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Transcript of CarePlan Psych Template
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7/30/2019 CarePlan Psych Template
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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.