1 DATABASE NURSING CARE PLAN CLIENT INITIALS _JS_ GENDER

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1 DATABASE NURSING CARE PLAN CLIENT INITIALS _JS_ GENDER Powered By Docstoc
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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)
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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.-------------------------------------------
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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.
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                                                                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.

				
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