1 RIVERSIDE COMMUNITY COLLEGE STUDENT________________________________ NURSING EDUCATION PROGRAM DATE _______________________ NURSING 63 DATABASE: NURSING CARE PLAN CLIENT INITIALS ___JS___ GENDER __F__ AGE__23___ DATE ADMITTED_March 21, 2005 ADMISSION (LEGAL) CATEGORY_5150 DTS/GD__________ OCCUPATION___Student______ IDENTIFY CLIENT’S STRENGTHS (Occupation, motivation, support systems, ability to communicate) JS is a student at the local community college working toward a degree in Accounting. She lacks motivation currently to improve herself due to extreme depression and S/I (suicide ideation) She lacks family support as JS has had a long history of psychiatric illness. JS is able to communicate her feelings verbally, however, she typically becomes self abusive as her depression increases. FAMILY INFORMATION: ________________________________________________________ _______________________________________________________________________________ CLIENT’S LIFE CYCLE STAGE (ERICKSON): __Young Adulthood - Intimacy vs. Isolation ___ Briefly describe the developmental tasks to be accomplished in that stage and contrast the client’s behavior: _To form a intense, lasting relationship or commitment to another person, a cause, an institution, or a creative effort. Intimacy requires the capacity to commit oneself. Ego dominate factor should have developed the capacity for self-realization and the ability to work with others. The avoidance of intimacy leads to a deep sense of isolation and consequent self-absorption. JS appears to be in the isolation stage of her life cycle due to her lack of interactions with others and noted self-absorption. (Townsend, 1997) DIAGNOSIS AND DEFINITION: Give detailed definition of admission psychiatric diagnosis. Include Axis III conditions with brief definition. Axis I: _296.3_Major_Depressive Disorder, Recurrent with psychotic features. A disturbance of mood involving depression or loss of interest or pleasure in the usual activities and pastimes. There is evidence of interference in social and occupational functioning for at least 2 weeks. There is no history of manic behavior and the symptoms cannot be attributed to use of substances or a general medical condition. Recurrent episodes of depression have occurred and there is impairment with reality testing: i.e. the presence of hallucinations and/or delusions. (Townsend, 1997) Axis II: _301.83 Borderline Personality Disorder, An instability in interpersonal relationships, mood, and self-image and affects, and marked impulsivity. The individual may have unstable and intense interpersonal relationships. There may be an identity disturbance: markedly and persistently unstable self-image or sense of self. Impulsivity and potentially self damaging behaviors with recurrent suicidal behavior, gestures or threats may be noted. Intense episodic disphoria, irritability, or anxiety usually lasting a few hours may occur. (American Psychiatric Association, 2000) Axis III: __H – Disease of the Digestive System Gastroesophageal reflux disease: (GERD), Typical caused by the relaxation of the lower esophageal sphincter (LES). Symptoms include heartburn, chest pain, dysphagia, dyspepsia, and a disturbing sensation of a lump in the throat. (Rayhorn, Argel, & Demchak, 2003) 2 Axis IV: _A – Problems with primary support group – conflict with family/significant other (Handout, n.d.) Axis V: _30_ - Unable to function in most areas, Delusional, hallucinations, serious impairment of communication, judgment (Handout, n.d.) BRIEF HISTORY: (Emphasis on psychosocial factors). Include allergies, work history, history of mental health care during lifetime. Describe fluctuations/progression in symptoms of the mental illness over time. Allergies:__NKA________________________________________________________________ Work history: _JS has not had a job. She report being disabled due to recurrent depression. She has been attending classes at RCC. JS would like to obtain a degree in accounting. She has been attending school on and off for the past 3 years and has started a total of 2 classes, but had to drop both classes due to increased depression and suicidal ideation. . History of mental health care: JS has been treated at ITF for the past 10 years. Her first encounter was at the age of 13. She had been molested by her step-father for 2 years before telling her mother. The mother refused to believe JS and initially CPS did not identify a problem in the home. After multiple hospitalizations CPS agreed to remove JS from the home. JS was placed in a level 9 group home where she continued to experience depression with suicide ideation and make “suicide attempts” by superficially cutting on her forearms. In time JS was placed in a variety of group home settings, until placement was located to meet her special needs with more intensive monitoring.. JS is now staying at a board and care where she has more “freedom”. As an adult JS continues to go in and out of the hospital at least 8 times per year, due to her mental illness and continued suicide ideations. Fluctuations/progression of symptoms:_JS remains angry with her family (mother) due to the molestation issue and lack of trust. There has been a progression of her depressive symptoms to the point that it interferers with her functioning in the community. At times JS is bothered with auditory hallucinations telling her to cut on herself or to die. These exacerbations of her symptoms usually occur when JS stops taking her medications for a few days. CLIENT ASSESSMENT: Write a complete narrative or PAIR (Problem, Assessment, Intervention, and Response) assessment of the client. Concentrate on the ABC’s (Affect, Appearance, Behavior, & Communication). Monitor for therapeutic and side effects of mediations and signs and symptoms of physical problems identified on Axis III. Additionally, some other areas to include are the client’s feelings about the illness and effect of the illness on the client’s job, family, and other significant parts of his/her life. In thinking about descriptive terms to use for you client, you might find the following document, Mental Status/Psychiatric Symptoms, of help. Complete the “Psychosocial Assessment.” 3/23/05 1030 P – DTS------------------------------------------------------------------------------------------------------------------- A – Oriented x3, reports she does not understand why she was brought to the hospital this time. States she was just walking in the street- the cars just needed to go around her. Brought in on 5150 for DTS as she was wondering the in middle of Van Buren causing cars to go around her. Observed by police officer in the middle of the street running at cars as they approached. Client was screaming “just hit me”. Continues to report a desire to die. States “I have noting to live for – I can’t even do school right!” Small scratches on left forearm noted. Reports she had these before coming to the hospital. Admission assessment checked and not scratches were noted. Notified Team Leader, who reported this was done today. Placed on 1:1 due to increased suicide ideation. Reports auditory hallucinations telling her to die. Refused to shower or put own clothes on today. Body odor noted. Encouraged to shower to assist with her self esteem, but she refused. Reports she did not sleep last night. According to report, client was up and down thought-out the night. At about 40 % of breakfast then eating crackers and milk brought for snack. Participates in groups with slow body movements and thought process. Seeks conversation with staff vs. peers. Blunted affect, avoids eye contact, pressured slurred speech.------------------------------------------- 3 I – Monitor on 1:1 for suicidal ideations. Encouraged participation in unit activities and verbalization of problems vs. self abusive behaviors. Education regarding the importance of medication compliance and rational for medication use. Inform of potential side effects that should be reported to nursing or physician. Encouraged to complete ADL’s. Provide safe secure environment with consistent limits. R – Agreed to take medications offered. Appears tired with slurred speech. No self abusive behaviors noted at this time. Continues to report S/I, but agreed to talk with staff when the urges are strong. Participating in most unit activities, however, continues to refuse to do ADL’s. Monitor closely on 1:1.--------- ----D. Glenore, RN, C CHEMOTHERAPY: Use the “Prescribed Medications” form to describe all the client’s medications. DSM-IV TR DIAGNOSIS ON ALL 5 AXES: Axis I: _296.3_Major_Depressive Disorder, Recurrent with psychotic features. Axis II: _301.83 Borderline Personality Disorder Axis III: __H – Disease of the Digestive System Axis IV: _A Axis V: _30_ - DISCHARGE PLANNING: The plan is to discharge the patient to Vista Pacifica upon stabilization. Continue with ordered medications. IMPACT OF CULTURE ON CLIENT’S MENTAL ILLNESS: NANSA DIAGNOSES: Select the three top priority diagnoses to develop in the NCP for you client. The document entitled “Nursing Diagnosis” is included as a resource. LABORATORY/DIAGNOSTIC TOOL: Record and explain lab tests pertinent to your client’s diagnosis/ses and prescribed medications. CONCEPT MAP: Complete as per policy. METHOD TEACHING PLAN: Complete as per policy. 4 CONCEPT MAP Developmental Stage of Life Cycle: Early Adulthood Task: Intimacy versus Isolation Health-Illness Continuum: Maximum Health Health <-----Illness Death Oxygen Needs/Circulation Elimination Nutrition/Hydration Room Air Incontinent Height: 68 inches VS for May 3, 2004: DSS, MOM prn, Mylanta prn Weight: 244.03 on 03/09/04 97.3F-85-20, Takes Ditropan and DDVAP Gained 21lbs in 3 months BP: 120/80 Eats 100% all meals Depakane level on Psychiatric Diagnoses: Teeth in good condition Axis I: Schizoaffective, Obsessive Compulsive Personality Disorder, 04-06-04, 45.7 Polysubstance Abuse On Regular Diet, was a Vegan Meds he is taking Axis II: Borderline Personality Disorder States “I like soul food” Ditrapan, DDVAP, Axis III: Incontinent Multivitamin, Mevacor, Axis IV: A, I DSS, Multivitamin, Axis V: Current GAF 30 Calcium Calcium, Melvacor, Problem List/Nursing Diagnosis Risperdal, Clozaril, Prioritize according to Maslow’s Hierarchy Depakote ER, 1. Altered Through Process Prn Meds: Mylanta, 2. Potential for Violence (self or others) MOM, Benadryl, Tylenol, Ativan 3. Impaired Verbal Communication Neurological/ 4. Powerlessness Safety/Sensory Neurovascular 5. Knowledge Deficit/Noncompliance Intellect below normal Poor insight, social judgment poor Awake, alert, oriented Anxiety/Concerns/Fear/Knowledge NeedsIrrational Ideas Flow of thought: Indecisive and Incoherence Depress thought content History of stating he is evil and Affect: Normal for Age/Culture No EPS or Tardive Dyskanesia wants to be dead. Hearing voices Mood: Elevated Repetitive Questions telling him to stab family Speech pattern: Normal Attempted suicide in 2000 by members and rape children General Attitude: “Good mood” ingesting 2 bottles of medication Paranoid thought disorder with a 12 pack of beer. Long and short term memory Emotions: “Happy” Interview Behavior: Sensitive Poly substance abuse in 2002 intact Ativan and Benadryl prn Risperdal, Clozaril, Depakote ER, Vocational Needs Risperdal, Clozaril, Depakote ER, Paxil, Benadryl, Ativan History Aggressive assault Schizoaffective D/O Paxil, Benadryl, Ativan OCD Ativan and Benadryl prn Love/Belonging/Culture Coping/Body Image Rest/Activity Comfort/Sexuality 24 y/o, single, white male Motor Activity: Normal for Age/Culture He likes exercising, plays cards, listen to the Repetitive physical movement pacing, hand Single, white male radio, reading, walking, and watching TV (A wrapping. Came from Sparr’s Village Lakers fan). Restlessness and fidgeting Does ADLs by himself Dislike gardening In a vocational program and separate dirty Aunt visits him every weekend Relationship with family and friends reduce, dishes on a rack and gets paid Aunt is the conservator Privileged to leave the facility for 1 hr and 30 and takes him shopping Lived in an institution for 10 yrs minutes to increase independence Refused to talk about how he Mother committed suicide, grandmother died. ended up in the facility Father unknown Takes Paxil for antidepressant Likes to wear brand name attire Tylenol prn Hygiene: Has body odor Grooming: Good 5 M.E.T.H.O.D. Daily Teaching Plan and Evaluation PATIENT INITIALS: LEARNERS PRESENT (circle): Client Family Sig. Other MEDICAL DIAGNOSES: Schizoaffective Disorder, Obsessive Compulsive Personality Disorder, and Polysubstance Abuse. TECHNIQUES: Discussion Q/A Demos Handout(s) Other __________ Date/Int Content Evaluation 05/20/04 M (Medications): Pt. is compliant wit this medication. When I was DG Risperdal: Decreases symptoms of psychoses. talking to him about his medications what they were Common side effects are aggressive behavior, headache, increased dreams, for and what type of side effects he refused to talk increased sleep duration, insomnia, sedation, visual disturbances and about it. I would have taught his aunt about the meds dizziness. Do not use alcohol and any anti-depressants when taking this but she was not available. medication. Notify doctor for sore throat, fever, unusual bleeding, rash, or tremors. Take medication as indicated. Clozaril: Decreased schizophrenic behavior. Common side effects are dizziness, sedation, headache, tremors, sleep problems, constipation, low blood pressure and fast heartrate. Take medication as indicated. Do not drive and not take medication with al notify health care professional promptly if sore throat, fever, lethargy, weakness, malaise, or flu-like symptoms occur. Paxil: Decreases panic attacks or obsessive-compulsive behavior. Common side effects are anxiety, dizziness, drowsiness, headaches, insomnia, weakness, constipation, diarrhea, dry mouth, sweating and tremor. Take medications as indicated. Do not double dose. Depakote: Decreases manic behavior. Common side effects drowsiness and dizziness. Do not use alcohol and any anti-depressants when taking this medication. Take medication as indicated. Overall: Continue taking medication even though you feel better or the illness symptoms are no longer evident. 05/20/04 E (Environment): Attend and participate in group therapies. Avoid Pt. will be going to a lower level board and care. The DG crowds which can cause anxiety. Do not go out alone and do not drive environment over there will be safe. when taking psychotic medications. Safe secure environment with consistent limits 05/20/04 T (Treatments): Be compliant with medications. Attend group therapies Pt. is compliant with medications, attend group DG and discuss issues with Psychiatrist regarding self and treatment. Follow therapies, and is cooperative with the healthcare the rules and regulations of the health care team. workers. 05/20/04 H (Health knowledge of disease): Pt. is unable to understand his condition he said that DG Schizoaffective disorder is a psychosis characterized by both affective he has something wrong with his head and he got it (mood disorder) and schizophrenic (thought disorder) symptoms, with from his parents. substantial loss of occupational and social functioning. This disorder can cause people to be extremely depressed or elated. They experience hallucinations and delusions. Obsessive compulsive personality disorder is an individual who are perfectionist and inflexible. They are preoccupied with rules, trivial details, and procedures. They are serious about their activities; they are rigid, controlling, and cold. Polysubstance abuse: Individuals who use psychoactive substances will take several kinds of substances either all together or in sequence. For example, abusers of cocaine may also take alcohol or Anxiolytics to contend with anxiety, or marijuana and opioid. 05/20/04 O (Outpatient/inpatient referrals): (including resources such as websites Would have suggested these websites to his family DG and organizations): but family was not present during my stay. patient has access to a computer and know how to use it- www.healthatoz.com www.webmd.com www.schizophrenia.com Referrals: Psychiatrist for medication monitoring Therapist for therapy AA/NA Social service for placement monitoring 05/20/04 D: (Diet): Regular Diet. Low cholesterol, low fat, well balanced meal with Pt. nodded his head appropriately. He said that he DG fruits, vegetables, carbohydrates and meat. Avoid junk food and alcohol. doesn’t drink alcohol but he loves to eat junk food. He said he can’t avoid junk food.