PBVI Nursing Care Plan

Mitch G Date: 8/16/2013 Course: Mental Health

I. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS: (what led up to this admission)? Patient is 41 year old white male, who weighs 165 pounds and 5 feet and 7 inches high, LEOBA by Jupiter Police. BA states patient believes people are trying to poison him, using RX drugs to cause fluid to exit his hips and impair his ability to walk and plus other somatic delusions. Pt arrived in handcuffs, calm and cooperative. His mood is a little apathetic and his affect blunted at times. Pt rambles some, but most of the time is goal oriented. He stated that he lives in Pioneer ALF in Miami and does not like it much and left 2 weeks ago, and is trying to make his way to Jacksonville and then DC, where He came originally. He reported in a matter of fact way that his Achilles tendons have some special sensors and because of that he was at a hospital 3 days ago. He reports being under psych care by Dr. Flattery in Broward and that he takes no meds. Reports many psych hospitalizations in the past. He was asked to change into a gown and he complied and He was offered diner, which he ate without suspicious, however a while later he asked if the food has any muscle relaxers. He was seen at our facility in Nov. 2009 and was treated for Schizophrenia and DC in Abilify 30 mg; while he returned to his ALF in Miami. In previous admission, he also showed signs of paranoia and delusions. He denied any medical issues besides what he stated previously about his Achilles tendons. His hygiene is very poor. He has been living in the street since leaving his ALF. He denied used of ETOH or drugs. Pt. discussed with Dr. Caro and he is to be placed on assault precautions. II. PAST MEDICAL/SURGICAL HISTORY: He suffered bipolar personality disorder or Schizophrenia, Delusional, earring voices, suicidal ideation, depression, and hopelessness, sleep disturbances. Achilles tendons problems. III. ADMITTING MEDICAL DIAGNOSIS: Paranoid personality disorder, Bi-polar, General Depression disorders, Schizophrenia, Sleep disorders

PBVI 9.12.12

PBVI Nursing Care Plan

IV. LABS: Lab Test WBC Purpose To check WBC values for diagnosing health problems. To determine the presence of infection Albumin To evaluate nutrition status 3.5-5.2 g/dL 4.4 g/dL Normal Normal Values 4.5-10.8 /uL 5.1 Client Results Interpretation of Abnormal Labs Within normal limit

PBVI 9.12.12

PBVI Nursing Care Plan

V. MEDS: Medication (Brand and Generic Names) Lexapro Trazadone Lorazepam Antianxiety Classification Antidepressant Prescribed Dose, Freq, Route 10mg, PO, HS 100 mg, PO, QHS 0.5 ml, Q12hrs, PO Reduce anxiety by increasing or facilitating the inhibitory neurotransmitter activity of GABA Short term relief of anxiety disorder or symptoms of anxiety with depression. Teach client side effects Encourage client to report excessive sleepiness or reoccurrence of anxiety Avoid alcohol. Report increase of depression or suicidal ideation Mechanism of Action Patient Specific Indications To treat anxiety and major depressive disorder Side effects/Nursing Implications

PBVI 9.12.12

PBVI Nursing Care Plan

PBVI 9.12.12

PBVI Nursing Care Plan

VI. NURSING DIAGNOSES: (minimum of 5, prioritized) 1. 2. 3. 4. 5. Risk for Self-Directed or Other Violence R/T suspiciousness, panic anxiety, catatonic excitement, command hallucination Risk for Violence R/T Auditory hallucination Disturbed Thought Process R/T Inability to trust Social isolation related to altered mental status Disturbed Sleep Pattern R/T Inadequate stimulation, poor sleep hygiene, and Substance used.

PBVI 9.12.12

PBVI Nursing Care Plan

PBVI 9.12.12

PBVI Nursing Care Plan

NURSING DIAGNOSIS STATEMENT Risk for Violence R/T Frightened, secondary to auditory hallucination and delusional thinking as manifested by : Assaultive toward others, Self and environment. OUTCOMES NOC: Patient will Avoid hurting self or assaulting other patients or staff, with assistance from staff. INTERVENTIONS NIC: 1. Acknowledge patients fear, hallucinations, and delusions. Be genuine and empathetic. 2. Assure patient that you will help him control behavior and keep him safe. Begin to establish a trusting relations 3. Offer patient choices of maintaining safety: staying in the seclusion room, medications to help him relax Avoid mechanical restraints and a show of force by having several persons approaching him at once hip. RATIONALES DOCUMENTATION EVALUATION

1.

Hallucinations and delusions change an individuals perception of environmental stimuli. Patient is truly frightened and is responding out of his need to preserve his own safety.

IN one and one meeting assessment, the acknowledgment of patients fear, hallucinations noted.

Goal met. Patient showed sign of progress and has avoided hurting self or assaulting other patients.

2.

Patient was re-assured that nursing staff will help him control behavior and keep him safe. Trust begun to establish.

Maslows Hierarchy Level: Safety

3. By giving patient choices, he will begin to develop a sense of control over his behavior. Seclusion and restraint are options only for persons exhibiting serious, persistent aggression. The persons safety must be protected at all times.

Several choices were offered to patient.

PBVI 9.12.12

PBVI Nursing Care Plan

NURSING DIAGNOSIS STATEMENT Disturbed Thought Processes Related Inability to trust As evidence by: Suspiciousness of others, resulting in Inappropriate use of defense mechanisms. . OUTCOMES NOC: Short-Term Goal Client will develop trust in at least one staff member within 1 week. INTERVENTIONS NIC: 1. Encourage same staff to work with client as much as possible Avoid physical contact.
1.

RATIONALES

DOCUMENTATION

EVALUATION

To promote development of trusting relationship.

Sincere and honest talks were established when communicating with client. No physical contact was established with client

Goal met. Client has developed trust within 1 week with at least one staff member.

2. Long-Term Goal Client will demonstrate use of more adaptive coping skills, as evidenced by appropriateness of interactions and willingness to participate in the therapeutic community.

2.

Suspicious clients may perceive touch as a threatening gesture. Suspicious clients often believe others are discussing them, and secretive behaviors reinforce the paranoid feelings. Honesty and dependability promote a trusting relationship.

3.

Maslows Hierarchy Level: Cognitive

Avoid laughing, whispering, or talking quietly where client can see but not hear what is being said. Be honest and keep all promises

3.

All the staff remained professional and refrained to laugh.

4.

4.

Long term Goal not met: Client has made progress by showing sign of coping skills and willingness to participate in the therapeutic community. Will continue with the intervention and later reevaluate client.

PBVI 9.12.12

PBVI Nursing Care Plan

NURSING DIAGNOSIS STATEMENT Social isolation related to altered mental status As evidence by clients statement of, When I have hallucinations, because of my schizophrenia, Im not appropriate in public. OUTCOMES NOC: Short Term Client will identify feelings of isolation by August 16 2013 at 1100. Long Term Client will participate in activities and programs at level of ability and desire by August 23, 2013 at 11:30am. INTERVENTIONS NIC: . Short term: 1. Establish a therapeutic relationship by being emotionally present and authentic. Discuss causes of perceived or actual isolation. Observe for barriers to social interaction. 2. RATIONALES DOCUMENTATION EVALUATION Goal met. 1. Being emotionally present and authentic fosters growth in relationships and decreases isolation (Ackley & Ladwig, pg. 768). The individuals experience of illness; the circumstances of everyday living that influence quality of life; and emotions, fears, and concerns all have a bearing on the way illness is managed (Ackley & Ladwig, pg. 768). isolation may be different for each individual; adequate information should be gathered so appropriate interventions can be planned. Varcarolis E.M & Halter M.J. (2010). Foundation of Psychiatric Mental health A clinical Approach, 6th Ed. Slouis, Missouri: Saunders Elsevier Townsend M.C. (2011). Nursing Diagnoses in Psychiatric Nursing, Care Plans and Psychotropic Medication, 8 th. Ed. Philadelphia, PA:F.A. Davis Company http://psychcentral.com/disorders/paranoid-personality-disorder-symptoms/ Therapeutic relationship was established with client. Short Term As of August 16. 2013 client identifies that he is socially isolated because he has limited interactions with others and does not have any hobbies. He also indicates that all of his family lives out of state. Goal in progress Long Term Evaluation set for August 23, 2013 at 11:30am. Client has made some progress toward goal. He attended Unity Day held at East side of Golden Jerome Center but did not stay for more than ten minutes.

2.

Causes of perceived or actual isolation was discussed with the client. Particular barriers to social interaction were observed.

3.

Maslows Hierarchy Level: Love and Belonging

3. Causes of social

PBVI 9.12.12