DATA

NURSING DIAGNOSIS (Client Problem)

help from others (social support, medical support)

 lack of social supports outside of the hospital, verbal statement of “I have no friends or family”  difficulty verbalizing health needs/wants (deficient communication)  lack of coping mechanisms  cognitive impairment – difficulty making decisions and caring for himself (lives in a group home)  unable to express ways to self-care  non-compliance with medication regimen before hospitalization and lack of interest to seek health care

Ineffective health maintenance r/t cognitive impairment, deficient communication skills, inability to make appropriate judgements, and ineffective individual coping as manifested by lack of knowledge about basic health practices, inability to take responsibility for meeting health practices, and impairment of social support systems

EXPECTED CLIENT OUTCOME (Dated Goal)

Patient will discuss fear of or blocks to implementing health regimen by end of shift (2100) Patient will identify coping skills and selfcare behaviours by end of shift (2100) Patient will follow mutually agreed on health care maintenance plan throughout his stay in the hospital Patient will meet goals for health care maintenance throughout stay in hospital and after discharge

NURSING INTERVENTIONS

DATED OFEVALUATION GOALS

client that the health care team is there to help him regardless of his situation  refer to additional or more intensive therapies as needed  assess patient’s feelings, values and reasons for not seeking health care/complying with meds and assess patient’s feelings regarding new plan of care and willingness to participate  assess the patient’s perception of health and personal factors that influence health status  help the patient to choose a healthy lifestyle that is best suited to individualized needs  teach the patient positive coping mechanisms and stress-reduction strategies  refer the patient to appropriate health care services as needed – this patient is already registered with CMHA, so it is important to remind him of all the services they offer to him  identify patient support systems and identify community support groups related to the illness

Patient did not identify reasons for lack of self-care and health maintenance and did not seem interested in the conversation. He identified coping mechanisms that he will utilize to manage his illness, which include: going for a walk, taking a nap, and listening to music. Patient stated that he will comply with new health regimen....