Capstone Project
Content
NURS 360
Capstone Project Template
PMH Care Plan
SN:
Pt.: Sex: _F_
Rachel Pascual
Age: ___15___
Date: _January 23, 2016
Date of Admission: _1/15/2016____
Transferred? X_No ___Yes: (Reason/Date)___________________________________
Income source: _______Unemployed
___________________________________
Legal Status: _________MH5a____________Expiration Date: _____N/A____
DSM Diagnosis:
I
Amphetamine induced mood disorder
Cannabis Use disorder moderate
Major depression recurrent severe
II
Rule out Borderline Personality Disorder
III
Asthma
IV
Patient was in Foster Care, but ran away from her foster homes; Lived with grandma at
one time until grandma was taken away for substance abuse; Lived with girlfriend and
infant of 8 months; Lived with Aunty
V
GAF 50-41: Serious symptoms such as suicidal ideations and attempts
1
Stimulant Related Disorder DSM V Criteria
A pattern of amphetamine-type substance, cocaine, or other stimulant
Patient
use leading to clinically significant impairment or distress, as manifested
by at least two of the following, occurring within a 12-month period
1. Stimulant is often taken in larger amounts or over a
longer period than was intended
2. Persistent desire or unsuccessful efforts to cut down or
control stimulant use
3.
A great deal of time is spent in activities necessary to
A great deal of time is spent in activities necessary to obtain the
obtain the stimulant, use the stimulant, or recover from
stimulant, use the stimulant, or recover from the effects
the effects
4. Craving, or a strong desire or urge to use the stimulant
5. Recurrent stimulant use resulting in a failure to fulfill
major role obligations at work, school, or home
Recurrent stimulant use resulting in a failure to fulfill major role
obligations at work, school, or home
6. Continued stimulant use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the stimulant
7. Important social, occupational, or recreational activities
are given up or reduced because of stimulant use
8. Recurrent stimulant use in situations in which it is
physically hazardous.
9. Stimulant use is continued despite knowledge of having
Stimulant use is continued despite knowledge of having a persistent or
a persistent or recurrent physical or psychological
recurrent physical or psychological problem that is likely to have been
problem that is likely to have been caused or
caused or exacerbated by the stimulant
exacerbated by the stimulant
2
What brought patient to the hospital?
Patient was bought to the hospital for suicidal ideations with acute psych for the level of
care.
Patient’s description of illness/issues:
Patient stated having drug problems and being addicted to marijuana and
methamphetamine. She also stated she is learning to stop smoking cigarettes. Patient
claimed wanting to hurt herself before, but has no desire or thoughts of suicide
anymore. She said she was being cared for by her grandmother because her
bioparental rights were terminated by 2 years old. She went through multiple foster
homes in different states and in Hawaii. She ran away from home and was arrested by
Honolulu Police Department due to an outstanding bench warrant when picked up by
her social worker.
Spirituality:
Patient stated “I practice Buddhism.” Patient carries a Buddhism book around with her.
Considerations r/t ethnicity or religion:
Patient believes in Buddha and the practice of this religion. In her chart, patient stated
practicing Buddhism and Christianity.
Patient’s Strengths:
Patient stated strengths are singing, being a good listener, and having the ability to
learn.
Patient’s Limitations:
Patient stated limitations are social skills and anger management. Patient reports
feeling frustrated with peers and gets irritated easily with others. She stated “child
welfare services are holding me from my future.”
Medications:
3
Order: Albuterol Sulfate (Proventil HFA) 2 puffs inhaled by mouth Q4 PRN 90mcg
inhaler 2 Puff
Drug class: Adrenergic Bronchodilators
Pt’s target sx: Tightness of chest; Shortness of breath; Difficulty breathing
Total 24h dose: 540 mcg
Recommended range: 2 inhalations q 4-6 hours (90mcg/spray) : L M H Max
Current Side effects: Depression, dizziness, fatigue, cough, abdominal pain
Order: Nicotine 7 mg/24 hr patch. 1 patch Transdermal Daily
Drug class: Smoking Cessation Agents
Pt’s target sx: Agitation and headache; Nicotine Withdrawals after giving up smoking
Total 24h dose: 7mg
Recommended range: 7 mg/day for two weeks : L M H Max
Current Side effects: Headache, insomnia, and rash
AXIS III: List all conditions even if they are not listed in multi-axial diagnoses or
on chart. (Particularly note any unstable conditions & all non-medication
interventions.)
1. Asthma
-Identify triggers
2.
3.
4.
BMI: 19.61 Category: Normal Range
(Height:
154.9 cm
Weight: 47.05 kg)
Food & fluid intake: 100% meals
Bladder & bowel status: Continent
Sleep pattern: Patient stated she has nightmares and has a hard time staying
asleep.
Total sleep/24 hrs: 1/17/2016: 8 hours and 30 minutes 1/19/216: 8 hours and 15
minutes 1/20/2016: 8 hours and 30 minutes (According to patient’s chart.)
(Circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning
awakening
Number of hrs of disruption:
None stated on chart; Patient does not know.
4
Naps: When?
Total nap time:
N/A
N/A
Lab & studies
Date/Panels in which all values were normal:
CBC Panel (1/15/2016)
WBC: 9.22
RBC: 4.26
Hbg: 12.1
Hct: 36.1
MCV: 84.7
MCH: 28.4
MCHC: 33.5
Neutrophil: 65.8
Lymphocyte: 28.1
Monocyte: 3.9
Eosinophil: 1.3
Basophil: 0.7
Nucleated RBC: 0.0
Platelet count: 235,000
Imm. Granulocyte: 0.2
Abs Neutrophil: 0.2
Abs Imm Granulo 0.02
RDW: 13.8
Hepatic Function Panel (1/15/2016)
SGOT (AST): 15
SGPT (ALT): 19
Alkaline Phosphate: 69
Bilirubin total: 0.3
Bilirubin direct: 0.1
Total Protein: 7.2
Albumin (West): 4.0
Bilirubin: 0.2
Date/Any abnormal labs:
Urine Panel (1/15/2016)
Ethanol : Negative
Amphetamine/Methamphetamine: Positive (High)
Barbituates: negative
Benzodiazepines: Negative
Cocaine: Negative
Methadone: Negative
Opiates: Negative
PCP/Phencyclidine: Negative
5
THC: Postive (High)
Metabolic
Glucose: 109 (high)
Anion Gap: 12 (low)
Labs you would expect but were not ordered: N/A
Glucose readings x 24h for all diabetic pts.: N/A
All drug screen findings:
Urine Panel (1/15/2016)
Ethanol : Negative
Amphetamine/Methamphetamine: Positive (High)
Barbituates: negative
Benzodiazepines: Negative
Cocaine: Negative
Methadone: Negative
Opiates: Negative
PCP/Phencyclidine: Negative
THC: Postive (High)
MENTAL STATUS ASSESSMENT:
Behavior:
Dressed: Patient dressed in clean yoga pants, a tank top, a jacket, and slippers. Her
hair was not brushed.
Motor Behavior: Patient did not exhibit unusual physical movements. Movements were
not delayed, rigid, jerky, nor quick.
Sleep Pattern: Per chart 8 hours and a half of sleep; Per patient, she says she wakes
up a lot at night because of nightmares and has a hard time staying asleep.
Appetite: Patient eats 100% of her food.
Suicidal/Homicidal Actions: Patient does not exhibit any suicidal/homicidal actions shift.
Odor: Odorless
Affect: Full/wide range-generally appropriate as evidenced by crying and having a
raised and shaky tone of voice when upset, but fought through her sadness by quickly
wiping her tears when told news that she was upset about. Her affect was appropriate
when she saw her aunty as evidenced by smiling and hugging her. Her affect was not
labile.
6
Mood: Patient’s moods were angry, dysphoric, and euthymic, but was congruent with
her affect and appropriate to her situation.
Sensorium:
Recent Memory: Patient was able to recall a couple hours after breakfast what she ate.
Remote Memory: Patient was able to recall when she got to The Family Treatment
Center and also the last time her Aunty came to visit her.
Judgment and Intellect: She is able to understand her situation, what it takes to get
discharged, and her treatment plan.
Imagery: Patient does not claim and does not exhibit delusions and hallucinations.
Cognition:
Fluent and even speech with no thought blocking, poverty of speech, flight of ideas,
neologism, ideas of reference, or circumstantiality. She is able to stay on topic and
engage in a conversation with others. She is able to comprehend conversations and
create abstract ideas as evidenced by thinking about her future. She is goal oriented as
evidenced by stating that she wants to go to back to school, go to college, and become
a nurse. She also stated that she wants to be better and think more optimistically.
Form
Flow
Interpersonal relationships:
Family: Her biological parents are in jail and she was living with her grandmother’s
house, but she left six months ago. She was a part of the foster care system, but ran
away. She has not seen sibling in a while. She claims her family now is her girlfriend
and her Aunty.
Peers: She said her friends are all older than her, but wants friends around her age. She
met one friend in the Family Treatment Center and said that this friend was her first
close friend in a while.
7
Staff: Patient stated she does not like the staff because they do not give her the therapy
she needs. She thinks the staff is not listening to her and making up/ exaggerating
things about her that are not true.
Gender preferences: Females; Patient claims to have a girlfriend.
Developmental level: (Assets & barriers)
Erikson’s Developmental level: Identity vs. Role Confusion (12-18 years old)
According to Erikson, during this stage the adolescent is going through rapid and
marked physical changes, preoccupied with their physical appearance, examines and
redefines themselves, family, peer group, and community, tries out different roles that
interests them, and sees peer groups to be very important. When the adolescent is
successful in this stage, he or she develops a confidence in self-identity and optimism;
however, if the adolescent is not successful, he or she develops role confusion.
This patient shows that she is going through this developmental level. Upon
asking how she feels about herself and her appearance, she confessed that she wishes
to be skinnier, prettier, and attractive. Her physical appearance seems to be important to
her as mentioned in Erikson’s theory. As for redefining herself, family, peer group
community, she is experiencing many events in her life that contributes to her definition
of these people and herself. As mentioned by this patient, she is trying to redefine
herself and be a better person. Family has not been stable in her life, but she is trying to
let people in and allow them to help her. For example, her aunty. Her friends were older
than her, but she mentioned wanting friends of her age. She mentioned this multiple
times, so her social life and peer support seems to be important and a priority. This
patient also mentioned that she is exercising her belief in Buddha which shows that she
trying out different roles and spiritualties.
Situation/Crisis
According to this patient, she is experiencing many changes in her life and these
changes heavily affects this developmental level. Setbacks that this patient may have
are having a low self-esteem, beliefs that the child welfare worker are holding her from
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her future and goals, not having a solid support group/family, possessing ineffective
coping skills, and having regrets and not completely accepting her previous decisions.
Hogan, M., Wagner, N., White, J., & Johnson, T. (2013). Child Health Nursing (3rd ed.).
Pearson Education, Inc.
Drugs: Substance abuse or dependence: (Include nicotine & any alcohol &
drugs. List by drug: Last date of use/Current acute intoxication or withdrawal
signs and symptoms when SN caring for pt./Used how long/Route/Usual
amount/Negative consequences)
Drug class
Tobacco
Last Use
12/1/2015
Acute intox or Length of
Route Usual amt. Negative Consequences
withdrawal sx? Time Used
Agitation and
Daily; “A
Smoke half a pack Agitation and headache
headache
couple
12/1/2015
Agitation and
years”
“A couple
Amphetamine 12/1/2015
headache
Agitation and
weeks”
More than 3 Smoke
day”
“a couple
headache
weeks
hits”
Cannabis
daily
Smoke
“4 pipes a Agitation and headache
Agitation and headache
Problems Identified In Hospital’s Master Treatment Plan:
1. Mood stability (irritable angry behavior)
2. Addiction to drugs/alcohol (History of drug/alcohol abuse)
3. Academic concerns (emotional and behavioral difficulties preventing full benefit from
educational opportunities)
Current Discharge Plan: Social worker states that patient may be going to Bobby
Benson Center, a residential campus providing chemical dependency treatment
programs, because previous plans to be discharged with Aunty changed. Aunty can’t be
licensed to be a foster parents and states she doesn’t think she can handle being
responsible for client’s fluctuating moods.
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Nursing interventions you performed this shift (Include safety and teaching!):
Patient-centered Care Analysis
PRIORITIZED PATIENT NEEDS
What are the patient’s 3 highest needs/problems?
(Use your best nursing judgment! It will be different than the master treatment
plan.) P=Problem, E= Evidence, S= Solution.
1. P: Safety
E: Unstable vital signs during admission, current use of substance abuse which may
withdrawal, history of throwing tantrums and being aggressive toward others
S: Maintain a safe, harm free environment, establish rapport and demonstrate
respect for patient, monitor vital signs, observe for signs and symptoms of substance
abuse withdrawal and drug-drug interactions to prevent complications.
2. P: Nutrition
E: Patient stating she hasn’t been eating very well before, has cravings of drugs,
loss a lot of weight since she’s been using drugs, physical body looks disproportional.
S: Measure how much food patient eats per meal; Assess patient’s thoughts on her
eating habits; Encourage patient’s carbohydrate intake.
3. P: Ineffective coping/ Strengthen individual’s coping skills
E: No parental support/guidance, depression, guilt associated with past behaviors,
and low self-esteem;
S: Provide patient with activities to assist with coping, teach alternative ways to
cope, determine social support, and assist patient in turning negative thoughts and
positive ones, and help the patient acknowledge problems that are beyond her control.
Do a self-esteem assessment on patient and determine how it affects her coping skills.
4. P: Knowledge deficit about substance abuse
E: Patient states not know what the substances can actually do to her body while
taking the drug. Patient denies knowledge of future consequences of substance abuse.
Patient claims to want to know more about what she can do.
S: Teach patient about substance abuse, symptoms, management, prevention, and
treatment.
10
Priority #
__3
CARE PLAN
Create 3 plans of care one for each of your priorities identified.
Nursing Diagnosis: Ineffective coping related to no parental support/guidance, depression, guilt associated with
past behaviors, and low self-esteem as evidenced by use of methamphetamines, tobacco, and cannabis, desire to
change lifestyle.
P: Ineffective coping
E: No parental support/guidance, depression, guilt associated with past behaviors, and low self-esteem
S: Provide patient with activities to assist with coping and finding alternative ways to cope, determine social support, and
teach patient how to turn negative thoughts into positive ones.
LT goal: Patient will continue to utilize coping methods in order to deal with external and internal stressors before and after
discharge.
ST goal: Patient will state one way of dealing with negative situations and difficult events at the end of the shift.
Scientific Rationale
(In complete sentences!)
Intervention & Frequency
Evaluation
(Reference in APA format, including page number)
Assist the patient with the identification
of negative, self-defeating thoughts and
situations with modifying them into more
realistic, positive thoughts whenever the
negative thoughts appear. This is called
Cognitive Behavioral Interventions.
This intervention promotes more accurate
and positive thoughts about the self,
others and unwanted situations (Fortinash
and Holoday-Worret, 2012, p. 242).
Help client make sense of the damage of
the drug dependence, “form correct
cognitive ability and behavioral style, and
consequently improve her quality of life
(Zhuan, An, & Zhao, 2014, p. 1240)
Patient will demonstrate participation in This intervention is used “to reframe
milieu and group activities such as
thinking with the support of others”
psychoeducational activities including
(Fortinash and Holoday-Worret, 2012, p.
deep breathing exercises and art therapy 242).
on a daily basis.
Teach alternative coping strategies to
stressors in addition to assist patient to
identify her perceived strengths and
limitations using the best learning style
that works best for the patient to meet
learning needs daily.
After patient talked to her doctor about the recent
change in the discharge planning and being upset
about it, she said she wants to stay positive. She
verbalized initially that she did not want to stay
longer in the mental hospital any longer, but after a
couple hours she said she does not mind as long as
she can go to Bobby Benson after and continue on
with her future. She realized she needs to stay here in
order to get and remain better/well.
Patient stated she did not benefit from the art therapy
because she was too distracted with what was on her
mind and the frustrations of being at the mental
hospital.
After the first deep breathing exercise, she stated the
therapy did not work for her. After a couple more
rounds of deep breathing, patient stated she felt a
little better.
This intervention encourages the patient
Patient stated her best way of coping while in the
“to focus on strengths rather than
hospital is singing and being in the music room
weaknesses so that the patient becomes jamming out to music with her peer.
aware of positive qualities and capabilities Patient was able to state her strengths and
that have helped with coping in the past” limitations. She stated her strengths were self-control,
(Fortinash and Holoday-Worret, 2012, p.
listening, and singing. She stated her limitations were
517). This intervention assists the
her anger and irritability, but she claimed to be
11
Determine the support this patient
already has. Provide emotional support
to the patient whenever the patient
needs it.
individual with working through developing working on it every day. She stated she wants “to stay
awareness that many life problems are
positive.”
related to substance abuse (Fortinash and
Holoday-Worret, 2012, p. 351). This
intervention helps the patient realize that
they are being “understood not as
something that someone has, but as
something that someone does, involving
recognizing a problem, finding a way to
change, and then starting and sticking with
that change strategy.” (Hamilton I., &
Watson, J. 2014, p.484).
This intervention helps to determine the
Patient’s parents are in jail and does not know where
support patient has. It also helps the
siblings are. Patient stated she has a girlfriend whom
patient stay motivated to adhere to
she can trust and rely on. She also stated she has her
treatment (Fortinash and Holoday-Worret, aunty who comes to visit her at the mental hospital
2012, p. 242). This intervention also
every other day. Aunty came to visit that clinical day.
establishes trust with the patient and helps Patient explained she has “no close normal friends
patient think about who are important to around her age,” however, she said she became really
the patient in the treatment process
good friends with one of the other patients in the unit.
(Fortinash and Holoday-Worret, 2012, p.
Patient stated she enjoyed student nurse’s company.
351.) Providing “empathy adopts a warm,
reflective, and understanding approach”
(Hamilton I., & Watson, J. 2014, p.484).
References:
Fortinash, K.M.& Holoday-Worret, P.A. (2012). Psychiatric Mental Health Nursing. (5th ed.).
St. Louis: Mosby.
Hamilton, I., & Watson, J. (2014). Managing substance use in the practice. Practice Nursing, 25(10), 480-485 6p.
Zhuang, S., An, S., & Zhao, Y. (2014). Effect of cognitive behavioural interventions on the quality of life in Chinese heroin-dependent individuals in
detoxification: a randomised controlled trial. Journal Of Clinical Nursing, 23(9/10), 1239-1248. doi:10.1111/jocn.12287
12
Scholarly Evidence Based Journal Article Review, Source and Implications to care:
Standardized PMH Assessment Tool(s):
Refer to PMH Capstone grading rubric to address all categories.
Work submitted is to be turned in a labeled folder.
13
Capstone Project Template
PMH Care Plan
SN:
Pt.: Sex: _F_
Rachel Pascual
Age: ___15___
Date: _January 23, 2016
Date of Admission: _1/15/2016____
Transferred? X_No ___Yes: (Reason/Date)___________________________________
Income source: _______Unemployed
___________________________________
Legal Status: _________MH5a____________Expiration Date: _____N/A____
DSM Diagnosis:
I
Amphetamine induced mood disorder
Cannabis Use disorder moderate
Major depression recurrent severe
II
Rule out Borderline Personality Disorder
III
Asthma
IV
Patient was in Foster Care, but ran away from her foster homes; Lived with grandma at
one time until grandma was taken away for substance abuse; Lived with girlfriend and
infant of 8 months; Lived with Aunty
V
GAF 50-41: Serious symptoms such as suicidal ideations and attempts
1
Stimulant Related Disorder DSM V Criteria
A pattern of amphetamine-type substance, cocaine, or other stimulant
Patient
use leading to clinically significant impairment or distress, as manifested
by at least two of the following, occurring within a 12-month period
1. Stimulant is often taken in larger amounts or over a
longer period than was intended
2. Persistent desire or unsuccessful efforts to cut down or
control stimulant use
3.
A great deal of time is spent in activities necessary to
A great deal of time is spent in activities necessary to obtain the
obtain the stimulant, use the stimulant, or recover from
stimulant, use the stimulant, or recover from the effects
the effects
4. Craving, or a strong desire or urge to use the stimulant
5. Recurrent stimulant use resulting in a failure to fulfill
major role obligations at work, school, or home
Recurrent stimulant use resulting in a failure to fulfill major role
obligations at work, school, or home
6. Continued stimulant use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of the stimulant
7. Important social, occupational, or recreational activities
are given up or reduced because of stimulant use
8. Recurrent stimulant use in situations in which it is
physically hazardous.
9. Stimulant use is continued despite knowledge of having
Stimulant use is continued despite knowledge of having a persistent or
a persistent or recurrent physical or psychological
recurrent physical or psychological problem that is likely to have been
problem that is likely to have been caused or
caused or exacerbated by the stimulant
exacerbated by the stimulant
2
What brought patient to the hospital?
Patient was bought to the hospital for suicidal ideations with acute psych for the level of
care.
Patient’s description of illness/issues:
Patient stated having drug problems and being addicted to marijuana and
methamphetamine. She also stated she is learning to stop smoking cigarettes. Patient
claimed wanting to hurt herself before, but has no desire or thoughts of suicide
anymore. She said she was being cared for by her grandmother because her
bioparental rights were terminated by 2 years old. She went through multiple foster
homes in different states and in Hawaii. She ran away from home and was arrested by
Honolulu Police Department due to an outstanding bench warrant when picked up by
her social worker.
Spirituality:
Patient stated “I practice Buddhism.” Patient carries a Buddhism book around with her.
Considerations r/t ethnicity or religion:
Patient believes in Buddha and the practice of this religion. In her chart, patient stated
practicing Buddhism and Christianity.
Patient’s Strengths:
Patient stated strengths are singing, being a good listener, and having the ability to
learn.
Patient’s Limitations:
Patient stated limitations are social skills and anger management. Patient reports
feeling frustrated with peers and gets irritated easily with others. She stated “child
welfare services are holding me from my future.”
Medications:
3
Order: Albuterol Sulfate (Proventil HFA) 2 puffs inhaled by mouth Q4 PRN 90mcg
inhaler 2 Puff
Drug class: Adrenergic Bronchodilators
Pt’s target sx: Tightness of chest; Shortness of breath; Difficulty breathing
Total 24h dose: 540 mcg
Recommended range: 2 inhalations q 4-6 hours (90mcg/spray) : L M H Max
Current Side effects: Depression, dizziness, fatigue, cough, abdominal pain
Order: Nicotine 7 mg/24 hr patch. 1 patch Transdermal Daily
Drug class: Smoking Cessation Agents
Pt’s target sx: Agitation and headache; Nicotine Withdrawals after giving up smoking
Total 24h dose: 7mg
Recommended range: 7 mg/day for two weeks : L M H Max
Current Side effects: Headache, insomnia, and rash
AXIS III: List all conditions even if they are not listed in multi-axial diagnoses or
on chart. (Particularly note any unstable conditions & all non-medication
interventions.)
1. Asthma
-Identify triggers
2.
3.
4.
BMI: 19.61 Category: Normal Range
(Height:
154.9 cm
Weight: 47.05 kg)
Food & fluid intake: 100% meals
Bladder & bowel status: Continent
Sleep pattern: Patient stated she has nightmares and has a hard time staying
asleep.
Total sleep/24 hrs: 1/17/2016: 8 hours and 30 minutes 1/19/216: 8 hours and 15
minutes 1/20/2016: 8 hours and 30 minutes (According to patient’s chart.)
(Circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning
awakening
Number of hrs of disruption:
None stated on chart; Patient does not know.
4
Naps: When?
Total nap time:
N/A
N/A
Lab & studies
Date/Panels in which all values were normal:
CBC Panel (1/15/2016)
WBC: 9.22
RBC: 4.26
Hbg: 12.1
Hct: 36.1
MCV: 84.7
MCH: 28.4
MCHC: 33.5
Neutrophil: 65.8
Lymphocyte: 28.1
Monocyte: 3.9
Eosinophil: 1.3
Basophil: 0.7
Nucleated RBC: 0.0
Platelet count: 235,000
Imm. Granulocyte: 0.2
Abs Neutrophil: 0.2
Abs Imm Granulo 0.02
RDW: 13.8
Hepatic Function Panel (1/15/2016)
SGOT (AST): 15
SGPT (ALT): 19
Alkaline Phosphate: 69
Bilirubin total: 0.3
Bilirubin direct: 0.1
Total Protein: 7.2
Albumin (West): 4.0
Bilirubin: 0.2
Date/Any abnormal labs:
Urine Panel (1/15/2016)
Ethanol : Negative
Amphetamine/Methamphetamine: Positive (High)
Barbituates: negative
Benzodiazepines: Negative
Cocaine: Negative
Methadone: Negative
Opiates: Negative
PCP/Phencyclidine: Negative
5
THC: Postive (High)
Metabolic
Glucose: 109 (high)
Anion Gap: 12 (low)
Labs you would expect but were not ordered: N/A
Glucose readings x 24h for all diabetic pts.: N/A
All drug screen findings:
Urine Panel (1/15/2016)
Ethanol : Negative
Amphetamine/Methamphetamine: Positive (High)
Barbituates: negative
Benzodiazepines: Negative
Cocaine: Negative
Methadone: Negative
Opiates: Negative
PCP/Phencyclidine: Negative
THC: Postive (High)
MENTAL STATUS ASSESSMENT:
Behavior:
Dressed: Patient dressed in clean yoga pants, a tank top, a jacket, and slippers. Her
hair was not brushed.
Motor Behavior: Patient did not exhibit unusual physical movements. Movements were
not delayed, rigid, jerky, nor quick.
Sleep Pattern: Per chart 8 hours and a half of sleep; Per patient, she says she wakes
up a lot at night because of nightmares and has a hard time staying asleep.
Appetite: Patient eats 100% of her food.
Suicidal/Homicidal Actions: Patient does not exhibit any suicidal/homicidal actions shift.
Odor: Odorless
Affect: Full/wide range-generally appropriate as evidenced by crying and having a
raised and shaky tone of voice when upset, but fought through her sadness by quickly
wiping her tears when told news that she was upset about. Her affect was appropriate
when she saw her aunty as evidenced by smiling and hugging her. Her affect was not
labile.
6
Mood: Patient’s moods were angry, dysphoric, and euthymic, but was congruent with
her affect and appropriate to her situation.
Sensorium:
Recent Memory: Patient was able to recall a couple hours after breakfast what she ate.
Remote Memory: Patient was able to recall when she got to The Family Treatment
Center and also the last time her Aunty came to visit her.
Judgment and Intellect: She is able to understand her situation, what it takes to get
discharged, and her treatment plan.
Imagery: Patient does not claim and does not exhibit delusions and hallucinations.
Cognition:
Fluent and even speech with no thought blocking, poverty of speech, flight of ideas,
neologism, ideas of reference, or circumstantiality. She is able to stay on topic and
engage in a conversation with others. She is able to comprehend conversations and
create abstract ideas as evidenced by thinking about her future. She is goal oriented as
evidenced by stating that she wants to go to back to school, go to college, and become
a nurse. She also stated that she wants to be better and think more optimistically.
Form
Flow
Interpersonal relationships:
Family: Her biological parents are in jail and she was living with her grandmother’s
house, but she left six months ago. She was a part of the foster care system, but ran
away. She has not seen sibling in a while. She claims her family now is her girlfriend
and her Aunty.
Peers: She said her friends are all older than her, but wants friends around her age. She
met one friend in the Family Treatment Center and said that this friend was her first
close friend in a while.
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Staff: Patient stated she does not like the staff because they do not give her the therapy
she needs. She thinks the staff is not listening to her and making up/ exaggerating
things about her that are not true.
Gender preferences: Females; Patient claims to have a girlfriend.
Developmental level: (Assets & barriers)
Erikson’s Developmental level: Identity vs. Role Confusion (12-18 years old)
According to Erikson, during this stage the adolescent is going through rapid and
marked physical changes, preoccupied with their physical appearance, examines and
redefines themselves, family, peer group, and community, tries out different roles that
interests them, and sees peer groups to be very important. When the adolescent is
successful in this stage, he or she develops a confidence in self-identity and optimism;
however, if the adolescent is not successful, he or she develops role confusion.
This patient shows that she is going through this developmental level. Upon
asking how she feels about herself and her appearance, she confessed that she wishes
to be skinnier, prettier, and attractive. Her physical appearance seems to be important to
her as mentioned in Erikson’s theory. As for redefining herself, family, peer group
community, she is experiencing many events in her life that contributes to her definition
of these people and herself. As mentioned by this patient, she is trying to redefine
herself and be a better person. Family has not been stable in her life, but she is trying to
let people in and allow them to help her. For example, her aunty. Her friends were older
than her, but she mentioned wanting friends of her age. She mentioned this multiple
times, so her social life and peer support seems to be important and a priority. This
patient also mentioned that she is exercising her belief in Buddha which shows that she
trying out different roles and spiritualties.
Situation/Crisis
According to this patient, she is experiencing many changes in her life and these
changes heavily affects this developmental level. Setbacks that this patient may have
are having a low self-esteem, beliefs that the child welfare worker are holding her from
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her future and goals, not having a solid support group/family, possessing ineffective
coping skills, and having regrets and not completely accepting her previous decisions.
Hogan, M., Wagner, N., White, J., & Johnson, T. (2013). Child Health Nursing (3rd ed.).
Pearson Education, Inc.
Drugs: Substance abuse or dependence: (Include nicotine & any alcohol &
drugs. List by drug: Last date of use/Current acute intoxication or withdrawal
signs and symptoms when SN caring for pt./Used how long/Route/Usual
amount/Negative consequences)
Drug class
Tobacco
Last Use
12/1/2015
Acute intox or Length of
Route Usual amt. Negative Consequences
withdrawal sx? Time Used
Agitation and
Daily; “A
Smoke half a pack Agitation and headache
headache
couple
12/1/2015
Agitation and
years”
“A couple
Amphetamine 12/1/2015
headache
Agitation and
weeks”
More than 3 Smoke
day”
“a couple
headache
weeks
hits”
Cannabis
daily
Smoke
“4 pipes a Agitation and headache
Agitation and headache
Problems Identified In Hospital’s Master Treatment Plan:
1. Mood stability (irritable angry behavior)
2. Addiction to drugs/alcohol (History of drug/alcohol abuse)
3. Academic concerns (emotional and behavioral difficulties preventing full benefit from
educational opportunities)
Current Discharge Plan: Social worker states that patient may be going to Bobby
Benson Center, a residential campus providing chemical dependency treatment
programs, because previous plans to be discharged with Aunty changed. Aunty can’t be
licensed to be a foster parents and states she doesn’t think she can handle being
responsible for client’s fluctuating moods.
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Nursing interventions you performed this shift (Include safety and teaching!):
Patient-centered Care Analysis
PRIORITIZED PATIENT NEEDS
What are the patient’s 3 highest needs/problems?
(Use your best nursing judgment! It will be different than the master treatment
plan.) P=Problem, E= Evidence, S= Solution.
1. P: Safety
E: Unstable vital signs during admission, current use of substance abuse which may
withdrawal, history of throwing tantrums and being aggressive toward others
S: Maintain a safe, harm free environment, establish rapport and demonstrate
respect for patient, monitor vital signs, observe for signs and symptoms of substance
abuse withdrawal and drug-drug interactions to prevent complications.
2. P: Nutrition
E: Patient stating she hasn’t been eating very well before, has cravings of drugs,
loss a lot of weight since she’s been using drugs, physical body looks disproportional.
S: Measure how much food patient eats per meal; Assess patient’s thoughts on her
eating habits; Encourage patient’s carbohydrate intake.
3. P: Ineffective coping/ Strengthen individual’s coping skills
E: No parental support/guidance, depression, guilt associated with past behaviors,
and low self-esteem;
S: Provide patient with activities to assist with coping, teach alternative ways to
cope, determine social support, and assist patient in turning negative thoughts and
positive ones, and help the patient acknowledge problems that are beyond her control.
Do a self-esteem assessment on patient and determine how it affects her coping skills.
4. P: Knowledge deficit about substance abuse
E: Patient states not know what the substances can actually do to her body while
taking the drug. Patient denies knowledge of future consequences of substance abuse.
Patient claims to want to know more about what she can do.
S: Teach patient about substance abuse, symptoms, management, prevention, and
treatment.
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Priority #
__3
CARE PLAN
Create 3 plans of care one for each of your priorities identified.
Nursing Diagnosis: Ineffective coping related to no parental support/guidance, depression, guilt associated with
past behaviors, and low self-esteem as evidenced by use of methamphetamines, tobacco, and cannabis, desire to
change lifestyle.
P: Ineffective coping
E: No parental support/guidance, depression, guilt associated with past behaviors, and low self-esteem
S: Provide patient with activities to assist with coping and finding alternative ways to cope, determine social support, and
teach patient how to turn negative thoughts into positive ones.
LT goal: Patient will continue to utilize coping methods in order to deal with external and internal stressors before and after
discharge.
ST goal: Patient will state one way of dealing with negative situations and difficult events at the end of the shift.
Scientific Rationale
(In complete sentences!)
Intervention & Frequency
Evaluation
(Reference in APA format, including page number)
Assist the patient with the identification
of negative, self-defeating thoughts and
situations with modifying them into more
realistic, positive thoughts whenever the
negative thoughts appear. This is called
Cognitive Behavioral Interventions.
This intervention promotes more accurate
and positive thoughts about the self,
others and unwanted situations (Fortinash
and Holoday-Worret, 2012, p. 242).
Help client make sense of the damage of
the drug dependence, “form correct
cognitive ability and behavioral style, and
consequently improve her quality of life
(Zhuan, An, & Zhao, 2014, p. 1240)
Patient will demonstrate participation in This intervention is used “to reframe
milieu and group activities such as
thinking with the support of others”
psychoeducational activities including
(Fortinash and Holoday-Worret, 2012, p.
deep breathing exercises and art therapy 242).
on a daily basis.
Teach alternative coping strategies to
stressors in addition to assist patient to
identify her perceived strengths and
limitations using the best learning style
that works best for the patient to meet
learning needs daily.
After patient talked to her doctor about the recent
change in the discharge planning and being upset
about it, she said she wants to stay positive. She
verbalized initially that she did not want to stay
longer in the mental hospital any longer, but after a
couple hours she said she does not mind as long as
she can go to Bobby Benson after and continue on
with her future. She realized she needs to stay here in
order to get and remain better/well.
Patient stated she did not benefit from the art therapy
because she was too distracted with what was on her
mind and the frustrations of being at the mental
hospital.
After the first deep breathing exercise, she stated the
therapy did not work for her. After a couple more
rounds of deep breathing, patient stated she felt a
little better.
This intervention encourages the patient
Patient stated her best way of coping while in the
“to focus on strengths rather than
hospital is singing and being in the music room
weaknesses so that the patient becomes jamming out to music with her peer.
aware of positive qualities and capabilities Patient was able to state her strengths and
that have helped with coping in the past” limitations. She stated her strengths were self-control,
(Fortinash and Holoday-Worret, 2012, p.
listening, and singing. She stated her limitations were
517). This intervention assists the
her anger and irritability, but she claimed to be
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Determine the support this patient
already has. Provide emotional support
to the patient whenever the patient
needs it.
individual with working through developing working on it every day. She stated she wants “to stay
awareness that many life problems are
positive.”
related to substance abuse (Fortinash and
Holoday-Worret, 2012, p. 351). This
intervention helps the patient realize that
they are being “understood not as
something that someone has, but as
something that someone does, involving
recognizing a problem, finding a way to
change, and then starting and sticking with
that change strategy.” (Hamilton I., &
Watson, J. 2014, p.484).
This intervention helps to determine the
Patient’s parents are in jail and does not know where
support patient has. It also helps the
siblings are. Patient stated she has a girlfriend whom
patient stay motivated to adhere to
she can trust and rely on. She also stated she has her
treatment (Fortinash and Holoday-Worret, aunty who comes to visit her at the mental hospital
2012, p. 242). This intervention also
every other day. Aunty came to visit that clinical day.
establishes trust with the patient and helps Patient explained she has “no close normal friends
patient think about who are important to around her age,” however, she said she became really
the patient in the treatment process
good friends with one of the other patients in the unit.
(Fortinash and Holoday-Worret, 2012, p.
Patient stated she enjoyed student nurse’s company.
351.) Providing “empathy adopts a warm,
reflective, and understanding approach”
(Hamilton I., & Watson, J. 2014, p.484).
References:
Fortinash, K.M.& Holoday-Worret, P.A. (2012). Psychiatric Mental Health Nursing. (5th ed.).
St. Louis: Mosby.
Hamilton, I., & Watson, J. (2014). Managing substance use in the practice. Practice Nursing, 25(10), 480-485 6p.
Zhuang, S., An, S., & Zhao, Y. (2014). Effect of cognitive behavioural interventions on the quality of life in Chinese heroin-dependent individuals in
detoxification: a randomised controlled trial. Journal Of Clinical Nursing, 23(9/10), 1239-1248. doi:10.1111/jocn.12287
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Scholarly Evidence Based Journal Article Review, Source and Implications to care:
Standardized PMH Assessment Tool(s):
Refer to PMH Capstone grading rubric to address all categories.
Work submitted is to be turned in a labeled folder.
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