Mental Health Nursing Care Plan

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1
University of Texas at Brownsville
Bachelor Science Nursing
Plan of Care (Based on Textbook)
Room No:

15

Pt’s Initials:

Student’s Name:

SA

M F

Patient’s Medical Diagnosis:

Age:

48

Date:

7/16/15

Psychosis

State a short term objective for yourself during this nursing care experience:
Learn and practice some of the skills that I learned the
last semester. Also practice the correct form of charting and using the nursing care plan.

Define in your words the current diagnosis:

It is the condition of the mind involving loss of contact with reality.

A mental disorder in which there is severe loss of contact with
Summary of diagnosis (Etiology and pathology) according to textbook:
reality. Evidenced by delusions, hallucinations, disorganized speech patterns, and bizarre or catatonic behavior. Psychotic disorders are
common features of schizophrenia, bipolar disorders, and some affective disorders. They can also result from substance abuse (such as
hallucinogens), substance withdrawal (such as delirium tremens), or side effects of some prescription drugs. Etiology: alterations in brain

structure and changes in dopamine neurotransmission. The dopamine changes are directly related to hallucination and delusions.
Symptoms according to textbook:

In psychotic states patients may express unusual ideas (such as that they can read the minds of
others, send radio messages directly to God or inanimate objects, travel to distant galaxies). These ideas are called delusions. Psychosis
is also marked by patients’ reports of hearing voices (auditory hallucinations) or seeing objects or persons not visible to others (visual
hallucinations). Auditory hallucinations are hallmarks of schizophrenic and manic states; visual hallucinations are characteristic of drug
intoxication or withdrawal. Disturbances in thought content and form, perception, affect, sense of self, volition, interpersonal relationships,
and psychomotor behavior occur. Thorough physical and psychiatric examinations rule out organic causes of the patient symptoms and
establish the diagnosis.
Treatment goals focus on meeting the patient’s physical and
psychosocial needs, and usually combine drug therapies with behavioral therapies, long-term psychotherapy, psychosocial rehabilitation,
and/or vocational counseling, requiring use of community resources. Patients with psychosis are treated effectively with neuroleptic drugs
(which appear to work by blocking postsynaptic dopamine receptors), such as haloperidol, risperidone, or chlorpromazine. Side effects of
some of these medications include dystonic reactions and tardive dyskinesia. The newer agents produce fewer of these extrapyramidal
symptoms. Treatment drugs also have sedative, anticholinergic, and orthostatic hypotension effects, and about 1% of patients taking these
agents experience neuroleptic malignant syndrome (life-threatening fever, muscle rigidity, and altered level of consciousness).

Textbook Medical Management (Dx studies and treatment):

Textbook Nursing Diagnosis
Based on Maslow’s Hierarchy
1) Constipation
2) Risk for violence
3) Anxiety
4) Risk for suicide
5) Disturbed sensory perception r/t biochemical imbalances
AEB violent behavior and noncompliances with taking
medications
References (Author & Page No.)

Admission
Date:

7/14/15

Procedures to be performed by students
Based on Nursing Diagnosis
1) Assess usual pattern of elimination and compared with present
pattern including size, frequency, color and quality
2) Assess physiological signs and external signs of anger.
3) Assess the client’s level of anxiety and physical reactions to anxiety.
Using the Hamilton Anxiety Scale.
4) Assess for any changes in mood, or behavior every 30 min to 1 hour
5) Assess and identify behavioral response that may indicate mental
problems

Nursing central: Taber’s dictionary, disease and disorders.

Number of days in Hospital:

2

2
Admitted Via:

Mode 
Amb:

Statement of Present Complaint:

n/a

PPD:

Reason:
y

Major Illness, Operations, Blood Transfusions or Pregnancies:
1 Psychosis
.
2 Bipolar disorder
.
3 Hyperlipidemia
.
4 Suicidal ideation
.
5 Depressive disorder
.
6 Schizophrenia
.
Health Maintenance:
Exercise Type:
n/a
Hobbies if any:
Tobacco  Type:
Cigarettes
Alcohol 
Type:
Other  Type:

Other
:

Court Ordered

Psychosis, exhibiting self, paranoia, delusions & auditory hallucinations

Last Hospital Admission Date: 8/24/06
Immunization Current (y/n): y

GENERAL INFORMATION

Mc
:

n/a

Frequency:

drug overdose
Notes Influenza
:

7.

n/a

8.

n/a

9.

n/a

10
.
11.

n/a

12
.

n/a

n/a

n/a

QTY/day x yrs.:

Quantity:
4/day 31 years

Beer

QTY/week:

12 cans/ week

Cocaine

QTY/week:

5 grams/ week

n/a

If quit,
date:
If quit,
date:

n/a

If quit,
date:

n/a

n/a

Allergies: Ibuprofen, naproxen
Medication
(including IVs)

Dose

Frequency

Route

Time
to be

Classification / Action / Rationale

Nursing Intervention

3
Lithium

300mg

QD

PO

0600,
1400,
2200

Mood stabilizer
Action
Alters cation transport in nerve and muscle.
May also influence reuptake of
neurotransmitters.
Therapeutic Effect(s):
Prevents/decreases incidence of acute manic
episodes.
Rationale:

MEDICATION

Manic episodes of bipolar I disorder
(treatment, maintenance, prophylaxis).

Assess mental status
(orientation, mood,
behavior) initially
and periodically.
Initiate suicide
precautions if
indicated.
Monitor intake and
output ratios. Report
significant changes
in totals. Unless
contraindicated,
fluid intake of at
least 2000–3000
mL/day should be
maintained. Weight
should also be
monitored at least
every 3 mo.
Lab Test
Considerations:
Evaluate renal and
thyroid function,
WBC with
differential, serum
electrolytes, and
glucose periodically
during therapy.
Toxicity Overdose:
Monitor serum
lithium levels twice
weekly during
initiation of therapy
and every 2 mo
during chronic
therapy. Draw blood
samples in the
morning
immediately before
next dose.
Therapeutic levels
range from 0.5 to 1.5
mEq/L for acute
mania and 0.6–1.2
mEq/L for long term
control. Serum
concentrations
should not exceed
2.0 mEq/L.
Assess patient for
signs and symptoms
of lithium toxicity
(vomiting, diarrhea,
slurred speech,
decreased
coordination,
drowsiness, muscle
weakness, or
twitching). If these
occur, report before
administering next
dose.

4
Quetiapine
SEROQUEL

300mg

At
bed
time

PO

2200

Antipsychotics, mood stabilizers
ACTION
Probably acts by serving as an antagonist of
dopamine and serotonin.
Also antagonizes histamine H1 receptors
and alpha1-adrenergic receptors.
Therapeutic Effect(s):
Decreased manifestations of psychoses,
depression, or acute mania.
RATIONALE
Schizophrenia.
Depressive episodes with bipolar disorder.
Acute manic episodes associated with
bipolar I disorder (as monotherapy [for
adults or adolescents] or with lithium or
divalproex [adults only]).
Maintenance treatment of bipolar I disorder
(with lithium or divalproex).
Adjunctive treatment of depression.

Monitor mental
status (mood,
orientation,
behavior) before and
periodically during
therapy.
Assess for suicidal
tendencies,
especially during
early therapy.
Restrict amount of
drug available to
patient. Risk may be
increased in
children,
adolescents, and
adults ≤24 yr.
Assess weight and
BMI initially and
throughout therapy.
Monitor BP (sitting,
standing, lying) and
pulse before and
frequently during
initial dose titration.
If hypotension
occurs during dose
titration, return to
the previous dose.
Observe patient
carefully when
administering to
ensure medication is
swallowed and not
hoarded or cheeked.
Monitor for onset of
extrapyramidal side
effects (akathisia–
restlessnessdystonia
– muscle spasms and
twisting motions; or
pseudoparkinsonism
– mask-like faces,
rigidity, tremors,
drooling, shuffling
gait, dysphagia).
Report these
symptoms; reduction
of dose or
discontinuation may
be necessary.
Trihexyphenidyl or
benztropine may be
used to control these
symptoms.
Monitor for tardive
dyskinesia
(involuntary
rhythmic movement
of mouth, face, and
extremities). Report
immediately; may be

5
Lorazepam
(Ativan)

1mg

prn

PO

Antianxiety agents
sedative/hypnotics
ACTION
Depresses the CNS, probably by
potentiating GABA, an inhibitory
neurotransmitter.
Therapeutic Effect(s):
Sedation.
Decreased anxiety.
Decreased seizures.
RATIONALE
Anxiety disorder (oral).
Preoperative sedation (injection).
Decreases preoperative anxiety and
provides amnesia.
Unlabeled Use(s):
IV: Antiemetic prior to chemotherapy.
Insomnia, panic disorder, as an adjunct with
acute mania or acute psychosis.

6
Pallaperidone
INVEGA
SUSTENNA

6mg QD

once
daily

PO

QD
0800

Antipsychotic
ACTION
May act by antagonizing dopamine and
serotonin in the CNS. Paliperidone is the
active metabolite of risperidone.
Therapeutic Effect(s):
Decreased manifestations of schizophrenia.
Decreased manifestations of schizoaffective
disorder.
RATIONALE
Acute treatment of schizoaffective disorder
(as monotherapy or as adjunct to mood
stabilizers and/or antidepressants).

Monitor patient's
mental status
(orientation, mood,
behavior) before and
periodically during
therapy. Monitor
closely for notable
changes in behavior
that could indicate
the emergence or
worsening of
suicidal thoughts or
behavior or
depression,
especially during
early therapy.
Restrict amount of
drug available to
patient.
Assess weight and
BMI initially and
throughout therapy.
Monitor BP (sitting,
standing, lying
down) and pulse
before and
periodically during
therapy. May cause
prolonged QT
interval, tachycardia,
and orthostatic
hypotension.
Observe patient
when administering
medication to ensure
that medication is
actually swallowed
and not hoarded or
cheeked.
Monitor patient for
onset of
extrapyramidal side
effects (akathisia–
restlessnessdystonia
– muscle spasms and
twisting motions; or
pseudoparkinsonism
– mask-like face,
rigidity, tremors,
drooling, shuffling
gait, dysphagia).
Report these
symptoms; reduction
of dose or
discontinuation of
medication may be
necessary.
Monitor for tardive
dyskinesia
(involuntary
rhythmic movement
of mouth, face, and

7
DOCUSATE

240mg

prn

PO

prn
qd

Laxative, stool softner
ACTION
Promotes incorporation of water into stool,
resulting in softer fecal mass.
May also promote electrolyte and water
secretion into the colon.
Therapeutic Effect(s):
Softening and passage of stool.

Assess for
abdominal
distention, presence
of bowel sounds,
and usual pattern of
bowel function.
Assess color,
consistency, and
amount of stool
produced.

RATIONALE
Prevention of constipation, soften stool

IV Solution

Rate (drops/minute)

Titration LML/hr

Access Port

Pump/Type

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a

n/a
May use back for more space!!

NEUROSENSORY

8
Best Response to Auditory
Hand Grip:
Eye Movement:
and/or Visual Stimulus
Equal
Normal

Age over 2 years (child/adult)
Unequal
Nystagmus
n/a
Orientation (5)
Weakness
Strabismus

n/a
Confused (4)
Right
Other
n/a
n/a
Inappropriate words (3)
Left
Mood/Affect:

n/a
Incomprehensible words (2)
Muscle Tone:
Happy
n/a
None: (1)
Normal
Content
n/a

Age 2 years and under (infant)
Arching
Quiet
n/a
Smiles, Listens, Follows (5)
Spastic
Withdrawn
n/a
n/a
Cries, consolable (4)
Flaccid
Sad
n/a
n/a
Inappropriate persistent cry (3)
Weak
Flat
n/a
n/a
Agitated, restless (2)
Decorticate
Hostile
n/a
n/a
No Response (1)
Decebrate
Fontanel/Window:
n/a
n/a
Eyes Open
Other
(pertaining to infant)
n/a
Spontaneously (4)
LOC:
Soft

To speech (3)
Alert/Oriented
Flat
n/a
n/a
To pain (2)
Sleepy
Sunken
n/a
n/a
No response (1)
Irritable
Tense
n/a

Best Motor Response
Comatose
Bulging
n/a
Obeys Commands (6)
Disoriented
Closed
n/a
n/a
Localizes pain (5)
Lethargic
Other
n/a
n/a
Flexion Withdrawal (4)
Awake
n/a

Flection Abnormal (3)
Sleeping
n/a
n/a
Extension (2)
Drowsy
n/a
n/a
None (1)
Agitated
n/a
n/a
COMA SCALE TOTAL:
12
Related Dx. Studies (lab work, x-rays, etc):
n/a
Collaborative Care Referral: n/a
Related NSG Dx:
Anxiety r/t unconscious conflict with reality AEB impaired attention.

CARDIOVASCULAR

Skin Color:


n/a
n/a
n/a

Pupils:
Right:
Size:
Reaction:

3

1

Left:

n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

Size:
Reaction:

3

1

CODE
7 mm
6 mm
5 mm
4 mm
3 mm
2 mm
1 mm

COMMENTS
Edema:
COMMENTS
n/a
+2 pitting edema to right arm.
Normal
No
n/a

Flushes
n/a
Yes

Pale
n/a
Chest Pain:
Cyanotic
n/a
No

Heart Sounds:
Yes
n/a
Normal
P
n/a

Other, Describe
n/a
Q
n/a
Apical Pulse Rate:
n/a
R
n/a
Regular
S
n/a
n/a
Irregular
n/a
T
n/a
Pacemaker:
Family Cardiac
Type
n/a
History:
Rate
n/a
No

Peripheral Pulses:
Yes
n/a
Present
Telemetry Monitor

Equal
No


Weak
n/a
Yes
n/a
Absent
n/a
Rhythm
n/a
Monitor, Lines, & Data:
n/a
Related Dx. Studies (lab work, x-rays, etc):
HGB: 13.8, HCT: 25.3, Platelets: 214,000
Related NSG Dx:
Knowledge deficit r/t lithium adverse effect AEB patient reporting unknown cause of palpitations.
Collaborative Care Referral: RC: hyperlipidemia.

PULMONARY

9
Respirations
:
Rate
Regular
Irregular
SOB
Dyspnea on

Cough:
18


n/a
n/a
n/a

None

Productive
n/a
Nonproductive
n/a
Describe
n/a

Explain

O2 at home

No

Auscultation: (clear, crackles, rhonchi,

Chest expansion
Symmetrical
Asymmetrical

n/a

wheezing)

Anterior

Posterior


n/a
n/a

Rt. Upper Lobe
Left Upper Lobe
Rt. Lower Lobe

n/a
n/a
n/a

n/a
n/a
n/a

GENITOURINARY / REPRODUCTIVE

GASTROINTESTINAL

10
Exertion n/a
Left Lower Lobe
n/a
n/a
Devices:
n/a
Related Dx. Studies (lab work, x-rays, etc):
n/a
Related NSG Dx:
Ineffective breathing pattern r/t medication regimen AEB patient taking Seroquel
Collaborative Care Referral: n/a
Abdomen:
STOOL:
Diarrhea:
n/a
Weight Fluctuation
Soft n/a
# BMs/day
1
Constipation:
Last 6 months
n/a

Rigid n/a
Last BM 2/2/15 Other:
Obese
n/a
pounds (+ -)
n/a
Non-tender n/a
Amount
n/a
Thin
n/a
Ideal weight for
Tender n/a
Formed
Emaciated
n/a
sex and age: 142 or less

Distended
Loose
n/a
Nourished
n/a
Present weight
149

Bowel Sounds:
Liquid
n/a
*******Nutrition:
Overweight
7
(lbs)
Present [P] /
P
Mucus
n/a
Refer to dietician
Underweight
n/a
(lbs)
Absent [A]
n/a
Ostomy
n/a
if available
RUQ
P
Type
DIET: 1800 calorie ADA
PURPOSE: to control the blood sugar and lose
RLQ
P
Incontinent
n/a
Tube feeding
n/a
weight or to lower the risk for heart problems.
LUQ
LLQ
Hypoactive
Hyperactive

P
P


n/a

Stool Color:
Brown
Black
Red Tinged
Bloody


n/a
n/a
n/a

Chewing Problem
Swallowing
Problem
Nausea/Vomiting
Poor Appetite

n/a
n/a
n/a
n/a
n/a

RESTRICTIONS: carbohydrates, fat, and protein

Devices:
n/a
Related Dx. Studies (lab work, x-rays, etc):
n/a
Collaborative Care Referral: RC: hyperlipidemia.
Related NSG Dx:
Constipation r/t medication regimen AEB verbalize fear of pain while defecating, inadequate fluid intake, and side effects of
lorazepam and seroquel
Bladder Habits:
n/a
Last void
LMP:
n/a
Pregnancies:
Frequency:
Color of urine Straw yellow
If any problem
n/a
Pregnant n/a
Dysuria
n/a
Amount
Sufficient
Describe
n/a
Weeks n/a
Nocturia
n/a
Appearance
Clear
n/a
Gravida/Para n/a
Urgency
n/a
Fluid & Electrolytes
5 cups
n/a
Date of last:
Hematuria
n/a
Total Shift Intake
5 cups
Last Pap Smear
n/a
Prostate Exam n/a
Retention
n/a
Previous 24 hrs
5 cups
Results
n/a
Testicular
n/a
Burning
n/a
Total Shift Output
5 cups
Breast self exam
n/a
self-exam n/a
Incontinence
Previous 24 hrs
5 cups
Use of
n/a
Daytime
n/a
Catheter
contraceptives
n/a
Nighttime
n/a
Intermittent
n/a
Type
n/a
Stress
n/a
Indwelling
n/a
Vaginal Discharge
n/a
Incontinence
n/a
Condom-cath.
n/a
Describe:
n/a
Occasional
n/a
Dialysis:
n/a
Othe
n/a
Access Site
n/a
Bleeding:
n/a
r
Amount:
n/a
Comments: n/a
Devices:
n/a
Related Dx. Studies (lab work, x-rays, etc):
Urine culture 7/14/15 Negative for UTI. No growth at <1000 CFU/mL. Na: 131 mEq/dL, K: 3.7,
Cl: 106, BUN: 11, Creatinine: 0.7
Related NSG Dx:
Risk for imbalanced fluid volume r/t hematocrit 25.3% and sodium levels 131 mEq/L
Collaborative Care Referral: n/a

MUSCULOSKELETAL

11
Musculoskeletal
Pain
Weakness
Contractures
Joint swelling
Paralysis
Deformity

n/a
n/a
n/a
n/a
n/a
n/a

Joint Stiffness
n/a
Cast
n/a
Amputation
n/a
Describe
n/a

Full ROM:
Limited ROM:
Gait:
Steady
Unsteady
Mobility in bed
(able to turn self)

n/a
n/a


n/a



Functional Independence Measure Levels
Total Assist (subject = < 25% effort)
Maximal Assist (subject = 25% effort +)
Moderate Assist (subject = 50% effort +)
Minimal Assist (subject = 75% effort +)
Supervision (stand-by assist, verbal cues)
Modified Independence (device needed)
Complete independence (timely, safety)

n/a
n/a
n/a
n/a
n/a
n/a



Devices:
n/a
Related Dx. Studies (lab work, x-rays, etc.): n/a
Collaborative Care Referral: n/a
Related NSG Dx.:
Risk for falls r/t medication AEB patient reported dizziness after taking lorazepam,
Skin Integrity: Indicate the location of any of the following on the chart to the right using the
designated letter:
A. rashes
n/a
E. pressure sores
n/a
B. lesions
F. recent scars


C. significant bruises / abrasions
n/a
G. presence of tubes / appliances
n/a
n/a
D. burns
n/a
H. other:

INTEGUMENTARY

Pressure Sore Potential Assessment

C

PARAMETERS
Mental Status

0
Alter

1
Lethargic

Activity
Mobility
Incontinence

Ambulatory
Full
None

Needs Help
Limited
Occasional

Oral nutrition
Oral fluid intake
Predisposing
diseases
(diabetes,
neuropathies,
vascular
disease,
anemias)

Good
Good
Absent

Fair
Fair
Slight

2
3
Semi-Comatose
Comatose
Count these conditions as double
as DOUBLE
Chair=fast
Bedfast
Very limited
Immobile
Usually of
Total of urine
urine
and feces.
Poor
None
Poor
None
Moderate
Severe

Skin Temperature:

0
0
0
0
0
1

1
Patients with scores of 10 or above should be
considered at risk.

Skin Color:

Score
0

Hx of skin
healing
problems:

WNL



WNL



Pale
Cyanotic
Ashen
Jaundice
Other, describe

n/a
n/a
n/a
n/a
n/a

Warm
Cool

n/a
n/a

Other, describe

Tight
Loose
Other, describe



Mouth:
Gums WNL
White Plaque
Lesions

TOTAL

n/a

Teeth:

WNL

n/a

Other, describe

n/a

Skin Turgor

n/a
missin
g

teeths
Dentures:

n/a
n/a

n/a


n/a
n/a

Upper
Lower:
Full:
Partial:

n/a
n/a
n/a
n/a

COMMENTS

Devices:
Related Dx. Studies (lab work, x-rays, etc): n/a
Related NSG Dx:
Risk for infection r/t open lacerations on extremities AEB patient touching and removing sutures with dirty hands.
Collaborative Care Referral: n/a
n/a
n/a
n/a
n/a

12
Mental Status:
Orientation Time
Place
Person
Situation

Perception






Hallucination
Delusion
Illusion
Describe:

Memory
PSYCHEMOTIONS

Affect Happy





Patient verbalized

Sad
Flat
Other, Describe





Intellectual Functioning

Patient

Able to Calculate

n/a

Able to Abstract

n/a

Judgment

n/a

Rational

n/a

is bipolar

of hearing voices.

n/a

Impulsive



n/a

Impaired

n/a

Immediate Recall



n/a

Recent Memory
Remote Memory

n/a
n/a

n/a
n/a

n/a
Suicidal Y/N
Y
n/a
Suicide Risk Y/N
Y
DEVELOPMENTAL STAGE ACCORDING TO ERIKSON
Theoretically:
Behaviorally:
Rationale:
Generativity vs. stagnation
Care
Career and work are the most important
things at this stage, along with family. Middle
adulthood is also the time wen people can
take on greater responsibilities and control.
Major Concerns Regarding Hospitalization / Illness
safety due to harm herself or others.

MISCELLANEOUS

Major Change in Life in the Past Year (Crisis / Loss / Others)
n/a
n/a
Related Dx. Studies (lab work, x-rays, etc.)
n/a
Collaborative Care Referral: n/a
Related NSG. Dx:
Risk for Violence r/t history of psychotic symptomatology as evidenced by distorted thinking that others are
trying to harm her
SLEEP / REST PATTERN
Habits
Feel Rested after
Problems: None
Use of Sleep

# hrs night
5
Sleep:
Y/N
Y
Early Waking
n/a
Aides:
Y/N
N
AM Nap Y/N
N
Comment
n/a
Insomnia
n/a
Describe
n/a
PM Nap Y/N
N
Nightmares
n/a
Related Dx. Studies (lab work, x-rays, etc.) n/a
n/a
Related NSG Dx:
Disturbed sleep pattern r/t interruptions AEB patient states nurse was in her room every hour with a flashlight.
Collaborative Care Referral: n/a

Occupation
Patient states
history of engagement
of prostitution
Employed Y/N
N
Retired N
Disability
N
Special Concerns: n/a

ROLES – RELATIONSHIP / HOME MAINTENANCE PATTERN
Support System
Private Pay
n/a
Spouse
n/a
Insurance
n/a
Neighbor / Friend
n/a
MDCR/ MDCD
n/a
Family in Same
No Known
n/a
Residence
n/a
Residence
n/a
Other Fam. Memb.
n/a
Patient Lives w/
n/a
None
n/a

Family Concerns Regarding
Hospitalization
n/a
n/a
n/a
n/a
n/a

Related NSG Dx:
Social isolation r/t alteration in mental status AEB absence of supportive significant other.
Collaborative Care Referral: n/a
VALUE-BELIEF PATTERN
Comments:
n/a
Religious / Spiritual Beliefs:

n/a

Patient request to contact minister / priest / rabbi:
 yes ✓ no
Name:
n/a
Phone Number: n/a
Related Dx. Studies (lab work, x-rays, etc.)
n/a
n/a
Related NSG Dx.
Spiritual distress r/t life changes AEB patient stated that she is a living sacrifice.
Collaborative Care Referral: n/a
Intended Destination

Problems with self care post discharge:

✓ yes

 no

EDUCATION NEEDS / DISCHARGE PLANNING

13
Post Discharge:
Patient is psychotic
and is not able to take care
Assessment
Analysis
Plan with brief If yes, explain:
Interventions
Evaluation
6 items Home n/aStatement
rationale for each oneof selfCorrelates with Was it normal
Undetermined n/a
Subjective
9 individual plans n/a
plan
or abnormal
other
devices needed post-discharge:
 yes ✓ no

&/or
NANDA 3 part
(3) Assessment Assistant
Put
here n/a
what Correlate with
Explain:
Patient
will
return
to
jail
If
yes,
explain:
Objective
Nursing
(3) activity
was done
interventions
n/a
Designate
with Diagnosis related
(3) action
Number them! Number them!
n/a or “O”
“S”
to As Evidence
Number them!
Previous Utilization of Community Resources:
Referral Date to Discharge:
by

Home Health n/a
Coordinator n/a
Hospice n/a
Home Health n/a
STG
Adult Day Care n/a
Social Service n/a
LTG
Church Group n/a
N.N.A. n/a
1. “S”Meals on Wheels n/aAnalysis
1. Assess the client’s
1. Validate Other n/a
1. Client was
“I feel anxious”
Statement:
anxiety
level
with
the
observations
by
not anxious
Home Aide n/a
Explain: Tropical Texas Behavioral
Health will fund a three day
Because
the
Hamilton
Anxiety
asking
the
client:
(Normal)
Other
stay in facility upon patient status.

medical
2. Client felt
Explain: Tropical client’s
Texas Behavioral
HealthScale.
n/a “Are you feeling
This is an important tool to
2. “S”
diagnosis is
dizziness in the
n/a
n/a anxious now?
assess anxiety.
“I feel
psychosis. The
morning
n/a dizzy”
n/a 2. Monitored

client
experiences
severe anxiety
episodes.

2. Assess side effects of
anti-anxiety
medication

side effects:
(abnormal)
drowsiness,
3. Client was
dizziness,
not aware of
Patient needs to be aware of
the possible side effects of the
disorientation,
current health
prescribed medication.
depression arrest problem.
Educational Needs:
n/a
3. Assess client’s
3. Asked the
(abnormal)
awareness of current
client if is aware
4. Client
health problem.
4. “S”
of
current
health
verbalized and
Barriers:
Past Experience:
n/a
This will help to prepare the
Reading Ability NANDA
n/a
“TV sound
3 part plan of care and to set the n/a problem
demonstrate a
short term and long term
Sensory
n/a 4. 5 min teaching breathing
makes
me Problems n/a nursing
goals.
Physical State n/a
Learning
Readiness:
Mentally
impaired
anxious”
diagnosis:
session
of
relaxation
4. Teach the client
Language n/a
breathing
technique
skills of cognitive
Other

Anxiety r/t
relaxation
(normal)
restructuring.
Explain: Patient is not
mentally stable.
unconscious
techniques
5. Client
Client can learn to control
Support
to be involved:verbalized
Patient does
5. “S”
conflict with
5. 5Systems
min teaching
thenot have a
anxious feelings, rather than
Present
Knowledge:
Aware
of
the
chronic
illness
and
the
family
support
system.
be controlled by them.
“I don’t need
reality AEB
session of
importance of
possible outcomes.
n/a
5.
Teach
the
necessity
medication”
impaired
prescribed
taking
of adherence to the n/a medication and
attention.
medications.
Teaching Plan and Expected Outcome:
Medications
Teach the patient about the importance of taking medication and
prescribecompliance.
medication.
side
effects.
(normal)
understanding name of medications, what is for
and side
Patients
needeffects.
to knowTeach
the the patient cognitive-behavioral activities such as active problem
6.
Implemented
6. Client
importance
of continuing
solving. Teach the client to drink plenty of fluids
and to consume
3-4gr of sodium. Teach the client to notice
stimuli that increase anxiety.
treatment.
6. “S”
STG:
a
5
min
teaching
verbalized
Teach the client skills of cognitive restructuring. Teach the client there are agencies for counseling, and support
groups for follow up
6. Teach
theanxiety.
client to
“I really
trust
By
therelaxation
end of techniques
session of anxiety anxiety
assistance.
Teach the
client
to decrease
you Collaborative
and I feel ICare shift
patient will notice stimuli that
triggers.
triggers.
Referral:n/a
increase
sense
of
can Related
tell you
be able to
7. 0900
Patient
(normal)
NSG Dx: Knowledge
deficit r/t mental
status AEB
reoccurring
psychotic
episodes.
anxiety.
anything”
verbalize
assisted to coping 7. Client
Anxiety triggers can be simple
techniques to
group session.
enjoyed coping
things, but it is important that
reduce anxiety
8.
0800
group session.
the client recognized them.
Lorazepam
PO
(normal)
7. Implement a
given
as
per
LTG:
8. Client
supportive therapy
physician’s orders
By discharge
tolerate
program.
Support groups helps to
patient will
medication
control symptoms.
9. Patient
report a
well. (normal)
8. Administer
enjoyed classical
reduction in the
9. Client stated
Lorazepam 1mg q6h
music during
level of anxiety
to feel relaxed
as prescribed.
breakfast
.
and no anxiety
Benzodiazepine is prescribed
triggers.
to control anxiety disorders
9. Provide client with
(normal)
a means to listen to
music of their choice
Other Comments:
n/a
3. “S”
n/a
“I am
n/a not sick”

n/a

Music helps to relax and
control anxiety.

14

RETHINK, REPLAN, REDO
Take the Plan on previous page with rationale and tell future nurses what needs to be done
1. Assess the client’s anxiety level with the Hamilton Anxiety Scale. Nurse continues with plan of care to assess the anxiety
level of the patient

2. Assess side effects of anti-anxiety. Nurse continues to assess the side effects of anti- anxiety medication.

3. Assess client’s awareness of current health problem. Nurse continues with assessment until patient verbalizes the
correct understanding of illness.

4. Teach the client skills of cognitive restructuring. Nurse continues with the teaching sessions because client liked the
dynamic.

5. Teach the necessity of adherence to the prescribe medication. Nurse continues with the teaching session until patient is
discharge.

15
6. Teach the client to notice stimuli that increase sense of anxiety. Nurse continues with the teaching session until patient
is discharge.

7. Implement a supportive therapy program. Nurse continues with supportive therapy until patient is discharge and case
manager should refer patient.

8. Administer Lorazepam 1mg q6h as prescribed. Nurse continues with prescribed medication until order is changed.

9. Provide client with a means to listen to music of their choice. Nurse continues with activity until change of care plan.

8/14

16
Assessment
6 items
Subjective
&/or
Objective
Designate with
“S” or “O”
1. “O”
Patient locked in facility for
safety
2. “O”
Patient diagnosis falls on
Axis I
3. “O”
Notice patient punching the
wall.
4. “S”
Patient stated to want to
punch cafeteria staff.

Analysis Statement
NANDA 3 part Nursing
Diagnosis related to As
Evidence by
STG
LTG
Analysis: Because the patient is
psychotic and locked in facility
for safety.
NANDA 3 part nursing
diagnosis:
Risk for Injury r/t impaired
thought process, violent out
burst, and prolonged
hallucinations AEB client in
locked facility for safety.
STG: By the end of shift the
patient will remain free of
injury

1. Assess judgment regarding
potentially dangerous activities.
Poor judgment and decision-making skills put
the client at risk for injury

2. Assess for physical or cognitive
function alterations that might lead
to unsafe behaviors.
Risk taking, hypersexuality, and decreased
ability to concentrate to racing thoughts place
the client at risk for injury.

3. Assess for suicidal ideation
Depression can be associated with suicidal
ideation.

4. Teach patient to follow up with
PCP referral to outpatient services
such as Tropical Behavioral Health,
Social Worker.
Patient needs to obtain ongoing support
systems for successful treatment plan.

5. Teach the client about behaviors
and responses to environmental
stimuli that may be harmful.

5. “O”
Patient was verbally
aggressive by cursing staff
6. “O”
Patient was seen pacing in
the hallway

Plan with brief rationale for each
one
9 individual plans
(3) Assessment
(3) activity
(3) action
Number them!

LTG: By discharge the patient
will recognize behaviors that
place self in potentially
dangerous situations

To help client to deal with life-long illness. To
be aware of stressors that may be harmful.

6. Teach patient effective coping
behaviors.
Interventions beyond the acute phase address
lifestyle management with an illness that alters
judgment.

7. Place the client in a room as
close as possible to the nurse’s
station.
In order to have a clear visual of the client

8. Speak in short, simple sentences
Communicate so that the client understands
within his or her attention span.

9. Provide a safe, structured
environment
The RN controls the environment in the locked
facility to prevent injury.

Interventions
Correlates with plan
Put here what was done
Number them!

1. Assessed judgment regarding
potentially dangerous activities
by asking patient how she will
react in different dangerous
scenarios.
2. Assessed attention span,
ability to concentrate, and
feelings of grandiosity by
interviewing the patient
3. Asked the patient directly if
have you thought about
harming yourself?
4. 10 min teaching session using
on the importance of following
with outpatient services and
introducing patient to social
worker.
5. 10 min teaching session on
how to avoid confrontations by
redirecting attention to the
room maintaining physical
distance from negative stressors.
6. 10 min teaching session on
how to deal with a stressful
situation by doing relaxation
techniques like deep breathing
exercises.
7. Moved client to a room next
to the nurse’s station.
8. Be careful not to move into
personal space, by remaining 23 feet away and speaking softly
and slowly.
9. Provided the client with
enough personal space so does
not disrupt others with
behaviors she cannot control.

1
w
(

2
t
(

3
h
o

4
i
s

5
v
r
n

6
b
s

7
c
(

8
m
p

9
c
p
S
a
w

L
b
f

17
RETHINK, REPLAN, REDO
Take the Plan on previous page with rationale and tell future nurses what needs to be done

1. Registered nurse assessed judgment regarding potentially dangerous activities by asking patient how she will
react in different dangerous scenarios. RN continues with assessment until discharge.
2. Registered nurse assessed attention span, ability to concentrate, and feelings of grandiosity by interviewing
the patient. RN continues with assessment until discharge.
3. Registered nurse asked the patient directly about thought of harming yourself? RN continue to assess for
suicidal ideations until patient is free of injury and suicide.

4. Registered nurse taught 10 min of the importance of following with outpatient services and introducing
patient to social worker. Social worker continues with care and case management please assist with referral.
5. Registered nurse taught 10 min on how to avoid confrontations by redirecting attention to the room
maintaining physical distance from negative stressors. RN continues with follow up.

6. Registered nurse taught 10 min on how to deal with a stressful situation by doing relaxation techniques like
deep breathing exercises. RN continues with compliance.
7. Registered nurse moved client to a room next to the nurse’s station. RN maintain patient near to nurse’s
station.
8. Registered nurse was careful not to move into personal space, by remaining 2-3 feet away and speaking
softly and slowly. RN continues with plan of care.
9. Registered nurse provided the client with enough personal space so does not disrupt others with behaviors
he cannot control. RN continues with plan of care.

18

Plan of Care Sheets
Assessment
6 items
Subjective
&/or
Objective
Designate with
“S” or “O”

1.
“S” Pt states, “They are
trying to turn me into a
cat.”
2.
“S” Pt states nobody
understands her.
3.
“S” Pt verbalizes
hearing voices to be a
sacrife.

NANDA 3 part Nursing Diagnosis
related to As Evidence by
STG
LTG

Analysis: Because the
patient verbalized that
others are trying to harm
her.

1. Assess environment, evaluate
situations that could become
violent
Rationale:

NANDA 3 part nursing
diagnosis:

2. Assess the client for
physiological signs and external
signs of anger.

Risk for Violence r/t history
of psychotic
symptomatology as
evidenced by distorted
thinking that others are
trying to harm her

Stressful environments can cause for pt
to get aggravated.

Rationale:
Anger signs may indicate a violent
outburst.

3. Assess for the presence of
hallucinations.
Rationale:
Command hallucinations may direct the
client to behave violently.

4. Administer and monitor drug
regimen.
Rationale:
Identify drug side or adverse effects that
may cause or exacerbate sensory or
perceptual problems.

4.
“O” lacerations on
both lower extremities
5.
“O” Pt shows hostile
behavior (screaming
and cussing down the
hall)

Plan (Intervention with brief
rationale) for each one
9 individual plans
(3) Assessment
(3) activity
(3) action
Number them!

STG: By the end of my shift
patient will be safe and free
from injury.
LTG: By discharge, Pt will
display nonviolent behavior
toward self and others in

5.Take action to minimize personal
risk: Use nonthreatening body
language. Maintain at least an
arm’s length distance from the
client; do not touch the client
without permission. Do not allow
client to block access to an exit. Be
aware of where other staff is at all
times.
Rationale:
Safety of client and others.

6.Collaborate with other health

Interventions (actually performed)
Correlates with plan
Put here what was done
Number them!

1.Assessed environment, and
surroundings, (patients and
activities around them)
2. Assessed the pt for physiological
signs and external signs of anger:
Internal signs of anger include
increased pulse rate, respiration
rate, and blood pressure; chills;
prickly sensations; nausea; and
vertigo. External signs include
increase muscle tone, changes in
body temperature, eye changes,
lips pressed together, flushing or
pallor, goosebumps, twitching and
sweating
3.Assessed patient for presence of
hallucinations over breakfast.
4.Administered
Lithium 300 mg q8h
Seroquel 300mg at bedtime.
5. Took action to minimize
personal risk by following protocol
and maintaining arm length
distance from client and
surrounded by staff at all times.
6. Collaborate with staff to
encourage patient to assist group.
7. Taught patient importance in
following drug regimen; and
adverse effects of Lithium. To
watch for blurred vision, increased
urination, diarrhea, vomiting and
tremors. Made clear the
importance of fluid intake (2-3 L
per day) and the importance tof
sodum intake (3-4 g/day).
8. Taught patient cognitive-

19
6.
“O” PT medical history
show past of substance
abuse

the, with the aid of
medications and nursing
interventions by showing no
signs of violence.

team members in providing
therapy an stimulating modalities
Rationale:
To achieve maximal gains tin function
and psychosocial well-being.

7. Teach patient about medications
actions, side effects, target
symptoms, and toxic reactions.
Rationale:
To avoid harmful interactions and/or
drug toxicity.

8.Teach patient cognitivebehavioral activities, Teach client
to confront own negative thought
patterns or unrealistic
expectations.
Rationale:
Cognitive-behavioral activities address
client’s assumptions, beliefs an attitudes
about their situations fostering
modification of these elements to be as
realistic as possible, becoming more
aware of their cognitive choices and
exercising greater control over their own
reactions.

9.Teach and encourage the use of
appropriate emergency community
resources.
Rationale:
It is necessary to get immediate help
when violence occurs.

behavioral activities such as active
problem-solving, and thought
stopping to confront own negative
thought patterns.
9. Instructed patient to contact
Tropical health, or 911 in case of
an emergency when she felt angry
or stressed.

20

RETHINK, REPLAN, REDO
Take the Plan on previous page with rationale and tell future nurses what needs to
be done

1. Nurse continues to assess environment, evaluate situations that could become violent

2. Nurse continues to assess the client for physiological signs and external signs of anger.

3. Nurse continues to assess for the presence of hallucinations

4. Nurse continues to Administer and monitor drug regimen (Lithium 300 mg q8h Seroquel 300mg at bedtime).

5. Nurse continues to take action to minimize personal risk: Use nonthreatening body language. Maintain at
least an arm’s length distance from the client; do not touch the client without permission. Do not allow client to
block access to an exit. Be aware of where other staff is at all times.

6. Nurse continues to collaborate with other health team members in providing therapy an stimulating
modalities

7. Nurse continues to teach patient about medications actions, side effects, target symptoms, and toxic
reactions.

8. Nurse continues to teach patient cognitive-behavioral activities, Teach client to confront own negative
thought patterns or unrealistic expectations.

9. Nurse continues to teach and encourage the use of appropriate emergency community resources.

21

8/14
Assessment
6 items
Subjective
&/or
Objective
Designate with
“S” or “O”

NANDA 3 part Nursing Diagnosis
related to As Evidence by
STG
LTG

1. “S” Pt yields, “Sacrifice is
needed”

NANDA 3 part nursing
diagnosis:

2. “O” Multiple laceration to
bilateral wrists and thighs.

Risk for Suicide r/t
schizophrenia after
depression, as evidence by
previous attempt to suicide.

3. “S” Pt yields,
“ I need to be Crucified”
4. “O” History of previous
suicide attempt
5. “S” Pt states,
“I wish I were dead”
6. “O” Psychiatric
illness/disorder. Depression,
Schizophrenia

STG: By the end of my shift
patient will remain safe and
unharmed.
LTG: By discharge, Pt will
continue group interventions
that can be useful to address
recurrent suicide attempts..

Plan (Intervention with brief rationale)
for each one
9 individual plans
(3) Assessment
(3) activity
(3) action
Number them!

Interventions (actually performed)
Correlates with plan
Put here what was done
Number them!

1. Assess Ms. S.A. the ability to
enter into a no-suicide contract.

1. If possible during admission
or when raptor has been
stablished with patient, a nosuicide contract has to be made.

Rational: Discussing feelings of self-harm
with a trusted person provides relief for the
client. A contract gets the subject out in the
open and places some of the responsibility for
safety with the client.

2. Conduct a thorough physical
assessment, focusing in
integumentary system.
Rational: New lacerations may indicate
continue to self-mutilation and access to sharp
object.

3. Assess for the influence of
cultural beliefs, norms, and values
on Ms. S.A.’s perceptions of
suicide.
Rational: What the individual believes about
suicide may be based on cultural perceptions.

4. Observe, record, and report any
changes in mood or behavior that
may signify increasing suicide risk
and document results of regular
surveillance checks.
Rational: Suicidal ideation often is not
continuous; it may decrease, then increase in
response to negative thinking or exposure to
stressors.

5. Encourage patient to
demonstrate care to herself, 5
children and sister.
Rational: The familial characteristics of care
and support may be associated fostering
resiliency in families. Resilience is the ability
to experience adverse conditions and
successfully overcome them (Calvert, 1997).

6. Refer for homemaker or
psychiatric home health care
services for respite, client
reassurance, and implementation
of a therapeutic regimen.
Rational: The Depression Care for Patients at
Home (Depression CAREPATH) program
provided assistance for medical and surgical
homebound clients as a routine part of clinical

2. During admission a physical
assessment has to be perform to
establish a data base, for
possible future self-injuries.
Physical assessment to be done
twice a day at 8:00 hrs and
20:00 hrs.
3. Assessment of cultural
beliefs, norms and values
should be performed once a day
at 13:00 after lunch, to identify
unique cultural responses to
stressors in determining
sensitive interventions to
prevent suicide.
4. Assessment for any changes
in mood or behavior at 8:00,
every 30 minutes to 1 hour,
which may signify increasing
suicide risk.
5. Today at 09:00 patient
consulted the Phycologist and
patient has been provided with
encouragement to self-care, it
has been provided access to her
favorite perfume and it has
been encourage to seek help
from her 5 children and sister
for moral support.
6. Before patient is discharged
home, provide home care

22
practice (Bruce et al, 2011)

7. Teach cognitive-behavioral
activities, such as active problem
solving, reframing (reappraising
the situation from a different
perspective), or thought stopping
(in response to a negative thought,
picturing a large stop sign and
replacing the image with a
prearranged positive alternative).
Teach the client to confront his or
her own negative thought patterns
(or cognitive distortions), such as
catastrophizing (expecting the very
worst), dichotomous thinking
(perceiving events in only one of
two opposite categories), or
magnification (placing distorted
emphasis on a single event).
Rational: Cognitive-behavioral activities
address client’s assumptions, beliefs, and
attitudes about their situations and foster
modification of these elements to be as
realistic and optimistic as possible.

8. Provide the client with phone
numbers of appropriate
community agencies for therapy
and counseling. NAMI is an
excellent resource for client and
family support.
Rational: Continuous follow-up care should be
implemented; therefore, the method to access
this care must be given to the client (Sun &
Long, 2008)

9. Teach the patient how to
recognize that the client is at
increased risk for suicide (changes
in behavior and verbal and
nonverbal communication,
withdrawal, depression, or sudden
lifting of depression).
Rational: A client may be at peace because a
suicide plan has been made and the client has
the energy to carry it out. Therefore, when
depression lifts, increased vigilance is
necessary (Sun & Long, 2008).

10. Administer Invega Sustenna
(Pallaperidone) 6 mg once a day
for treatment of schizoaffective
disorder.
Rational: Antipsychotic, Action: May act by
antagonizing dopamine and serotoninin the
CNS. Paliperidone is the active metabolite of
risperidone.

assistance as patient preferable
company.
7. At 9:00 hrs, 14:00 hrs, and
before bed 19:00 hrs, it has
continue with teaching Ms.S.A.
cognitive-behavioral activities,
with will continue increasing
with positive and optimistic
attitude.
8. Before patient is been
discharge home, it has been
provided the patient with
NAMI Rio Grande Valley
(National Alliance on Mental
Illness) support group phone
number (956) 624-4960.
9. During team conference
meeting today at 13:00 hrs with
client, it has been provided
teaching on how to recognize
risk for suicide behaviors.
10. 6 milligrams of
Paliaperidone has been
administered at 08:00 hrs after
breakfast, once a day, every
day.

23

RETHINK, REPLAN, REDO
Take the Plan on previous page with rationale and tell future nurses what needs to
be done

1. A no-suicide contract has been signed by patient, which is kept in a secure place, Registered Nurse have easy
access to contract as need it, if Ms. S.A. becomes suicidal.
2. Registered Nurse needs to continue with physical assessment twice a day at 08:00 and 20:00, and Patient
Care Technician needs to report any new injuries to Registered Nurse if new injuries appear between
Registered Nurse Assessments.

24
3. Registered Nurse needs to continue with assessment of cultural beliefs, norms and values once a day at
13:00, to obtain a better understanding on patient’s perceptions of suicide.
4. Patient Care Technician, needs to constantly assess for any changes in Ms. S.A. mood or behavior, starting
from 08:00 the time the patient’s wakes up on frequency of every 30 minutes to an hour and provide results to
Registered Nurse.
5. Registered Nurse and Phycologist should continue to encourage to care to herself, her children and sister,
with the goal to create a positive boding for faster psychologic recuperation.
6. Referral has been made to psychiatric home health, Social worker will keep follow-up three days after
discharge for patient compliance.
7. Psychiatric Nurse continue with cognitive-behavioral activities daily, and continue increasing the level as
Psychiatrics orders.
8. Registered Nurse, and Social worker, before MS. S.A. is discharged home please reassure that the patient has
the number for NAMI Rio Grande Valley support group, 956-624-4960.
9. Psychiatric Nurse, please review teaching with Ms. S.A. about how to recognize if she becomes at risk for
suicide, also provide this information in writing.
10. As per Psychiatrist medicine prescription, continue with Paliaperidone 6 mg by mouth, daily. Paliaperidone
6mg po qd #30 + 2 refills prescription has been sent to Walgreens, FM 802. Medication will be ready to pick up
on 07/29/2015.

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