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    Attachment #4 Psych Care Plan Document

    RN PROGRAMPSYCHIATRIC NURSING CLINICAL CARE PLAN #_____

    Student Name: Joanne Smith Clinical Date: 6/18/10

    Patient Initials: ZH Clinical Site: VAMC

    Age: 38 y.o.

    Height: 65

    Weight: IN KG 127.3 Kg

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    DIAGNOSTIC AND STATISICAL MANUAL OF

    MENTAL DISORDERS

    Axis I: PRIMARY PSYCHIATRIC DIAGNOSES

    EXCLUDING MENTAL RETARDATION AND

    PERSONALITY DISORDERS

    Major Depressive Disorder; Generalized Anxiety

    Disorder

    Axis II: MENTAL RETARDATION, PERSONALITY

    DISORDERSDeferred

    Axis III: MEDICAL CONDITIONS

    Diabetes Type I; hysterectomy five years ago.

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    Axis IV: PSYCHOSOCIAL AND ENVIRONMENTAL

    PROBLEMSPoor support system; marital discord.

    Axis V: Current GAF: (Overall psychological

    functioning - if available) 50

    PAST MEDICAL/PSYCHIATRIC HISTORY: Patient

    has Diabetes Mellitus Type I; hysterectomy fiveyears ago; treated as an outpatient for major

    depression and suicide attempt two years ago.

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    FAMILY HISTORY: Patients mother and aunt have a history of depression; fatherhas a history of Diabetes and was abused as a child. States she has an okrelationship with her mother, but is estranged from her father. She states that herfather drank a lot and physically and emotionally abused her. She is married with two

    grown children who live out of state; she does not have grandchildren. States thather relationship with her husband is strained.

    STAGE OF DEVELOPMENT (Include developmental theorist and behaviors indicativeof achievement of developmental tasks):

    Theorist: Erikson. What is the stage that the client is in, based on age, andwhat should he/she be accomplishing? E.g.,

    Erikson. Generativity v. Stagnation. Being creative and productive, planningfor future generations.

    Evidence: Is he/she accomplishing the tasks of this stage? Why or why not?E.g.,

    Patient is not meeting this life task. She wants to die and feels hopeless andhelpless. She isolates herself; states she has no interests, has stopped attendingchurch, and avoids her best friend. Does not feel she has anything to look forward to.

    SPIRITUAL BELIEFS: Patient believes in God but is conflicted since she wants to die.

    CULTURAL BELIEFS: Believes that the man is the head of the household. Her familyis important to her.

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    ASSESSMENT (Please be specific)

    General Assessment and Motor Behavior:

    (Hygiene and Grooming; Appropriate Dress; Posture; Eye Contact; UnusualMovements or Mannerisms; Speech)Patient is dressed in jeans, t-shirt, and black tennis shoes. Her posture isslumped, no direct eye contact. She constantly taps her foot when talkingand occasionally pats her right knee with her right hand. Speech is slow,volume low.

    Mood and Affect: (Expressed Emotions; Facial Expressions)Patient states that she is depressed and wants to die. Her affect is blunted,congruent to verbal expressions. She frowns frequently and occasionallycries when discussing her feelings.

    Thought Process and Content: (Content: what the client is thinking; Process:how the client is thinking; Clarity of Ideas; Self-harm or Suicidal Urges)

    Patient states that she wants to die. She thinks that she has wasted her lifeand states that she has nothing to look forward to. No delusional statements.

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    Sensorium and Intellectual Processes: (Orientation; Confusion; Memory;Abnormal Sensory Experiences or Misperceptions; Concentration; AbstractThinking Abilities)Patient is oriented to date, time, place, and situation. She is not confused.Memory is intact. This was assessed by asking her when she was marriedand what she ate for breakfast. She denies having any hallucinations. Shedemonstrated difficulty concentrating by having to ask me to repeatquestions. Abstract thinking intact: She was able to interpret the proverb,People in glass houses shouldnt throw stones.

    Judgment and Insight: (Judgment: interpretation of the environment; Decision-making Ability; Insight: understanding ones own part in his/her currentsituation)

    Patient states that she is hospitalized because she is depressed and feels likeshe wants to die; insight is poor since she is unable to verbalize her feelings.Judgment is poor, as she has tried to commit suicide in the past. She statesthat she has contributed to the current situation by threatening to herhusband that she was going to kill herself. She also stated that she hadstopped taking her antidepressant medication three weeks ago.

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    Self-Concept: (Personal View of Self; Description of Physical Self; Personal

    Qualities or Attributes)

    She does not believe that she is a worthwhile person, even though she

    states that she has raised two good children. She feels that she is

    overweight and ugly. She cannot verbalize any strengths at this time.

    Roles and Relationships: (Current roles; Satisfaction with Roles; Success at

    Roles; Significant Relationships; Support Systems)

    Her two children live out of state, and she is not able to see them often.

    States that she and her husband fight a lot. Her only support system is a

    best friend and her church, although she reports that she has stoppedgoing to church and at times avoids her best friend.

    Physiologic and Self-Care Issues: (Eating Habits; Sleep Patterns; Health

    Problems; Compliance with Medications; Ability to Perform ADLs)

    She states that she eats approximately 50% of her meals and eats threetimes a day while in the hospital, but that she tends to overeat when she is

    home. She is compliant with taking her medications. She admits that she

    is not careful with managing her diabetes. She reports that she sleeps 5-6

    hours per night and has frequent awakenings. She is able to

    independently perform ADLs.

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    MEDICATIONS

    Please include trade & generic name, dosage, action, reason your patient is receiving this medication,

    major side effects, and nursing implications. PLEASE NOTE THAT YOU WILL BE DOING THREE

    PSYCHIATRIC DRUGS (OR RELATED) IF NONE, THESE WILL BE CHOSEN BY YOUR INSTRUCTOR.

    Trade

    NameSeroquelGeneric

    NameQuetiapineDose600 mgFrequency:at bedtimeRouteP.O.

    Drug ActionActs as anantagonist of

    dopamine and

    serotonin to

    decrease

    manifestations

    of psychoses,

    depression, or

    acute mania.Patient taking

    for psychosis.

    Is DoseAppropriate

    ?YesPTs WeightIN KG

    127.3 Kg

    AdverseReactionsThe most common

    side effects

    include dizziness

    and weight gain.

    Other side effects

    can include

    sedation,

    extrapyramidalsymptoms, tardive

    dyskinesia,

    palpitations,

    NursingImplicationsIt is important

    to monitor the

    patients

    mental status

    for mood,

    orientation,

    and behavior.

    Also, assessfor suicidal

    tendencies,

    weight, and

    blood pressur

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    LAB DATA & DIAGNOSTIC EVALUATION

    Include date

    LAB OrderedHemoglobin A1C

    Client

    Values8.1% H

    Normal Values4.8-5.6 % Indication for Diseases / IllnessThe most common reason for an elevated

    Hemoglobin A1C is diabetes mellitus, in whichthe relative lack of physiologically active insulin

    results in an increased blood glucose level andcan lead to acidosis and a comatose state.

    LAB OrderedCholesterol, TotalTriglyceridesHDL Cholesterol

    ClientValues160171 H39 L

    Normal Values100-169 mg/dL0-149 mg/dL>39 mg/dL

    Indication for Diseases / IllnessMany clinical conditions can cause an increasein serum cholesterol levels also can cause

    increased in triglyceride levels. Patients with

    nephritic syndrome, pancreatic dysfunction,

    diabetes, toxemia pregnancy, and

    hypothyroidism have elevated triglyceride levels.Low levels ofHDL can indicate an increased

    incidence of CHD (congenital heart disease).

    Low levels can be due to genetics and some

    change in lifestyle factors can increase HDL.

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    PSYCHIATRIC MANAGEMENT

    NOTE IF PATIENT DOES NOT HAVE A PSYCHIATRIC DX, OR ONLY HAS ONE,

    YOUR INSTRUCTOR WILL CHOOSE THESE FOR YOU.

    PSYCHIATRIC

    DIAGNOSIS

    PRIMARY (The Axis diagnosis, not thenursing diagnosis.)

    Major Depressive Disorder

    SECONDARY (The Axis diagnosis, notthe nursing diagnosis.)

    Generalized Anxiety DisorderDefine WHAT IS IT?

    Major Depressive disorder is

    (Give your reference.)

    WHAT IS IT?

    (Give your reference.)

    Etiology

    Whatmay have caused or

    contributed to the

    illness in this

    patient?

    Loss of friend, mother and aunthave been diagnosed with

    depression, abuse, death of

    family member, etc.

    She and husband fight a lot, etc.

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    PathophysiologyPsychological and

    physiological

    causes.

    Include physiological (for

    instance, neurotransmitters)

    and psychological factors; E.g.,

    degree of depression is

    comparable with the persons

    sense of helplessness and

    hopelessness (Videbeck,2011), etc.

    Clinical

    Manifestations

    (textbook)

    Usually involves 2 or more

    weeks of sad mood or lack of

    interest in activities, have low

    Self-esteem, changes in weight,

    sleep, energy, concentration,and decision-making (Videbeck,

    2011), etc.

    Actual

    Manifestations

    What do you see?

    Patient expresses feelings of

    hopelessness and helplessness

    and states that she wants to

    die. She has gained 30 pounds

    in the last three months.

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    PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS

    EXAMPLES

    1. Risk for suicide.

    2. Ineffective individual coping.3. Altered thought processes.

    4. Low self-esteem.

    5. Social isolation.

    List all nursing diagnosis relevant to patient condition &based on assessment. It is not necessary to include the

    related to oras evidenced by for this list.

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    NURSING

    DIAGNOSIS(NANDA

    APPROVED)

    EXPECTED

    OUTCOME(Measurable Goal)

    NURSING INTERVENTIONS(What do you plan to do?)

    THREE interventions for short

    term AND long term.

    RATIONALE(Why are you doing

    this?) (Must give

    references.)

    EVALUATION

    (Be specific!)

    Risk for suicide

    related to

    feelings of

    helplessness

    and feelings of

    low self worth

    as evidenced

    by expression

    that she wants

    to die and past

    suicide

    attempt.

    Short term: The

    patient will be free

    from harm for the

    remainder of the

    shift.

    Long term: The

    patient will be able

    to identify three

    positive aspects

    about herself by

    discharge.

    1) Initiate a no self-harm contract,

    and monitor the patient frequently.

    2) Spend time with the patient.

    3) Encourage the patient to focus

    on strengths and accomplishments.

    + three

    interventions/rationales for

    long term goal.

    1) A contract getsthe subject out in the

    open and places some

    of the responsibility for

    the clients safety with

    the client (Townsend,

    2008, p. 119).2) Spending time

    with the patient

    provides a feeling of

    safety and conveys

    that you believe the

    patient is a

    worthwhile person

    (Townsend, 2008).3) This will minimize

    negative ruminations

    about the past and

    perceived failures

    Videbeck, 2011).

    SHORT TERM: WHAT DID

    YOU SEE? E.g.,

    Patient was free harm

    throughout the shift on (day

    you were there).

    LONG TERM: WHAT

    WOULD YOU HOPE TO

    SEE? E.g.,

    Patient stated that she is a

    good mother, a loyal friend,

    and an honest person.

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    References

    (APA format)

    (APA format double spaced, second line

    indented. See APA manual or the MCI

    Resource & Style Guide for Paper Writing)

    Videbeck, S.L. (2008). Psychiatric-mental health nursing

    (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.