Case Scenario # 7

Psychiatric Nursing Care

INSTRUCTIONS: For this case scenario, you will develop a Nursing Care Plan
using SNL, the Standardized Nursing Languages of NANDA, NOC and NIC (NNN).
You will be completing the blank care plan that accompanies this scenario.

• J.S. is a 19 year old college freshman, who was referred from the emergency
room following an overdose of approximately 40 acetaminophen extra strength.
He was cleared medically. He had been in outpatient counseling once a week
since an initial overdose six months ago. Last night the patient was caught shop
lifting and was charged with a crime, and now he has a court date pending. He
was released to his family.
• Shortly after his return home he ingested the tablets. He did not tell anyone
until he was discovered to be vomiting profusely and taken to the emergency
room by his mother. He told the physician that when he took them he wanted to
die. His mood and affect are depressed and blunted. He states his appetite
and sleep have been poor and he believes he has lost 10 pounds over the last
month. He is anhedonic and his grades are dropping due to inability to
concentrate. He is unable to describe any reason for this. He has thought of
suicide in spite of intervention.
• There is no evidence of psychosis or a thought disorder.

Functional Health Patterns

• Nursing assessment data is organized in Functional Health Patterns. Functional

Health Patterns can help direct the choice of Nursing Diagnoses. The eleven
functional health patterns are Health Perception-Health Management;
Cognitive-Perceptual; Nutritional-Metabolic; Elimination; Activity-Exercise;
Sleep/Rest; Self-Perception/Self-Concept; Role/Relationship;
Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief.

• The Functional Health Pattern that is most relevant for J.S. is:

Role/Relationship
Step 1. Choosing the Nursing Diagnosis (es)

The following nursing diagnoses are appropriate for J.S In practice, you may
select additional nursing diagnoses.

Nursing Diagnosis: Risk for violence, self-directed

Definition: Behaviors in which an individual demonstrates that
he/she can be physically, emotionally, or sexually
harmful to self.
Risk Factors: Age 15- 19, single, mental health (severe
depression), emotional status, suicidal ideation

Nursing Diagnosis: Ineffective individual coping

Definition: Inability to form a valid appraisal of the stressors,
inadequate choices of practiced responses, and/or
inability to use available resources
Defining Characteristics: Lack of goal-directed behavior/resolution of
problem including: sleep disturbance, abuse of
chemicals agents. Decreased use of social support;
poor concentration, inadequate problem solving.

Nursing Diagnosis: Altered nutrition, less than body requirements

Definition: The state in which an individual is experiencing an
intake of nutrients insufficient to meet metabolic
needs.
Defining Characteristics: lack of interest in food
Related Factors: inability to ingest food due to psychological
factors

• While all of these nursing diagnoses are appropriate, for purposes of this
exercise, let’s use
Risk for violence, self-directed

• On the nursing care plan form, write in the nursing diagnosis, and check the
risk factors (etiology) for J.S.

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Step 2. Choosing the Nursing Outcomes (NOCs)

• The next step is to select nursing outcomes that can best affect this
nursing diagnosis.

• Listed below are two appropriate nursing outcomes for J.S.

Nursing Outcomes
Suicide Self-restraint
Indicators:
• Seeks help when feeling self-destructive
• Verbalizes control of impulses
• Refrains from gathering means for suicide
• Does not require treatment for suicide gestures or attempts.
• Upholds suicide contract

Mood Equilibrium
Indicators:
• Exhibits impulse control
• Reports adequate sleep
• Exhibits concentration
• Reports normal appetite
• Absence of suicide ideation
• Shows interest in surroundings
• Select one of the above listed nursing outcomes for this care plan
exercise, go to the nursing care plan and check the indicators that you
think will best measure your patient’s progress towards the outcome that
your have chosen.
• You will need to RATE your patient’s current status for each indicator.
• Now that you have chosen your outcome for J.S., you will need to select
the interventions that will best meet this outcome.

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 Step 3. Choosing the Nursing Interventions
• If you have chosen the NOC, Suicide Self-Restraint, continue
below to select your interventions and activities.

If you have chosen the NOC, Mood Equilibrium, continue to that

•
section to select your interventions and activities.
______________________________________________________________

NOC – Suicide Self-Restraint

The following two Nursing Interventions: Suicide Prevention and
Surveillance –Safety are appropriate for J.S. Review the activities listed
below each NIC and select 5. Write these five activities on the care plan.

NIC – Suicide Prevention - Activities (NIC3 pg. 620)

• Determine whether • Encourage the person
patient has specific to make a verbal no-
suicide plan identified suicide contract
• Determine history of • Protect patient from
suicide attempts harming self
• Demonstrate concern • Remove dangerous
about patient’s welfare items from the
patient’s environment
• Facilitate discussion of • Instruct patient and
factors or events that significant other in
precipitated the signs, symptoms, and
suicidal thoughts basic physiology of
depression
• Observe closely during • Escort patient during
suicidal crisis off-ward activities, as
appropriate
• Facilitate support of • Instruct family on
patient by family and possible warning signs
friends or pleas for help
patient may use
• Place patient in least
restrictive environment
that allows for necessary
level of observation
• Refrain from negatively
criticizing
• Place patient in room with
protective window
coverings, as appropriate
• Instruct family that
suicidal risk increases for
severely depressed
patients as they begin to
feel better
• Provide psychiatric
counseling, as appropriate
• Refer patient to
psychiatrist, as needed.

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NIC – Surveillance - Safety Activities (NIC3 pg. 635)
• Monitor patient for • Determine degree of • Provide appropriate level of
alterations in physical surveillance required by supervision/surveillance to
or cognitive function patient, based on level of monitor patient and to
that might lead to functioning and the allow therapeutic actions,
unsafe behavior hazards present in as needed
environment
• Place patient in least • Initiate and maintain • Communicate information
restrictive precaution status for about the patient’s risk to
environment that patient at high risk for other nursing staff
allows for necessary dangers specific to the
level of observation care setting
• Monitor environment
for potential safety
hazards

NOC, Mood Equilibrium

NIC, Mood Management
• Select 5 nursing activities that are appropriate for this patient and write them
on the care plan in the activity column for Mood Management.

Mood Management - Activities (NIC3 pg.457)

Monitor self care
activities
Monitor cognitive
functioning
Administer mood-
stabilizing medications
Monitor fluid & nutritional Assist pt to maintain a normal
intake cycle of sleep/wakefulness
Encourage pt to take an Teach new coping & problem-
active role in treatment solving skills

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The second NIC for the NOC, Mood Equilibrium is Medication Management
Again, select 5 nursing activities that are appropriate for J.S. and write them on
the care plan in the activity column for Medication Management

Medication Management - Activities (NIC 3, pg.451)

Monitor pt for the Monitor for adverse Monitor for non-
therapeutic effect of the effects of the drug therapeutic drug
medication interactions
Teach pt/family the Teach pt/family the Provide pt/family with
effects & side effects of method of medication written information to
the medication administration enhance self
administration
Instruct pt/family when
to seek medical care

Congratulations!

You have successfully completed your first nursing care plan using the
standardized nursing language vocabularies of NANDA, NOC, and NIC.

1. If you wish to received CE for this educational activity, please complete the
evaluation form and return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls , 6B12
Ann Arbor, Michigan 48109-0436
2. If you are working with a coordinator please give your quiz, evaluation and
completed nursing care plan to your coordinator.

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 Psychiatric Care
NURSING DIAGNOSIS: Patient Name
Defining Characteristics (Signs & Symptoms)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏
Related Factors (Etiology)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏
NOCs (Outcomes)
Measurement Scale Score:
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
Suicide:
5 = Consistently demonstrated
Self ❏ Seeks help when feeling self-destructive
Restraint ❏ Verbalizes control of impulses
❏ Refrains from gathering means for suicide
❏ Does not require treatment for suicide
gestures or attempts
❏ Upholds suicide contract
DATE/TIME
INITIALS

Measurement Scale Score:

1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
Mood 5 = Consistently demonstrated
Equilibrium ❑ Exhibits impulse control
❑ Reports adequate sleep
❏ Reports normal appetite
❑ Exhibits concentration
❏ Shows interest in surroundings
DATE/TIME
INITIALS
NICs (interventions) ACTIVITIES: MODIFICATIONS:
❑

Suicide ❑
Prevention ❑

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❑:

Surveillance - ❏
Safety ❏

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏

❏
Mood
❏
Management
❏

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏

❏
Medication
❏
Management
❏

DATE/TIME
 OTHER INTERVENTIONS: SIGNATURE BOXES:
• •
• •

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