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PMH Care Plan
Student Nurse Reporting Form
SN: Jonathan Onigama
Pt.: Sex: Male
Age: 17
Date: 10/02/2015
Date of Admission: September 17, 2015
Medications:
Order: Melatonin 3 mg PO qhs (before bedtime).
Drug class: sedative/hypnotic
Pts target sx: insomnia/sleep aide
Total 24h dose: 3 mg
Recommended range: 0.3-10 mg at bedtime
: L M H Max
Current Side effects: None noted/assessed
Order: Hydroxyzine Pamoate 25 mg PO, TID, q4h PRN
Drug class:
antianxiety agent, antihistamine w/anticholinergic and sedative effects.
Pts target sx: itching/scratching (pruritis), insomnia, anxiety
Total 24h dose: 75 mg/24 hours
Recommended range: 25-100 mg 4 times/day for anxiety; for antipruritic effects: 25
mg 3-4 times/day
: L M H Max
Current Side effects: None noted/assessed
Order:
Drug class:
Total 24h dose:
L M H Max
Current Side effects:
Order:
Drug class:
Total 24h dose:
L M H Max
Current Side effects:
Order:
Drug class:
Total 24h dose:
L M H Max
Current Side effects:
AXIS III: List all conditions even if they are not listed in multi-axial diagnoses or
on chart. (Particularly note any unstable conditions & all non-medication
interventions.)
1. Stress/Anxiety Induced Pruritis/Hives & Scratching.
Patient is taking Hydroxyzine Pamoate PRN for the itching/scratching. Coping
strategies are also demonstrated for patient to learn to better cope with stress.
2. Insomnia
Patient is taking hydroxyzine pamoate prn for insomnia, and melatonin as a sleep
aid to help patient go to sleep. Insomnia may be associated with depression and/or
stress therefore treatment also include stress management and learning
positive/effective coping strategies.
3.
4.
BMI: 34.5
: Category: Obese
(Height: 57
Affect: When alone patient has a flat affect, however when approached or spoken to,
patient portrays a full/wide-range affect. Patient portrays an anxious mood when
sharing feelings regarding certain subjects (see behavior).
Sensorium: Patient is alert and oriented. Attention span, concentration, and abstract
thinking are intact. See cognition for more information.
Imagery: Patient does not have any sensory disturbance such as visual or auditory
hallucination. Patient does portray behaviors indicating stress or anxiety as evidence by
scratching/itchy, fidgeting with hands/legs, etc.
Cognition: Patient is alert and oriented x3 (person, place, and time). The patients
attention span and concentration is intact as evidence by current events (sports).
Patients memory (short-term) is intact as evidence by recalling 3 objects/words after 5
minutes. Patient has fair insight as evidence by identifying the reason for admission
and the cause of it, however the patient has poor judgment as evidence by recent
suicidal thoughts and having a history of suicide attempts/self-harm. Abstract thinking is
intact as evidence by appropriately participating in coping exercise(psycho
Health/Education group) relating animals living in natural/harsh environment to humans
coping with our surroundings, events, and other factors.
Interpersonal relationships: Patient does not like father and does not get along with
biological parents. Patient is unsure of his status with his girlfriend. Patient mentions
having friends, but avoids describing the strength of the bond/friendship between them.
Due to religious beliefs, patient is unable to associate with members of the church or
family members of the same faith, due to not acknowledging and accepting the family
religion.
Drugs: Substance abuse or dependence: (Include nicotine & any alcohol &
drugs. List by drug: Last date of use/Current acute intoxication or withdrawal
signs and symptoms when SN caring for pt./Used how long/Route/Usual
amount/Negative consequences)
Drug class
Last Use
Marijuana
9/14/15
none
(THC)
Route
Usual amt.
Negative
N/A;
Consequences
None noted at the time
14 y/o
couple
of interview or
times a
assessment.
Smoking
year
strategies. Student nurse also conducted a TM33 and assessed for risk of self-harm or
suicidal thoughts. Patient scored a 3 on the TM33/suicide risk evaluation tool, which is
considered low risk.
Patient-centered Care Analysis
PRIORITIZED PATIENT NEEDS
What are the patients 4 highest needs/problems?
(Use your best nursing judgment! It will be different than the master treatment
plan.) P=Problem, E= Evidence, S= Solution.
1. P: Safety related to risk of Suicide
E: Patient had recent thoughts of self-harm/suicide at the time of admission and has
a history of SI/SA via substance abuse (overdosing on medication from cabinet). Patient
has depression
S: Staff/Student nurse can conduct a TM-33 (suicide risk evaluation). Staff or nurse
in charge of care can ask patient if there was any prior attempts to commit suicide or
harm self. If there is a risk for suicide, nurse can make a contract with patient for
him/her to disclose any/all impulse to harm self or suicide to the staff immediately and
agree to participate in treatment plan to reduce/eliminate suicidal behaviors (Gulanick,
2014). Staff/nurse should assess for any support group, plan or intent to commit
suicide. Encourage/educate patient on community/public resources i.e. hotlines, etc for
ongoing support, and teach patient cognitive-behavioral self-management responses to
suicidal thoughts (Gulanick, 2014).
2. P: Ineffective coping
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Priority # 1
CARE PLAN
Nursing Diagnosis: Risk of Suicide related to recent thought of SI/SA and history of SA.
P: Safety related to risk of suicide
E: Patient had recent thoughts of self-harm/suicide at the time of admission and has a history
Evaluation
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2014).
Develop a verbal or written contract
stating that the patient will not act on
impulse to do self-harm at time of
admission. Review and update contract
as needed.
(Gulanick,
A written or verbal agreement establishes Patient and staff continuously work on verbal/written
permission to discuss the subject of
contract to promote safety. Patient does not act on
suicide, makes a commitment to not act on impulse and is safe. Over time, with improvement to
impulse and cause self-harm or to others, the patients overall wellbeing, contract can be
and establish a plan for when impulses
revised as needed. A contract was establish at the
time of admission, and has been revised since.
occur (Gulanick, 2014).
Patient appears to have better impulse control
through CBT/DBT activities.
Patients are able to recognize and respond Patient is able to demonstrate a variety of CBT/DBT
better to early thoughts of suicide.
strategies and verbalize positive alternative to the
Patients are able to identify triggers, and negative/suicidal thought. Patient will demonstrate
negative talk/thoughts and develop
and utilize better coping skills. The patient is able to
positive approaches to counter the
inform staff and nursing student about negative
thoughts, and the ability to stop and think of
negative thoughts (Gulanick, 2014).
consequence and attempts to initiate positive self talk
and other coping strategies.
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that the patients diagnosis may not be MDD, but rather adjustment disorder based on symptoms shown. The patient
does have a history of self-harm and suicide attempts via overdosing with Tylenol and other medications found in his
homes med cabinet, but on the unit the patient is overall well. Patient does portray a flat/depressed affect, but when
approached or encouraged to participate in activities, the patient will actively do so and show a full/wide range of
emotions, moods, and affect. The patient portrays symptoms of stress and anxiety when talking/thinking about being
discharged back to biological parents, breaking up with girlfriend, getting into conflicts with the father. The in hospital
treatment plan was to reduce and eliminate SI/SA tendencies, while promoting CBT/DBT activities along with learning
coping/stress management strategies, and participating in group activities with patients his age. The social worker also is
involved in setting up living conditions with the parents and has been actively working with the school for more support for
the patient as well as assisting the patient and father to come to terms and agree on lifestyle and living situation changes.
Individual and family counseling has been brought up and patient and family agreed to participate. There are other
precautions being taken, which can be found in its respective care plan. With the summary of the plan of care for the
patient, this article coincides with the treatment plan that the MD and the staff at Kahi Mohala constructed. Aside for
individual and family counseling, the patient has been actively participating in PAIs, DBT/CBT, and coping/stress
management classes. Thats why I felt that this article was relevant to my patients plan of care.
Assessment Tool(s):
TM33/Suicide risk assessment tool was used:
The patient has agreed to tell staff if he/she is feeling unsafe. At the time of interview the patient stated that he has
no plan or thought of committing suicide. Patient has no plan of eloping or running away. The patient admits to having a
history or suicide attempt of low lethality (overdose on Tylenol, medication from medicine cabinet at home). The patient
describes feelings of anger/rage towards father and hopelessness, but has no morbid thoughts at this time. The student
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nurse feels that the patients replies are trustworthy, and this admission was due to feeling unsafe and thoughts of hurting
self due to argument with parents and breaking up with his girlfriend. Based on patients reply and according to the
assessment tool, the patient scored a 3, which is considered low risk or no precaution.
Assessment tools that were not used but could have been utilized:
Coppersmith Self Esteem Tool
Burns Depression Checklist
Burns Anxiety Inventory
The student nurse was not able to utilize these assessment tools, but was aware of the usefulness of these tools to
assess for level of depression, anxiety, and self-esteem which all play a role in positive and maladaptive coping strategies
and ultimately/potentially suicide. The student nurse was not able to utilize these tools due to the patients schedule with
on unit schooling and group activities conducted by the staff. The student nurse was able to conduct a TM33, which is
important to the student nurses priority #1 problem and plan of care.
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References:
References:
Deglin,J.,&Vallerand,A.(2011).Davis'sdrugguidefornurses(12thed.).Philadelphia,PA:F.A.Davis.(formedications)
Fortinash,K.,&HolodayWorret,P.(2012).MoodDisorders:Depression,Bipolar,andAdjustmentDisorders.InPsychiatricmental
healthnursing(5thed.,pp.241242).St.Louis,MO:ElsevierMosby.
Gulanick,M.,&Myers,J.(2014).Riskforsuicide.InNursingcareplans:Diagnoses,interventions,andoutcomes(8thed.,pp.185
188).Philadelphia,PA:Elsevier:Mosby.
Layous,K.,Chancellor,J.,Lyubomirsky,S.,Wang,L.,&Doraiswamy,P.M.(2011).DeliveringHappiness:TranslatingPositive
PsychologyInterventionResearchfortreatingMajorandMinorDepressiveDisorders.JournalofAlternative&
ComplementaryMedicine,17(8),6756839p.doi:10.1089/acm.2011.0139
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