Graded nursing care plan PDF

Preview

Summary

Comprehensive nursing care plan...

Description

CSUSM School of Nursing Graded Nursing Care Plan – N261/ N361 Student name:

Patient initials: JP

Date: 10/28/2019

Relevant Patient Data: (5 pts.) (Include issues of family system, sociocultural factors, environmental factors development state, patterns of living, healthcare systems factors)

Age range: 29 Gender: Male to female transgender Primary Language: English Family system: has a 18 year old sister that she is “kind of close with”, she “hates” her mother and thinks she is a “psychopath” Religion: not religious Sociocultural factors: Education and Occupation: graduated high school, does not have a job, plays video games online Social support: does not have friends, “roommates and staff in group home sexually harassed me” Use of cultural remedies or practices for his or her condition: not obtained Environmental factors: lives in group home, called “alpha project”, lives with roommates and group home staff, dislikes the home Developmental stage (Erickson): Intimacy vs Isolation: Client is most likely incapable of intimacy, as she is paranoid and does not trust others. She has isolated herself from society because of this. Patterns of living: does not appear to carry out ADLs, enjoys reading and playing video games, paranoia and voices appear to distract patient from self-care activities Healthcare systems factors: MediCal, primary care provider not specified, was residing in alpha project group home before hysteric outburst and then was transferred UCSD Hillcrest Medical Center, psychiatric inpatient hospitalization Available resources: no income, alpha project group home History Presenting Symptoms/Problem (include health state factors here) (3 pts) Date of Admission: 10/25 Presenting Problem for current admission: unspecified psychosis Subjective data: appears sad, frustrated, paranoid Objective data: has hysteric episode in group home because believed roommates and staff were “sexually harassing” her Past Psychiatric History: schizophrenia, paranoia, psychosis, depression Relevant Family History: believes mother is a “psychopath”

Relevant Childhood History: mother “did not treat me well growing up” History or Current Substance Abuse and type (Alcohol and types of drugs): cannabis, tobacco Legal Status: 5150 DTS/GB exp 10:28, 14:51, UCSD Hillcrest Medical Center, psychiatric inpatient hospitalization Psychiatric Mental Health Assessment: Attach completed assessment tool (6 pts.) Status Exam: Attach assessment tool (MMSE or MOCA or SLUMS) (2 pts) Identify the pertinent findings in the Nursing Mental Health Assessment or Mini-Mental Status Exam and explain the underlying psychopathology (3pts) JP is male to female transgender and was admitted for unspecified psychosis. She came to the hospital because she had a hysteric episode where she was shouting in her room. This happened because she believes that she was sexually abused in her group home by roommates and staff. She also believes that 100 people are out to get her. She is schizophrenic and has auditory hallucinations. She says that the voices do not control her and that she feels like they are characters in her head. They are not command in nature. She has a disheveled appearance and does not keep up with her ADLs. She is depressed, paranoid, frustrated and psychotic. She was reluctant to talk to me at first, however opened up as the conversation progressed. She appeared distracted, asked me to repeat questions, and kept looking up. She also kept flipping through her book and putting her hands to her head, as if she was distressed or was hearing voices. Despite having a history of suicidal ideations, she does not currently report being suicidal. She is medication compliant. She believes that her medications are working and are helping her get rid of her brain fog. She has delusions of others being able to hear her thoughts. She received a 30/30 on her MiniMental Status Exam, showing that she does not have cognitive loss. Schizophrenia is a disease in which the individual experiences positive symptoms of hallucinations and delusions. Hallucinations are most commonly auditory and visual, but can be tactile, gustatory, or olfactory. Auditory hallucinations are false perceptions of sound, commonly manifested as voices in the individual’s head. These voices can command the individual to do something harmful. Visual hallucinations may consist of falsely formed images or flashes of light. Delusions include delusions of persecution, grandeur, reference, control or influence, somatic, or nihilistic. In addition, the individual can exhibit religiosity, paranoia, magical thinking, and have an altered formation of thought. The individual can also exhibit negative symptoms, such as anhedonia, avolition, apathy, alogia, affective flattening, and apraxia. These symptoms may make it difficult for the individual to function in the community. They can have impaired social interaction or social isolation, and they can become paranoid, depressed, unmotivated, or gravely disabled (Townsend, 2015).

Self-Care Requisites (8 pts) Universal: Abilities to control and regulate a sufficient intake of: Air, water and food: Met. Needs are supplied by alpha project group home.

Elimination/Excrement: Met. Elimination/excretion needs are unimpaired. Activity and rest: Partially met. She does not participate in many activities. She does not have a job, but plays video games, and reads. She “does not do much for fun these days”. She sleeps 7-8 hours each night. Solitude and social interaction: Unmet. She does not have friends. She does not see her family often. She is around roommates and staff members, however feels “sexually harassed” by them. She spends most of her time alone. Prevention of hazards: Unmet. She is a hazard to herself and others. She was admitted because of a hysteric episode of shouting in her room. She has previous suicidal ideations with the plan to cut, however reports she is not suicidal anymore. Promotion normalcy in function and development: Partially met. She was previously homeless, but was given shelter by the alpha project group home. She has schizophrenia, paranoia, depression, and delusions, but says medications are helping her with her “brain fog”. Self care abilities in coping with stressors: Unmet. She acts out in a hysteric way. Her mental health problems make her unable to perform ADLs. She believes others are the source of her problems. Developmental self-care requisites: Abilities to meet maturational needs: changing needs associated with development. Unmet. She is unable to care for herself, even though she was supplied a group home. Her mental health problems are affecting her ability to be a functioning member in the community, affecting friendships and relationships, and are stunting her personal growth. Abilities to meet situational crisis: prevention of deleterious effects on development/function related to life events (pregnancy, loss of loved one, marriage, divorce etc).: not obtained Health deviation self care requisites Abilities in: Seeking and securing appropriate medical help. Unmet. Does not seek appropriate medical help. Is held at the hospital on a 5150 and is excited to leave. Being aware of and taking care of pathologic conditions. Partially met. Patient describes her condition as “depression with psychotic features and paranoid schizophrenia.” She previously has not taken care of her conditions, however now that she is admitted involuntarily, she has been taking the medication prescribed to her, which she believes have been helpful with her “brain fog”. She does not think her conditions are problems, believes her behaviors are justified, and does not want to change. Effectively carrying out prescribed diagnostic, therapeutic, or rehabilitative measures. Partially met. She is taking her medication as prescribed, but she is not attending group therapy, she is reluctant to speak to people, she does not think she has a problem, and she does not plan to work on herself or change while she is in the hospital. Being aware of and taking care of side effects of medical care measures. Unmet. She is unaware of side effects and does not appear to be taking care of herself. Modifying self-concept and self-image, accepting health state and need for health care. Unmet. She has accepted her health state but does not believe that her health state is the problem. She blames others for her behaviors, such as justifying the hysteric outburst because of the “sexual harassment” claims and her mother treating her poorly as she was growing up. She does not think she needs medical help. She says her doctors are “narcissistic” and are keeping her in the hospital “against my will”.

Learning to live with the effects of pathological conditions and medical care measures. Partially met. She is taking her new medications. She is aware of her conditions but is not owning up to how they are creating problems for her. She is unable to retain shelter due to her conditions. __________________________________________________________________________________________ Evaluate the Self-Care Requisites (4 pts) and determine the power of the self-care agent to meet requisites in each category (universal, developmental & health deviation) If therapeutic self-care demand is not met by SCA (or DCA), determine the nursing system(s) needed and state the nursing diagnoses NANDA format (problem, etiology, statement) under the appropriate category Risk for other-directed violence r/t lack of trust (suspiciousness of others) and rage reactions AEB hysteric outburst in group home. Persecutory delusions are the most common manifestation of schizophrenia. Individuals with these delusions believe that they are being malevolently treated in some way. They often think they are being plotted against, followed and spied on, cheated, or harassed. The individual my obsess over it, and it becomes the focus of their delusional thinking. The individual may direct complaints toward legal authorities or people of power, and lack of satisfaction may result in violence toward the object of the delusion (Townsend, 2015). JP has persecutory delusions that cause her to think that she is being sexually harassed by staff and roommates. The lack of support and trust she receives is causing her to act out in hysterical behavior. She is a threat to others because her hysterical outbursts can potentially harm others. Disturbed sensory perception: auditory r/t withdrawal into the self AEB client states he has “voices” that are similar to “characters in his head”, client has a listening pose (looking up), client puts his hands on head, and poor concentration. Schizophrenia is a disease in which the individual experiences hallucinations and delusions. This disease can cause the individual to become paranoid, depressed, withdraw from family and friends, have problems with keeping a job or going to school, or develop a lack of motivation. Commonly, the individual experiences auditory hallucinations that may or may not command self-harm or harm to others (Townsend, 2015). JP’s schizophrenia has ostracized her from the community. She was previously homeless before living in a group home, however, was unable to retain that shelter because of her hysteric outbursts relating to her delusions and paranoia. She does not have a support system, a job, or motivation. She experiences auditory hallucinations, however, says they are “not command” in nature. Ineffective coping r/t inability to trust AEB believing staff and roommates “sexually harassed” her, believing doctors are “narcissistic”, inability to perform ADLs, inability to recognize she has a problem. Individuals with schizophrenia may exhibit positive symptoms (delusions and hallucinations) and negative symptoms (a lack of something that others experience). These symptoms may make it difficult for the individual to cope with stressors in a healthy way. In response to stressors, individuals may exhibit aggression, self-harm behaviors, anhedonia, avolition, apathy,

Date of test: ______________ 10/27/19 NL Values Value (Pre-clinical)

REASON FOR ABNORMALITY: How do these compare with months/weeks prior if abnormal?

alogia, affective flattening, or apraxiaPlace (Townsend, 2015). JP acts out in aggression, has a history of suicidal ideations, has a H or L after HEMATOLOGY lack of pleasure forWBC activities, has a lack of motivation, 3 3 and has difficulty performing ADLs. 5.6

x10 /mm 4.0-10.5 6 3 x10 /mm 4.2-5.4 Current Findings in Clinical Facility Database (2 pts) Hgb 15.1 g/dL 12.5-15.6assessment findings) (lab findings-complete attached forms, diagnostic tests, procedures, and previous 47.8 %** 39-49 Lab findings: Hct **SEE LABS LIST BELOW Platelets 146 X10^3/mm^3 140-400 Neutrophils/Segs 45-65 RBC

Bands Lymphocytes

20-40

Monocytes Medications (use, dose, action, contraindications, side effects, and 2-10 mode of administration) (3 pts) Eosionophils 0-3knowledge of medications related to symptoms Include client past history and current medication adherence and current Basophils medicines/herbal practices Alternative or complimentary 0-1 Sedimentation Rate Na

137 mmol/L 135-145 4.1 mmol/L 3.5-5.0 Dosage &CL Classification Times Action Common Side Effects & Nsg Implications 96 RoutemEq/L 95-106 Route CO2 24 mEq/L 24-31 1mg Benzodiazepines PO TID Depresses CNS by potentiating Side Effects: apnea, cardiac arrest, dizziness, BUN 16 mg/dL GABA 8-23 hangover, lethargy, physical dependence Creatinine Implications: conduct regular assessment of 0.81 mg/dL 0.4-1.2 continued need glucose for treatment, assess mental Glucose 121 mg/dL 70-110 Stress causes elevated status and degree of anxiety Ca++/ PO4 8.4-10.2 1 patch Smoking deterrents patch daily Provides a source of nicotine during Side Effects: headache, insomnia,

All Scheduled

Meds

K

Generic/ Trade Name

Lorazepam/ Ativan

Nicotine

Mg+

controlled withdrawal from cigarette smoking

Protein/ Albumin ALT/SGPT AST/SGOT Amylase/Lipase

Risperidone/ Risperdal

1mg

12 34

HgbA1c-(if DM) antipsychotic

units/L units/L PO

BID

Troponin

0-45 10-40 Antagonizes dopamine and serotonin in the CNS

Other pertinent:

Valproic Acid Level Lithium Level Drug Screen Result

PRN Meds

ETOH Cannabis

+

Cultures/Micro

Type (blood,urine, Fecal, sputum, sp. fluid)

tachycardia, burning at the patch site, erythema, pruritus Implications: assess smoking hx prior to therapy, assess for symptoms of smoking withdrawal, evaluate progress in smoking cessation periodically Side Effects: Neuroleptic malignant syndrome, suicidal thoughts, EPS, increased dreams, agranulocytosis, anaphylaxis Implications: Monitor for changes in behavior that could be indicative of suicidal thoughts or depression, assess weight and symptoms of hyperglycemia, polydipsia, polyuria, and polyphagia

Date

Results/ Organisms

Rationale for use in this patient

Sedation, decreased anxiety

Lessened symptoms of nicotine withdrawal (insomnia, headache, irritability)

Decreased symptoms of schizophrenia and psychosis

Generic/ Trade Name

Dosage & Route

Route

Times

Acetaminophen/ 650 mg Antipyretics, Tylenol Nonopioid analgesics

PO

Q4h

Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primary in the CNS

Lorazepam/ Ativan

PO

Q4h

Depresses CNS by potentiating GABA

1mg

Classification

Benzodiazepines

Action

Common Side Effects & Nsg Implications

Side Effects: hepatotoxicity, toxic epidermal necrolysis, Stevens-Johnson Syndrome, renal failure, hypertension, hypotension, rash Implications: assess pain intensity prior and 30-60 min following administration, assess overall health status and alcohol usage before administrating, assess for rash Side Effects: apnea, cardiac arrest, dizziness, hangover, lethargy, physical dependence Implications: conduct regular assessment of continued need for treatment, assess mental status and degree of anxiety

Rationale for use in this patient

Analgesia, antipyresis

(Vallerand & Sanoski, 2019) Potential Drug Interactions Lorazepam (benzo) and risperidone (antipsychotic) may cause sedation, respiratory depression, coma, and death Lorazepam with smoking may increase metabolism and decrease effectiveness Risperidone and other CNS depressants, including alcohol, sedative hypnotics, or opioid analgesics may increase CNS depression Acetaminophen and barbiturates, phenytoin, and carbamazepine may increase the risk of acetaminophen-induced liver damage. (Vallerand & Sanoski, 2019)

GRADED Patient Care Plan (24 points) Date of Patient Care

10/28/19

NANDA Diagnosis 3 NSG DX (6 pt)

Expected Outcomes (1 outcome for each nsg dx (3pts)

Risk for other- Client will not harm others directed during her hospitalization. violence r/t lack of trust (suspiciousnes s of others) and rage reactions AEB hysteric outburst in group home.

Nursing Interventions with Rationales (12 pt) Include 5 nsg interventions and 5 Rationales for each Nsg Dx Observe client’s behavior frequently (every 15 minutes). Do this when carrying out routine activities so as to avoid creating suspiciousness in the individual. Close observation in necessary so that intervention can occur if required to ensure client (and other’s safety). Try to redirect the violent behavior with physical outlets for the client’s anxiety (e.g. punching bag). Physical exercise is a safe and effective way of

Evaluation of Expected Outcome (3pts) Met Not met Partially met Describe assessment data Met Patient feels paranoid and frustrated about being “sexually harassed”, however has not tried to harm others. Medications are helping to calm client.

relieving pent-up tension. Staff should maintain and convey a calm attitude toward the client. Anxiety is contagious and can be transmitted from staff to client. Administer tranquilizing medications as ordered by the physician. Monitor medication for its effectiveness and for any adverse side effects. The avenue of the “last restrictive alternative” must be selected when planning interventions for a psychiatric client. Maintain a low level of stimuli in client’s environment (low lighting, few people, simple décor, low noise level). Anxiety level rises in a stimulating environment. A suspicious, agitated client may perceive these as threatening. (Townsend, 2014)

Disturbed sensory perception: auditory r/t withdrawal into the self AEB client states he has “voices” that are similar to “characters in his head”, client has a listening pose (looking up), client puts his hands on head, and poor

Client will discuss content of auditory hallucinations with the nurse in two days.

Observe client for signs of hallucinations (listening pose, laughing or talking to self, stopping midsentence). Early intervention may prevent aggressive responses to command hallucinations. An attitude of acceptance will encourage the client to share the content of the hallucination with you. Ask, “What do you hear the voices saying to you?” This is important in order to prevent possible injury to the client or others from command hallucinations. Do not reinforce the hallucination. Use words such as “the voices” instead of “they” when referring to the hallucination. Words like “they” validate that the voices are real. Help the client to understand the connection between increased anxiety and the presence of hallucinations.

Partially met

Client explained that the auditory hallucinations are “not command’ in nature, and that she feels like she “has control o...