Mental Health Care Plan
· Physical Assessment Section
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.
Do not leave anything blank, put not available (N/A), within normal limits (WNL), or “Unable to assess due to…..”
· Psychosocial Assessment Section
. For Erikson’s stages of development, use the client’s age to determine what stage they are in. If a previous stage has not been successfully passed, add a description of this stage as well. For example, “Although the client is currently in the generativity vs. stagnation stage, he has not completed the intimacy vs. isolation stage as evidenced by ….
. Write complete sentences in the section.
· Pathophysiological section
. Refer to resources in the course shell for APA help. Use a database for the article, do not use Google. Databases will give you a scholarly article, and Google will send you elsewhere.
. Do not forget to list references and use at least one in-text citation.
. You may use your textbook as a secondary reference; however, one outside source (scholarly article) is required. Webpages such as WebMD are not considered scholarly articles. A scholarly article is peer-reviewed and published in a journal.
· Nursing Process Section
. Use critical thinking skills to determine the priorities for the client. Safety is usually at the top of the list, but not always.
. Use quotes for the “subjective data” if possible.
· For SMART outcomes
.
. The timely component is often missed. Make sure there is a measurement of time included such as: “By time of discharge, Q shift, Q HS, Q AM, etc.…”
· Make interventions timely as well: “for 10 minutes Q shift, By discharge, etc.…”
PATIENT/CLIENTDATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name:
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Week: 6
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Dates of Care:
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Demographics and Brief History
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Patient Initials
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Sex
F
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Age
6
1
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Room
SMN 15TH FL BH
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Admitting Date
11/
2
7/20
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Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Psychiatric evaluation. PT is a 61years old present from SFHED to SM-C for further psychiatric evaluation. Bought in by EMS found screaming on neighbor’s porch screaming and singing.
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Attending physician/Treatment team:
Krushen Pillary, DO (Attending)
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Precautions: High fall risk, sexual acting out, Assault
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Primary Diagnosis:
Bipolar affective disorder, manic severe with psyc behavior
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Co-morbidities:
Delusional
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Allergies: No known allergies
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Code Status: Full Code
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Isolation: (type and reason)
None
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Admission Height: 170.2cm (5.7)
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Admission Weight: 87.ikg (192 lb)
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Arm Band Location (colors & reasons) White color. For identification and medication administration.
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Past Medical History: (pertinent & how managed) Anxiety, PSTD (Post traumatic stress disorder)
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Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)
Patient was seen this morning for fall. Assessment limited due to current mental state. Sleeping, slurring word but denies pain. Patient does not appear to be in distress.
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Physical Assessments and Interventions: (Include all pertinent data)
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Vital signs:
Time
11/27/20
T
97.9 F
P
8
4
beat/min
R
18 breath/min
B/P
127/82 mmHg
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General Appearance:
Assessment: Sleepy and cooperative. Appears stated age. Not in distress. Disheveled
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GI:
Diet: Regular Diet. No known Allergies
Blood Glucose: (time & date) 98 11/27/20
Last bowel movement: (time & date) Pt stated
Pertinent Labs/Test: Glucose test
Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
Normal bowel sound, non – tender, non- distended, no masses, no diarrhea or vomiting, no constipation. PT denies any difficulty having bowel movement.
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Respiratory:
Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Pt has even skin tone, no nasal flaring or use of accessory muscle, no cyanosis to lips or nailbeds or pallor, no clubbing, no cough, no shortness of breath. Pt denies difficulty breathing.
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Neurosensory:
Alert & Orientated: Pt was AOx4 during the time of visit. She was able to state her full name, place, date and time. Pt denies
Follows commands: Pt was able to follow command
Speech Comprehensible: Normal rate, rhythm, tone, and normal volume
Pertinent Labs/Test:
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness). There was no record of loss of consciousness, pupils are equal, round accommodating, no involuntary movement was observed as at the time visit.
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Cardiovascular:
Pertinent Labs/Test:
Assessments/Interventions:
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) Pulses are equally strong +2 with no vibration in the strength noted. Pt denies chest pain.
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Musculoskeletal:
Activity: Patient stated that she likes to sing
Casts/Slings: None as at the time of visit
Assessments/Interventions:
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers) Provide supportive environment, patient was observed walking around with good balance, the joint reveals no warmth, swelling, or any deformities. Patient denies any pain in the joint.
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Renal:
Pertinent Labs/Test:
Assessments/Interventions: (location, bruit, thrill) (urine-quality, burning with urination, hematuria, incontinent, continent, I & O)
Patient denies any difficulty urinating
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Skin:
Braden Score: 22
Pertinent Labs/Test:
Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toenails, wounds, drains, bed type) Skin color is consistent with the genetic background, no signs of Bruises, wound or skin breakdown. Skin turgor was less than
3
seconds.
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Pain:
Pain score: No pain
Assessments/Interventions:
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)
Patient denies having any pain
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Gyn:
Gravida/Para: N/A
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge)
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Safety:
Bed Rails: Psych unit has no bed rails
Bed alarms: There is no bed alarm but there is counsellor that always monitoring the patient and makes round every 15 minutes.
Fall risk: Maintain fall precaution
Assistive Devices: No device but there are precautions to keep the patient save.
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Advance Directives/Ethical considerations:
AD: None but the chart indicated that the resources and information for advance directives will be provided at time of discharge
POA: There is no documentation to show POA
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Lab Values
Results
Normal Lab Values
Significance to your patient (if applicable)
WBC
5.9
4.5-11.0
Normal
RBC
4.04
4.7-6.1
HGB
12.4
13.5-17.5
HCT
37.2
41-50
MCV
91.9
MCH
30.2
27-33
Normal
MCHC
33.3
33.4-35.5
Platelets
305
150-400
Normal
RDW
13.0
11.8-
MPV
8.8
9.4-12.3
Glucose
98
70-100
Normal
BUN
8
7-20
Normal
Creatinine
0.60
0.6-1.3
Normal
Sodium
136
135-145
Normal
Potassium
3.4
3.5-5.5
Cloride
98
96-100
Normal
Calcium
9.1
8,5-10.2
Normal
Salicylate
Not recorded
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Psycho/Social Assessment
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·
Level of education
· Not on file
· Occupation
· Not on file
· Race/Ethnic Background or Identification
· Not on file
· Religion/Spiritual Beliefs
· Not on file
· Communication needs: (verbal, nonverbal, barriers, languages)
· Not on file
· Special Talents/Interests/Skills
· Not on file
· Environment (home and community)
· Not on file
· ADLs (sleep/rest; diet; exercise/mobility; elimination; substance use)
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·
·
·
·
· Family Structure/History: No family history on file
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Stage of Development: (Erikson’s Stage of Development, what stage is the client currently in and previous stages that the client may not have successfully completed) K.F is a 61-year-old female, he was admitted to the ER for psychiatric evaluation. Patient stated that she is 61years old and a divorcee. She was brought in by EMS found screaming on neighbor’s porch screaming and singing. Exhibiting bizarre behavior and appearing to respond to internal stimuli. However, according to Erikson’s stage of development this patient is in the stage seven. Generality vs stagnation (Middle- age; CARE) is the longest period of a human’s life. It is the stage in which people are usually working and contributing to society in some way and perhaps raising their children. If a person does not find proper ways to be productive during this period, they will probably develop feelings of stagnation. The patient supposed to have family that she cares for or cared about her which could have made her feel unproductive and disconnected from the society.
Middle-age is a time to think about leaving a legacy, to be productive, and to contribute to society.
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Support System: Pt with one sitter for safety
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Stressors/Stress Management Practices: Pt is encouraged to verbalize thought and feelings,
Encouraged to socialize with peers,
Encourage to practice effective coping skills and talk to staff about concerns.
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Pathophysical Discussion: For this section include appropriate references and use APA format
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Discuss the current disease process:
Bipolar disorder is characterized by recurrent episodes of mania and depression which suggests that mood instability and an impaired regulation of emotional states may be the core of the disorder (K,Usher 2015)
PATHOPHYSIOLOGY
The symptoms include:
· Mood swings
· Elevated mood
· Anger
· Anxiety
· General discontented
· Loss of interest or, or pleasure in activities
· restlessness
· delusion
· hyperactivity
The potential risk factors for psychiatric disorders can be classified as genetic, social or psychological (e.g. personality, environmental stressors and somatic disorders).
Social characteristics, a family history of mood disorders and some personality features were analyzed as risk factors for bipolar and depressive disorders by means of logistic regression. (Angst, J 2003)
References
Stegmayer, K., Usher, J., Trost, S., Henseler, I., Tost, H., Rietschel, M., Falkai, P., & Gruber, O. (2015). Disturbed cortico-amygdalar functional connectivity as pathophysiological correlate of working memory deficits in bipolar affective disorder. European Archives of Psychiatry & Clinical Neuroscience, 265(4), 303–311. https://doi-org.resu.idm.oclc.org/10.1007/s00406-014-0517-5
References
Angst, J., Gamma, A., & Endrass, J. (2003). Risk factors for the bipolar and depression spectra. Acta Psychiatrica Scandinavica. Supplementum, 108, 15. https://doi-org.resu.idm.oclc.org/10.1034/j.1600-0447.108.s418.4.x
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Discuss the etiology of the patient’s illness:
Bipolar disorder often runs in families, and research suggests that this is mostly explained by heredity—people with certain genes are more likely to develop bipolar disorder than others. Many genes are involved, and no one gene can cause the disorder.
But genes are not the only factor. Some studies of identical twins have found that even when one twin develops bipolar disorder, the other twin may not. Although people with a parent or sibling with bipolar disorder are more likely to develop the disorder themselves, most people with a family history of bipolar disorder will not develop the illness.
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Also note the complications that may occur with treatments and patient’s overall prognosis:
Complications that may occur are post stroke depression, shy, guilty, hopelessness, anxiety, insomnia, insecurity, maladaptive behavior. Drug anti – depressant may increase the suicide ideation among younger adults but among older people symptoms will be reduced.
Prognosis: The natural course of bipolar disorder varies. Without treatment, manic and depressive episodes tend to occur more frequently as people get older, causing increasing problems in relationship or at work. It often takes persistence of find the most helpful drug combination that has the fewest side effect. Treatment can be very effective; many of the symptoms can be diminished and, in some cases, eliminated. As a result, many people with bipolar disorder are able to function completely normally and have highly successful lives.
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Attach a research article pertaining to diagnosis of patient. Write a summary about the article:
Patients with BD experience recurrent episodes of pathologic mood states, characterized by manic or depressive symptoms, which are interspersed by periods of relatively normal mood. There are two major types of BD. Bipolar I disorder (BD I) is defined by the presence of at least one episode of mania, whereas bipolar II disorder (BD II) is characterized by at least one episode of hypomania and depression. The main distinction between mania and hypomania is the severity of the manic symptoms: mania results in severe functional impairment, it may manifest as psychotic symptoms, and often requires hospitalization. The duration of mood episodes is highly variable, both between patients and in an individual patient over time, but, in general, a hypomanic episode may last days to weeks, a manic episode lasts weeks to months, and a depressive episode may last months to years. Although a history of depressive episodes is not required to make a diagnosis of BD I by the DSM‐5 criteria, in practice most patients do experience depressive episodes; however, depressive episodes are required for a diagnosis of BD II.
Reference
McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530–542. https://doi.org/10.1002/2327-6924.12275
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Medications
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Classification
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Dose
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Route
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Freq
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Purpose/Mechanism of Action
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Significant Side Effects / Adverse Reactions
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Nursing Implications
|
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Haloperidol
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5mg
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oral
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PRN q6h
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Treatment of Tourette syndrome and schizophrenia, EMS sedation of severity, agitated or delirious pts
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Drowsiness, dizziness, urinary retention, tachycardia, hypotension, confusion, rash, nausea, and vomiting EPS
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Avoid abrupt withdrawal, avoid use with alcohol, CNS depressant, avoid changing positions, wear protective cloth, and sunglasses due to photosensitivity.
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Lorazepam
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1mg
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oral
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PRN Q6r
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Management of anxiety and irritability disorder in psychotics, treatment of insomnia, adjust therapy for endoscopic, procedures, relief of postoperative anxiety
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Drowsiness, fatigue, ataxia, blurred vision, constipation, dry mouth, neutropenia, respiratory disorder, orthostatic hypotension
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Smoking may decrease effectiveness, avoid use with alcohol, CNS depressant, may be habit-forming if used longer than 4 months. Do not discontinue abruptly after long term use.
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Lorazepam Injection
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1mg
intramuscular
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PRN Q6h
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Management of Anxiety
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Drowsiness, fatigue, ataxia, blurred vision, constipation, dry mouth, neutropenia, respiratory disorder, orthostatic hypotension.
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Smoking may decrease effectiveness, avoid use with alcohol, CNS depressant, may be habit-forming if used longer than 4 months. Do not discontinue abruptly after long term use.
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Paliperidone
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234mg
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once
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Management of symptoms schizophrenia
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Extreme tiredness, dizziness, restlessness, agitation, headache, dry mouth, weight.
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Monitor for development of neuroleptic malignant syndrome.
Assess for suicidal tendency especially during
Early therapy.
Monitor blood pressure
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risperidone
Magnesium hydroxide
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Antipsychotics / Antimanic agent
400mg/5ml
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1mg
15ml
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Oral
oral
oral
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2times a day
Daily PRN
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Schizophrenia/ decreased symptoms of psychoses, bipolar mania, or autism.
Constipation
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Aggressive behavior,
Extrapyramidal reaction
Constipation
Diarrhea
Visual disturbances
Decreased libido.
Circulatory collapse, hypothermia, pulmonary edema, flushing, drowsiness
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Monitor for development of neuroleptic malignant syndrome.
Assess for suicidal tendency especially during
Early therapy.
Monitor blood pressure.
Check serum magnesium level prior administration, Assess for drug interaction, drug incompatibility.
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Nursing Diagnosis
:
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.
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Priority
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Nursing Diagnosis
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Related to
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As Evidence By
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Rationale (reason for priority)
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1
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Risk for violence
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Screaming on neighbor’s porch
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Extreme hyperactivity/physical agitation
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Patient will be free of dangerous levels of hyperactive motor behavior with the aid of medications and nursing interventions within the first 24 hours.
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2
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Disturbed sleep pattern.
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symptoms of mania.
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Slurring word
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Patient safety is a piority
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3
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Impaired social interaction
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Withdrawal mood
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Social isolation
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The patient is unable to socialize
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4
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Impaired verbal communication
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Altered perception
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Difficulty communication
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Impaired cognition
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Assessment as evident by (AEB) or data collection relative to the nursing diagnosis
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Patient Goal(s)
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Patient Outcome (objective, expected or desired outcomes or evaluation parameters)
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Interventions/
Implementations
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Ongoing as nursing student will have to go back for evaluation
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Social isolation related to lack of family support as evidence by patient stated that she is a divorcee
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Creating a support system and ensuring close supervision.
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Patient will remain safe while in the hospital with the aid of nursing intervention
Patient will attend group and stayed in day room most of the shift
Patient will demonstrate appropriate social interaction
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Provide safe environment, free from harmful things for patient.
Encourage patient to talk freely about feelings
Talk to the client in a calm manner and allow her to express herself
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Ongoing as nursing student will have to go back for evaluation
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis
Patient Goal(s)
Patient Outcome (objective, expected or desired outcomes or evaluation parameters)
Interventions/
Implementations
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Evaluation
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Difficulty communication related to impaired verbal communication as evidenced by not answering question appropriately
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Pt will be able to communicate in a manner that can be understood by others by the time of discharge
Patient will be able to communicate clearly and improve the ability to think clearly and more logically
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Patient will express thought and feelings in a coherent, logical, goal directed manner.
Patient will spend time with one or more people in structured activity neutral topics
Patient will demonstrate reality-based thought in verbal communication
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Assess if incoherence in speech is chronic or if it is more sudden, as in an exacerbation of symptoms.
Identify the duration of the psychotic meditation of the client.
Keep voice in a low manner and speak slowly as much as possible
Keep the environment calm, quiet, and as free from stimuli as possible.
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ongoing.
Partial meet
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Assessment as evident by (AEB) or data collection relative to the nursing diagnosis
Patient Goal(s)
Patient Outcome (objective, expected or desired outcomes or evaluation parameters)
Interventions/
Implementations
Evaluation
|
Ineffective coping related to unable to care for self as evidence by helplessness
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Patient will develop a new coping skill that do not involve self – harming
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*Patient will be encouraged to care herself
*Patient will identify at least one goal for future
*Patient will name at least one acceptable alternative to her situation.
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. *During crisis situation patients are unable to think clearly, alternatives can be considered.
*Given patient a support to dealing with strong emotions and gaining a sense of control over her live
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Ongoing as nursing student will have to go back for evaluation
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis
Patient Goal(s)
Patient Outcome (objective, expected or desired outcomes or evaluation parameters)
Interventions/
Implementations
Evaluation
Guidelines for Nursing Process
Nursing diagnosis consists of the diagnostic label, “related to” and the “as evidence by” components (see below).
Diagnostic label: Is selected from the NANDA International Diagnosis.
Related to: the condition or etiology of the problem the patient is experiencing. Should be in domain of nursing practice that nursing interventions can aggect. Should be the medical diagnosis.
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Assessment as evident by (AEB), or data collection relative to the nursing diagnosis
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Patient Goal(s)
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Outcome (objective, expected or desired outcomes or evaluation parameters
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Interventions/
Implementations
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Evaluation
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Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.
Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.
Types of data: subjective & objective
Sources of data
Nursing health history
Physical examination
Diagnostic data
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“A statement of purpose describes the aim of nursing care” (Osborn et. al., p. 113)
Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis)
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May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.
Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)
Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis.
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Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).
Implementation – the carrying out of the planned nursing interventions (Osborn, et al., 2010)
Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.
Interventions should reflect indendent nursing practice as well as collaborative practice.
Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.
Interventions should include specific like schedules, food choices, frequency, etc….
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Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).
Essentially this is a reassessment of the patient and the responses as to the interventions implemented.
Compare actual patient behaviors with expected behaviors.
Give reasons why or why not each outcome has been met.
Consider the effectiveness of the nursing intervention, time elements.
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PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name:
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Week:
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Dates of Care:
|
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Demographics and Brief History
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Patient Initials
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Sex
F
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Age
2
5
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Room
1
5th
Admitting Date
3
/23/21
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Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? PT comes in for psch evaluation
.
Admits to SI with plan of choking herself. She tried to overdose on Tylenol about a year ago. Denies HI. Pt has been hearing voices to harm herself for few days. PT has not been taking her medication since 3 months ago states there is a lot of family issues going on.
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Attending physician/Treatment team:
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Precautions:
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Primary Diagnosis: Anxiety, Depression, PSTD (Post traumatic stress disorder), OCD (Obsessive compulsive disorder
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Co-morbidities: Delusional
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Allergies: No known Allergies
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Code Status: Full Code
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Isolation: (type and reason)
None
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Admission Height:
5.7
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Admission Weight:
68kg(150lb)
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Arm Band Location (colors & reasons)
Right Arm. For identification and medication administration.
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Past Medical History: (pertinent & how managed) Anxiety, Depression, PSTD (Post traumatic stress disorder), OCD (Obsessive compulsive disorder)
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Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)
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Physical Assessments and Interventions: (Include all pertinent data)
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Vital signs:
Time
3/28/21
T
98.7 F
P
90 beat/min
R
18 breath/min
B/P
115/77 mmHg
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General Appearance
·
Grooming/Clothing
·
· Hygiene
·
· Posture
·
· Gait
·
· Obese/average or normal/ underweight
·
· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings
·
|
Activities of Daily Living
· Sleep/rest
·
· Diet
·
· Exercise/mobility
·
· Elimination
·
· Hygiene
·
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|
GI
Diet:
Blood Glucose (time & date):
Last bowel movement (time & date):
Pertinent Labs/Test:
Assessments:
· Stool
·
· Bowel sounds
·
· Tenderness, distention
·
· Appetite, nausea, vomiting
·
Interventions:
|
Respiratory:
Assessments:
· Lung sounds
·
· Cough, sputum
·
· SOB
·
Interventions:
|
|
Neurosensory:
Alert & Orientated:
Follows commands:
Speech Comprehensible:
Pertinent Labs/Test:
Assessments:
· LOC
·
· Pupils
·
· Glascow Coma Scale
·
· Dizziness
·
· Headaches
·
· Tremors
·
· Tingling, weakness, paralysis, or numbness
·
Interventions:
|
Cardiovascular:
Pertinent Labs/Test:
Assessments
· Peripheral pulses
·
· Heart sounds (murmurs or bruits)
·
· Edema
·
· Chest pain, discomfort, palpitations
·
Interventions:
|
|
Musculoskeletal:
Activity:
Casts/Slings:
Assessments:
· Strength, weakness
·
· ROM
·
· Gait (documented under appearance)
· Pain
·
· Fractures, amputations, or transfers
·
Interventions:
|
Renal:
Pertinent Labs/Test:
Assessments:
· Bruit, thrill, location
·
· Urine-quality
·
· Burning with urination, hematuria
·
· Incontinent, continent, I & O
·
Interventions:
|
|
Skin:
Braden Score:
Pertinent Labs/Test:
Assessments
· Bruising, wounds, drains
·
· Turgor
·
· Surgical incisions
·
· Finger & toe nails
·
Interventions:
|
Pain:
Pain score:
Assessments/Interventions:
· Scale used
·
· Location, duration, intensity, character
·
· Exacerbation, relief
·
Interventions:
·
|
|
Gyn:
Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test:
Assessment
· Bleeding
·
· Discharge
·
Interventions:
|
Safety:
Bed Rails:
Bed alarms:
Fall risk:
Assistive Devices:
Interventions:
·
|
|
Advance Directives/Ethical considerations:
AD:
POA:
|
|
Lab Values
Results
Normal Lab Values
Significance to your patient (if applicable)
WBC
5.7
4
.5-11.0
Normal
RBC
4.28
3.63-5.04
HGB
12.3
12.0-15.3
HCT
37.1
34.7-45.1
MCV
86.8
80.0-100.0
MCH
28.7
26.0-34.0
Normal
MCHC
33.1
32.5-35.8
Platelets
Not recorded
RDW
13.1
11.9-15.9
Normal
MPV
8.8
6.8-10.2
Glucose
98
70-99
Normal
BUN
8
7-20
Normal
Creatinine
0.65
0.6-1.2
Normal
Sodium
135
133-144
Normal
Potassium
3.7
3.5-5.2
Cloride
104
98-107
Calcium
Not recorded
Salicylate
Not recorded
Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)
Lab Value
Results
Normal Lab
Values
Significance to your patient (if applicable)
10 Panel Toxicology/Drug Screen: if available
Lab Value
Results
Normal Lab
Values
Significance to your patient (if applicable)
Blood Alcohol Level/Ethyl Serum Level: if available
Lab Value
Results
Normal Lab
Values
Significance to your patient (if applicable)
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Psycho/Social Assessment
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· Level of education
· Not on file
· Occupation
· Not on file
· Race/Ethnic Background or Identification
· Not on file
· Religion/Spiritual Beliefs
· Not on file
· Communication needs: (verbal, nonverbal, barriers, languages)
· Not on file
· Special Talents/Interests/Skills
· Not on file
· Environment (home and community)
· Not on file
· Family Structure/History: No family history on file
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Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)
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Support System:
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Stressors/Stress Management Practices:
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Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article.
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Discuss the current disease process:
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Discuss the etiology of the patient’s illness:
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Also note the complications that may occur with treatments and patient’s overall prognosis:
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Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:
.
References
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1
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Medications
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Classification
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Dose
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Route
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Freq
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Purpose/Mechanism of Action
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Significant Side Effects / Adverse Reactions
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Nursing Implications
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Lorazepam
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1mg
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oral
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PRN
Q6r
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Management of anxiety and irritability disorder in psychotics, treatment of insomnia, adjust therapy for endoscopic, procedures, relief of postoperative anxiety
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Drowsiness, fatigue, ataxia, blurred vision, constipation, dry mouth, neutropenia, respiratory disorder, orthostatic hypotension
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Smoking may decrease effectiveness, avoid use with alcohol, CNS depressant, may be habit-forming if used longer than 4 months. Do not discontinue abruptly after long term use.
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risperidone
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Antipsychotics / Antimanic agent
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1mg
Oral
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2times a day
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Schizophrenia/ decreased symptoms of psychoses, bipolar mania, or autism.
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Aggressive behavior,
Extrapyramidal reaction
Constipation
Diarrhea
Visual disturbances
Decreased libido.
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Check serum magnesium level prior administration, Assess for drug interaction, drug incompatibility
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Ativan
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Zoloft
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Nursing Process Section
Nursing Diagnosis
:
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.
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Priority
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Nursing Diagnosis
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Related to
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As Evidence By
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Rationale (reason for priority)
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1
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2
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3
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4
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Complete a table for the top two priorities listed in the table above. A minimum of 3 interventions are required for each nursing diagnosis, and one intervention must be an individual patient teaching and one must include a teaching for the patient’s family/caregivers (if applicable- i.e., patient is not homeless and/or has no family).
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Table for Nursing Diagnosis Number 1
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Assessment
· Signs and symptoms relative to the nursing diagnosis, as evidence by
· 2 objective
· 2 subjective
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Patient Outcome
· SMART
· Specific
· Measurable
· Attainable
· Realistic
· Timely
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Interventions/Implementations
· Includes interventions/ nursing actions directly relating to pt. outcomes
· Specific in action, frequency and contain rationale
· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes
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Evaluation
· Includes all data that is listed as criteria in outcomes
· Outcomes are determined to be met, partially met, or not met
· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set
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Table for Nursing Diagnosis Number 2
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Assessment
· Signs and symptoms relative to the nursing diagnosis, as evidence by
· 2 objective
· 2 subjective
Patient Outcome
· SMART
· Specific
· Measurable
· Attainable
· Realistic
· Timely
Interventions/Implementations
· Includes interventions/ nursing actions directly relating to pt. outcomes
· Specific in action, frequency and contain rationale
· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes
Evaluation
· Includes all data that is listed as criteria in outcomes
· Outcomes are determined to be met, partially met, or not met
· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set
