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

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Summary

Client care plan on a mental health unit ...

Description

Name: Date: Room: Client Initials: CLUSTERED DATA

 diagnosis of major depressive disorder which has worsened over the last few months and has never been treated in the past

NURSING DIAGNOSIS (Client Problem)

EXPECTED CLIENT OUTCOME (Dated Goal)

Risk for suicide r/t major depressive disorder, recent suicide attempt, sudden euphoric recovery from major depression, feelings of helplessness and low self-esteem, and poor coping skills

Patient will not harm self throughout his stay in the hospital and will continue to not cause self-harm after he is discharged.

 feelings of happiness, euphoria, and energy after suicidal attempt

Patient will maintain connectedness in relationships and will utilize his social supports for coping purposes throughout his stay in the hospital and after discharge.

 verbal statements of helplessness and low self-esteem due to ongoing issues at home and in his marriage

Patient will talk about his feelings and disclose suicidal ideations if present throughout his stay in the hospital

 unemployed

Patient will seek immediate help if he begins to experience suicidal thoughts in the community

 recent severe suicide attempt that lead to hospitalization

 increased alcohol use

 when patient was feeling depressed and suicidal, he did not

Ineffective health maintenance r/t lack of ability to make good

Patient will discuss fear of or blocks to implementing health

NURSING INTERVENTIONS

DATED EVALUATION OF GOALS

 perform mental status examinations every shift and assess suicidal ideation every shift and when appropriate (e.g. if client is exhibiting new behaviours)

Patient did not experience thoughts of self- harm by end of shift at 2100 and identified his family  assess the patient’s ability to enter as protective factors into a no-suicide and no self-harm and excellent contract; this gets the subject of suicide support systems. out in the open and discussing feelings Patient stated that of self-harm with a trusted person he would inform provides relief for the patient nurses of any suicidal ideation and would not cause  be alert for warning signs of suicide, such as making statements of death, harm to himself. getting affairs in order, behaving Patient verbalized recklessly, becoming withdrawn, or understanding of even becoming euphoric the importance to seek help from both  assess patient’s relationship with his family members social supports and ask him to identify and professional how they can help him help in the event he feels suicidal again in the future.  refer patient to mental health counselling and other community resources that will be utilized after discharge  ask client to identify positive coping mechanisms, social supports, and professional help in the event of suicidal thoughts  assess patient’s feelings, values and reasons for not seeking health care and assess patient’s feelings regarding

During the mental status exam, the patient verbalized

CLUSTERED DATA

know where to go for professional help, and stated that he felt as though he could not open up to his wife about his mental health problems  patient stated that he knew he needed help, but he did not know where to go and figured he could just “brush it off”  patient felt as though he had no social supports due to his marital problems and that his daughters moved away for school  patient had negative coping mechanisms such as consuming alcohol and isolating himself socially to avoid dealing with his problems

NURSING DIAGNOSIS (Client Problem)

judgements regarding ways to obtain help and ineffective family and personal coping amb history of lack of healthseeking behaviour and impairment of personal support systems

EXPECTED CLIENT OUTCOME (Dated Goal)

NURSING INTERVENTIONS

regimen by end of shift (2100)

new plan of care and willingness to participate

Patient will follow mutually agreed on health care maintenance plan throughout his stay in the hospital

 assess the patient’s perception of health and personal factors that influence health status

Patient will meet goals for health care maintenance throughout stay in hospital and after discharge

 assess for family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen  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 – in this case, the patient will be referred to mental health counseling and community resources such as assertive community treatment  identify patient support systems and identify community support groups related to the illness

DATED OFEVALUATION GOALS

why he did not seek help when he knew he should have. Patient verbalized that he will comply with his new health care regime as he is determined to get better and “have a fresh start”. Patient has been referred to community resources that will aid him to cope with his illness and maintain his health care plan....