Vermont Technical College Associate Degree Nursing Program Care Plan Form NUR 2030/2040 Student Name: Courtney

Warrington (CVS 8/13) Date: 12/5/13 Nursing Unit: Brattleboro Retreat

My client is a 27 year old Caucasian female who was admitted March 2012. She has the following DSM IV diagnoses: Axis I- Psychosis with PTSD Axis II- Borderline personality disorder Medications include: Modafinil, Fluphenazine, Lyrica, Fluoxetine, Atorvastatin, Clonazepam, Benztropine, Clonidine, and Chlorpromazine.

Nursing Diagnosis

Expected Client Outcome (Goal) and Criteria

Nursing Interventions

Underlying Scientific Principle(s) of Nursing Interventions

Evaluation

Short term goal: 1. Risk for self- or other- directed violence r/t psychosis AEB self-inflicted wounds and angry outbursts of aggression towards staff Client will not harm self or other in the next 8 hours Within the next 2 days client will recognize signs of escalating anger and report them to staff for intervention Long term goal: Client will not harm self or others within the next 14 days

Maintain a low stimuli environment with few people, ambient lighting, low noise Maintain a 1:1 with client, with constant observation for escalating behavior Allow client some control over her situation by offering choices to de-escalate behavior Ensure enough staff

A high stimulus environment increases anxiety (Townsend 2012, p. 531) Close observation allows quick intervention to self or other directed anger, preventing a dangerous situation before it can begin (Townsend 2012, p. 531) Giving client some control over her situation may decrease her anxiety (Townsend 2012, p. 531)

Client has decreased selfviolence and decreased violence towards others with interventions in place Meets expected outcome criteria of no harm to self or others in next 14 days, and reporting feelings of anger to staff within the next 2 days

available quickly for a show of support if necessary

Sufficient staff support shows the client there is control over the situation, ensures staff and client safety (Townsend 2012 p. 531) Reduce the clients ability to use objects to harm herself and others in an altered mental state

Remove dangerous objects from the clients environment

Only when other interventions have been exhausted and client continues to dangerously escalate, proving a harm to herself or others, physical or mechanical restraints may be necessary

Exhausting other methods ensures least restrictive alternative is being used Reduces risk of harm to patient and staff when client cannot be talked down (Townsend 2012, p. 531)

2. Risk for suicide related to psychosis AEB client stating I have to kill myself or when I die I will have no soul, and recent suicide attempt (11/2013)

Short term goal: Client will not harm herself in next 8 hours

Removal of dangerous object from client environment

Client safety is first priority (Townsend 2012, p. 313)

Client has no attempts of self-harm Able to communicate feelings of self-harm to staff for assistance and

Provide constant Long term goal: Will not observation and 1:1 harm self in the next 14 support to client

days. Use caution when administering medications Encourage client to express feelings r/t desire to commit suicide Client will remain medication compliant (court order) Maintain honesty and consistency in interactions

Constant observation prevents client from selfharm Suicidal client may store medication to attempt overdose (Townsend 2012, p. 314) suicidal behaviors may be viewed as anger turned inward on the self. If this anger can be verbalized in a non-threatening environment, the client may be able to eventually resolve these feelings (Townsend 2012, p. 314). Consistently taking medication will decrease episodes of psychosis, thereby decreasing suicidal ideation Building a rapport with client will allow her to more easily express negative feelings and thoughts of self-harm to trusted staff

early intervention Consistent compliance with medication results in decrease of psychotic symptoms

Decreased episodes of psychosis resulting in suicidal ideations within 30 days