care plan 2

Description

Hi! Please follow the following instructions for this care plan:

This is a psychiatric care plan and attached you will find the template in which you have to answer in, there is rubric by which everything has to be followed, and a document with ways to describe the Mental Health Assessment portion. There is also an example of what it should look like

This is the information to be used:

42 yrs old, male, came into the hospital for voluntary admission for suicidal ideation due to auditory hallicinations that were telling him to harm himself. History of substance use, dependency on (Flakka) and marijuana. Diagnosis: Schizophrenia . Allergies: none. Support System: both parents (mom and dad) (live in another state). Has 6 siblings (3 from the dad side and 3 from the mom side). Occupation: none. Single. Highest grade completed: high school. Weight: 180 lbs. Health insurance: N/A. Significant primary caregiver: the mother. Language: english.

For diagnostic results: Put the mini mental exam results which is 30 . Put EKG :normal sinus rhythm detected with possible left atrial enlargement.

Surgical Procedures: N/A

Past Health history: include the following psych and regular past history: say that the client stated that she was receiving psychiatric therapy and has a history of rhabdomyolysis with a history of a seizure at 2 years old”. Write that she has a past of anxiety attacks. Patient has a history of acute rhabdomyolysis .

History of Present Illness: Write about how the client has a history of schizophrenia and had an episode of suicidal ideation. Has a history of substance use, dpendency on (Flakka), depression, anxiety, hallicinations. Explain how the pt was seen at another hospital and was in the ED for auditory hallucinations and suicidal hallucinations 2 days ago.

For the Mental Health Assessment: You can use the attached document for tips on how to write it. Make sure this is detailed please.

Some abnormal things to include for this assessment (include the normal things yourself please) these are key points:

Put somehere that the pt reports agitation, anxiety, insomnia, auditory hallucinations, denies depression.

Appearance: poor eye contact, lethargic.

Speech: slowed rate, low volume.

Mood affect: depressed constricted affect

Thought content: paranoid

Suicidality: eveidence of suicidal intent but no homicidial ideation.

For patho, use the diagnosis and describe it using APA 7th edition with in text citations.

Baseline and Current Vital Signs: BP: 141/87, Pulse: 74, RR:18, SPO2, 98%.

Allergies: none

Diet with rationale: Regular diet because they have no limitations to their diet. explain a little more.

Activity Order: suicide risk, Limitations: N/A

For labs, use the following (APA CITATIONS TOO FOR RATIONALE) put the unit as well for each

Creatinine 1.48 (explain how this is relevant to the medication used which risperdone and explain why its important to check it.)

Calcium 8.0 (explain how this is relevant to the med used which is risperdone and explain why its important to check it)

BUN: 26 (explain how this is relevant to the med used which is ativan and explain why its important to check it)

Hgb: 11 and Hct: 35 (explain how this is relevant to the med used which is risperdone and explain why its important to check it)

For IVs: N/A do not put anything in this section, just delete it

For Medications, Include the following:

Risperidone, ativan, cogentin, haldol, and benadryl. Make sure to follow the instructions as stated on the top of column. Make sure to be specific and detailed. Make sure to use in text citation in APA format for rationale, therapeutic range, and nursing implications. please include the therapeutic range. make sure to include generic and brand names.

For nursing theorists, must find the theory use at least 2, and explain it using APA in- text citations.

For the 3 Nursing Diagnosis, MUST USE NANDA #1.

Make sure the first diagnosis put on the list is the one that exemplifies that safety of the client such as suicidal ideation in this case. When describing the rationale of importance, make sure it is APA citation.

NOW:

When explaining the nursing diagnosis with the goals sections, follow these instructions and the ones on the sample.

– Make sure to write all three nursing diagnosis, but only dive into the most important one and write one short term goal with one long term goals and 3 interventions per goal and a rationale per intervention. YOU MUST TAKE INTO ACCOUNT CULTURAL CONSIDERATIONS.

nursing interventions must have the person completing it, the action, frequency and what’s the role of the nurse. cultural considerations and mention the suicide hotline for the discharge teaching. make sure to use credible sources. make sure to use in text when necessary as well. thank you

– for subjective and objective data, info may be made up.

-Expected outcomes must be realistic and measurable. please make sure that each goal has 3 interventions. Nursing interventions must state action, frequency and person who is going to carry these out. Patient’s cultural, developmental and psychosocial status must be considered in nursing interventions

For the discharge plan, include how you will educate the client and the family among other things.

FOR THE GENOGRAM COMPUTED AT THE END:

MUST CONSIST OF PAST 2 GENERATIONS. MAKEUP THAT THE GRANDMA ON THE MOM’S SIDE HAS A HISTORY OF ANXIETY/DEPRESSION. see if this can be computer generated.

Make sure this has a reference page at the end with all the references!!!Please make sure it sounds complete and realistic

Thank you!!Please make sure its well organized and you adhere to my instructions, thank you. Please make sure its well detailed with no grammatical errors.

MAKE SURE YOU USE CREDIBLE SCHOLARY SOURCES

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Unformatted Attachment Preview

Assessment:
Mental Status Examination:
I. Appearance: Observed
• General: appears stated age, appears older/younger than stated age,
• Health status: appears healthy, sickly, ill
• Habitus: normal, underweight, overweight, obese
• Gait:
o Normal
o Unsteady, limp, shuffle
o Utilizes device for assistance: cane, crutches, walker
o Gait ataxia: wide gait, difficulty standing with feet together
o Gait apraxia: hard time getting started with walking/looks like a shuffling gait
• Clothes:
o Appropriately dressed, casual dress, neatly dressed
o Inappropriately dressed, loosely fitted clothing, tightly fitted clothing, disheveled,
stained, ragged, dirty, bizarre, provocative
• Grooming:
o Well-groomed, meticulous, overly meticulous, makeup appropriate
o Unkempt, self-care neglected, unshaven, makeup bizarre
• Hygiene:
o Appropriate,
o Poor, malodorous: body odor, alcohol, feces, cigarette smoke, halitosis
• Distinguishing features:
o Observable bruises, needle marks, cuts/scars evident of self-harm,
o Tattoos, body piercing,
o Bandages, braces (of limbs), prosthetic devices
o Missing limb, missing teeth, dental erosion, jaundice, profuse sweating,
o Goiter, coughing, wheezing, sneezing
II. Attitude (towards examiner):
• Cooperative, open, engaging, focused, flattering, charming, friendly, attentive,
interested, relaxed
• Uncooperative, hostile, defensive, aggressive, agitated, guarded
• Apathetic, withdrawn, shy
• Evasive, suspicious, paranoid, secretive, controlling, guarded, resistant
• Easily distracted, entitled
• Seductive, eager to please
III. Behavior: Observed
• Eye contact:
o Maintains eye contact
o Avoids eye contact, fixed eye contact, hesitant to make eye contact, fleeting eye
contact
• Posture:
o Comfortable, erect
o Slumped, slouched
o Guarded
• Mannerisms/gestures: normal, expressive, overt, dramatic
• Psychomotor activity
o Retardation: slowed movements
o Agitation: unable to sit still, wringing hands, rocking, picking at skin/clothing,
pacing, excessive movement, compulsive
o Unusual Movements: tremor, lip smacking, tongue thrust, mannerisms, grimaces
o Catatonia: Extreme motor inactivity or hyperactivity: present as immobility with
muscular rigidity, or inflexibility
o Akathisia: a form of agitation characterized by inner restlessness with inability to
stay still
o Automatism: Spontaneous verbal or motor behavior without patient awareness.
o Choreoathetosis: Involuntary combination of chorea (irregular migrating
contractions) and athetosis (twisting/writhing).
o Dystonia: Twisting/repetitive movement or abnormal fixed posturing.
o Tremor: Unintentional, rhythmic, oscillatory movement
• Commands: able to follow commands and requests, unable to follow commands and
requests
IV. Level of Consciousness: Observed
• Alert, vigilant
• Hypervigilant
• Fluctuating
• Drowsy, lethargic, stuporous, asleep, comatose,
• Confused
V. Mood: Inquired (self-reported by patient)
• Questions to ask:
o “How are your spirits?” “How are you feeling?”
o “Have you been discouraged/depressed/low/blue lately?”
o “Have you been energized/elated/high/out of control lately?”
o “Have you been angry/irritable/edgy lately?”
• Descriptors
o Euthymic
o Elevated, euphoric, animated, cheerful, excited, happy, jovial
o Hyperthymic (intense display of emotion)
o Dysphoric, sad, depressed, despairing, pessimistic, detached, dysphoric, hopeless,
indifferent, overwhelmed, remorseful, guilty
o Angry, hostile, irritable, high strung, tense, irate, confrontational, impatient
o Worried, anxious, nervous, apprehensive, fearful, frightened, panicked
o Apathetic, dull
VI. Affect: Observed
• Congruency (appropriateness to situation): congruent or incongruent to mood/thoughts
• Fluctuations of emotional state
o Stable: mood is appropriate, neither rapid/sluggish to change
o Labile: mood is rapidly shifting
o Anhedonic: incapable of pleasurable response
• Range and depth of feelings shown:
o Broad/full: normal range
o Restricted: reduction in individuals’ expressive range
o Blunted: limited intensity of emotional expression
o Flat: no change in emotions
VII. Speech:
• Quantity:
o Spontaneous, expansive, talkative, hyper-talkative
o Poverty of speech (little is said), monosyllabic, mute
• Rate:
o Normal rate, normal paucity
o Pressured speech (frenzied speech driven by sense of urgency), rapid, slowed,
hesitant, long pauses in between answers
• Volume/Tone:
o Normal volume, normal intonation,
o Dramatic, loud, strong, soft, weak, monotone
• Fluency/Rhythm:
o Coherent, clear, with appropriately placed inflections
o Incoherent, aphasic, hesitant
• Articulation:
o Fluent, good articulation,
o Dysarthria (mechanical dysfunction with speech), difficulty enunciating,
o Stuttering, slurred, mumbling, echolalia
VIII. Thought Process:
• General:
o Linear, coherent, goal-directed (answers questions, doesn’t move onto other
topics)
o Impoverished (slow thinking, doesn’t share may ideas)
o Illogical: does not make sense when speaking
o Incoherent: disorganized, no meaning to what they say
o Rapid: racing thoughts and rapid thinking
• Types of thought process alterations:
o Circumstantial: Inability to answer a question without giving excessive,
unnecessary detail. Does eventually return to the original point.
o Tangential: Wandering from the topic and never returning to it or providing the
information requested.
o Loosening of associations: Incoherent slippage of ideas further and further from
point of discussion.
o Flight of ideas: Rapid shift from one topic to another.
o Perseveration: Repetition of a particular response (e.g., word or phrase),
regardless of the absence or cessation of a stimulus.
o Thought blocking: Abrupt cessation of speech without explanation in the middle
of a sentence.
o Word salad: incoherent or incomprehensible connections of thoughts (most severe
disorganization)
o Clang associations: thoughts are associated by the sound of words versus their
meaning
o Neologism: inventing new words or phrases, or using words in idiosyncratic ways
IX. Thought Content: Inquired and Observed
• General:
o Normal thought content, absent of delusions, obsessions, preoccupations,
hallucinations, suicidal ideation, homicidal ideation
o Poverty of thought: A global reduction in the quantity of thought.
o Overabundance of thought: A global increase in the quantity of thought.
• Delusions: Fixed, false beliefs that do not change even when presented with evidence
counter to them, and are outside of cultural, societal or religious norms.
o Somatic delusion: Delusion that one’s bodily function, sensation or appearance is
abnormal.
o Delusion of grandeur: Delusion of possessing superior qualities such as fame,
wealth or supernatural powers.
o Paranoid delusion: Delusion of mistreatment, usually persecution (e.g., being
spoken about behind one’s back, “people are out to get me”).
o Delusion of reference: Delusion where an otherwise insignificant event is
misconstrued as having special significance specifically to oneself.
o Delusion of thought insertion: Delusion where one believes one’s thoughts to be
externally placed from an outside party.
o Delusion of thought control: Delusion where one believes one is being controlled
by an outside party or parties, and self-control is lost.
o Delusion of thought broadcasting: Delusion where one’s thoughts are made
known to everyone in the outside world.
o Erotomanic delusion: Delusion where one believes that prominent figures or
superstars are in love with or in a relationship with oneself, when that is not the
case in reality.
o Nihilistic delusion: Delusion where one believes that nothing is real. This is in
contrast to derealization or depersonalization, which have more to do with an
altered reality, not the lack of it.
• Depersonalization: Loss of all sense of identity, wherein one’s thoughts and feelings
are no longer felt to be one’s own.
• Derealization: A change in the perception or experience of the external world to where
it feels unrealistic.
• Illusion: A misinterpretation of existing stimuli.
• Hallucination: A perception perceived in the absence of any existing stimuli.
o Visual hallucinations
o Auditory Hallucinations: most common type
▪
▪
▪
▪
▪
•
•
•
•
•
•
•
Does the patient hear one or several voices?
Are the voices male or female?
Are the voices people they know or are they unfamiliar?
Are the voices simple statements or complex statements?
Do the voices engage in a conversation with the patient or comment on the
patients thoughts?
▪ Are they commanding in nature?
Hypnagogic hallucination: A hallucination experienced before falling asleep.
Hypnopompic hallucination: A hallucination experienced upon waking up from sleep.
Obsessions: Repeated intrusive and unwanted thoughts, images or urges.
Compulsions: Repetitive behavior or mental acts in response to obsessions.
Phobias: Persistent fear or an object or situation.
Suicidal ideation: Thoughts of, or preoccupation with, suicide.
Homicidal ideation: Thoughts of, or preoccupation with, homicide.
X. Judgement: decision-making ability, up to clinician’s judgement
• Impaired: patients who are acutely intoxicated
• Poor: in the context of acute psychosis, schizophrenia, dementia
• Good: patient is aware and makes decisions in a way that doesn’t put others in harm
• Appropriate/inappropriate for age and life stage
XI. Insight: awareness/understanding of situation
• Poor: denial of their Sx/Dx
• Fair: may have some understanding but fail to understand it emotionally or grasp the
impact on their life
• Good: good intellectual and emotional understanding of their Sx/Dx. Understand their
own limitations/strengths
• Intellectual insight: admission that the patient is ill, and Sx or failures in social
adjustment are caused by patients own particular irrational feelings or disturbances
without applying this knowledge to future experiences.
• True emotional insight: emotional awareness of the motives and feelings within the
patient and the important persons in her life, which can lead to basic changes in
behavior
• Questions to ask
o “What brings you here today?”
o “What seems to be the problem?”
o “What do you think is causing your problems?”
o “How do you understand your problems?”
o “How would you describe your role in this situation?”
o “Do you think that these thoughts, moods, perceptions, are abnormal?”
o “How do you plan to get help for this problem?”
o “What will you do when _____________ occurs?”
o “How will you manage if ____________ happens?”
o “If you found a stamped, addressed envelope on the street, what would you do
with it?”
o
“If you were in a movie theater and smelled smoke, what would you do?”
XII. Suicide/Homicide:
• Suicidality – Possible questions for patient:
o “Do you ever feel that life isn’t worth living? Or that you would just as soon be
dead?”
o “Have you ever thought of doing away with yourself? If so, how?”
o “What would happen after you were dead?”
o ASSESS IDEATION/PLAN/INTENT & self-harm
• Homicidality – Possible questions for patient:
o “Do you think about hurting others or getting even with people who have
wronged you?”
o “Have you had desires to hurt others? If so, how?”
o ASSESS IDEATION/PLAN/INTENT
XIII. Misc:
• Motivation: good motivation/effort, limited, variable
• Memory: intact for recent memory, intact for remote memory, limited or deficient for
recent or remote memory
• Attention: attentive, variable attention, distracted
XIV. Cognition (MMSE):
• General consciousness: alert, drowsy, lethargic, stuporous, comatose
• Orientation: x4 (person, time, place, situation)
o “What is your full name?”
o “Where are we at (floor, building, city, county, and state)?”
o “What is the full date today (date, month, year, day of the week, and season of the
year)?”
o “How would you describe the situation we are in?”
• Attention: WORLD backwards, serial 7s from 100
• Language: name objects, repeat words/sentences
• Calculation: ability to add/subtract (serial 7s)
o (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting 7
from that number as far as you can go.”
o (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3
from that number as far as you can go.” [Monitor for speed, accuracy, effort
required, and monitor patient reactions to the request]
o “Add these numbers: (15 + 12 + 7)”
o “Multiply these numbers: (25 x 6)”
o “If something costs 78 cents and you give the cashier one dollar, how much
change should you get back?”
• Right hemisphere: intersecting pentagons, clock-face
• Abstraction: explain similarities between objects, understand simple proverbs
o Similarities – “How are the following items similar?”
▪ “an apple and an orange” (round ~concrete, fruit ~abstract)
▪ “a chair and a table” (made of wood ~concrete, furniture ~abstract)
▪ “a watch and a ruler” (measurement instruments ~abstract)
o Proverbs – “How would you describe the meaning of the following sayings?”
▪ “People living in glass houses should not throw stones.”
▪ “A bird in the hand is worth two in the bush.”
▪ “You shouldn’t cry over spilt milk.”
▪ “Two heads are better than one.”
• Memory: immediate (repeat after me), short-term (what were the words?)
o Recent Memory – Possible questions for patient:
▪ “What is my name?”
▪ “What medications did you take today?”
▪ “What time was your appointment with me for today?”
o Remote Memory – Possible questions for patient:
▪ “Where were you when you first heard about 9/11”
▪ “What is your Social Security number?”
▪ “What were the dates of your graduation from high school, college, graduate
school?”
▪ “When and where did you get married?”
o Immediate Memory (also see XIII.-A. above) and New Learning – Suggested
patient instructions:
▪ “I am going to ask you to remember three words (color, object, animal – e.g.,
blue, table, and horse) and I will ask you to repeat them to me in 5 minutes.
Please repeat them now after me: blue, table, and horse.” – 5 minutes elapse
– “What were those three words I asked you to remember?” [Monitor
accuracy of response, awareness of whether responses are correct, tendency
to confabulate or substitute other words, ability to correct themselves with
category clue and multiple choice].
• Praxis: engage, applying, exercising, realizing or practising ideas
EVALUATION RUBRICS
Care Plan Rubric:
I. Assessment – 32
1. Gathers data to include health assessment
2. Pathophysiology/Psychopathology described and source/reference
stated using APA format (no dictionary definitions)
3. Past health history and social determinants of health
4. History of present illness
5. Current lab data and explanation of values: rationale for the values.
6. Diagnostic Data
7. Medications: (brand/generic/classification) & rationale and references
8. Genogram –
(4)
(4)
(4)
(4)
(4)
(4)
(4)
(4)
32 pts
II. Nursing Diagnosis – 12 points
1. Prioritized NANDA diagnosis and rationale
2. Significant subjective & objective data & rationale
3. Nursing Theorist related to care
(4)
(4)
(4)
12 pts
III. Plan of Care/Outcomes – 16 points
1. Short and long term goals achievable.
2. Expected outcomes are measurable and time limited
3. Expected outcomes are patient centered
4. Expected outcomes flow from the Nursing Diagnosis
(4)
(4)
(4)
(4)
16 pts
IV. Interventions/Implementation – 16 points
1. Nursing interventions state action, frequency and person who
is going to carry these out
2. Enable achievement of the expected outcomes
3. Patient’s cultural, developmental and psychosocial
status is considered in nursing interventions
4. Rationale for actions stated and referenced (APA)
(4)
(4)
(4)
(4)
16 pts
V. Evaluation – 8 points
1. States whether expected outcomes are met or not
2. Discharge Plan/Patient Teaching
(4)
(4)
8 pts
Transfer Scores to Clinical Evaluation Form for Midterm (Care plan 1) THEN Final (Care plan 2)
Outstanding
Meets
Mostly Meets
Minimally Meets
Does Not Meet
Expectations
4
3
2
1
0
STUDENT NAME
DATE
Unit
Room/Bed
Social Determinants of Health: This header
can be placed above occupation. It includes
occupation, health insurance, current work
status, etc.
Religion
Age
Sex
Language
Weight
Height BMI
Current psych and medical diagnosis
Support system
Marital status
Occupation
Siblings
Health insurance
Name of significant other/primary caregiver
Current work status
Highest grade completed
Alcohol/Smoking/ Drug use/Sexual and
Reproductive health
Diagnostic Data and Results:
Surgical procedures (current and past): N/A
Past Health History:
Genogram: Use back of page
History of Present Illness:
Health Assessment
Mental Health Assessment:
Appearance:
Behavior:
Speech:
Affect:
Mood:
Thought Process:
Thought Content:
Cognition:
Pathophysiology (please write in your own words) – Cite References in APA format
Baseline and current vital signs/Frequency
Allergies/Side effects
Diet with rationale
Activity order
_
Limitations/prosthetic devices
_
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #1
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #2
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #3
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #4
Results
Results
Results
Results
Rationale of abnormal results
Rationale of abnormal results
Rationale of abnormal results
Rationale of abnormal results
INTRAVENOUS SOLUTION #1
Type N/A
ML/HR
INTRAVENOUS SOLUTION #2
Type
gtts/min
ML/HR
Additives
Additives
Rationale for solution
Rationale for solution
INTRAVENOUS SOLUTION #3
Type
INTRAVENOUS SOLUTION #4
Type
ML/HR
gtts/min
ML/HR
Additives
Additives
Rationale for solution
Rationale for solution
gtts/min
gtts/min
MEDICATION
NAME
BRAND/GENERIC
CLASSIFICATION
DOSE /
ROUTE
ORDERED
TIMES
ADMINISTERED
RATIONALE FOR
ADMINISTERING
THERAPEUTIC
RANGE FOR
AGE/WEIGHT If
Applicable
NURSING IMPLICATIONS
Required Patient Education
CITATIONS
MEDICATION
NAME
BRAND/GENERIC
CLASSIFICATION
DOSE /
ROUTE
ORDERED
TIMES
ADMINISTERED
RATIONALE FOR
ADMINISTERING
THERAPEUTIC
RANGE FOR
AGE/WEIGHT If
Applicable
NURSING IMPLICATIONS
Required Patient Education
CITATIONS
NURSING THEORIST
CITE REFERENCES
NURSING DIAGNOSES – NANDA
DESCRIBE RATIONALE FOR PRIORITY ORDER
LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY)
UTILIZE THEORY (NEEDS THEORY/NURSING THEORY) FOR RATIONALE
SAMPLE DIRECTION PAGE: Do not leave in when turning care plan into Faculty
ASSESSMENT DATA
SUBJECTIVE/
OBJECTIVE/
CONTRIBUTING
FACTORS
NURSING DIAGNOSIS
NANDA
PLAN
OUTCOME CRITERIA
(CLIENT CENTERED)
Must flow from Diagnosis
and be individualized
INTERVENTIONS
(NURSE CENTERED)
Cite References
RATIONALE FOR
INTERVENTIONS
EVALUATION
Include subjective
and objective
components.
Use a NANDA
diagnosis which has
three (3) parts:
State the overall plan as
client centered, e.g.,:
Make the
interventions nurse
centered.
State the principle or
scientific rationale for
the nursing
intervention(s).
Look at the outcome criteria.
•”The client will…”
Assess
physiological,
psychosocial,
developmental,
cultural and
spiritual
dimensions.
•Part I: NANDA
statement of nursing
problem
“Alternation in
nutrition: Less than
body requirements”
•Subjective
Document client’s
exact words
relevant to the
diagnosis.
•Part 2: relating to a
nursing etiology:
“relating to
inadequate nutritional
intake”
“I’m not hungry”
•Objective
Document data that
is measurable,
specific, and
relevant to the
nursing diagnosis.
“Weight = 48 Kg”
“Lack of
subcutaneous fat”
•Part 3: manifested by
the assessed signs
and symptoms:
“manifested by low
body weight and
emaciation.”
Relate the plan to the
nursing diagnosis:
Indicate what the
nurse will do to assist
the client in achieving
the outcome criteria,
e.g.,
•.”have adequate
nutritional intake”
•The nurse will…”
Indicate a measurable
outcome criteria by
including time
frame/amount/range:
State frequency/time
/amount so any nurse
can carry out the
plan:
•”as evidenced by…”
1) Document all food
intake for 3 days.
1) the ability to create a
balanced meal plan by
day (7).
2) gaining 1-2 lbs/wk
until FDA recommended
weight is achieved.
(3) etc.
2) Determine and
make available
client’s favorite foods
by day 2.
3) etc.
Include the reference
for the rationale.
State whether the client
achieved the outcome criteria,
e.g.,
“The client gained 2 lbs within
the past 7 days…”
NOTE:
If the outcome criteria was not
achieved or only partially
achieved, the nurse needs to go
back to the beginning, e.g., the
“assessment” and make
revisions or changes as
necessary.
ASSESSMENT DATA
SUBJECTIVE/
OBJECTIVE/
CONTRIBUTING
FACTORS
NURSING DIAGNOSIS
NANDA (North
American Nursing
Diagnosis
Association)
PLAN
OUTCOME CRITERIA (CLIENT
CENTERED)
Must flow from Diagnosis and be
individualized
INTERVENTIONS
(NURSE CENTERED)
Cite References
RATIONALE FOR
INTERVENTIONS
EVALUATION
ASSESSMENT DATA
SUBJECTIVE/
OBJECTIVE/
CONTRIBUTING FACTORS
NURSING DIAGNOSIS
NANDA (North
American Nursing
Diagnosis
Association)
PLAN
OUTCOME CRITERIA (CLIENT
CENTERED)
Must flow from Diagnosis and be
individualized
INTERVENTIONS
(NURSE CENTERED)
Cite References (APA)
RATIONALE FOR
INTERVENTIONS
EVALUATION
Discharge Plan / Patient Teaching
Social Determinants of Health
Unit: Psychiatric
unit
Age: 35
Weight: 190 lbs
Room/Bed: 103
Religion: Catholic
Sex: Female
Language: English
Height: 5’6″BMI: 30.68
Marital status: Single
Current psych and medical diagnosis: Bipolar 1,
severely depressed without psychotic features
Support system: Both parents (mother and
father)
Occupation: Former babysitter
Siblings: 2 (one older sister and one younger
brother)
Health insurance: Not applicable
Name of significant other/primary caregiver:
Mother
Current work status: Unemployed
Highest grade completed: University degree
Genogram: Back of page
Alcohol/Smoking/ Drug use/Sexual and
Reproductive health: Patient denies alcohol
and drug use
Diagnostic Data and Results: The Mini-Mental Exam yielded a score of 30, indicating intact cognitive function.
Surgical procedures (current and past): N/A
Past Health History:
• Psychiatric therapy received
• History of rhabdomyolysis
• History of seizure at 2 years old
• History of anxiety attacks
History of Present Illness:
The patient has a longstanding history of bipolar disorder and anxiety. She has been experiencing frequent and consistent anxiety attacks, which
have led to thoughts of self-harm. Her psychiatrist recommended voluntary admission to seek help and support during this challenging time.
Health Assessment
Mental Health Assessment:
Appearance: The patient appears to be of stated age, 35 years old, with a disheveled appearance. She maintains poor hygiene, with malodorous
body odor noted. Her attire is unkempt, indicating a lack of attention to personal grooming. The patient’s posture is slumped, and she appears
withdrawn and apathetic. Eye contact is avoided, and she exhibits hesitant movements.
Behavior: The patient demonstrates psychomotor agitation, as evidenced by an inability to sit still, constant wringing of hands, and pacing. She
appears restless and exhibits compulsive behaviors such as picking at her skin and clothing. Additionally, the patient displays automatisms, engaging
in spontaneous verbal and motor behaviors without awareness.
Speech: The quantity of the patient’s speech is markedly reduced, with minimal spontaneous communication. When prompted, she responds with
monosyllabic answers and long pauses between statements. The rate of speech is slowed, and the patient struggles to articulate her thoughts, often
hesitating before speaking.
Affect: The patient’s affect is congruent with her depressed mood. She displays restricted emotional expression, with a limited range of feelings
shown. There is a notable absence of pleasure in response to stimuli, indicative of anhedonia. The patient appears emotionally blunted, with minimal
fluctuations in her emotional state.
Mood: The patient’s mood is consistently depressed, with a pervasive sense of sadness and hopelessness. She describes feelings of worthlessness
and guilt, as well as thoughts of self-harm. Despite attempts to engage her in conversation, the patient remains fixated on negative thoughts and
experiences.
Thought Process: The patient’s thought process is characterized by a preoccupation with negative and self-deprecating thoughts. She demonstrates
a rigid and perseverative thinking pattern, repeatedly dwelling on past failures and perceived shortcomings. There are no overt signs of formal thought
disorder or disorganized thinking. Suicidal ideation is present, but the patient denies homicidal ideation.
Thought Content: The content of the patient’s thoughts is predominantly negative and self-critical. She expresses suicidal ideation, endorsing
thoughts of ending her life as a means of escaping emotional pain. The patient denies experiencing auditory or visual hallucinations but admits to
feeling overwhelmed by intrusive thoughts of self-harm.
Cognition:
The patient’s cognitive functioning appears intact based on her ability to engage in conversation and follow simple commands. However, her
attention and concentration are compromised, as evidenced by frequent distractions and difficulty maintaining focus. Memory recall is intact for
recent events and distant memories. There are no signs of perceptual disturbances or delusional beliefs.
Pathophysiology (please write in your own words) – Cite References in APA format Baseline and current vital signs/Frequency:
•
•
•
•
Blood Pressure (BP): 126/76 mmHg
Pulse: 67 beats per minute
Respiratory Rate (RR): 17 breaths per minute
Oxygen Saturation (SPO2): 100%
Bipolar 1 disorder is a complex mental health condition characterized by recurrent
episodes of mania and depression. In this disorder, the brain’s neurotransmitter
levels, particularly those of dopamine, serotonin, and norepinephrine, become
dysregulated, leading to fluctuations in mood and behavior (Mclntyre & Calabrese,
2019). During manic episodes, individuals experience heightened energy levels,
Allergies/Side effects:
impulsivity, euphoria, and reduced need for sleep. Conversely, depressive
• Allergies: None reported
episodes are marked by profound sadness, lethargy, feelings of worthlessness,
and suicidal ideation. The exact etiology of bipolar disorder remains unclear, but
genetic predisposition, environmental factors, and neurobiological abnormalities
are believed to contribute to its development. Neuroimaging studies have revealed
structural and functional changes in the brain, including alterations in the prefrontal
cortex, amygdala, and hippocampus, which are involved in emotional regulation
and mood stability (Jentsch, Merz, & Wolf, 2019). Effective management of bipolar
disorder often involves a combination of pharmacotherapy, psychotherapy, and
lifestyle modifications aimed at stabilizing mood, preventing relapses, and
improving overall quality of life.
Activity order
References
Cena, H., & Calder, P. C. (2020). Defining a healthy diet: evidence for the role of
contemporary dietary patterns in health and disease. Nutrients, 12(2), 334.
Jentsch, V. L., Merz, C. J., & Wolf, O. T. (2019). Restoring emotional stability:
Cortisol effects on the neural network of cognitive emotion regulation. Behavioral
brain research, 374, 111880.
McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: the clinical
characteristics and unmet needs of a complex disorder. Current medical research
and opinion, 35(11), 1993-2005.
_
Diet with Rationale:
• Regular diet: The patient does not have any dietary
restrictions or limitations mentioned. A regular diet is
recommended to ensure adequate nutritional intake and
promote overall well-being. A balanced diet consisting
of fruits, vegetables, whole grains, lean proteins, and
healthy fats is necessary to support physical and mental
health (Cena & Calder, 2020).
__________________________________________________
Activity Order:
• Activity Order: Not applicable
• Frequency: Not applicable
Limitations/prosthetic devices: None reported
_
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #1
PERTINENT LABORATORY
DATA Lab Test #2
PERTINENT LABORATORY
DATA Lab Test #3
PERTINENT LABORATORY
DATA Lab Test #4
Lithium Serum Level
hCG (Pregnacy Test)
Creatinine:
Platelet Count
Results0.9 mEq/L
Results: 4 mIU/mL
Results: 0.8 mg/dL
Results: 250,000 per microliter
Rationale of abnormal results:
Rationale of abnormal results:
Rationale of abnormal results:
Lithium is a mood-stabilizing
medication used to treat bipolar
The hCG exam results can indicate Creatinine is collected through
disorder. The therapeutic range for whether or not a patient is positive
urine or a blood serum test to show
lithium is typically between 0.6 to for pregnancy. A test result that is
metabolic function in regard to
1.2 mEq/L. A level of 0.9 mEq/L
kidney function. Such levels can
less than 5 mIU/mL indicates a
falls within the therapeutic range, negative result meaning that the
indicate poor kidney function as
indicating appropriate medication patient is not pregnant. However, a
evidenced by low or high levels of
adherence and potential efficacy in score of greater than 25 mIU/mL is a creatinine. A normal range for
managing mood symptoms
serious indication that the patient is woman can be 0.6 to 1.1 mg/dL
(Volkmann et al., 2020). However, positive for being pregnant. These
and for men, it can be 0.7 to 1.3
close monitoring is required to
results are significant in accordance mg/dL. Such results are important
prevent toxicity, as levels above 1.5 this patient’s medication list due to
to take into consideration for the
mEq/L can lead to adverse effects the usage of Lithium. There are
patient due to the usage of Lithium.
such as tremors, confusion,
The usage of Lithium can cause
serious contraindications between
seizures, and even coma.
high levels of creatinine due to its
the usage of Lithium and a patient
excretion through the kidneys. This
who is pregnant as it poses a
result indicates that there is no
cardiac risk for the fetus.
impact on the kidneys.
Rationale of abnormal results:
The normal range for platelet count
is typically between 150,000 to
400,000 platelets per microliter. A
platelet count of 250,000 per
microliter falls within the normal
range, indicating adequate platelet
levels for normal blood clotting and
hemostasis. This result suggests no
significant abnormalities in platelet
production or function, which is
crucial for preventing excessive
bleeding or clotting disorders
(Sijimol, 2021). It is important to
take into consideration the platelet
count for this patient due to the
usage of antipsychotics such as
Zyprexa or Abilify. In rare cases,
such medications can cause a
decrease in platelet aggregation
that can lead to thrombocytopenia
(Sahoo et al., 2016)
INTRAVENOUS SOLUTION #1
Type N/A
ML/HR
INTRAVENOUS SOLUTION #2
Type
gtts/min
ML/HR
Additives
Additives
Rationale for solution
Rationale for solution
INTRAVENOUS SOLUTION #3
Type
INTRAVENOUS SOLUTION #4
Type
ML/HR
gtts/min
ML/HR
Additives
Additives
Rationale for solution
Rationale for solution
gtts/min
gtts/min
MEDICATION DOSE /
NAME
ROUTE
BRAND/GENE ORDERED
RIC
CLASSIFICAT
ION
Lithium
(Eskalith)
TIMES
RATIONALE FOR
ADMINISTER ADMINISTERING
ED
600 mg PO Twice daily
BID
THERAPEUTIC
RANGE FOR
AGE/WEIGHT If
Applicable
Lithium is a mood stabilizer Therapeutic range:
commonly used to manage 0.6-1.2 mEq/L
bipolar disorder. It works by
modulating neurotransmitter
levels in the brain,
particularly serotonin and
norepinephrine, which are
implicated in mood
regulation (Tondo et al.,
2019). Regular monitoring
of lithium levels is essential
to ensure therapeutic
efficacy and prevent
toxicity.
NURSING IMPLICATIONS
Required Patient Education
CITATIONS
Nursing Implications:
Atiyah, A. H.
(2021). Saliva versus
• Monitor serum lithium levels
Blood Therapeutic Drug
regularly, aiming for
therapeutic levels between 0.6 Monitoring of Lithium
Among Jordanian
to 1.2 mEq/L.
Patients (Doctoral
• Assess for signs of lithium
dissertation, University
toxicity, including nausea,
vomiting, tremors, confusion, of Petra (Jordan)).
and ataxia.
Tondo, L., Alda, M.,
• Encourage adequate fluid
Bauer, M., & Bergink, V.
intake and monitor renal
function, as lithium is excreted (2019). Clinical use of
primarily through the kidneys lithium salts: guide for
users and
(Atiyah, 2021).
prescribers. International
Patient Education:
journal of bip