Comprehensive Psychiatric Nursing Care Plan

8/3/2019 Comprehensive Psychiatric Nursing Care Plan

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Keisa Williams

10/27/2011

Comprehensive Psychiatric Nursing Care Plan

I. Assessment

D.W. is a 15 year old female transferred from the Round Rock emergency room after cutting her

left arm with a razor. Patient became upset earlier in the day because one of her foster sisters told her she

acting schizophrenic. She reports being really upset lately that she will not be able to see her older

boyfriend anymore. Her foster mother says that she responds to voices that she hears and that she wants

her home but that she needs to get help first. Her foster family thinks that she may have given up and

the cutting was a suicide attempt, but she denies this. D.W. was hospitalized in July of 2010 to November

of 2010 at Cedar Crest due to fighting. She has had no suicide attempts since living with her current

foster family. Her biological mother is currently missing. She has a family history of bipolar and

schizophrenia. Her biological mother is mentally retarded. D.W. is currently being treated for Chlamydia

and a urinary tract infection. D.W will continue her home medications and continue impatient care for her

aggressive behavior towards her foster family and herself.

D.W. states that she is feeling great and appears clean and groomed with normal speech. Her

judgment and insight are fair. She denies any suicidal or homicidal thoughts, hallucinations, or delusions.

She is calm and cooperative and her affect is constricted. She has focus and is alert and orientated to

person, place, time, and situation. Her thought process seems logical and her remote, immediate, and

recent memory is intact. D.W. reports her strengths as singing. She reports that writing, reading, listening

to loud music, talking, getting a hug, or finding a quiet place helps her to cope.

D.W. has been diagnosed on Axis I with a mood disorder not otherwise specified and

schizophrenia. Mood disorder not otherwise specified is a mood disorder that doesnt fit in any other

category and its cause is unclear. Short term symptoms often include mood swings, unexplained


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irritability, or unexplained aggression. D.W. has shown both aggression and irritability. Schizophrenia is

characterized by a loss of thought processes and of emotional responsiveness. Symptoms include

auditory hallucinations; delusions, disorganized speech and thinking, and can include social and

occupational dysfunction. D.W. has previously had auditory hallucinations and social dysfunction. Her

Axis II diagnosis is deferred and her Axis III diagnosis includes Chlamydia and a urinary tract infection.

Her Axis IV or psychosocial diagnosis include her being in CPS custody, her biological mother is

missing, she has become aggressive to her foster family, her grades are dropping, and she can no longer

see her older boyfriend. Her Axis V GAF score is 35 (my score on assessment). A score of 35 is

indicative of some impairment in reality testing or communication or major impairment in

several areas such as work or school, family relations, judgement, thinking, or mood. She is still

failing classes and not in school but is has signed a nonviolence contract and stopped dating the

older man. Her score of 30, on admission pinpoints behavior is considerably influenced by

delusions or hallucinations or serious impairment in communication or judgment or inability to

function in almost all areas. On admission she was having auditory hallucinations, skipping

school, failing classes, dating a man that was 18 years older than her, attacking her foster family,

and cutting herself.

II. Planning and Intervention

D.W. is at risk for self harm related to history of self injury as evidenced by statement of self

cutting and signs of old scar on both forearms and lower legs. She is also at risk for harm to others related

to history of violence as evidenced by her recent aggression towards foster family. D.W. is also at risk for

disturbed sensory perception: auditory related to altered sensory perception as evidenced by her auditory

hallucinations of her name being called in crowds. At this current time her highest priority nursing

diagnosis is risk for self harm because of her history of cutting her wrists and legs.


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For one short term goal D.W. will sign a no harm contract that identifies steps to take when urges

return per shift. This will be a written contract with the nurse that identifies steps to take when the urge to

self injure occurs. This will encourage responsibility for healthy behavior and reduce frequency and

severity of her behavior (Elizabeth M. Varcarolis, 2011). D.W. will also express feelings related to stress

and tension instead of acting out behaviors during every shift. This will give her insight to what her

behavior means and give the nurse insight into future interventions (Elizabeth M. Varcarolis, 2011).

D.W. will verbalize knowledge of 5 alternate ways of dealing with her stress and emotions by

10/27/2011. Learning new ways to cope can decrease the frequency and severity of her behavior

(Elizabeth M. Varcarolis, 2011). A long term goal for her would that she will participate in a therapeutic

regimen for one month. This will encourage her to identify her emotional triggers for self harm and

educate her on how to control her urges. This may also help her break the pattern of self destructive

behavior. If this plan of care is consistent and maintained, I think that it would be very effective in

helping D.W. decrease her urge to hurt herself. If the patient remains unharmed, shows no indications of

harming herself, and can show that she has learned new coping skills then this plan can be successful.

D.W. is currently taking Abilify, Lexapro, Vyvanse, Vistaril, and Zyprexa. She takes 30

milligrams per day of Abilify for schizophrenia and agitation associated with schizophrenia. She is taking

Lexapro 20 milligrams per day for generalized anxiety disorder. She is prescribed Vyvanse 70 milligrams

per day to manage attention deficit hyperactivity disorder. The 50 milligrams of Vistaril that she takes

every 6 hours is to control her anxiety and agitation. The 10 milligrams every 6 hours of Zyprexa that she

takes is for maintenance of schizophrenia.

III. Discharge Planning

D.W. currently has no discharge plans. A realistic plan for her would begin with a review

with the patient and family about goals that have been attained and goals that still may need to be

attained. Discharge instructions, medication instructions, and follow-up appointments will also need to

be discussed and signed. Transportation and housing arrangements will also need to be addressed. A


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safety plan needs to be discussed with the family discussing stressors to be prepared for, steps that can

be taken to reduce stress, support persons/places, and contact/resources that the patient can use if

immediate help is needed.

IV. Prevention

One strategy of relapse prevention for D.W. would include providing stress management.

It is important that she participates in activities that increase her coping skills and help with

management of tension and stress. Activities for this include her interests with singing, reading,

writing, and listening to music when she is stressed out. If she understands that she will better

cope and change her behaviors if she uses her energy to do something productive she will be less

likely to cause herself harm. Another strategy to prevent relapse in D.W. is to encourage her to

stay involved in group meetings, activities, and family meetings in order for her to talk freely

about her feelings and ways of dealing with her anger and frustration. This will allow her to deal

with overwhelming emotions.

V. Student Learning

I felt saddened by D.W.s situation. It made immediately feel like another child was going to be

lost to the system. I do have hope for her however because she has a very determined foster family that

wants to see her get help. I think that she responded well to me and wanted to share. I learned from D.W.

that life as a foster child is hard and often times are filled with resentment and anger. The knowledge that

I gained from this experience can be applied to almost any situation involving you adolescent children

who are trying to find themselves and acceptance.


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Master Nursing Care Plan NURSING MENTAL STATUS EVALUATION & NURSING

ASSESSMENT

Date of Evaluation: 10.25.2011 Name of Evaluator: Keisa Williams

Patient's Initials: D.W. Age: 15 Gender: F Race/Ethnicity: African American /Black

Date of Admission: 10.17.11 Weight: 167.6 Height: 55 *BMI: 27.9

Type of Admission: Voluntary Involuntary

Presenting Problem (Include Stressors, Suicidal/Homicidal Ideations/Plan/Method, Hallucinations,

Delusions, Maladaptive Coping Related to Current Admission):

* Cutting left wrist with razor, punched foster sister because she said she was acting like a

schizophrenic, shoved foster mom, biological mom missing, auditory hallucinationsname

being called. Other stressors include people getting in my face and people talking behind my

back.

Past Psychiatric History:

Course of Illness (Include Stressors, Suicidal/Homicidal Ideations, Hallucinations, Delusions):

* Stressors include people getting in my face and people talking behind my back, biological

mom recently missing, and cant see boyfriend who is 18 years older than she is.

Past Suicide Attempts (Include Methods):

* Patient denies any SA.

Past Psychiatric Hospitalizations (Include Reasons for Previous Admissions):

* July to November 2010 - Cedar Crestfor fighting

Family Psychiatric History:

* Biological mom is MR. She has a biological family history of Bipolar and Schizophrenia.

Past Psychiatric Medication History (Include Medications and Compliance/Noncompliance):

* Vyvanse for 2 monthscompliant

Current Health Problems


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Use of Alcohol or Drugs Immediately Prior to Admission

* Patient denies

On table below, use Symbols Option on e-tool bar to mark relevant cues or mark with pen. Give narrative

description forcued items that are marked.

APPEARANCE COMMENTS AND/OR PROBLEMSIDENTIFIED

Clean

GroomedDisheveled Dirty

Manner of Dress: Appropriate Unkempt Dirty

Seductive Tattoos : Describe:__________ Piercings : Describe:__________

General State of Nutrition: Good

General State of Health: UTI, Chlamydia

Eye Contact: Good Fair Poor Pupil Dilation Pupil Constriction

Posture Gait Appears stated age older younger

General Description:

erewrwew

SPEECH

Rate: Normal Slow Rapid ExcessiveVolume: Loud SoftAmount: Impeded Absent

Tonal Quality:

Other: Pressured Stuttering Slurring

MOTOR ACTIVITY COMMENTS AND/OR PROBLEMSIDENTIFIED

Level of Activity: Normal Increased

DecreasedType of Activity: Tics Tremors


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Unusual Mannerisms: Compulsions

MOOD/AFFECTAffect: RangeBroad Flat Constricted Blunted

Bright Anxious Sullen Expansive

Angry/Aggressive

Affect: StabilityStable Labile

Affect: AppropriatenessCongruent Incongruent

Stated Mood (What the patient says):Great

PERCEPTIONS

Hallucinations: Auditory Visual Tactile

Gustatory Olfactory Illusions NoneDescribe:

THOUGHT CONTENT

Delusions: Persecutory Religious Somatic Grandiose None

Suicidal

No Plan (Only Suicidal Thoughts) With Plan Method: (Describe): Actual Attempt (Prior to Admission) Homicidal

No Plan (Only Homicidal Thoughts) With Plan Method: (Describe): Self Mutilation (Describe): None

Depersonalization

Hypochondriasis Ideas of Reference

Magical Thinking Obsessions

Phobias

Clarity of Content: Coherent Confusion Vagueness

THOUGHT PROCESSES COMMENTS AND/OR PROBLEMSIDENTIFIED

Circumstantial Flight of Ideas Loose


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Association

Neologisms Tangential Thought Blocking

Word Salad Perseveration CoherentLEVEL OF CONSCIOUSNESS

Orientation: TimePlacePerson Lethargic Confused Alert

MEMORY (Assess informally only)

RemoteRecentImmediate

erer

JUDGMENT

Good Fair Poor Inconsistent VariableDescribe:INSIGHT

Good Fair Poor Inconsistent

Describe:PSYCHOLOGICAL TESTING RESULTS OF NOTE

Describe:

SUBSTANCE ABUSE (If positive for history and/or currentuse, describe)

COMMENTS AND/ORPROBLEMS IDENTIFIED

Past Use: No YesCurrent Use: No Yes: (Last Use:_____________)If Yes: Alcohol Drugs (include types below) Tobacco OtherDescribe, including how much consumed on a typical

day/week, and when was last use?

PSYCHOSOCIAL ASSESSMENT

CULTURAL ASSESSMENT

With what racial/ethnic or cultural group(s) does the patient identify?

(Example: Hispanic, Asian American, gang member, etc.)

* Young African American child in the foster system


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How does this identification influence beliefs about mental illness?

* Adolescents living with foster parents or in group homes have about four times the rate of

serious psychiatric disorders than those living with their own families (P., C., & S., 2010)Foster

care children in low socioeconomic statuses are usually on some form of medication for mental

illness. They are more likely to develop a mental illness (National Alliance of Mental Illness,2009). They have dealt with issues surrounding mental illness and have been removed from

homes affected by mental illness and drug abuse (Jim McDermott, 2008). The foster care system

is compromised by 45% of African American children. Mental illness is frequently stigmatizedand misunderstood in the African American community (National Alliance of Mental Illness,

2009). African American women see mental illness as a weakness and as being shameful and

embarrassing (Ward & Heidrich, 2009).

What does the patient think brought on his/her mental illness?

* Stress from family

What alternative treatments has the patient tried?

* None

*How does race/ethnicity/cultural identification effect:

a. Communication styleher age and developmental stage make her very defensive and mouthy.

1. View of authority figures - particularly medical personnel

* At her age she is most likely trying to be independent and tests authority.

2. Role of gender - Are there defined roles for women and men or topics that only men or women can

engage in?

* No

b. Are there rules about non-verbal communication such as touch, eye contact?

* No

c. What are the cultural rules about discussing personal and family issues outside the family?

* No

d. What is the role of the family in caring for the patient?

* To provide care, discipline, and nurture. The foster parent is also one of the biggest advocates for a

child in the foster system.

Language:a. What is the patients first language?

Englishb. Is the patient fluent in English?

Yes


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c. Does the patient need special assistance with language (Is a translator needed)?No

d. Are pamphlets and other written material provided in the patients primary language?Yes

SPIRITUALWhat gives life meaning?Is patient active in a spiritual community? No YesIf Yes, Describe:

PATIENT STRENGTHS AND ASSETS INVENTORY(Mark all applicable and add additional assets, as identified)

Support of family & friends Motivated for treatment EducationCapable of insight into problems Good social support networkLeisure interestsPossesses technical/vocational skills Capable of independent living Sense of humorReligious affiliation/support network Good physical health Recreational interests

(If checked, describe):

D.W. has a supportive foster family who wants to see her get better. She says that she hopes to become

more confident and responsible after living on the unit. She can understand the reasons she was admitted.

D.W. likes to sing, read, write, and enjoys music. She uses these recreational and leisure activities to copewith her problems.

Psychiatric Diagnosis (Axis I)

Diagnosis: Mood Disorder NOS; Schizophrenia

Corroborating Evidence of Diagnostic Criteria from the 1:1 Interview:

D.W. says that she often hears her name being called in crowds.


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She has recently been very upset because of the courts telling her she can no longer see her older

boyfriend. She feels that people are talking behind her back. Her aggression towards her fosterfamily.

Disorders of the Personality or Mental Retardation (Axis II)

Diagnosis: Deferred

Corroborating Evidence of Diagnostic Criteria from the 1:1 Interview:

General Medical Conditions (Axis III)

Diagnosis: Chlamydia, Urinary Tract Infection

Psychosocial/Environmental Problems (Axis IV) (Describe)

A. Problem with Primary Support Group: Biological mother is missing, Aggressive towards foster family

B. Problem Related to the Social Environment: Can no longer see older boyfriend

C. Educational Problems: Recently failed 2 classesusually a B/C student

D. Occupational Problem

E. Housing Problems: Foster Care

F. Economic Problems


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G. Problems with Access to Health Care Services

H. Problems Related to Interaction with the Legal System/Crime : CPS custody

I. Other Psychosocial and Environmental Problems ____________________________________

(If checked, describe):

Global Assessment Functioning (Axis V)

____ 91-100 Superior Functioning ____ 41-50 Serious Symptoms ____ 1-10 Persistent Danger

____ 81-90 Minimal Symptoms ____ 31-40 Difficulty Functioning ____ 0 Inadequate Information

____ 71-80 Transient Symptoms X 21-30 Inability to Function

____ 61-70 Mild Symptoms ____ 11-20 Some Danger of Hurting Self or Others

____ 51-60 Moderate Symptoms

GAF Score at time of Admission: 30

D.W. is failing classes/not attending school, does not have many stable friendships (on and off she callsthem), and has lost most contact with her biological family (mother is missing). She is dating a man 18years older than her, she cuts herself, has auditory hallucinations, and she is aggressive to her foster

family.

GAF Score at present time (your score) 35


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D.W. is failing classes/not attending school, does not have many stable friendships (on and off she callsthem), and has lost most contact with her biological family ( mother is missing).

Developmental Milestones

Adolescence: 12 to 18 Years

(Must be completed on patients age 18 or less.)

Summarize assessment referencing theorist, (e.g., Erikson, Piaget, etc.):

According to Erikson this is a stage of finding our identity, struggling socially, and coming to an

understanding with moral issues. D.W. is definitely struggling socially. She doesnt have many stablefriendships and is struggling in school. She has yet to come to grips with the idea that being aggressive

towards your family is wrong. She is moody, mouthy, intense, impulsive, and has thinking that she is

indestructible. She seems to be trying to delve into the next developmental stage of Young adulthood: 18

to 35 before she is ready. She is trying to develop a meaningful relationship by dating an older man and

has contracted an STD from him multiple times,


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Works Cited

Arlene F. Harder, M. M. (Revised 2009). The Developmental Stages of Erik Erikson. Retrieved 10 27,

2011, from Learning Place Online.com:

http://www.learningplaceonline.com/stages/organize/Erikson.htm

Elizabeth M. Varcarolis, R. M. (2011). Manual of Psychiatric Nursing Care Planning: Assessment Guides,

Diagnoses, and Psychopharmacology. St. Louis: Saunders.

Jim McDermott, M. C. (2008, 5 8). Prescription Psychotropic Drug Use Among Children in Foster Care.

Retrieved 10 27, 2011, from American Academy of Child and Adolescent Psychiatry:

http://www.aacap.org/cs/root/legislative_action/statement_of_christopher_bellonci_md_before_the_

house_subcommittee_on_income_security_and_family_support

National Alliance of Mental Illness. (2009, 11 8).African American Community Mental Health FACT

SHEET. Retrieved 10 27, 2011, from National Alliance of Mental Illness (NAMI):

http://www.nami.org/Content/ContentGroups/Multicultural_Support1/Fact_Sheets1/AfricanAmerican_

MentalHealth_FactSheet_2009.pdf

P., G., C., H., & S., R. (2010). Position Statement. . . on Foster Care International Society of Psychiatric-

Mental Health Nurses.Journal of Child & Adolescent Psychiatric Nursing , 23(1): 36-9 (23 ref).

Texas Health and Human Services Commission. (2011, 2 09). Update on the Use of Psychotropic

Medications in . Retrieved 10 27, 2011, from Health and Human Services Commission 2002-2010:

http://www.hhsc.state.tx.us/medicaid/OCC/Psychoactive_Medications.html

Ward, E. C., & Heidrich, S. M. (2009). African American women's beliefs about mental illness, stigma, and

preferred coping behaviors. Research in Nursing & Health , 32, 480492.

Comprehensive Psychiatric Nursing Care Plan

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