Mental Health, Care plan

Kalabi

MHCarePlan1.docx

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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name:Kehinde Alabi

Week: 4

Dates of Care: 07/24/2021

Demographics and Brief History

Patient Initials

E. R

Sex

Age

41YRS

Room

1407

Admitting Date

07/21/2021

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

“I was hearing voices telling me to hurt myself”

Attending physician/Treatment team:

Ryan k Berggren, MD

Physician

Psychiatry

Satya Shah, LCPC (Social worker)

Rushdi H Alul, DO ( Internal Medicine)

Precautions

SP- Suicide prevention

SIB- Suicidal injurious behavior

FF- Finger foods

NP- No pencils

Primary Diagnosis:

Depression with SI (Management per Psych

Co-morbidities:

Allergies:

No Known Allergy

Code Status:

Full code

Isolation: (type and reason)

No Isolation

Admission Height:

6’2”

Admission Weight:

112kg

Arm Band Location (colors & reasons) Right hand/white

Past Medical History: (pertinent & how managed)

Anemia,

Asthma

Herpes Simple

HIV (HCC)

Hypertension

Schizoaffective disorder (HCC)

Schizophrenia ( HCC)

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

No event has occurred since hospitalization

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

Time	8:00am	12:00pm
T	96.2	97.5
P	80	88
R	14	16
B/P	153/99	140/82

General Appearance

· Grooming/Clothing

· Hygiene

· Posture

· Gait

· Obese/average or normal/ underweight

· Average

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

· Tattoos

Activities of Daily Living

· Sleep/rest

· Diet

· Exercise/mobility

· Elimination

· Hygiene

Diet:

Blood Glucose (time & date):

Last bowel movement (time & date):

Pertinent Labs/Test:

Assessments:

· Stool

· Bowel sounds

· Tenderness, distention

· Appetite, nausea, vomiting

Interventions:

Respiratory:

Assessments:

· Lung sounds

· Cough, sputum

· SOB

Interventions:

Neurosensory:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments:

· LOC

· Pupils

· Glascow Coma Scale

· Dizziness

· Headaches

· Tremors

· Tingling, weakness, paralysis, or numbness

Interventions:

Cardiovascular:

Pertinent Labs/Test:

Assessments

· Peripheral pulses

· Heart sounds (murmurs or bruits)

· Edema

· Chest pain, discomfort, palpitations

Interventions:

Musculoskeletal:

Activity:

Casts/Slings:

Assessments:

· Strength, weakness

· ROM

· Gait (documented under appearance)

· Pain

· Fractures, amputations, or transfers

Interventions:

Renal:

Pertinent Labs/Test:

Assessments:

· Bruit, thrill, location

· Urine-quality

· Burning with urination, hematuria

· Incontinent, continent, I & O

Interventions:

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments

· Bruising, wounds, drains

· Turgor

· Surgical incisions

· Finger & toe nails

Interventions:

Pain:

Pain score:

Assessments/Interventions:

· Scale used

· Location, duration, intensity, character

· Exacerbation, relief

Interventions:

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test:

Assessment

· Bleeding

· Discharge

Interventions:

Safety:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Interventions:

Advance Directives/Ethical considerations:

AD: Advance Directives information offered to patient at time of Psychosocial assessment. Patient accepted state of Illinois Advanced Directives Disclosure.

POA: N/A

Lab Values	Results	Normal Lab Values	Significance to your patient (if applicable)
WBC	4.6
RBC	4.55
HGB	14.0
HCT	41.9
MCV	92.1
MCH	30.8
MCHC	33.4
Platelets	169
RDW	13.8
MPV	8.4
Glucose	95
BUN	18
Creatinine	0.97
Sodium	138
Potassium	4.1
Chloride	106
Calcium	9.0
Salicylate	N/A

Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)

Lab Value	Results	Normal Lab Values	Significance to your patient (if applicable)
HIV TESTS	Detected	Detected	Known
HIV by PCR	2,698	Less than 20	Known
HIV QT BY PCR	3.43	Less than 1.30	known

10 Panel Toxicology/Drug Screen: if available

Lab Value	Results	Normal Lab Values	Significance to your patient (if applicable)

Blood Alcohol Level/Ethyl Serum Level: if available

Lab Value

Results

Normal Lab

Values

Significance to your patient (if applicable)

Psycho/Social Assessment

· Level of education

· Occupation

· Race/Ethnic Background or Identification

· Religion/Spiritual Beliefs

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

· Special Talents/Interests/Skills

· Environment (home and community)

· Family Structure/History:

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)

Support System:

Stressors/Stress Management Practices:

Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article.

Discuss the current disease process:

Discuss the etiology of the patient’s illness:

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

Psychopharmacology

Major categories of antidepressants include cyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRIs), and atypical antidepressants. The choice of which antidepressant to use is based on the client’s symptoms, age, and physical health needs; drugs that have or have not worked in the past or that have worked for a blood relative with depression; and other medications that the client is taking.

Researchers believe that levels of neurotransmitters, especially norepinephrine and serotonin, are decreased in depression. Usually, presynaptic neurons release these neurotransmitters to allow them to enter synapses and link with postsynaptic receptors. Depression results if too few neurotransmitters are released, if they linger too briefly in synapses, if the releasing presynaptic neurons reabsorb them too quickly, if conditions in synapses do not support linkage with postsynaptic receptors, or if the number of postsynaptic receptors has decreased. The goal is to increase the efficacy of available neurotransmitters and the absorption by postsynaptic receptors.

antidepressants establish a blockade for the reuptake of norepinephrine and serotonin into their specific nerve terminals. This permits them to linger longer in synapses and to be more available to postsynaptic receptors. Antidepressants also increase the sensitivity of the postsynaptic receptor sites (Burchum & Rosenthal, 2018).

In clients who have acute depression with psychotic features, an antipsychotic is used in combination with an antidepressant. The antipsychotic treats the psychotic features; several weeks into treatment, the client is reassessed to determine whether the antipsychotic can be withdrawn and the antidepressant maintained.

Evidence is increasing that antidepressant therapy should continue for longer than the 3 to 6 months originally believed necessary. Fewer relapses occur in people with depression who receive 18 to 24 months of antidepressant therapy. As a rule, the dosage of antidepressants should be tapered before being discontinued.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:

References

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications
Albuterol (Ventolin) 108 ( 90 Base) MCG/ACT inhaler		2puff

Nursing Process Section

Nursing Diagnosis:

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1
2
3
4

Complete a table for the top two priorities listed in the table above. A minimum of 3 interventions are required for each nursing diagnosis, and one intervention must be an individual patient teaching and one must include a teaching for the patient’s family/caregivers (if applicable- i.e., patient is not homeless and/or has no family).

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Mental Health, Care plan

Medications

Classification

Dose

Route

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

Interventions/Implementations

Evaluation

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

Interventions/Implementations

Evaluation