NURS 360

Capstone Project
PMH Care Plan
Student Nurse Reporting Form
SN: Charleen Kahapea Date: October 10, 2015
Pt.: Sex: F

Age: 13

Date of Admission: August 23, 2015

Transferred? ___No _X_Yes: (Reason/Date) 8/23/15 from QMC West

Income source: Patient is currently living in a shelter and is not employed, she is a
student
Legal Status: MH-5 Expiration Date: none
DSM Diagnosis:
I Conduct Disorder, Attention Deficit Hyperactivity Disorder, Bipolar I Disorder, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Post Traumatic
Stress Disorder
_________________________________________________________________
II Obsessive Compulsive Disorder
__________________________________________________________________
III none
_____________________________________________________________________
IV Disruption of family by divorce, removal from the home, neglect of child, academic
problems, foster family, living in a shelter, arrest
______________________________________________________________________
V GAF = 50
______________________________________________________________________
What brought patient to the hospital?
Patient was brought in by Honolulu Police Department after aggressive behavior at shelter. Patient was there for one month. Was non-compliant with medications for 3 days. Running in the
streets in front of cars to get polices attention, and acting out. Throwing rocks at care home staff
and peers. Patient was also to be harassing female peers at shelter. Group home staff reporting some bizarre behaviors

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Patients description of illness/issues:

Patient reports having conflict with peers, loosing temper, fighting/assaulting people, threatening
others, running away, and feelings of being unsafe.

Spirituality:
Patient reports believing in God, but does not attend church

Considerations r/t ethnicity or religion:

Patient reports none

Patients Strengths:
From my assessment patient is friendly, easily approachable, loves to laugh and be happy, and
likes to be involved in activities.

Patients Limitations:
From my assessment patient likes to be the center attention, once she is comfortable with you,
she tends to become clingy, needy, and a little bossy. She disregards the rules at times and just
laughs when you tell her not to do something. She is somewhat heavily concerned about what
people think about her.

Medications:
Order: quetiapine tab (Seroquel) 50 mg PO at bedtime
Drug class: Atypical antipsychotic Pts target sx: acute treatment of depressive
episodes associated with Bipolar I disorder.
Total 24h dose: 50 mg
Recommended range: 50-300 mg daily : L M H Max
Current Side effects: low risk for EPS. Moderate risk for diabetes mellitus, weight gain,
and dyslipidemia. Other effects include cataracts, sedation, orthostatic hypotension,
and anticholinergic effects.
Order: quetiapine tab XR (Seroquel XR) 300 mg PO daily (1800)
Drug class: Atypical antipsychotic Pts target sx: acute treatment of depressive
episodes associated with Bipolar I disorder.
Total 24h dose: 300 mg
Recommended range: 300-800 mg daily : L M H Max
Current Side effects: low risk for EPS. Moderate risk for diabetes mellitus, weight gain,
and dyslipidemia. Other effects include cataracts, sedation, orthostatic hypotension,
and anticholinergic effects.

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Order: Lithium cap 600 mg PO BID (09, 17)

Drug class: Antipsychotic/ Mood Stabilizer
Pts target sx: mood stabilizer associated with Bipolar I disorder
Total 24h dose: 1200 mg
Recommended range: 900-1800 mg day : L M H Max
Current Side effects:
Order: acetaminophen (Tylenol) tab 325 mg PO Q6H PRN
Drug class: nonopijoid analgesic Pts target sx: mild to moderate pain/fever
Total 24h dose: not to exceed 4000mg/day
Recommended range: 325-650 mg q4-6 hr prn : L M H Max
Current Side effects: drowsiness, nausea, vomiting, abdominal pain, and rash
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. *none mentioned in the chart or by the patient
2.
BMI: 23.42 Category: normal weight (18.5-24.9) (Height: 152.4 cm Weight: 54.4 kg)
Food & fluid intake: pt states 100% for breakfast and lunch, and drinks throughout the
day (I also observed patient with cups of water throughout the day)
Bladder & bowel status: patient states having no problems with bowel or bladder, able
to go regularly once every one to two days.
Sleep pattern: patient states she sleeps throughout the night and most times wakes up
on her own
Total sleep/24 hrs: average 10 hours (within the four days of the charted sleep
hours)
(Circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning awakening
*Patient does not report having any problems sleeping, but chart stated insomnia r/t
mood disorders
Number of hrs of disruption: patient states none
Naps: When? patient states that she stays up during the day and does not nap
Total nap time: N/A

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Lab & studies

Date/Panels in which all values were normal: 8/23/15
- CBC w/ diff (except Platelet)
- Basal metabolic panel (except Glucose, Creatinine, and Anion Gap)
- Lithium level
Date/Any abnormal labs: 8/23/15
- Platelet 351 (H)
- Glucose 106 (H)
- Creatinine (0.5L)
- Anion Gap 12 (L)
Labs you would expect but were not ordered: none
Glucose readings x 24h for all diabetic pts.: N/A
All drug screen findings: Urine drug screen, #2 (Medical) findings all negative

MENTAL STATUS ASSESSMENT:

Behavior: Cooperative for the most part, a little dramatic, compulsive and inappropriate at times, good eye contact, a little impulsive at times, and sometimes gets fixated on
one topic where she starts asking the same questions about that topic (i.e. when she
kept asking me if her underwear was showing because her leggings were low and I told
her yes and to pull her pants up, she didnt and then she would bend over to ask if her
underwear was showing again). Easily distracted.
Affect: Appropriate to situation, consistent with mood, very silly and giggly at times.
Mood was elevated and euphoric.
Sensorium: Alert and oriented to time, place, and person
Imagery: Patient did not show any signs of unusual imagery
Hallucinations? Patient denies any hallucinations.
Cognition: Thought process linear. At times tangential and having flight of ideas.
Thought content patient denies suicidal/homicidal ideations.

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Interpersonal relationships: Patient got along with some of her peers, other peers
she rubbed the wrong way. There was this one incidence where she was in the recreation room with her group and then the other group was transitioning in the court yard to
the other side of the building. She told one of the girls oh look there is so and so and
the girl she was talking to told her I told you I am not talking to her, which made her
upset at my patient.
Developmental level: My patient is in special education services at school and repeated 6th grade to disruptive behaviors.
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

Acute intox or
withdrawal
sx?

Length of
Time
Used

Route

Usual

Negative Conse-

amt.

quences

*None noted substance abuse for my patient

Problems Identified In Hospitals Master Treatment Plan:
1.

Safety- will not harm others AEB no assaultive behavior towards others.
- Assess for homicidality using TM-48.

2. Symptom management-Patient will exhibit decreased acting out behaviors AEB no

seclusion/restraints/staff directed time out for 2 consequective days.
- Assess patient responsiveness
- Monitor patient participation in treatment
3. Symptom management-Patient will increase accountability for unit AEB by showing
safety and decreased acting out behaviors
- Assess patient responsiveness to positive supports
- Assess patient dependence on staff for symptom management
4. Discharge-Patient verbalizes and executes a discharge plan AEB by completing of
discharge education

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Current Discharge Plan: To return to Ka Pa Ola Community Shelter for girls. Reconcile medications and obtain further information from group home and outpatient
providers. Encourage medication compliance and provide safety, structure, and limits.
Nursing interventions you performed this shift (Include safety and teaching!):
Mental status exam, self harm risk assessment, encouraged to join group therapy, encouraged patient to make good choices while recovering, such as focusing on getting
better first before thinking about boys and relationships, and encouraged patient to follow instructions and rules on the unit when she was standing on the furniture.
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
E: was admitted for risk for harm to self and others
S: Assess patient for homicidal/suicidal ideations, come up with a plan to recognize
triggers of feelings for homicidal/suicidal ideations and how to manage them)
2. P: Medication compliance
E: not taking medications before being admitted tot he hospital
S: Teaching patient importance about being on medications and having her comply
with her medications so she can feel better.
3. P: Managing aggressive behaviors
E: before being admitted patient was aggressive towards peers and staff at group
home
S: Teaching patient triggers that cause aggressiveness and coping skills to manage
her aggressiveness.
4. P: Patient will take accountability for her actions
E: in her chart it mentioned she was running in front of cars and trying to get hit to
get the polices attention
S: Teaching patient her choice to make good and bad decisions and the
consequences of her actions. Teach her insight to her decisions.

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Priority # _1_ CARE PLAN

Nursing Diagnosis: Risk for self harm to self or others
P: Safety
E: admitted for risk of self harm to self and others
S: Assess patient for homicidal/suicidal ideations, come up with a plan to recognize triggers and a plan
how to manage them.
LT goal: Patient complies to treatment plan to reduce risk for suicidal/homicidal behaviors by discharge.
ST goal: Patient discloses all pulses to self/others harm and talks to staff immediately by end of shift.

Intervention & Frequency

Scientific Rationale
(In complete sentences!)
(Reference in APA format,
including page number)

Evaluation

Assess patient every shift for

risk of suicidal/homicidal
ideations

- People who are suicidal

I completed a suicide/self harm asremain ambivalent about
sessment for my shift and patients
wanting to end their lives.
risk was none.
- Patients may view suicide
as the only way to relieve
severe, persistent, or recurrent emotional pain.

Assess for risk factors that

may increase the potential for
a suicidal/homicidal attempt

- It is a myth that suicide

occurs without forewarning.
It is also a myth that there
is a typical type of person
who commits suicide. The
potential for suicide exists
in all people.
- Depressed patients are at
great risk for suicide. During this time, emotional
blunting is reduced and
feelings of sadness and
grief may have great force.
Depressed suicidal
thoughts may continue after other symptoms have
remitted.

Patient able to recognize risk factors

for her such as guilt, shame, anger,
rage, and impulsitivity.

Provide a safe environment

- Suicide precautions are

used to prevent the patient
from acting on sudden selfdestructive impulses.
These measures include
removing potentially harmful objects (e.g., electri- cal
appliances, sharp instruments, belts and ties, glass
items, and medications)
and maintaining visual contact with the patient at all
times.

Patient is being monitored frequently

by staff of their activities around the
clock. The patient was in a controlled
group where the staff knew where
she was at all times. Patient had to
inform staff when she wanted to go in
and out of her room and when she
wanted to go bathroom.

In her chart there was also an assessment done by the staff where the
patient identified her problems such
as conflict with peers and feeling unsafe. Also triggers such as not being
listened to and contact with family.
Warning signs included acting hyper
and being rude to name a few.

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Develop a verbal or written

contract stating that the patient will not act on impulse to
do self-harm. Review and
update the contract as needed.

- The patient benefits from

talking about suicide
ideation with trusted staff. A
written or verbal agreement
establishes permission to
discuss the subject, makes
a commitment not to act on
impulse, and defines a plan
of action in case impulse
occurs.

In the chart I found she has difficulty

telling and reporting the truth. Patient
needs highly structured setting that
has clear and consistent expectations, where staff follow through with
behavior support plan and are firm
and consistent in a nurturing way.
She needs a reward system. Also
mentioned that patient will identify
anxiety triggers and coping strategies, use coping skills to replace aggressive behaviors, and follow structured schedule.

Gulanick, M., & Myers, J. (2011). Gulanick: Nursing Care Plans, 7th edition resources. Retrieved from https://evolve.elsevier.com/Resources/2221_global_0001#/content/
289363957
Scholarly Journal Article review, Source and Implications:
Gilea, B. L., & ONeill, R. M. (2013) Disruptive Mood Dysregulation Disorder. Retrieved
from https://www.counseling.org/docs/default-source/default-document-library/
disruptive-mood-dysregulation-disorder.pdf?sfvrsn=2
This article defines Disruptive mood dysregulation disorder (DMDD), a new diagnosis in The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM5;
American Psychiatric Association [APA], 2013), is characterized by chronic, severe persistent irritability in children and adolescents. Characteristics include behaviors outside the normal range of childhood behavior (Gilea and ONeill). Also including tempers that out of control verbally and physically. The article also states that children
demonstrate low frustration tolerance and exhibit difficulties with emotional regulation,
distress tolerance, and behavioral self-control.Mentioned also in the article in order to
meet the diagnostic criteria for DMDD, children must demonstrate outbursts at least
three times per week for a period of at least one year across at least two of the following
settings: home, school, and with peers. Interestingly the article states that DMDD
cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar, in which my patient is also diagnosed Oppositional defiant disorder (ODD). It does
not go into detail the reason, but I assume maybe they (the hospital) could not clearly

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determine if she was either DMDD or ODD. As furthering ruling out of other medical
disorders may be necessary. DMDD is also found to be an early childhood development and not to be confused with the child acting out during stressful circumstances.
Tool(s): Suicide/Self-Harm Risk Assessment included and results were none for the patient at the time.

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