Care Plan

Student Name:

Week:

Dates of Care:

Demographics and Brief History

Patient

Initials

DM

Sex

M

Age

59

Room

202-1

Admitting Date

11/01/2022

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Patient tried to commit suicide.

Attending physician/Treatment team:

Khan Aqeel A. MD

Precautions:

Hypertension

Primary Diagnosis:

Depression with suicide ideation

Co-morbidities:

Hypertension

Allergies:

No know allergies

Code Status:

Full code

Isolation: (type and reason)

No Isolation

Admission Height:

69.2 in

Admission Weight:

100.5 kg

Arm Band Location (colors &

reasons)

On the right arm white color

Past Medical History: (pertinent & how managed)

Mild mental retardation, bipolar disorder, generalized anxiety disorder, alcohol abuse, hypertension, sleep apneas

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome) Patient was put under suicide precaution.

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

General Appearance

Assessment:

Patient appeared clean but his hair was not well combed. His clothes were clean and appeared appropriate to age.

Activities of Daily Living

· sleep/rest

o Patient said he able to sleep eight hours and more in the night and an hour or more during the day.

· Diet Patient eats three square meals and some snacks each day.

o

· Exercise/mobility Patient walks perfectly without any assistive device .

o

· Elimination o Patient said he moves his bowls daily without any problem.

· Hygiene

o Patient takes his shower daily and brushes his teeth twice daily and changes his clothes daily. He said he does his laundry twice in the week.

GI

Diet:

Blood Glucose (time & date):

Last bowel movement (time & date):

Pertinent Labs/Test:

Assessments/Interventions:

· Stool

· Bowel sounds : Patient said he moves his bowels at least once a day without any difficulty

· Tenderness, distention:

· Appetite, nausea, vomiting:

· Interventions:

o Patient urinates well without any pain or burning during urination

Respiratory:

Assessments/Interventions:

· Lung sounds

· Cough, sputum

· SOB

· Interventions:

o Patient has no respiration problems. His breathing sounds are clear, no cough or difficulty breathing.

Neurosensory:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

· Slow

Pertinent Labs/Test:

Assessments/Interventions:

· LOC

· Pupils

· Glascow Coma Scale

· Dizziness

· Headaches

· Tremors

· Tingling, weakness, paralysis, or numbness

· Interventions:

o

Cardiovascular:

Pertinent Labs/Test:

Assessments/Interventions:

· Peripheral pulses

· Heart sounds (murmurs or bruits):

· Edema:

· Chest pain, discomfort, palpitations:

· Interventions:

o

Musculoskeletal:

Activity:

Casts/Slings:

Assessments/Interventions:

· Strength, weakness:

· ROM:

· Gait: patients’ gait was good and smooth.

· Pain: Patient said he had no pain and score zero for pain

· Fractures, amputations, or transfers: Patient had no fractures on him.

· Interventions:

o

Renal:

Pertinent Labs/Test:

Assessments/Interventions:

· Bruit, thrill, location:

· Urine-quality:

· Burning with urination, hematuria:

· Incontinent, continent, I & O:

· Interventions:

o

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:

· Bruising, wounds, drains:

· Turgor: 2+

· Surgical incisions: Patient had no surgical incisions.

· Finger & toe nails: Finger and toe nails were neatly kept.

· Interventions:

Pain:

Pain score:

Assessments/Interventions:

· Scale used: Numerical

· Location, duration, intensity, character • Exacerbation, relief • Interventions:

o

o Patient has no bruises or surgical incision sites on his skin. He has turgor was 2+.

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test:

Assessment/Interventions:

· Bleeding:

· Discharge:

· Interventions:

o

Safety:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Advance Directives/Ethical considerations:

AD:

POA:

Lab Values

Results

Normal Lab Values

Significance to your patient (if applicable)

WBC

7.1 L

5.2-12.4

RBC

4.27 L

4.7-6.2

HGB

12.4 L

12.0-15.0

HCT

37.9 L

37-50%

MCV

89

95.3

MCH

29.1

27-31

MCHC

32.8

32-36

Platelets

153

151-401

RDW

14.7

12-15%

MPV

N/A

7-9

Glucose

N/A

70-99

BUN

N/A

7-25

Creatinine

1.1

0.6-1.3

Sodium

137

135-145

Potassium

3.6

3.5-5.2

Cloride

9.8

98-107

Calcium

8.9

8.6-10.3

Salicylate

N/A

<30

Pathophysical Discussion: For this section include appropriate references and use APA format

Discuss the current disease process:

Psycho/Social Assessment

· Level of education

o High School

· Occupation

o Unemployed

· Race/Ethnic Background or Identification

o Caucasian

· Religion/Spiritual Beliefs

o Does not go to church

· Communication needs: (verbal, nonverbal, barriers, languages)

o

· Special Talents/Interests/Skills

o Patient lives to sweep, mob, and dust to keep his environment clean so he has implemented it since he came to the unit to help keep it clean and safe for everyone,

· Environment (home and community) o

· Family Structure/History:

· Patient lives in a group home but has a sister who supports him.

Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)

Patient is in the middle age group of Erikson’s stage of Development.

Support System:

Patient lives in a group home and said his sister and group members are his support system and they are always there for him.

Stressors/Stress Management Practices:

Patient said he normally takes a walk and talks to friends in the group home to relief his stress.

Discuss the etiology of the patient’s illness:

Also note the complications that may occur with treatments and patient’s overall prognosis:

Attach a research article pertaining to diagnosis of patient. Write a summary about the article:

.

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Acetaminophen

Pain Medication

650 mg

Oral

Q4

Pain and Fever

-Rash, Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric, diarrhea.

-Monitor for signs and symptoms

-Monitor potential abuse from psychological dependence

Simethicone

15 mg

Oral

PRN Q6

Syspesia

-Severe dizziness, trouble breathing, rash, itching, swelling

Benztropine Mesylate

Anticholinergic

2 mg

IM

PRN Q12

Extra Paramedial Symptoms

-Drowsiness, dizziness, nausea, vomiting, constipation, blurred vision, tachycardia

-Access therapeutic effectiveness

-Monitor for muscle weakness

-Monitor for signs and symptoms

Haloperidol

Psychotherapeutic

5 mg

Oral

Q 6

Psychotic symptoms

-Weakness, insomnia, tachycardia, blurred vison, respiratory depression, diaphoresis

-Monitor for therapeutic effectiveness and exacerbation of seizure activity

Haloperidol lactated

Psychotherapeutic

5 mg

IM

PRN Q6

Psychotic symptoms

-Weakness, insomnia, tachycardia, blurred vison, respiratory depression, diaphoresis

-Monitor for therapeutic effectiveness and exacerbation of seizure activity

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Lorazepam

Anxiolytic

2 mg

IM

Q 6

PRN

Moderate to severe agitation

-Sedation, weakness, nausea, vomiting, anorexia, hypertension or hypotension, confusion, and anterograde amnesia

-Do not drink large volumes of coffee or alcoholic beverages

-Supervise patient who exhibits depression with anxiety

Lorazepam

Anxiolytic

2 mg

Oral PO

Q 6

PRN

Mild agitation

-Sedation, weakness, nausea, vomiting, anorexia, hypertension or hypotension, confusion, and anterograde amnesia

-Do not drink large volumes of coffee or alcoholic beverages

-Supervise patient who exhibits depression with anxiety

Magnesium Hydroxide

Antacid

30 mL

Oral

PRN Daily

Constipation

-Nausea, vomiting, abdominal cramps, hypotension, bradycardia, respiratory depression, weakness, and dehydration, coma

-Moniotr seum magnesium with signs of hypermagnesemia

-Prolong frequent use of laxative

Trazodone

Antidepressant

50mg

Oral PO

PRN Oral

Insomnia

-Light-headedness, dizziness, muscular twitches and aches, diarrhea, hematuria

-Monitor pulse rate

-Observe patient’s level of activity

-Monitor for symptoms of hypotension

Risperidone

Antipsychotic

4 mg

Oral PO

B.I.D.

Interferes with dopamine binding region of the brain

-Weakness, headache, blurred vision, insomnia, cough, urinary retention, hyperglycemia

-Monitor closely neurologic status of older adults

-Be aware of the risk of orthostatic hypotension

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Depression

Hopelessness

Patient’s history of different mental disorders.

This is number 1 due to the patient possibly visiting the hospital multiple times and feeling like there’s no for of treatment available for them.

2

Suicide Ideation

Preoccupied mental status

History if suicide attempts

This is number 2 because the patient has a past history of suicide attempts and could possibly be thinking about committing suicide again.

3

4

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

This is made evident by the patient’s past medical history of general anxiety disorder, bipolar disorder, alcohol abuse, and mild mental retardation.

-To determine degree of impairment

-To assess coping abilities and skills

-To assist client to deal with current situation

-Patient will seek help when experiencing self-destructive impulses.

-Patient will have a behavioral manifestation of absent depression.

-Patient will have satisfaction with social circumstances and achievements of life goals.

-Patient will identify at least two-three people he/she can seek out for support and emotional guidance when he/she is feeling self-destructive before discharge.

-Patient will not inflict any harm to self or others.

-Educate patient about depression

-Provide for patient’s physical needs

-Assume active role in initiating communication

-Patient’s ability to assess current situation accurately.

-Patient’s ability to identify ineffective coping behaviors and consequences.

-Verbalization of awareness of own coping abilities and of feelings congruent with behavior.

-Meet physiological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

This is evident by the patient attempting to commit suicide in the past on numerous occasions.

-To provide for meeting psychological needs

-To promote wellness

-Patient will verbalize understanding of treatment plan

-Patient will refrain from attempting suicide.

-Patient will remain safe while in the hospital, with the aid of nursing intervention and support.

-Patient will stay with a friend or family if the person still has the potential for suicide.

-Patient will identify at least one goal for the future.

-Encourage the client to talk freely about feelings and help plan alternative ways of handling disappointment, anger, and frustration.

-Encourage the client to avoid decisions during the time of crisis until alternatives can be considered.

-Arrange for the client to stay with family or friends. A hospitalization is considered if there is no one is available especially if the person is highly suicidal.

-The patient engages more in social activities.

-The patient can express her feelings and insecurities.

-The patient can perform her activities of daily living.

-The patient recognizes the importance of counseling and regularly attends one

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis

Patient Goal(s)

Patient Outcome

(objective, expected or desired outcomes or evaluation parameters)

Interventions/ Implementations

Evaluation

Assessment as evident by (AEB), or data collection relative to the nursing diagnosis

Patient Goal(s)

Outcome (objective, expected or desired outcomes or evaluation parameters

Interventions/

Implementations

Evaluation

Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.

Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.

Types of data: subjective

& objective

Sources of data

Nursing health history

Physical examination

Diagnostic data

“A statement of purpose describes the aim of nursing care” (Osborn et. al., p.

113)

Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis)

May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.

Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)

Stated realistic behavioral terms that can be observed, measured and

relevant to the identified nursing diagnosis.

Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).

Implementation – the carrying out of the planned nursing interventions (Osborn, et al.,

2010)

Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.

Interventions should reflect indendent nursing practice as well as collaborative practice.

Interventions should reflect the needs of this specific patient not a generic listing of possible interventions.

Interventions should include specific like schedules, food choices, frequency, etc….

Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).

Essentially this is a reassessment of the patient and the responses as to the interventions implemented.

Compare actual patient behaviors with expected behaviors.

Give reasons why or why not each outcome has been met.

Consider the effectiveness of the nursing intervention, time elements.