Mental Health Clinical Care Plan PDF

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Adilene Morales Nursing diagnosis: Impaired ability to perform or complete ADLs independently related to catatonic depression, as evidenced by inability or unwillingness to bring food to mouth and inability or unwillingness make it to restroom without assistance/wheelchair. Short-term Goal: By the end of shift, client will walk to restroom with little to no assistance (no wheelchair). Long-term Goal: By discharge from treatment, client will be able to perform ADLs to the best of her ability and demonstrate a willingness to do so. Unfulfilled needs will be met by caregiver.

Intervention Assess client’s level of inability to perform ADLs; note areas of strength and impairment. Assess client’s food preferences. Encourage independence when performing ADLs but intervene when necessary. Provide positive reinforcement for ADLs performed independently. Allow enough time for client to complete ADLs to the best of her ability. Keep strict records of food and fluid intake. Document independence level.

Rationale This knowledge is required to develop an adequate plan of care for client Client is more likely to accept/feed herself foods that she particularly enjoys. Successful performance of independent activities enhances recovery. Client safety, however, is priority. Positive reinforcement enhances self-esteem and encourages repetition. Allowing enough time encourages client to try. This information is necessary to acquire an accurate nutritional assessment and level of independency to measure progress.

Outcome criteria:  

By the end of shift, client walked to bathroom with assistance instead of using wheelchair. By the end of shift, with assistance, client ate cold foods, which she preferred....