NSG 335 - Care Plan Example PDF

Preview

Summary

Clinical Paperwork and Care Plan Example...

Description

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

NSG 335 Care Plan

NURSING ASSESSMENT GUIDE Student Name:

Jane Doe

Admission Date:

Voluntary

Clinical Date:

Age:

4/12/19

40

Admission Type (voluntary or committed) Gender:

Female

Race:

Caucasian

Marital Status:

Divorced

Allergies:

NKA

Admitting Diagnoses: Major Depressive Disorder, Substance Abuse Psychosocial Issues: Recent divorce, past and recent domestic abuse

Events Leading to Current Admission The pt. was transferred from St. Vincent Kokomo ED after presenting with depression and suicidal ideation. She admits frequent suicidal thoughts with plan to overdose on pills and/or cut wrists.

Patient’s Psychiatric History Major Depressive Disorder with psychotic features Suicide attempts x 4 since 2002 Homicidal ideation- ex boyfriend Substance Abuse- ETOH, Marijuana, Prescription Opioids, Inhalants

1

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Trauma History (rape, molestation, abuse, neglect, partner/domestic violence. Include physical and verbal): Reports molestation by an uncle and a cousin from 1985-1990 Reports physical and verbal spousal abuse

Current Medical History: Any current acute or chronic issues causing need for treatment at this time. Acid Reflux Past Medical History: Include surgeries, hospital stays, long term illness, STI, Falls, TBI Appendectomy 2013 Family’s Psychiatric History: Mother- Major Depressive D/O Sister- Eating D/O Father- Alcohol Abuse Be sure to identify any suicides attempts or completions in the family

Substance Use/Abuse (current and past history, including drug(s) of choice, how much, how often, longest period of sobriety, date of last use BE SURE TO INCLUDE CAFFIENE/ENERGY DRINKS, NICOTINE, ILLICIT AND PRESCRIPTION DRUGS ): ETOH- currently drinks 6-8 beers/day, started at age 11, with ½ glass of wine every other day and a few beers with friends Marijuana- currently most days, started at age 13 Inhalants- started at age 16, stopped using a few years ago Energy drinks/caffeine- 2-3 “Redbulls”/day, 3-4 cups of coffee

2

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Sleeping Patterns: Typically sleeps 4-6 hours per night, awakens multiple times throughout the night, and has difficulty getting back to sleep and staying asleep

Appetite, Diet, and Eating Patterns: Patient reports poor appetite, stating she is unable to eat due to anxiety and depression. She eats mostly “junk” foods and fast foods. Admits to a recent weight loss of 10 lbs over the last 2 months.

Elimination (bowel and bladder): Irregular bowel habits, alternating between constipation and diarrhea. No problems with bladder.

Personal Hygiene and ADLs: Patient presents as disheveled and unkempt. Hair appears oily and she has a faint body odor.

Support System: Patient reports a fair support system, listing 2 friends who check in on her occasionally, perhaps 1-2 times per week. They argue often however, and she occasionally goes several weeks without hearing from them. She is estranged from her parents and has a reported “terrible” relationship with her sister. She has been married and divorced twice, and has had multiple relationships that have just “not worked out”. 3

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Cultural/Spiritual Background: Patient states she attended church on occasion as a child. She states she is “Christian” and occasionally prays, but admits that she has felt “angry towards God” the last few years.

Educational Background: The patient has a high school education. She attended culinary school, but has never worked as a chef.

Work and Leisure Activities: The patient currently works at Walmart, approximately 24 hours per week. She has had this job for approximately 4 months. Prior to this job she has been unemployed for months at a time. Leisure activities include singing and talking with her friends.

Pertinent Physical Assessment: The patient is alert and oriented X 4, and she appears to have no motor deficits. She is slightly overweight for her frame, and appears disheveled. Her skin is pale with acne across her face. Her nails are very short, cuticles ragged. She appears anxious, evidenced by wringing her hands and chewing her nails.

4

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Pertinent Lab Values /Diagnostic procedures (abnormal values, rationale, and all lab values associated with psychotropic medications.) Urine drug screen positive for Cannabinoids

Growth and Development (Erikson’s current stage with rationale, ie. Patient’s chronological age with usual developmental task and psychosocial crisis; Was the crisis successfully or unsuccessfully resolved. Why or why not? The patient is chronologically in the Middle Adulthood stage of Generativity vs. Self Absorption. She is currently struggling with successful resolution of this stage, evidenced by difficulty in maintaining loving relationships. She has also had difficulty with finding work that she enjoys and stays with for longer than a few months. Possibly her non-resolution of this current stage stems from the crisis of abuse she endured during her school age years (Industry vs. isolation).

Defense Mechanisms (provide examples) Intellectualization- The pt. refers to her childhood sexual abuse and her more recent marital abuse in a remote and detached manner, without emotion. Denial- Denies that her substance use may be causing any of her issues, stating that she has had “really bad bosses” as related to her employment. Also states that her family has “always been negative and hard to get along with”.

5

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Patient Symptoms/DSM V Criteria (include references) 1. Define each diagnosis and give symptoms of diagnosis. Use your text for this information and give page. 2. In your definition of diagnosis and symptoms, highlight the diagnosis and symptoms that your patient has demonstrated.

Sample Charting (Brief summary of patient’s mental status, written in paragraph form) The patient is slightly overweight for her body frame, appears disheveled and unkempt, but appears stated age. She does make eye contact when speaking and is cooperative. Appears anxious, evidenced by biting nails and wringing hands. Some lability of emotion noted, as she is sometimes tearful, then unexpectedly she angrily comments on other patients who pass by. Speech clear and of soft volume. She denies that her substance use is an issue, but blames others- her family, friends, and boss/coworkers for not “giving me a break”. Pt. has no evidence of hallucinations or delusions. States she is not currently suicidal or homicidal but has fleeting thoughts of how she might harm herself, including taking pills and cutting her wrists. Will continue to monitor behavior and maintain 15-minute safety checks. Will provide therapeutic support.

6

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Epidemiology 1. Research the epidemiology of the client’s main diagnosis for: • Global – •

National –

•

State –

•

Local -

2. Social Determinants of Health Identify the client’s home zip code/census tract. a. What social determinants of health are contributing to their health issues?

b. What social determinants of health are contributing to their wellness?

7

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

NURSING CARE PLAN Nursing Diagnosis (NANDA)

Patient Goals (include a minimum of 1

Include R/T (etiology), AEB (signs/symptoms/ defining

long term and 2 short term measurable goals

characteristics) for 2 priority nursing diagnoses

per nursing diagnosis) Goals should be measurable, timelimited and realistic

Risk for Suicide

Long Term:

- Related to: History of suicide attempts, estranged relationships, poor work history and disrupted family life, chronic substance abuse

Pt. will demonstrate alternative ways of dealing with negative feelings and emotional stress within 2 weeks Short Term: - Identify at least 2 people she can call for support and emotional guidance when she is feeling selfdestructive by discharge. - Attend and participate in group therapy by day 2 of hospital stay.

Planned Nursing Interventions and Rationale (minimum of 5 interventions & rationale per nursing diagnosis- total of 10) 1. Determine level of suicide precautions needed. (Does pt. have a plan, admit prior suicide attempts, abuse substances, lack social support?) (A high risk pt. will need constant supervision and a safe environment)

2. Encourage patient to talk freely about feelings and help patient plan alternative ways to handle anger and frustration (Patient can learn alternative ways of dealing with overwhelming emotions and gain a sense of control over her life)

*Cite the reference(s) used (Varcarolis, 2015) 8

Patient Response and Your Evaluation of Interventions 1-10

1. The patient was very open about her past and present history with suicidal ideations and attempts. She stated understanding of precautions, having come in voluntarily for them.

2. The patient was open about her feelings regarding her depression and suicide attempts, but avoided discussion about her substance use. She did seem to enjoy the goals group, and did contribute to the conversation.

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

MEDICATIONS Drug Name (generic & trade)

Drug Class & Dose

Reason Prescribed

Lexapro

SSRI

Depression

(Escitalopram))

10mg orally daily

Pt. Understanding of Drug & Nurse Education ( Include education important for patient to know) Pt. knows it is for depression. Avoid ETOH, while taking, inform provider of all OTC’s, report distressing side effects (weight gain, sleep or sexual problems), report to MD any increasing suicidal thoughts

9

Nursing Considerations

Most Common Side Effects & Most Common Serious Effects

Monitor therapeutic effectiveness, observe for worsening depression or suicidality, monitor periodic hepatic labs and CBC

Nausea. Insomnia, somnolence, HTN, Palpitations, dysmenorrhea

NSG 335 Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

*Cite the reference(s) used

10...