Nursing Care Plan - Mental health care plan PDF

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Mental health care plan...

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The University of Texas at Arlington College of Nursing Psychiatric Mental Health Nursing of Individuals, Families and Groups - NURS 3481 Student Name: Faith Avila________ Unit: Adult_

Date: 6/7/2019

Students are responsible for thoroughly assessing their client in order to provide safe care during current and future clinical experiences. Students are responsible for planning, implementing, and evaluating their own nursing interventions each day during their assigned rotation. Provide supporting behavioral examples for any categories checked below that are significant—you can expand and type in the boxes below:

CLIENT DEMOGRAPHICS and PSYCHOSOCIAL ASSESSMENT (Check applicable fields and provide supporting data/evidence for each checked item) Client Initials: DM Age: 22 Date of admission: 6/4/2019 DSM-5 Psych Diagnosis: Gender: Male _X Female__ Admission Status: Voluntary __Involuntary: X Ethnicity Caucasian _X_Hispanic __Black __Asian __Native American __Other: Current Legal Status No legal problems/issues ___ Parole ___ Probation ___ Charges pending _X__ Previous jail ____ Previous prison ___ Has a guardian __ Pending Charges __ Other___ Marital Status Married ___ Single ___ Divorced _X__ Separated ___ Widowed ___ Living Together___ Education High School _X_ AA __ BA __ MA __ Ph.D. __Technical/Trade School __ Symptoms Anxiety__ Depressed Mood _X_Anhedonia __Sleep disturbance _ X_ Fatigue __ Appetite Change __ Racing thoughts _X_ Guilt__ Grief _X_Hopelessness _X_Worry __ Hallucinations __Crying Spells __Risky behavior __Irritability_ X_ Other: Psychosocial Stressors Support __Family _X_Abuse __Housing X__Economic __Employment__ Trauma _X_ Education __Life-cycle transition __Healthcare access __ Legal problems____ Other: Developmental History Describe the client’s childhood: __X_ Traumatic ___ Significant loss ___ Uneventful ___ Describe any traumatic experiences in the childhood: (Include age when they occurred): “My step-father physically abused me starting at the age of 5. I was hit over the head with a bat and thrown into walls and furniture.” Family History Depression __Suicide __Violence X__Anger __Homicide __Bipolar __ ADHD __ Schizophrenia __PTSD __Anxiety __Alcohol abuse __ Other substance abuse __ Personality Disorder __ Dementia’s___ Psychosis____ Other: Healthy Behaviors Diet __Exercise __Spiritual Practice __Socialization _X_Traditions __ Other: Abuse History In the past year, have you been physically abused by another person? Y_X__ N___ Are you in any abusive relationship? Y___ N__ X_ Have you ever been sexually abused? If yes, by whom? Y___ N_X__ Have you witnessed any form of abuse? Y___ N_X__ Treatment History Previous Mental Health/Addiction Treatment? Y__X_ N___ Describe: “I have been in and out of Millwood facility since the age of 5.” MENTAL STATUS ASSESSMENT Appearance Appears younger __older than age __Scars _X_Piercings __Tattoos _X_ Well-nourished X__Malnourished __Obese __ Other: Grooming Well-kempt __Self neglect __Disheveled _ X_Malodorous__ Flamboyant __Other: Attitude Cooperative _X_Uncooperative __Hostile __Aggressive __Inappropriate __Other: Speech Clear _X_Coherent _X_Normal _X_Pressured __Soft-spoken __Stuttering __Profanity __ Impoverished __Monotone __Mumbled __Slurred __Animated/Excited __ Abrupt __ Difficulty finding words __Spontaneous speech __Confabulation __ Loud__ Soft __ Impressionistic __ Little detail ___ Hesitant/Halting __Slurring words __No speech __ Poor articulation ___ Perseveration ___ Other: Psychomotor Normal gait _X_Propulsive gait __Shuffling gait __ Ataxic __Uncoordinated __ Tics _ Grimaces __ Abnormal movements __ Hand wringing __Posture stooped _ X_ Hyperactive __ Bradykinesia__ Retarded __Agitated __Clumsy __ Unsteady __ Falls easily__ Other: Mood Euthymic __ Depressed _X_Elevated __Reserved __Irritable __Sad __ Angry __ Despondent ___ Anxious __ Melancholic __ Tearful __ Other:

The University of Texas at Arlington College of Nursing Psychiatric Mental Health Nursing of Individuals, Families and Groups - NURS 3481 Affect Thought Process

Thought Content

Insight

Judgement

Cognition Intellectual Ability

Normal Range__ Flat __Tearful __Labile __ Constricted__ Sad _ X_ Bright __ Blunt __ Depressed _X_ Broad __Restricted __Inappropriate __ Congruent __ Organized __ Clear/understandable_X_ Logical __ No formal thought disorder __ Concrete __ Illogical __Paranoia __ Simplistic __ Strained __ Loose associations __ Preoccupations __Perseveration __Some disorganization X__ Disorganized __ Obsessive thoughts__ Tangential __Circumstantial __ Suspiciousness __ Neologisms __Clang associations __Word salad__ Difficult to follow __ Other: Delusions __Illusions __Audio Hallucinations __Visual Hallucinations __ Phobias __Compulsions __Obsessions __ Preoccupations __Suicide _ X_ Homicide __Aggression X__Paranoid ideation __Depersonalization ___ Other: Good __ Fair __ Poor _ X_ Awareness of behavior and impact on others: Y__ N_X_ Understanding problems/issues related to illness: Y__ N_ X_ Agrees that illness requires treatment Y_X_ N__ Other: Good __ Fair __ Poor _X_ Difficulty predicting results of choices Y_X_ N__ Able to learn from some experiences Y__ N_ X_ Able to anticipate outcomes Y__ N_ X_ Able to use feedback & learn from mistakes Y__ N__ Other: Alert and oriented Y_X_ N__ No distractibility __Distracted _X_High distractibility __ Short-term memory intact Y_X_ N__ Long-term memory intact Y_X_ N__ Other: Average _X_Above average __Below average __ Intellectual Disability Diagnosis Y__ N_X_

RISK ASSESSMENT Suicide Homicide Aggression Substance Use

Psychosis

Falls

Denies __ Plan: Y_X_ N__ Lethality: Y_X_ N__ Past History: Y_X_ N__ Suicide Risk: Low__ Medium __High_X_ Denies _X_Ideation: Y__ N_X_ Plan: Y__ N__X Lethality: Y__ N_X_ Past History: Y__ N_X_ Homicide Risk: Low_X_ Medium __High__ Denies _X_Ideation: Y__ N_X_ Plan: Y__ N_X_ Lethality: Y__ N_X_ Past History: Y__ N_X_ Aggression Risk: Low_X_ Medium __High__ Denies __Current Use _X_Past History _X_ Past Treatments __ Previous 12-Step Group___ Current Use Y_X_ N__ Type Heroin,marijuana,caffeine______Amount: 12+ cups of alcohol or caffeine. Frequency: Daily Substance Use Risk: Low__ Medium __High_X_ Distortion of reality __ Loss of contact with reality __ Delusions __ Hallucinations __ Thought disorder __ Social withdrawal __ Impaired role functioning __ Drug intoxication __ Metabolic causes __ Schizophrenia __ Bipolar disorder _ X_ Schizoaffective disorder __Family history of psychosis __ Client history of psychosis__ Psychosis Risk: Low_X_ Medium __High__ Age:...