Psych Care Plan

DADE MEDICAL COLLEGE NURSING DEPARTMENT
THIS IS A DADE MEDICAL COLLEGE DOCUMENT. POSSESSION OF THIS DOCUMENT IS AN ACKNOWLEDGEMENT THAT IT AND ITS CONTENT ARE THE EXCLUSIVE PROPERTY OF DADE MEDICAL COLLEGE INC.
Nursing Care Plan Form
Students Name: ___Luis A. Zapata_______________________ Clients Initials: __ N. F.__________________________________ D.O.B.: _______03/26/82______ ___________________________
Date: ______________6/28 /12____________ Sex: __________M_____________________ Age: ________30__ yrs___________________
Time: ______9:00_____________________ Admission Date: ______6/14/12_ ______ Race: ___ Caucasian __ __________
Allergies: ________NONE________________________________________________________________________________________________________________
Admitting Psychiatric Diagnosis (es): __Depression NOS/ Anxiety___( suicidal ideation)____ ______________________ ______________________________________________________________________________ Surgical Procedure (s) (include date): ________N/A_______________________________________________________________________________________________________________________ What brought you to the Institution (Hospital, Home) ___Backer Act, It was a miss understanding______________________________________________________________________________________________ History of present illness: ___Pt it been in and out of this facility since 2001___________________________________________________________________________________________ Clients Understanding of Illness: ___Pt understans and identifies the early symptoms of depression______________________________________________________________________________ Past medical history: ___Schizophrenia, suicidal ideation, allusination, Psychosis__________________________________________________________________________________
NRF1036 1/11/2012 Page 1 of 13

What Medications are you currently taking, when/why? Medication(s) 1 2 3 4 5 6 7 8 9 10 11 12

Benztropine Mesylate Divalproex Sodium Haloperidol Lorazepam
Time
Daily Twice a day Twice a day Every 4 hrs
Why
Benztropine mesylate is used to treat the symptoms of Parkinson's disease and tremors caused by other medical problems or drugs. Anticonvulsant antipsychotics Relive anxiety
Are your medication(s) causing you discomfort? If yes, please explain.
NO___________________________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________________________________
NRF1036 1/11/2012 Page 2 of 13

Medications: (Topical; PO; IM; sub Q; IV)

Name/Dose Route/Frequency
Benzotropine Mesylate 2mg PO 1-2 mg
Safe/ Range
Mechanism of Action
Indication(s)
Side Effects
Nursing Consideration(s)
PO/ qd
Blockade of the central Parkinsonian CNS (Confusion), Monitor for constipation, Monitor I&O ratio qd/bid/tid, max acethylcholine receptors in the symptoms, EPS CV(Palpitations), (urinary output decreased), Assess for CNS, neurotransmitters are associated w. GI(paralyticileus), also mental Status, Assess for mental Status 6mg a day balanced neuroleptic products hyperthermia,heat stroke Max 60mg/kg/day Increases levels of (Gaba) acid Manic Disorders in brain, which decreases S. A. associated w/BD Suicidal ideation, hepatic Monitor Blood test(Hct, Hgb, RBC,Platelets) failure, pancreatitis Monitor Liver functions, Assess Mood
Divalproex Sodium 500mg PO/ BID Haloperidol 10 Mg PO/BID Lorazepam 2 mg IM/QID
Max 100mg/day Depresses( cerebral Cortex,
Psychotic disorders, Seizures, Cardiac arrest, Assess mental Status, Check for swallowing hepatitis, Laryngospasm Monitor I&O ratio, Monitor BP Tachycardia, apnea, Asses degree of Anxiety, hallucination, Monitor BP, Monitor hepatic functions.
Hypothalamus, limbic system) control of tics. Max 10mg/day Potentiates the action of GABA Anxiety, insomnia, Which depresses the CNS
irritability in psych D. dizziness, confusion
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Lab Values
Chemistry Sodium Potassium Chloride C02 Calcium Phosphorus Cholesterol Albumin T-Protein Bun Creatinine Magnesium Uric Acid Biliburin Amylase Lipase LDH HDL LDL Urinalysis Color Turbidity SG PH Glucose Ketone
NRF1036
Normal Value
135-145 3.5-5.2 95-110 19-34 8.4-10.2
Clients Value
141 4.3 104 25 8.9
Date
6/14/12 6/14/12 6/14/12 6/14/12 6/14/12
Hematology RBC HGB HTC MCV MCH MCHC WBC Neurophils Bands Segments Eosinophils Basophils Lymphocytes Monocytes Plat Coagulation Normal studies PT PTT Prothrombin Time Bleeding Time
Normal Value
4.5-5.9 13-18 40-52 81-97 26-34 31-37 3.6-11 36-66
Clients Value
4.84 14.4 43.0 88.7 29.7 33.4 10.1 63.8
Date
6/14/12 6/14/12 6/14/12 6/14/12 6/14/12 6/14/12 6/14/12 6/14/12
3.5-8.7 6-22 0.6-1.3
7.0 15 0.9
6/14/12 6/14/12 6/14/12
0.1-1.1
0.2
6/14/12
0.0-5.0 0.0-1.0 1.1-4.7 0.0-10.0 7.4-10.4
3.6 0.6 2.2 0.8 11.0
6/14/12 6/14/12 6/14/12 6/14/12 6/14/12
Test(Normal)
70-110
95
6/14/12
TSH Bun/creat
1/11/2012 Page 5 of 13

Chemistry Blood Protein Bilirubin Urobilinogen Nitrate Leukocytes Cast RBC Crystals WBC Epithelial Cells Miscellaneous
Normal Value
Clients Value
Date
Hematology Osmolality RDW MPV AIC-Hgb ALT(SGPT) AST(SGOT T.bilirubin HDL LDL VLDL CHOL/HDL
Normal Value
Clients Value
Date
16 19
6/14/12 6/14/12
Relate the clinical significance of abnormal lab values above: _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________
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Diagnostic Tests
X-RAYS/ CT SCAN/ US/MRI/EKG etc
RESULTS (Please include date of tests results)
/ NRF1036
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Page 7 of 13

Brief Textbook Picture

(Include etiology, pathophysiology, signs & symptoms, medical treatments, prognosis, etc. Compare to Client)
Textbook
Compare to Client
DEPRESSION
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and physical well-being Signs & Symptoms. sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, or restless( Suicidal ideation) Medical Treatment. some patients with clinical depression are treated with psychotherapy, and some are prescribed antidepressants. Others are prescribed antidepressants and psychotherapy. Prognosis. In the vast majority of cases, the prognosis for depression is good. Of course, is true only when someone is in treatment for depression. Untreated depression usually doesn't go away by itself, and often gets worse with time
Pt reports he feels: Empty, worthless, irritable and restless
Pt is under psychotherapy groups Pt has be prescribed antidepressants
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Stage of Development
Describe the Clients stage of development according to Piaget, Freud or Eriksons Theory. Compare the developmental stage to the client
Theory Client
Eriksons Theory Stage of Development

Intimacy vs. Isolation ( focused)Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and
Pt is not in a relationship, but pt is in Sexual Precaution, because he has been Improper with the female Staff asking them to go to the back of his room so they can masturbate him.
Isolation.
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NURSING CARE PLAN

Assessment Subjective Data:
I Felt suicidal, like I was going to Walk in front of a car
Nursing Diagnosis
Compromised Family coping r/t highly
Short-term Goals
By the end of the shift patient will
Long-term Goals
By discharge pt will cope with the
Conflicted family relationship AEB Inability to self consistent limits
be calm and relaxed, he will verbalized no more suicidal ideation .
anxiety and depression in a better way. He will recognized his stress triggers. He will fell comfortable contacting the
Risk Diagnosis:
suicidal line.
Objective Data:
Pt is was admitted to the unit with suicidal ideation, pt has a plan in how to accomplish it .
Risk for suicidal r/t ineffective coping
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NURSING CARE PLAN (Continuation)

Nursing Interventions/Implementation
Family participation in professional care . Mutual goal setting Anger control assistance
Mood Management Redirect patient when is need it Administer medication Teach pt. and family about help line Monitor Liver Toxicity. Will help to have a reality check Pt is easy to redirect Pt complies with medication
Scientific Rationales
Involvement of family will increased Awareness Help to improved coping To better manage of feelings
Evaluation
Family member are more knowledgeable about soon s disease.
Modification
Pt. verbalized understanding of new techniques
To improve sign and symptoms
Helpful in case other mechanism dont help Pt shows me the help line card on his wallet Side effect of drugs Pt labs came in normal range
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Page 12 of 13

Psych Care Plan

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DADE MEDICAL COLLEGE NURSING DEPARTMENT

Nursing Care Plan Form

Date: ______________6/28 /12____________ Sex: __________M_____________________ Age: ________30__ yrs___________________

DADE MEDICAL COLLEGE NURSING DEPARTMENT

What Medications are you currently taking, when/why? Medication(s) 1 2 3 4 5 6 7 8 9 10 11 12

Are your medication(s) causing you discomfort? If yes, please explain.

DADE MEDICAL COLLEGE NURSING DEPARTMENT

Medications: (Topical; PO; IM; sub Q; IV)

Divalproex Sodium 500mg PO/ BID Haloperidol 10 Mg PO/BID Lorazepam 2 mg IM/QID

Max 100mg/day Depresses( cerebral Cortex,

irritability in psych D. dizziness, confusion

DADE MEDICAL COLLEGE NURSING DEPARTMENT

3.5-8.7 6-22 0.6-1.3

6/14/12 6/14/12 6/14/12

0.0-5.0 0.0-1.0 1.1-4.7 0.0-10.0 7.4-10.4

3.6 0.6 2.2 0.8 11.0

6/14/12 6/14/12 6/14/12 6/14/12 6/14/12

DADE MEDICAL COLLEGE NURSING DEPARTMENT

DADE MEDICAL COLLEGE NURSING DEPARTMENT

X-RAYS/ CT SCAN/ US/MRI/EKG etc

RESULTS (Please include date of tests results)

DADE MEDICAL COLLEGE NURSING DEPARTMENT

Brief Textbook Picture

Pt reports he feels: Empty, worthless, irritable and restless

Pt is under psychotherapy groups Pt has be prescribed antidepressants

DADE MEDICAL COLLEGE NURSING DEPARTMENT

Eriksons Theory Stage of Development

DADE MEDICAL COLLEGE NURSING DEPARTMENT

NURSING CARE PLAN

Conflicted family relationship AEB Inability to self consistent limits

be calm and relaxed, he will verbalized no more suicidal ideation .

Risk for suicidal r/t ineffective coping

DADE MEDICAL COLLEGE NURSING DEPARTMENT

NURSING CARE PLAN (Continuation)

Pt. verbalized understanding of new techniques

To improve sign and symptoms

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Date: __6/28 /12 Sex: M_ Age: 30 yrs___________