Case Studies and Nursing Care Plans for Chapter 3: The Psychiatric Nursing Evaluation

Case Study#1 Evaluation

Mr. B is a 60 year old married African American. Who is a Vietnam Vet. He was referred
to the Mental Health Clinic by his primary doctor for Symptoms of Post Trauma Stress
Disorder (PTSD). He reports having nightmares and waking up in a cold sweat.
Recently, he was in a car accident and also learned that his best friend died from a heart
attack. He reports that he has had an increased irritability and isolation. Mr. B reports
only getting 4-5 hours of sleep per night and that he has a decreased appetite and he has
lost 15 lbs in last month. Mr. B denies any suicide or homicidal ideation.
Nursing Care Plan for Case Study 1:
Care Plan 3-1: Example of a
Nursing Diagnosis
Diagnosis:
DSM-IV Diagnosis:
Outcomes

Interventions

Evaluations

Case Study#2 Culture

Mrs. H. is a 33 year old Hispanic female who was originally from Puerto Rico. She
works in a factory and many of her co-workers became concerned about her talking about
being controlled by the voodoo. The Employee Assistance Program (EAP) evaluated
Mrs. H. and thought she might be a danger to herself since she was so distraught over the
consequences of the voodoo. The complete full nursing assessment revealed that what
was perceived as a thought disorder was actually instead culturally related. She was
presenting with severe anxiety related to the voodoo beliefs. Mrs. H. reports not sleeping
and she wakes up frequently throughout the night and reports somatic symptoms of
anxiety. Of particular note was the nurses sensitivity to the patients presentation of
symptoms related to culture. What might have been perceived as delusional was normal
within the culture.

Nursing Care Plan for Case Study 2:

Care Plan 3-2: Example of a
Nursing Diagnosis
Diagnosis:
DSM-IV Diagnosis:
Outcomes

Interventions

Evaluations