care plan east campus corregido

7/17/2019 Care Plan East Campus CORREGIDO

http://slidepdf.com/reader/full/care-plan-east-campus-corregido 1/24

University of Texas at Brownsville

Bachelor Science Nursing

Plan of Care (Based on Textbook

!oo" No# 1$ Student%s Na"e# Corte& 'itdsy )on&ale& !a"iro *s+inosa ,leana Saen& Sa"antha

Pt%s ,nitials# S- . / -ge# 0 2ate# 341541$

Patient%s .edical 2iagnosis# Psychosis

State a short ter" ob6ective for yourself during this nursing care ex+erience# 'earn and +ractice so"e of the skills that , learned the

last se"ester7 -lso +ractice the correct for" of charting and using the nursing care +lan7

2efine in your words the current diagnosis# ,t is the condition of the "ind involving loss of contact with reality7

Su""ary of diagnosis (*tiology and +athology according to textbook# - "ental disorder in which there is severe loss of contact withreality7 *videnced by delusions hallucinations disorgani&ed s+eech +atterns and bi&arre or catatonic behavior7 Psychotic disorders are

co""on features of schi&o+hrenia bi+olar disorders and so"e affective disorders7 They can also result fro" substance abuse (such as

hallucinogens substance withdrawal (such as deliriu" tre"ens or side effects of so"e +rescri+tion drugs7 *tiology# alterations in brain

structure and changes in do+a"ine neurotrans"ission7 The do+a"ine changes are directly related to hallucination and delusions7

Sy"+to"s according to textbook# ,n +sychotic states +atients "ay ex+ress unusual ideas (such as that they can read the "inds of

others send radio "essages directly to )od or inani"ate ob6ects travel to distant galaxies7 These ideas are called delusions7 Psychosis

is also "arked by +atients% re+orts of hearing voices (auditory hallucinations or seeing ob6ects or +ersons not visible to others (visual

hallucinations7 -uditory hallucinations are hall"arks of schi&o+hrenic and "anic states8 visual hallucinations are characteristic of drug

intoxication or withdrawal7 2isturbances in thought content and for" +erce+tion affect sense of self volition inter+ersonal relationshi+s

and +sycho"otor behavior occur7 Thorough +hysical and +sychiatric exa"inations rule out organic causes of the +atient sy"+to"s and

establish the diagnosis7

Textbook .edical .anage"ent (2x studies and treat"ent# Treat"ent goals focus on "eeting the +atient%s +hysical and

+sychosocial needs and usually co"bine drug thera+ies with behavioral thera+ies long9ter" +sychothera+y +sychosocial rehabilitation

and4or vocational counseling re:uiring use of co""unity resources7 Patients with +sychosis are treated effectively with neurole+tic drugs

(which a++ear to work by blocking +ostsyna+tic do+a"ine rece+tors such as halo+eridol ris+eridone or chlor+ro"a&ine7 Side effects of

so"e of these "edications include dystonic reactions and tardive dyskinesia7 The newer agents +roduce fewer of these extra+yra"idal

sy"+to"s7 Treat"ent drugs also have sedative anticholinergic and orthostatic hy+otension effects and about 1; of +atients taking these

agents ex+erience neurole+tic "alignant syndro"e (life9threatening fever "uscle rigidity and altered level of consciousness7

Textbook Nursing 2iagnosis

Based on .aslow%s <ierarchy

Procedures to be +erfor"ed by students

Based on Nursing 2iagnosis

1 Consti+ation 1 -ssess usual +attern of eli"ination and co"+ared with +resent +attern including si&e fre:uency color and :uality

= !isk for violence = -ssess +hysiological signs and external signs of anger7

> -nxiety > -ssess the client%s level of anxiety and +hysical reactions to anxiety7Using the <a"ilton -nxiety Scale7

0 !isk for suicide 0 -ssess for any changes in "ood or behavior every >? "in to 1 hour

$ 2isturbed sensory +erce+tion r4t bioche"ical i"balances

-*B violent behavior and nonco"+liances with taking"edications

$ -ssess and identify behavioral res+onse that "ay indicate "ental

+roble"s

!eferences (-uthor @ Page No7 Nursing central# Taber%s dictionary disease and disorders7

-d"ission

2ate#

341041$ Nu"ber of days in <os+ital# =



G E N E R A L I N F O R M A T I O N

-d"itted Aia# .ode

-"b#

n4a .c

#

n4a ther

#

Court rdered

State"ent of Present Co"+laint# Psychosis exhibiting self +aranoia delusions @ auditory hallucinations

'ast <os+ital -d"ission 2ate# 4=04?5 !eason# drug overdose

,""uni&ation Current (y4n# y PP2# y Notes

#

,nfluen&a

.a6or ,llness +erations Blood Transfusions or Pregnancies#

1

7

Psychosis 37 n4a

=

7

Bi+olar disorder 7 n4a

>7

<y+erli+ide"ia 7 n4a

0

7

Suicidal ideation 1?

7

n4a

$7

2e+ressive disorder 117 n4a

5

7

Schi&o+hrenia 1=

7

n4a

<ealth .aintenance#

*xercise Ty+e# n4a /re:uency# n4a Duantity# n4a

<obbies if any#

Tobacco Ty+e# Cigarettes DTE4day x yrs7# 04day >1 years ,f :uit

date#

n4a

-lcohol

Ty+e#

Beer DTE4week# 1= cans4 week ,f :uit

date#

n4a

ther Ty+e# Cocaine DTE4week# $ gra"s4 week ,f :uit

date#

n4a

-llergies# ,bu+rofen na+roxen

.edication

(including ,As

2ose /re:9

uency

!oute Ti"e

to be

Classification 4 -ction 4 !ationale Nursing ,ntervention



M E D I C

A T I O N

'ithiu" >??"g D2 P ?5??

10??==??

.ood stabili&er

-ction

-lters cation trans+ort in nerve and "uscle7

.ay also influence reu+take ofneurotrans"itters7

Thera+eutic *ffect(s#

Prevents4decreases incidence of acute "anice+isodes7

!ationale#

.anic e+isodes of bi+olar , disorder

(treat"ent "aintenance +ro+hylaxis7

-ssess "ental status(orientation "ood

behavior initially

and +eriodically7

,nitiate suicide +recautions if

indicated7

.onitor intake andout+ut ratios7 !e+ortsignificant changes

in totals7 Unless

contraindicated

fluid intake of atleast =???F>???

"'4day should be

"aintained7 Geight

should also be"onitored at least

every > "o7

'ab Test

Considerations#*valuate renal and

thyroid function

GBC withdifferential seru"

electrolytes and

glucose +eriodically

during thera+y7Toxicity verdose#

.onitor seru"

lithiu" levels twice

weekly duringinitiation of thera+y

and every = "o

during chronic

thera+y7 2raw bloodsa"+les in the

"orning

i""ediately before

next dose7Thera+eutic levels

range fro" ?7$ to 17$

"*:4' for acute

"ania and ?75F17="*:4' for long ter"

control7 Seru"

concentrations

should not exceed=7? "*:4'7

-ssess +atient for

signs and sy"+to"s

of lithiu" toxicity(vo"iting diarrhea

slurred s+eech

decreased

coordinationdrowsiness "uscle

weakness or

twitching7 ,f these

occur re+ort before

ad"inistering nextdose7



Duetia+ine

S*!DU*'

>??"g -t

bedti"e

P ==?? -nti+sychotics "ood stabili&ers

-CT,NProbably acts by serving as an antagonist of

do+a"ine and serotonin7

-lso antagoni&es hista"ine <1 rece+tors

and al+ha19adrenergic rece+tors7

Thera+eutic *ffect(s#2ecreased "anifestations of +sychoses

de+ression or acute "ania7

!-T,N-'*

Schi&o+hrenia7

2e+ressive e+isodes with bi+olar disorder7

-cute "anic e+isodes associated with bi+olar , disorder (as "onothera+y Hfor

adults or adolescentsI or with lithiu" or

dival+roex Hadults onlyI7

.aintenance treat"ent of bi+olar , disorder(with lithiu" or dival+roex7

-d6unctive treat"ent of de+ression7

.onitor "entalstatus ("ood

orientation

behavior before and

+eriodically duringthera+y7

-ssess for suicidal

tendencieses+ecially duringearly thera+y7

!estrict a"ount of

drug available to

+atient7 !isk "ay beincreased in

children

adolescents and

adults J=0 yr7-ssess weight and

B., initially and

throughout thera+y7

.onitor BP (sittingstanding lying and

+ulse before and

fre:uently duringinitial dose titration7

,f hy+otension

occurs during dose

titration return tothe +revious dose7

bserve +atient

carefully when

ad"inistering toensure "edication is

swallowed and not

hoarded or cheeked7

.onitor for onset ofextra+yra"idal side

effects (akathisiaF

restlessnessdystonia

F "uscle s+as"s andtwisting "otions8 or

+seudo+arkinsonis"

F "ask9like faces

rigidity tre"orsdrooling shuffling

gait dys+hagia7

!e+ort these

sy"+to"s8 reductionof dose or

discontinuation "ay

be necessary7

Trihexy+henidyl or ben&tro+ine "ay be

used to control these

sy"+to"s7

.onitor for tardivedyskinesia

(involuntary

rhyth"ic "ove"ent

of "outh face and

extre"ities7 !e+orti""ediately8 "ay be



'ora&e+a"

(-tivan

1"g +rn P-ntianxiety agentssedative4hy+notics

-CT,N

2e+resses the CNS +robably by +otentiating )-B- an inhibitory

neurotrans"itter7

Thera+eutic *ffect(s#Sedation72ecreased anxiety7

2ecreased sei&ures7

!-T,N-'*-nxiety disorder (oral7

Preo+erative sedation (in6ection7

2ecreases +reo+erative anxiety and

+rovides a"nesia7Unlabeled Use(s#

,A# -ntie"etic +rior to che"othera+y7

,nso"nia +anic disorder as an ad6unct with

acute "ania or acute +sychosis7



Palla+eridone

,NA*)-

SUST*NN-

5"g D2 once

daily

P D2

???

-nti+sychotic-CT,N

.ay act by antagoni&ing do+a"ine and

serotonin in the CNS7 Pali+eridone is the

active "etabolite of ris+eridone7Thera+eutic *ffect(s#

2ecreased "anifestations of schi&o+hrenia7

2ecreased "anifestations of schi&oaffectivedisorder7

!-T,N-'*

-cute treat"ent of schi&oaffective disorder

(as "onothera+y or as ad6unct to "oodstabili&ers and4or antide+ressants7

.onitor +atientKs"ental status

(orientation "ood

behavior before and

+eriodically duringthera+y7 .onitor

closely for notable

changes in behaviorthat could indicatethe e"ergence or

worsening of

suicidal thoughts or

behavior orde+ression

es+ecially during

early thera+y7

!estrict a"ount ofdrug available to

+atient7

-ssess weight and

B., initially andthroughout thera+y7

.onitor BP (sitting

standing lyingdown and +ulse

before and

+eriodically during

thera+y7 .ay cause +rolonged DT

interval tachycardia

and orthostatic

hy+otension7bserve +atient

when ad"inistering

"edication to ensure

that "edication isactually swallowed

and not hoarded or

cheeked7

.onitor +atient foronset of

extra+yra"idal side

effects (akathisiaF

restlessnessdystonia F "uscle s+as"s and

twisting "otions8 or

+seudo+arkinsonis"

F "ask9like facerigidity tre"ors

drooling shuffling

gait dys+hagia7

!e+ort thesesy"+to"s8 reduction

of dose or

discontinuation of

"edication "ay benecessary7

.onitor for tardive

dyskinesia

(involuntary

rhyth"ic "ove"entof "outh face and



2CUS-T* =0?"g +rn P +rn

:d

'axative stool softner

-CT,N

Pro"otes incor+oration of water into stool

resulting in softer fecal "ass7.ay also +ro"ote electrolyte and water

secretion into the colon7

Thera+eutic *ffect(s#Softening and +assage of stool7

!-T,N-'*

Prevention of consti+ation soften stool

-ssess forabdo"inal

distention +resence

of bowel sounds

and usual +attern of bowel function7

-ssess color

consistency anda"ount of stool

+roduced7

,A Solution !ate (dro+s4"inute Titration '.'4hr -ccess Port Pu"+4Ty+e

n4a n4a n4a n4a n4a

n4a n4a n4a n4a n4a

n4a n4a n4a n4a n4a

n4a n4a n4a n4a n4a

.ay use back for "ore s+aceLL



N E U R O S E N S O R Y

Best !es+onse to -uditory <and )ri+# *ye .ove"ent# Pu+ils#

and4or Aisual Sti"ulus *:ual ✓ Nor"al ✓ !ight#

-ge over = years (child4adult Une:ual n4a Nystag"us n4a Si&e# >

rientation ($ ✓ Geakness n4a Strabis"us n4a !eaction# 1

Confused (0 n4a !ight n4a ther n4a

,na++ro+riate words (> ✓ 'eft n4a .ood4-ffect# 'eft#

,nco"+rehensible words (= n4a .uscle Tone# <a++y n4a Si&e# > None# (1 n4a Nor"al ✓ Content n4a !eaction# 1

-ge = years and under (infant -rching n4a Duiet n4a

S"iles 'istens /ollows ($ n4a S+astic n4a Githdrawn n4a C2*

Cries consolable (0 n4a /laccid n4a Sad n4a 3 ""

5 ""

$ ""

0 ""

> ""

= ""

1 ""

,na++ro+riate +ersistent cry (> n4a Geak n4a /lat n4a

-gitated restless (= n4a 2ecorticate n4a <ostile ✓

No !es+onse (1 n4a 2ecebrate n4a /ontanel4Gindow# n4a

*yes +en ther n4a (+ertaining to infant n4a

S+ontaneously (0 ✓ 'C# Soft n4a

To s+eech (> n4a -lert4riented n4a /lat n4a

To +ain (= n4a Slee+y n4a Sunken n4a

No res+onse (1 n4a ,rritable ✓ Tense n4aBest .otor !es+onse Co"atose n4a Bulging n4a

beys Co""ands (5 n4a 2isoriented n4a Closed n4a

'ocali&es +ain ($ n4a 'ethargic n4a ther n4a

/lexion Githdrawal (0 n4a -wake ✓

/lection -bnor"al (> n4a Slee+ing n4a

*xtension (= n4a 2rowsy n4a

None (1 n4a -gitated n4a

C.- SC-'* TT-'# 1=

!elated 2x7 Studies (lab work x9rays etc# n4a

Collaborative Care !eferral# n4a

!elated NS) 2x# Anxiety r/t unconscious conflict it! re"lity AE# i$%"ire& "ttention'

C A R D I O

( A S C U L A R

Skin Color# C..*NTS

n4a

*de"a# C..*NTS

M= +itting ede"a to right ar"7 Nor"al ✓ No n4a

/lushes n4a Ees ✓

Pale n4a Chest Pain#

Cyanotic n4a No ✓

<eart Sounds# Ees n4a

Nor"al ✓ P n4a

ther 2escribe n4a D n4a

-+ical Pulse !ate# n4a ! n4a

!egular n4a S n4a

,rregular n4a T n4a

Pace"aker# /a"ily Cardiac

Ty+e n4a <istory#

!ate n4a No ✓

Peri+heral Pulses# Ees n4a

Present ✓ Tele"etry .onitor

*:ual ✓ No ✓

Geak n4a Ees n4a

-bsent n4a !hyth" n4a

.onitor 'ines @ 2ata# n4a

!elated 2x7 Studies (lab work x9rays etc# <)B# 1>7 <CT# =$7> Platelets# =10???

!elated NS) 2x# nowledge deficit r4t lithiu" adverse effect -*B +atient re+orting unknown cause of +al+itations7

Collaborative Care !eferral# !C# hy+erli+ide"ia7



) U L M O N A R Y

!es+irations#

Cough# = at ho"e No -uscultation# (clear, crackles, rhonchi

!ate 1 None ✓ Chest ex+ansion n4a wheezing -nterior Posterio

!egular ✓ Productive n4a Sy""etrical ✓

,rregular n4a Non+roductive n4a -sy""etrical n4a !t7 U++er 'obe n4a n4a

SB n4a 2escribe n4a *x+lain n4a 'eft U++er 'obe n4a n4a

2ys+nea on n4a !t7 'ower 'obe n4a n4a



*xertion n4a 'eft 'ower 'obe n4a n4a

2evices# n4a


!elated NS) 2x# ,neffective breathing +attern r4t "edication regi"en -*B +atient taking Sero:uel


G A S T R O I N T E S T I N A L

-bdo"en# ST'# 2iarrhea# n4a Geight /luctuation

Soft n4a O B.s4day 1 Consti+ation# ✓ 'ast 5 "onths n4a

!igid n4a 'ast B. =4=41$ ther# bese n4a +ounds (M 9 n4a

Non9tender n4a -"ount n4a Thin n4a ,deal weight for

Tender n4a /or"ed ✓ *"aciated n4a sex and age# 10= or less

2istended ✓ 'oose n4a Nourished n4a Present weight 10

Bowel Sounds# 'i:uid n4a Nutrition# verweight 3 (lbs

Present HPI 4 P .ucus n4a Refer to dietician Underweight n4a (lbs

-bsent H-I n4a sto"y n4a if available

!UD P Ty+e

!'D P ,ncontinent n4a Tube feeding n4a

'UD P Stool Color# Chewing Proble" n4a

''D P Brown ✓ Swallowing n4a<y+oactive ✓ Black n4a Proble" n4a

<y+eractive n4a !ed Tinged n4a Nausea4Ao"iting n4a

Bloody n4a Poor -++etite n4a

2evices# n4a


Collaborative Care !eferral# !C# hy+erli+ide"ia7

!elated NS) 2x# Consti+ation r4t "edication regi"en -*B verbali&e fear of +ain while defecating inade:uate fluid intake and side effects oflora&e+a" and sero:uel

G E N I

T O U R I N A R Y / R E ) R O D U C T I ( E

Bladder <abits# n4a 'ast void '.P# n4a Pregnancies#

/re:uency# Color of urine Straw yellow ,f any +roble" n4a Pregnant n4a

2ysuria n4a -"ount Sufficient 2escribe n4a Geeks n4a

Nocturia n4a -++earance Clear n4a )ravida4Para n4a

Urgency n4a /luid @ *lectrolytes $ cu+s n4a 2ate of last#<e"aturia n4a Total Shift ,ntake $ cu+s 'ast Pa+ S"ear n4a Prostate *xa" n4a

!etention n4a Previous =0 hrs $ cu+s !esults n4a Testicular n4a

Burning n4a Total Shift ut+ut $ cu+s Breast self exa" n4a self9exa" n4a

,ncontinence Previous =0 hrs $ cu+s Use of n4a

2ayti"e n4a Catheter contrace+tives n4a

Nightti"e n4a ,nter"ittent n4a Ty+e n4a

Stress n4a ,ndwelling n4a Aaginal 2ischarge n4a

,ncontinence n4a Condo"9cath7 n4a 2escribe# n4a

ccasional n4a 2ialysis# n4a

ther

n4a -ccess Site n4a Bleeding# n4a

-"ount# n4a

Co""ents# n4a2evices# n4a

!elated 2x7 Studies (lab work x9rays etc# Urine culture 341041$ Negative for UT,7 No growth at Q1??? C/U4"'7 Na# 1>1 "*:4d' # >73

Cl# 1?5 BUN# 11 Creatinine# ?73

!elated NS) 2x# !isk for i"balanced fluid volu"e r4t he"atocrit =$7>; and sodiu" levels 1>1 "*:4'


DIET* 1?? calorie -2-

PU!PS*# to control the blood sugar and lose

weight or to lower the risk for heart +roble"s

!*ST!,CT,NS# carbohydrates fat and +rote



M U S C U L O S + E L E T A L

.usculoskeletal /ull !.# n4a /unctional ,nde+endence .easure 'evels

Pain n4a Roint Stiffness n4a 'i"ited !.# n4a Total -ssist (sub6ect Q =$; effort n4a

Geakness n4a Cast n4a )ait# Steady ✓ .axi"al -ssist (sub6ect =$; effort M n4a

Contractures n4a -"+utation n4a Unsteady n4a .oderate -ssist (sub6ect $?; effort M n4a

Roint swelling n4a 2escribe n4a .obility in bed .ini"al -ssist (sub6ect 3$; effort M n4a

Paralysis n4a (able to turn self ✓ Su+ervision (stand9by assist verbal cues n4a

2efor"ity n4a .odified ,nde+endence (device needed n4a

Co"+lete inde+endence (ti"ely safety ✓

2evices# n4a

!elated 2x7 Studies (lab work x9rays etc7# n4a


!elated NS) 2x7# !isk for falls r4t "edication -*B +atient re+orted di&&iness after taking lora&e+a"

I N T E G U M E N T A R Y

Skin ,ntegrity# ,ndicate the location of any of the following on the chart to the right using the

designated letter#

n4a -7 rashes n4a *7 +ressure sores

✓ B7 lesions ✓ /7 recent scars

n4a C7 significant bruises 4 abrasions n4a )7 +resence of tubes 4 a++liances

n4a 27 burns n4a <7 other#

Pressure Sore Potential -ssess"entP-!-.*T*!S ? 1 = > Score

.ental Status -lter 'ethargic Se"i9Co"atose Co"atose ?

Count these conditions as doubleas 2UB'*

-ctivity -"bulatory Needs <el+ Chairfast Bedfast ?

.obility /ull 'i"ited Aery li"ited ,""obile ?

,ncontinence None ccasional Usually of

urine

Total of urine

and feces7

?

ral nutrition )ood /air Poor None ?

ral fluid intake )ood /air Poor None ?

Predis+osing

diseases

(diabetesneuro+athies

vascular

diseaseane"ias

-bsent Slight .oderate Severe 1

Patients with scores of 1? or above should beconsidered at risk7

TT-'

1

Skin Color# Skin Te"+erature# <x of skin

healing

n4a Teeth# GN' n4a

GN' ✓ GN' ✓ +roble"s# n4a ther describe "issing

Pale n4a Gar" n4a ther describe n4a teeths

Cyanotic n4a Cool n4a

-shen n4a Skin Turgor 2entures#

Raundice n4a Tight ✓ .outh# n4a U++er n4a

ther describe n4a 'oose n4a )u"s GN' ✓ 'ower# n4a

ther describe n4a Ghite Pla:ue n4a /ull# n4a

'esions n4a Partial# n4a

2evices#


!elated NS) 2x# !isk for infection r4t o+en lacerations on extre"ities -*B +atient touching and re"oving sutures with dirty hands7


C O M M E N T S n4a

n4a

n4a

n4a

C



) S Y C , E M O T I O N S

.ental Status# Perce+tion -ffect <a++y ✓ ,ntellectual /unctioning

rientation Ti"e ✓ <allucination ✓ Sad ✓ -ble to Calculate n4a

Place ✓ 2elusion ✓ /lat ✓ -ble to -bstract n4a

Person ✓ ,llusion ✓ ther 2escribe Patient Rudg"ent n4a

Situation ✓ 2escribe# Patient verbali&ed is bi+olar !ational n4a

.e"ory of hearing voices7 n4a ,"+ulsive ✓,""ediate !ecall ✓ n4a n4a ,"+aired n4a

!ecent .e"ory n4a n4a n4a Suicidal E4N E

!e"ote .e"ory n4a n4a n4a Suicide !isk E4N E

2*A*'P.*NT-' ST-)* -CC!2,N) T *!,SN

Theoretically# Behaviorally# !ationale#

)enerativity vs7 stagnation Care Career and work are the "ost i"+ortantthings at this stage along with fa"ily7 .iddle

adulthood is also the ti"e wen +eo+le cantake on greater res+onsibilities and control7

.a6or Concerns !egarding <os+itali&ation 4 ,llness safety due to har" herself or others7

.a6or Change in 'ife in the Past Eear (Crisis 4 'oss 4 thers n4a

n4a

!elated 2x7 Studies (lab work x9rays etc7 n4aCollaborative Care !eferral# n4a

!elated NS)7 2x# Ris- for (iolence r/t !istory of %syc!otic sy$%to$"tolo.y "s ei&ence& 0y &istorte& t!in-in. t!"t ot!ers "re

tryin. to !"r$ !er

M I S C E L L A N E O U S

S'**P 4 !*ST P-TT*!N

<abits /eel !ested after Proble"s# None ✓ Use of Slee+

O hrs night $ Slee+# E4N E *arly Gaking n4a -ides# E4N N

-. Na+ E4N N Co""ent n4a ,nso"nia n4a 2escribe n4a

P. Na+ E4N N Night"ares n4a

!elated 2x7 Studies (lab work x9rays etc7 n4a

n4a

!elated NS) 2x# 2isturbed slee+ +attern r4t interru+tions -*B +atient states nurse was in her roo" every hour with a flashlight7


!'*S F !*'-T,NS<,P 4 <.* .-,NT*N-NC* P-TT*!N

ccu+ation Su++ort Syste" Private Pay n4a /a"ily Concerns !egarding

Patient states S+ouse n4a ,nsurance n4a <os+itali&ation n4a

history of engage"ent Neighbor 4 /riend n4a .2C!4 .2C2 n4a n4a

of +rostitution /a"ily in Sa"e No nown n4a n4a

*"+loyed E4N N !esidence n4a !esidence n4a n4a

!etired N ther /a"7 .e"b7 n4a Patient 'ives w4 n4a n4a

2isability N None n4a

S+ecial Concerns# n4a

!elated NS) 2x# Social isolation r4t alteration in "ental status -*B absence of su++ortive significant other7


A-'U*9B*',*/ P-TT*!N

Co""ents# n4a

!eligious 4 S+iritual Beliefs# n4a

Patient re:uest to contact "inister 4 +riest 4 rabbi# yes ✓ no

Na"e# n4a Phone Nu"ber# n4a

!elated 2x7 Studies (lab work x9rays etc7 n4a

n4a

!elated NS) 2x7 S+iritual distress r4t life changes -*B +atient stated that she is a living sacrifice7


,ntended 2estination Proble"s with self care +ost discharge# ✓ yes no



E D U C A T I O N N E E D S / D I S C

, A R G E ) L A N N I N G Post 2ischarge# ,f yes ex+lain# Patient is +sychotic and is not able to take care

<o"e n4a of self

Undeter"ined n4a n4a

other ✓ -ssistant devices needed +ost9discharge# yes ✓ no

*x+lain# Patient will return to 6ail ,f yes ex+lain# n4a

n4a

n4a

Previous Utili&ation of Co""unity !esources# !eferral 2ate to 2ischarge#

<o"e <ealth n4a Coordinator n4a

<os+ice n4a <o"e <ealth n4a

-dult 2ay Care n4a Social Service n4a

Church )rou+ n4a N7N7-7 n4a

.eals on Gheels n4a ther n4a

<o"e -ide n4a *x+lain# Tro+ical Texas Behavioral <ealth will fund a three day

ther ✓ stay in facility u+on +atient status7

*x+lain# Tro+ical Texas Behavioral <ealth n4a

n4a n4a

n4a n4a

ther Co""ents# n4a

n4an4a

n4a

*ducational Needs# n4a

Barriers# Past *x+erience# n4a

!eading -bility n4a n4a

Sensory Proble"s n4a n4a

Physical State n4a 'earning !eadiness# .entally i"+aired

'anguage n4a

ther ✓

*x+lain# Patient is not "entally stable7

Su++ort Syste"s to be involved# Patient does not have a

Present nowledge# -ware of the chronic illness and the fa"ily su++ort syste"7

+ossible outco"es7 n4a

n4a

Teaching Plan and *x+ected utco"e# .edications co"+liance7 Teach the +atient about the i"+ortance of taking "edication and

understanding na"e of "edications what is for and side effects7 Teach the +atient cognitive9behavioral activities such as active +roble"

solving7 Teach the client to drink +lenty of fluids and to consu"e >90gr of sodiu"7 Teach the client to notice sti"uli that increase anxiety7

Teach the client skills of cognitive restructuring7 Teach the client there are agencies for counseling and su++ort grou+s for follow u+

assistance7 Teach the client relaxation techni:ues to decrease anxiety7

Collaborative Care !eferral#n4a

!elated NS) 2x# nowledge deficit r4t "ental status -*B reoccurring +sychotic e+isodes7

Assess$ent

1 ite$s

Su02ectie

3/or

O02ectie

Desi.n"te it!

4S5 or 4O5

An"lysis

St"te$ent

NANDA 6 %"rt

Nursin.

Di".nosis rel"te&

to As Ei&ence

0y

STG

LTG

)l"n it! 0rief

r"tion"le for e"c! one

7 in&ii&u"l %l"ns

869 Assess$ent

869 "ctiity

869 "ction

Nu$0er t!e$:

Interentions

Correl"tes it!

%l"n

)ut !ere !"t

"s &one

Nu$0er t!e$:

E"lu"tion

;"s it nor$"l

or "0nor$"l

Correl"te it!

interentions

Nu$0er t!e$:

<' 4S5

4I feel "nxious5

=' 4S5

4I feel &i>>y5

6' 4S5

4I "$ not sic-5

?' 4S5

4T( soun&

$"-es $e

"nxious5

@' 4S5

4I &ont nee&

$e&ic"tion5

1' 4S5

4I re"lly trust

you "n& I feel I

c"n tell you

"nyt!in.5

An"lysis

St"te$ent*

#ec"use t!e

clients $e&ic"l

&i".nosis is

%syc!osis' T!e

client

ex%eriences

seere "nxiety

e%iso&es'

NANDA 6 %"rt

nursin.

&i".nosis*

Anxiety r/t

unconscious

conflict it!

re"lity AE#

i$%"ire&

"ttention'

STG*

#y t!e en& of

s!ift %"tient ill

0e "0le to

er0"li>e

tec!niBues to

re&uce "nxiety

LTG*

#y &isc!"r.e

%"tient ill

re%ort "

re&uction in t!e

leel of "nxiety

<' Assess t!e clients

"nxiety leel it! t!e

,"$ilton Anxiety

Sc"le'T!is is "n i$%ort"nt tool to

"ssess "nxiety'

=' Assess si&e effects of

"nti"nxiety

$e&ic"tion)"tient nee&s to 0e ""re of

t!e %ossi0le si&e effects of t!e

%rescri0e& $e&ic"tion'

6' Assess clients

""reness of current

!e"lt! %ro0le$'T!is ill !el% to %re%"re t!e

%l"n of c"re "n& to set t!e

s!ort ter$ "n& lon. ter$

.o"ls'

?' Te"c! t!e client

s-ills of co.nitie

restructurin.'

Client c"n le"rn to control"nxious feelin.s r"t!er t!"n

0e controlle& 0y t!e$'

@' Te"c! t!e necessity

of "&!erence to t!e

%rescri0e $e&ic"tion')"tients nee& to -no t!e

i$%ort"nce of continuin.

tre"t$ent'

1' Te"c! t!e client to

notice sti$uli t!"t

incre"se sense of

"nxiety'Anxiety tri..ers c"n 0e si$%le

t!in.s 0ut it is i$%ort"nt t!"tt!e client reco.ni>e& t!e$'

' I$%le$ent "

su%%ortie t!er"%y

%ro.r"$'Su%%ort .rou%s !el%s to

control sy$%to$s'

' A&$inister

Lor">e%"$ <$. B1!

"s %rescri0e&'#en>o&i">e%ine is %rescri0e&

to control "nxiety &isor&ers

7' )roi&e client it!

" $e"ns to listen to

$usic of t!eir c!oiceMusic !el%s to rel"x "n&

control "nxiety'

<' ("li&"te

o0ser"tions 0y

"s-in. t!e client*

4Are you feelin.

"nxious no

=' Monitore&

si&e effects*

&rosiness

&i>>iness

&isorient"tion

&e%ression "rrest

6' As-e& t!e

client if is ""re

of current !e"lt!

%ro0le$

?' @ $in te"c!in.

session of

0re"t!in.

rel"x"tion

tec!niBues

@' @ $in te"c!in.

session of

%rescri0e&

$e&ic"tion "n&

si&e effects'

1' I$%le$ente&

" @ $in te"c!in.

session of "nxiety

tri..ers'

' H7HH )"tient

"ssiste& to co%in.

.rou% session'

' HHH

Lor">e%"$ )O

.ien "s %er

%!ysici"ns or&ers

7' )"tient

en2oye& cl"ssic"l

$usic &urin.

0re"-f"st'

<' Client "s

not "nxious

8Nor$"l9

=' Client felt

&i>>iness in t!e

$ornin.

8"0nor$"l9

6' Client "s

not ""re of

current !e"lt!

%ro0le$'

8"0nor$"l9

?' Client

er0"li>e& "n&

&e$onstr"te "

0re"t!in.

rel"x"tion

tec!niBue

8nor$"l9

@' Client

er0"li>e& t!e

i$%ort"nce of

t"-in.

$e&ic"tions'

8nor$"l9

1' Client

er0"li>e&

"nxiety

tri..ers'

8nor$"l9

' Client

en2oye& co%in.

.rou% session'

8nor$"l9

' Client

toler"te

$e&ic"tion

ell' 8nor$"l9

7' Client st"te&

to feel rel"xe&

"n& no "nxiety

tri..ers'

8nor$"l9



RET,IN+ RE)LAN REDO

T"-e t!e )l"n on %reious %".e it! r"tion"le "n& tell future nurses !"t nee&s to 0e &one

<' Assess t!e clients "nxiety leel it! t!e ,"$ilton Anxiety Sc"le' Nurse continues it! %l"n of c"re to "ssess t!e "nxi

leel of t!e %"tient

=' Assess si&e effects of "nti"nxiety' Nurse continues to "ssess t!e si&e effects of "nti "nxiety $e&ic"tion'

6' Assess clients ""reness of current !e"lt! %ro0le$' Nurse continues it! "ssess$ent until %"tient er0"li>es t!e

correct un&erst"n&in. of illness'

?' Te"c! t!e client s-ills of co.nitie restructurin.' Nurse continues it! t!e te"c!in. sessions 0ec"use client li-e& t!e

&yn"$ic'

@' Te"c! t!e necessity of "&!erence to t!e %rescri0e $e&ic"tion' Nurse continues it! t!e te"c!in. session until %"tient

&isc!"r.e'



1' Te"c! t!e client to notice sti$uli t!"t incre"se sense of "nxiety' Nurse continues it! t!e te"c!in. session until %"tien

is &isc!"r.e'

' I$%le$ent " su%%ortie t!er"%y %ro.r"$' Nurse continues it! su%%ortie t!er"%y until %"tient is &isc!"r.e "n& c"

$"n".er s!oul& refer %"tient'

' A&$inister Lor">e%"$ <$. B1! "s %rescri0e&' Nurse continues it! %rescri0e& $e&ic"tion until or&er is c!"n.e&'

7' )roi&e client it! " $e"ns to listen to $usic of t!eir c!oice' Nurse continues it! "ctiity until c!"n.e of c"re %l"n

410



Assess$ent

1 ite$s

Su02ectie

3/or

O02ectie

Desi.n"te it!

4S5 or 4O5

An"lysis St"te$ent

NANDA 6 %"rt Nursin.

Di".nosis rel"te& to As

Ei&ence 0y

STG

LTG

)l"n it! 0rief r"tion"le for e"c!

one

7 in&ii&u"l %l"ns

869 Assess$ent

869 "ctiity

869 "ction

Nu$0er t!e$:

Interentions

Correl"tes it! %l"n

)ut !ere !"t "s &on

Nu$0er t!e$:

17

Patient locked in facility forsafety

=7 Patient diagnosis falls on

-xis ,

>7

Notice +atient +unching the

wall7

07 S

Patient stated to want to

+unch cafeteria staff7

$7

Patient was verbally

aggressive by cursing staff

57

Patient was seen +acing in

the hallway

An"lysis* #ec"use t!e %"tient is

%syc!otic "n& loc-e& in f"cility

for s"fety'

NANDA 6 %"rt nursin.

&i".nosis*

Ris- for In2ury r/t i$%"ire&

t!ou.!t %rocess iolent out

0urst "n& %rolon.e&

!"llucin"tions AE# client in

loc-e& f"cility for s"fety'

STG* #y t!e en& of s!ift t!e

%"tient ill re$"in free of

in2ury

LTG* #y &isc!"r.e t!e %"tient

ill reco.ni>e 0e!"iors t!"t

%l"ce self in %otenti"lly

&"n.erous situ"tions

<' Assess 2u&.$ent re."r&in.

%otenti"lly &"n.erous "ctiities'

Poor judgment and decision-making skills put

the client at risk for injury

=' Assess for %!ysic"l or co.nitie

function "lter"tions t!"t $i.!t le"&

to uns"fe 0e!"iors'!isk taking hy+ersexuality and decreased

ability to concentrate to racing thoughts +lace

the client at risk for in6ury7

6' Assess for suici&"l i&e"tion2e+ression can be associated with suicidal

ideation7

?' Te"c! %"tient to follo u% it!

)C) referr"l to out%"tient sericessuc! "s Tro%ic"l #e!"ior"l ,e"lt!

Soci"l ;or-er'Patient needs to obtain ongoing su++ort

syste"s for successful treat"ent +lan7

@' Te"c! t!e client "0out 0e!"iors

"n& res%onses to eniron$ent"l

sti$uli t!"t $"y 0e !"r$ful' To hel+ client to deal with l ife9long illness7 To

be aware of stressors that "ay be har"ful7

1' Te"c! %"tient effectie co%in.

0e!"iors',nterventions beyond the acute +hase address

lifestyle "anage"ent with an illness that alters 6udg"ent7

' )l"ce t!e client in " roo$ "s

close "s %ossi0le to t!e nurses

st"tion',n order to have a clear visual of the client

' S%e"- in s!ort si$%le sentencesCo""unicate so that the client understands

within his or her attention s+an7

7' )roi&e " s"fe structure&

eniron$entThe !N controls the environ"ent in the locked

facility to +revent in6ury7

<' Assesse& 2u&.$ent re."r

%otenti"lly &"n.erous "cti

0y "s-in. %"tient !o s!e

re"ct in &ifferent &"n.erou

scen"rios'

=' Assesse& "ttention s%"n

"0ility to concentr"te "n&

feelin.s of .r"n&iosity 0y

interiein. t!e %"tient

6' As-e& t!e %"tient &irect

!"e you t!ou.!t "0out

!"r$in. yourself

?' <H $in te"c!in. sessionon t!e i$%ort"nce of follo

it! out%"tient serices "n

intro&ucin. %"tient to soci"

or-er'

@' <H $in te"c!in. session

!o to "oi& confront"tion

re&irectin. "ttention to t!e

roo$ $"int"inin. %!ysic"l

&ist"nce fro$ ne."tie stre

1' <H $in te"c!in. session

!o to &e"l it! " stressfu

situ"tion 0y &oin. rel"x"tio

tec!niBues li-e &ee% 0re"t!

exercises'' Moe& client to " roo$ n

to t!e nurses st"tion'

' #e c"reful not to $oe i

%erson"l s%"ce 0y re$"ini

6 feet ""y "n& s%e"-in. s

"n& sloly'

7' )roi&e& t!e client it!

enou.! %erson"l s%"ce so &

not &isru%t ot!ers it!

0e!"iors s!e c"nnot contr



RET,IN+ RE)LAN REDO

T"-e t!e )l"n on %reious %".e it! r"tion"le "n& tell future nurses !"t nee&s to 0e &one

<' Re.istere& nurse "ssesse& 2u&.$ent re."r&in. %otenti"lly &"n.erous "ctiities 0y "s-in. %"tient !o s!e

re"ct in &ifferent &"n.erous scen"rios' RN continues it! "ssess$ent until &isc!"r.e'

=' Re.istere& nurse "ssesse& "ttention s%"n "0ility to concentr"te "n& feelin.s of .r"n&iosity 0y interiein

t!e %"tient' RN continues it! "ssess$ent until &isc!"r.e'

6' Re.istere& nurse "s-e& t!e %"tient &irectly "0out t!ou.!t of !"r$in. yourself RN continue to "ssess for

suici&"l i&e"tions until %"tient is free of in2ury "n& suici&e'

?' Re.istere& nurse t"u.!t <H $in of t!e i$%ort"nce of folloin. it! out%"tient serices "n& intro&ucin.

%"tient to soci"l or-er' Soci"l or-er continues it! c"re "n& c"se $"n".e$ent %le"se "ssist it! referr"l'

@' Re.istere& nurse t"u.!t <H $in on !o to "oi& confront"tions 0y re&irectin. "ttention to t!e roo$

$"int"inin. %!ysic"l &ist"nce fro$ ne."tie stressors' RN continues it! follo u%'

1' Re.istere& nurse t"u.!t <H $in on !o to &e"l it! " stressful situ"tion 0y &oin. rel"x"tion tec!niBues li-

&ee% 0re"t!in. exercises' RN continues it! co$%li"nce'

' Re.istere& nurse $oe& client to " roo$ next to t!e nurses st"tion' RN $"int"in %"tient ne"r to nurses

st"tion'

' Re.istere& nurse "s c"reful not to $oe into %erson"l s%"ce 0y re$"inin. =6 feet ""y "n& s%e"-in.

softly "n& sloly' RN continues it! %l"n of c"re'

7' Re.istere& nurse %roi&e& t!e client it! enou.! %erson"l s%"ce so &oes not &isru%t ot!ers it! 0e!"iors

!e c"nnot control' RN continues it! %l"n of c"re'



Plan of Care Sheets

Assess$ent

1 ite$s

Su02ectie

3/or

O02ectie

Desi.n"te it!

4S5 or 4O5

NANDA 6 %"rt Nursin. Di".nosis

rel"te& to As Ei&ence 0y

STG

LTG

)l"n 8Interention it! 0rief

r"tion"le9 for e"c! one

7 in&ii&u"l %l"ns

869 Assess$ent

869 "ctiity

869 "ction

Nu$0er t!e$:

Interentions 8"ctu"lly %e

Correl"tes it! %l"

)ut !ere !"t "s &

Nu$0er t!e$:

<'

4S5 )t st"tes 4T!ey "re

tryin. to turn $e into "

c"t'5

='4S5 )t st"tes no0o&y

un&erst"n&s !er'

6'

4S5 )t er0"li>es

!e"rin. oices to 0e "

s"crife'

?'4O5 l"cer"tions on

0ot! loer extre$ities

@'

4O5 )t s!os !ostile

0e!"ior 8scre"$in.

"n& cussin. &on t!e

!"ll9

An"lysis* #ec"use t!e

%"tient er0"li>e& t!"t

ot!ers "re tryin. to !"r$

!er'

NANDA 6 %"rt nursin.&i".nosis*

Ris- for (iolence r/t !istory

of %syc!otic

sy$%to$"tolo.y "s

ei&ence& 0y &istorte&

t!in-in. t!"t ot!ers "re

tryin. to !"r$ !er

STG* #y t!e en& of $y s!ift

%"tient ill 0e s"fe "n& free

fro$ in2ury'

LTG* #y &isc!"r.e )t ill

&is%l"y noniolent 0e!"ior

to"r& self "n& ot!ers in

<' Assess eniron$ent e"lu"te

situ"tions t!"t coul& 0eco$e

iolent

R"tion"le*Stressful environments can cause for pt

to get aggravated.

=' Assess t!e client for

%!ysiolo.ic"l si.ns "n& extern"l

si.ns of "n.er' Rationale !nger signs may indicate a violent

outburst.

6' Assess for t!e %resence of

!"llucin"tions' Rationale

"ommand hallucinations may direct theclient to behave violently.

?' A&$inister "n& $onitor &ru.

re.i$en'!ationale#,dentify drug side or adverse effects that

"ay cause or exacerbate sensory or +erce+tual +roble"s7

@'T"-e "ction to $ini$i>e %erson"l

ris-* Use nont!re"tenin. 0o&y

l"n.u".e' M"int"in "t le"st "n

"r$s len.t! &ist"nce fro$ t!e

client &o not touc! t!e client

it!out %er$ission' Do not "llo

client to 0loc- "ccess to "n exit' #e

""re of !ere ot!er st"ff is "t "ll

ti$es' Rationale

Safety of client and others.

1'Coll"0or"te it! ot!er !e"lt!

<'Assesse& eniron$ent "

surroun&in.s 8%"tients "n

"ctiities "roun& t!e$9

=' Assesse& t!e %t for %!ys

si.ns "n& extern"l si.ns of

Intern"l si.ns of "n.er inc

incre"se& %ulse r"te res%i

r"te "n& 0loo& %ressure c%ric-ly sens"tions n"use"

erti.o' Extern"l si.ns inc

incre"se $uscle tone c!"n

0o&y te$%er"ture eye c!"

li%s %resse& to.et!er flus!

%"llor .oose0u$%s titc!

se"tin.

6'Assesse& %"tient for %res

!"llucin"tions oer 0re"-f

?'A&$inistere&

Lit!iu$ 6HH $. B!

SeroBuel 6HH$. "t 0e&ti$

@' Too- "ction to $ini$i>e

%erson"l ris- 0y folloin.

"n& $"int"inin. "r$ len.&ist"nce fro$ client "n&

surroun&e& 0y st"ff "t "ll

1' Coll"0or"te it! st"ff to

encour".e %"tient to "ssist

' T"u.!t %"tient i$%ort"n

folloin. &ru. re.i$en "

"&erse effects of Lit!iu$'

"tc! for 0lurre& ision i

urin"tion &i"rr!e" o$it

tre$ors' M"&e cle"r t!e

i$%ort"nce of flui& int"-e

%er &"y9 "n& t!e i$%ort"n

so&u$ int"-e 86? ./&"y9'

' T"u.!t %"tient co.nitie



1'

4O5 )T $e&ic"l !istory

s!o %"st of su0st"nce

"0use

t!e it! t!e "i& of

$e&ic"tions "n& nursin.

interentions 0y s!oin. no

si.ns of iolence'

te"$ $e$0ers in %roi&in.

t!er"%y "n sti$ul"tin. $o&"lities Rationale

#o achieve ma$imal gains tin functionand psychosocial well-being.

' Te"c! %"tient "0out $e&ic"tions

"ctions si&e effects t"r.et

sy$%to$s "n& toxic re"ctions' Rationale

#o avoid harmful interactions and%ordrug to$icity.

'Te"c! %"tient co.nitie

0e!"ior"l "ctiities Te"c! client

to confront on ne."tie t!ou.!t

%"tterns or unre"listic

ex%ect"tions' Rationale"ognitive-behavioral activities address

client&s assumptions, beliefs an attitudes

about their situations fosteringmodification of these elements to be as

realistic as possible, becoming more

aware of their cognitive choices ande$ercising greater control over their own

reactions.

7'Te"c! "n& encour".e t!e use of

"%%ro%ri"te e$er.ency co$$unity

resources' Rationale 't is necessary to get immediate help

when violence occurs .

0e!"ior"l "ctiities suc!

%ro0le$solin. "n& t!ou

sto%%in. to confront on n

t!ou.!t %"tterns'

7' Instructe& %"tient to con

Tro%ic"l !e"lt! or 7<< in

"n e$er.ency !en s!e fe

or stresse&'



RETHINK, REPLAN, REDO

Take the Plan on previous pae !ith rationale an" tell future nurses !hat nee"s t

#e "one

<' Nurse continues to "ssess eniron$ent e"lu"te situ"tions t!"t coul& 0eco$e iolent

=' Nurse continues to "ssess t!e client for %!ysiolo.ic"l si.ns "n& extern"l si.ns of "n.er'

6' Nurse continues to "ssess for t!e %resence of !"llucin"tions

?' Nurse continues to A&$inister "n& $onitor &ru. re.i$en 8Lit!iu$ 6HH $. B! SeroBuel 6HH$. "t 0e&ti$

@' Nurse continues to t"-e "ction to $ini$i>e %erson"l ris-* Use nont!re"tenin. 0o&y l"n.u".e' M"int"in "t

le"st "n "r$s len.t! &ist"nce fro$ t!e client &o not touc! t!e client it!out %er$ission' Do not "llo client0loc- "ccess to "n exit' #e ""re of !ere ot!er st"ff is "t "ll ti$es'

1' Nurse continues to coll"0or"te it! ot!er !e"lt! te"$ $e$0ers in %roi&in. t!er"%y "n sti$ul"tin.

$o&"lities

' Nurse continues to te"c! %"tient "0out $e&ic"tions "ctions si&e effects t"r.et sy$%to$s "n& toxic

re"ctions'

' Nurse continues to te"c! %"tient co.nitie0e!"ior"l "ctiities Te"c! client to confront on ne."tie

t!ou.!t %"tterns or unre"listic ex%ect"tions'

7' Nurse continues to te"c! "n& encour".e t!e use of "%%ro%ri"te e$er.ency co$$unity resources'



8/14

Assess$ent

1 ite$s

Su02ectie

3/or

O02ectie

Desi.n"te it!

4S5 or 4O5

NANDA 6 %"rt Nursin. Di".nosis

rel"te& to As Ei&ence 0y

STG

LTG

)l"n 8Interention it! 0rief r"tion"le9

for e"c! one

7 in&ii&u"l %l"ns

869 Assess$ent

869 "ctiity

869 "ction

Nu$0er t!e$:

Interentions 8"ctu"lly %erfo

Correl"tes it! %l"n

)ut !ere !"t "s &on

Nu$0er t!e$:

<' 4S5 )t yiel&s 4S"crifice isnee&e&5

=' 4O5 Multi%le l"cer"tion to

0il"ter"l rists "n& t!i.!s'

6' 4S5 )t yiel&s

4 I nee& to 0e Crucifie&5

?' 4O5 ,istory of %reious

suici&e "tte$%t

@' 4S5 )t st"tes

4I is! I ere &e"&5

1' 4O5 )syc!i"tric

illness/&isor&er' De%ression

Sc!i>o%!reni"

NANDA 6 %"rt nursin.&i".nosis*

Ris- for Suici&e r/t

sc!i>o%!reni" "fter

&e%ression "s ei&ence 0y

%reious "tte$%t to suici&e'

STG* #y t!e en& of $y s!ift

%"tient ill re$"in s"fe "n&

un!"r$e&'

LTG* #y &isc!"r.e )t ill

continue .rou% interentionst!"t c"n 0e useful to "&&ress

recurrent suici&e "tte$%ts''

<' Assess Ms' S'A' t!e "0ility toenter into " nosuici&e contr"ct'

Rational (iscussing feelings of self-harm

with a trusted person provides relief for the

client. ! contract gets the subject out in the

open and places some of the responsibility for

safety with the client.

=' Con&uct " t!orou.! %!ysic"l

"ssess$ent focusin. in

inte.u$ent"ry syste$' Rational )ew lacerations may indicatecontinue to self-mutilation and access to sharp

object.

6 . Assess for t!e influence of

cultur"l 0eliefs nor$s "n& "lues

on Ms' S'A's %erce%tions ofsuici&e'

Rational *hat the individual believes about

suicide may be based on cultural perceptions.

?' O0sere recor& "n& re%ort "ny

c!"n.es in $oo& or 0e!"ior t!"t

$"y si.nify incre"sin. suici&e ris-

"n& &ocu$ent results of re.ul"r

sureill"nce c!ec-s' Rational Suicidal ideation often is not

continuous+ it may decrease, then increase in

response to negative thinking or e$posure to

stressors.

@' Encour".e %"tient to

&e$onstr"te c"re to !erself @c!il&ren "n& sister' Rational #he familial characteristics of care

and support may be associated fosteringresiliency in families. Resilience is the ability

to e$perience adverse conditions and

successfully overcome them "alvert, /0.

1' Refer for !o$e$"-er or

%syc!i"tric !o$e !e"lt! c"re

serices for res%ite client

re"ssur"nce "n& i$%le$ent"tion

of " t!er"%eutic re.i$en' Rational #he (epression "are for Patients at 1ome (epression "!R2P!#10 program

provided assistance for medical and surgical

homebound clients as a routine part of clinical

<' If %ossi0le &urin. "&$ior !en r"%tor !"s 0een

st"0lis!e& it! %"tient "

suici&e contr"ct !"s to 0e

=' Durin. "&$ission " %!y

"ssess$ent !"s to 0e %erfo

est"0lis! " &"t" 0"se for

%ossi0le future selfin2urie

)!ysic"l "ssess$ent to 0e

tice " &"y "t *HH !rs "n&

=H*HH !rs'

6' Assess$ent of cultur"l0eliefs nor$s "n& "lues

s!oul& 0e %erfor$e& once

"t <6*HH "fter lunc! to i&e

uniBue cultur"l res%onses

stressors in &eter$inin.

sensitie interentions to

%reent suici&e'

?' Assess$ent for "ny c!"n

in $oo& or 0e!"ior "t *H

eery 6H $inutes to < !our

!ic! $"y si.nify incre"s

suici&e ris-'

@' To&"y "t H7*HH %"tient

consulte& t!e )!ycolo.ist

%"tient !"s 0een %roi&e&

encour".e$ent to selfc"r

!"s 0een %roi&e& "ccess t

f"orite %erfu$e "n& it !"

0een encour".e to see- !e

fro$ !er @ c!il&ren "n& si

for $or"l su%%ort'

1' #efore %"tient is &isc!"

!o$e %roi&e !o$e c"re



practice 3ruce et al, 450

' Te"c! co.nitie0e!"ior"l

"ctiities suc! "s "ctie %ro0le$

solin. refr"$in. 8re"%%r"isin.

t!e situ"tion fro$ " &ifferent

%ers%ectie9 or t!ou.!t sto%%in.

8in res%onse to " ne."tie t!ou.!t%icturin. " l"r.e sto% si.n "n&

re%l"cin. t!e i$".e it! "

%re"rr"n.e& %ositie "ltern"tie9'

Te"c! t!e client to confront !is or

!er on ne."tie t!ou.!t %"tterns

8or co.nitie &istortions9 suc! "s

c"t"stro%!i>in. 8ex%ectin. t!e ery

orst9 &ic!oto$ous t!in-in.

8%erceiin. eents in only one of

to o%%osite c"te.ories9 or

$".nific"tion 8%l"cin. &istorte&

e$%!"sis on " sin.le eent9' Rational "ognitive-behavioral activities

address client&s assumptions, beliefs, andattitudes about their situations and foster

modification of these elements to be asrealistic and optimistic as possible.

' )roi&e t!e client it! %!one

nu$0ers of "%%ro%ri"te

co$$unity ".encies for t!er"%y

"n& counselin.' NAMI is "n

excellent resource for client "n&

f"$ily su%%ort' Rational "ontinuous follow-up care should beimplemented+ therefore, the method to access

this care must be given to the client Sun 6

7ong, 45580

7' Te"c! t!e %"tient !o to

reco.ni>e t!"t t!e client is "tincre"se& ris- for suici&e 8c!"n.es

in 0e!"ior "n& er0"l "n&

noner0"l co$$unic"tion

it!&r""l &e%ression or su&&en

liftin. of &e%ression9' Rational ! client may be at peace because a

suicide plan has been made and the client has

the energy to carry it out. #herefore, whendepression lifts, increased vigilance is

necessary Sun 6 7ong, 45580.

<H' A&$inister Ine." Sustenn"

8)"ll"%eri&one9 1 $. once " &"y

for tre"t$ent of sc!i>o"ffectie

&isor&er' Rational !ntipsychotic, !ction 9ay act by

antagonizing dopamine and serotoninin the

")S. Paliperidone is the active metabolite ofrisperidone.

"ssist"nce "s %"tient %refe

co$%"ny'

' At 7*HH !rs <?*HH !rs "

0efore 0e& <7*HH !rs it !"

continue it! te"c!in. Ms

co.nitie0e!"ior"l "cti

it! ill continue incre"sit! %ositie "n& o%ti$ist

"ttitu&e'

' #efore %"tient is 0een

&isc!"r.e !o$e it !"s 0ee

%roi&e& t!e %"tient it!

NAMI Rio Gr"n&e ("lley

8N"tion"l Alli"nce on Men

Illness9 su%%ort .rou% %!o

nu$0er 87@19 1=??71H'

7' Durin. te"$ conference

$eetin. to&"y "t <6*HH !r

client it !"s 0een %roi&e

te"c!in. on !o to reco.n

ris- for suici&e 0e!"iors'

<H' 1 $illi.r"$s of

)"li"%eri&one !"s 0een

"&$inistere& "t H*HH !rs

0re"-f"st once " &"y ee

&"y'



RETHINK, REPLAN, REDO

Take the Plan on previous pae !ith rationale an" tell future nurses !hat nee"s t

#e "one

<' A nosuici&e contr"ct !"s 0een si.ne& 0y %"tient !ic! is -e%t in " secure %l"ce Re.istere& Nurse !"e e"

"ccess to contr"ct "s nee& it if Ms' S'A' 0eco$es suici&"l'

=' Re.istere& Nurse nee&s to continue it! %!ysic"l "ssess$ent tice " &"y "t H*HH "n& =H*HH "n& )"tient

C"re Tec!nici"n nee&s to re%ort "ny ne in2uries to Re.istere& Nurse if ne in2uries "%%e"r 0eteen

Re.istere& Nurse Assess$ents'



6' Re.istere& Nurse nee&s to continue it! "ssess$ent of cultur"l 0eliefs nor$s "n& "lues once " &"y "t

<6*HH to o0t"in " 0etter un&erst"n&in. on %"tients %erce%tions of suici&e'

?' )"tient C"re Tec!nici"n nee&s to const"ntly "ssess for "ny c!"n.es in Ms' S'A' $oo& or 0e!"ior st"rtin.

fro$ H*HH t!e ti$e t!e %"tients "-es u% on freBuency of eery 6H $inutes to "n !our "n& %roi&e results t

Re.istere& Nurse'

@' Re.istere& Nurse "n& )!ycolo.ist s!oul& continue to encour".e to c"re to !erself !er c!il&ren "n& sister

it! t!e .o"l to cre"te " %ositie 0o&in. for f"ster %syc!olo.ic recu%er"tion'

1' Referr"l !"s 0een $"&e to %syc!i"tric !o$e !e"lt! Soci"l or-er ill -ee% follou% t!ree &"ys "fter

&isc!"r.e for %"tient co$%li"nce'

' )syc!i"tric Nurse continue it! co.nitie0e!"ior"l "ctiities &"ily "n& continue incre"sin. t!e leel "s

)syc!i"trics or&ers'

' Re.istere& Nurse "n& Soci"l or-er 0efore MS' S'A' is &isc!"r.e& !o$e %le"se re"ssure t!"t t!e %"tient !

t!e nu$0er for NAMI Rio Gr"n&e ("lley su%%ort .rou% 7@11=??71H'

7' )syc!i"tric Nurse %le"se reie te"c!in. it! Ms' S'A' "0out !o to reco.ni>e if s!e 0eco$es "t ris- for

suici&e "lso %roi&e t!is infor$"tion in ritin.'

<H' As %er )syc!i"trist $e&icine %rescri%tion continue it! )"li"%eri&one 1 $. 0y $out! &"ily' )"li"%eri&o

1$. %o B& J6H K = refills %rescri%tion !"s 0een sent to ;"l.reens FM H=' Me&ic"tion ill 0e re"&y to %ic- u

on H/=7/=H<@'

care plan east campus corregido

Documents