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NURSING CARE PLAN

Nursing Units: Crescent Pine Psychiatric Center (Adult Unit B)



Pt.s Initials: MM____ Room_ Age 42yrs_______ Diagnosis: Schizophrenia and Major Depressive Disorder (NEC)
________________________________________________________

Allergies (BuSpar/BusPIRONE) _______________________________________________________________________________________________________________

Presenting Problem and Pertinent Past Medical and Psychiatric History ( include prescribed, OTC or street medication(s) taken at home):
Patient is a 42yrs old African American woman was Admitted involuntarily to the Crescent Pine Psychiatric hospital. She was brought from her Assisted Living Home by EMT in
an ambulance for expressing suicidal thoughts of harming herself with no self injuring. She states I couldnt do it anymore not being able to do anything for myself, I want to go
home. Pt. has a previous history of a suicide attempt by drug overdose for which she was hospitalized at Crescent Pine in last year December 2011. She states I hated spending
my Christmas here last year and I hated spending my Easters here also. Pt. has a history of schizophrenia and MMD; a surgical history of Gastric Bypass (lost 125 lbs) and Breast
reduction and tonsillectomy in 02/2010, and has medical Hx (Anemia). Denies suicidal, homicidal thoughts, auditory hallucination, alcohol, tobacco, and drugs abuse. She is
feeling depressed because of conflicts with her adopted mother and sister mistreating her and not showing her any love. They states that she is stupid and sick in the head, and they
does not care about her. She has been on some of these medications since her was last discharge from Crescent Pine and is currently taking them here. They include: : Trazodone
(Desyrel)150mg tab PO at HS daily, Sertraline(Zoloft) 50mg tablet PO daily for (depression), Klonopin (Clonazepam)1mg PO BID for (anxiety, start 04/4/12-04/11/12 stop),
Risperidone (Risperdal) 2mg tab PO daily to reduce psychosis and depression (Pt. refused Meds, she believes it makes her feels suicidal),Psyllium PKT(Metamucil) 2TBSP
PO daily, Loratadine (Claritin/Alavert) 10mg tab PO for Allergy, Latuda(Lurasidone ) 80mg, daily for (depression), Ativan(Lorazepam)2mg Tab PO q 6hours Prn for
agitation, and Benadryl 25mg PO q 6 hours for (Insomnia). VS: 04/10/12= Bp,162/96, Temp 97.9, P 70, RR 20. Will continue to monitor Pt.

DSM IV - TR Actions of Psychotropic Medications (Document Reference)
Axis I (psychiatric clinical disorders)-Schizophrenia(paranoid type) Depressive
Disorder NOS
Risperidone (Risperdal) mood stabilizers 2 mg PO daily to reduce psychosis, but (Pt.
refused meds she believes it makes her feels suicidal.
It is an antipsychotic used to treat bipolar mania and manage psychotic disorders. It
selectively blocks serotonin and dopamine receptors in the CNS to suppress psychotic
symptoms.SE: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS,
aggressive behavior, dizziness, extrapyramidal reactions, headache, dreams, sleep
duration, insomnia, sedation, fatigue, impaired temperature regulation, nervousness,
Tardive Dyskinesia. Tablets: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
Trazodone (Desyrel) 150mg tab PO at HS daily-antidepressant use to tx major
depression and Insomnia and anxiety. It alters the effects of serotonin in the CNS; MAO
inhibitors should be stopped at least 14 days before Trazodone therapy. Trazodone should
be stopped at least 14 days before MAO inhibitor therapy. SE: SUICIDAL THOUGHTS,
drowsiness, confusion, dizziness, fatigue, hallucinations, headache, insomnia, nightmares,
slurred speech, syncope, weakness .Tablets (IR): 50 mg, 100 mg, 150 mg, 300 mg
Tablets (ER) 150 mg, 300 mg

Axis II (personality & developmental disorders) -Deferred Sertraline (Zoloft) 50mg tablet PO daily for (depression), it is an antidepressant; Pt. is
taking this meds for depressant and (social phobia). Inhibits neuronal uptake of serotonin
in the CNS, thus potentiating the activity of serotonin. Has little effect on norepinephrine
or dopamine. SE: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL
THOUGHTS, dizziness, drowsiness, fatigue, headache, insomnia, agitation, anxiety,
confusion, emotional liability, impaired concentration, manic reaction, nervousness,
weakness, yawning. Tablets: 25 mg, 50 mg, 100 mg

Klonopin (Clonazepam) 1mg PO BID for (anxiety, start 04/4/12-04/11/12 stop),
anticonvulsant; pt. is taking this med for anxiety. Anticonvulsant effects may be due to
presynaptic inhibition. Produces sedative effects in the CNS, probably by stimulating
inhibitory GABA receptors. Prevention of seizures. Decreased manifestations of panic
disorder. Adjunct management of acute mania, acute psychosis, or insomnia.SE:
SUICIDAL THOUGHTS, behavioral changes, drowsiness, fatigue, slurred speech,
ataxia, sedation, abnormal eye movements, diplopia, and nystagmus. Tablets: 0.5 mg, 1
mg, 2 mg.
Axis III (general medical conditions) seasonal allergy rhinitiss, tachycardia,
Anemia, and constipation, SP Gastric Bypass, Breast Reduction, and Tonsillectomy
Psyllium PKT (Metamucil) 2TBSP PO (laxatives to relief and prevention of
constipation) pt is taking this meds as a stool softener. Management of simple or chronic
constipation, particularly if associated with a low-fiber diet. Useful in situations in which
straining should be avoided (after MI, rectal surgery, and prolonged bed rest). Combines
with water in the intestinal contents to form an emollient gel or viscous solution that
promotes peristalsis and reduces transit time.SE Bronchospasm, cramps, intestinal or
esophageal obstruction, nausea, vomiting. 2.53.5 and g/dose or packet
.

Ativan (Lorazepam) 2mg Tab PO q 6hours Prn for agitation- Antianxiety,
sedative/hypnotic, and analgesic adjuncts. Depresses the CNS, probably by potentiating
GABA, an inhibitory neurotransmitter. Pt is taking this med PRN for agitation.SE:
dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred speech, forgetfulness,
confusion, mental depression, rhythmic myoclonic jerking in pre-term infants, paradoxical
excitation. Tablets: 0.5 mg, 1 mg, 2 mg, and Injection: 2 mg/mL, 4 mg/mL
Latuda (Lurasidone) 80mg, pt take daily for (depression and Psychosis), Treatment of
schizophrenia, schizophrenic behavior. Its effect may mediated via effects on central
dopamine Type 2 (D
2
) and serotonin Type 2 (5HT
2A
) receptor antagonism.SE:
NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, akathisia, drowsiness,
parkinsonism, agitation, anxiety, cognitive/motor impairment, dizziness, dystonia, tardive
Dyskinesia, blurred vision, AGRANULOCYTOSIS, anemia, leukopenia.
Loratadine (Claritin/Alavert) 10mg tab PO for Allergy-it is an antihistamines, pt is
taking to relief of symptoms of seasonal allergies (Rhinitis). Blocks peripheral effects of
histamine released during allergic reactions and decreased symptoms of allergic reactions
(nasal stuffiness; red, swollen eyes, itching).SE: confusion, drowsiness (rare), paradoxical
excitation, blurred vision, dry mouth, GI upset, photosensitivity, rash, weight gain.
Tablets: 5 mg, 10 mg and Syrup: 5 mg/5 mL.
Benadryl 25mg PO q 6 hours for (Insomnia). Benadryl (Diphenhydramine) PO PRN
HS adult and children greater 12 yrs given at bedtime for nighttime sleep aid. It is an
antihistamine, and antitussives use for mild nighttime sedation, Significant CNS
depressant and anticholinergic properties, Antagonizes the effects of histamine at H
1
-
receptor sites; does not bind to or inactivate histamine, Decreased symptoms of histamine
excess (sneezing, rhinorrhea, nasal and ocular pruritus, ocular tearing and redness,
urticaria).95% metabolized by the liver.SE: drowsiness, dizziness, headache, paradoxical
excitation (increased in children), blurred vision, tinnitus, hypotension, palpitations,
anorexia, dry mouth, constipation, nausea, Dysuria, frequency, urinary retention,
photosensitivity, chest tightness. Nursing Assessments: assess for confusion, delirium, fall
risk(Institute measures to prevent falls), Assess sleep patterns, when used for insomnia,
administer 20 min before bedtime and schedule activities to minimize interruption of
sleep, and may Administer with meals or milk to minimize GI irritation.
Axis IV (psychosocial and environmental problems) - Family conflict with Mother and sister(Primary support system), non -compliance with
meds, death of her brother

Axis V (global assessment of functioning) - On admission 20-30, but now 50.
Signs & Symptoms of Physical and Psychiatric Problems Nursing Implications of Psychotropic Medications (Document Reference)
S/I Past history of O.D. attempts Latuda (Lurasidone) 80mg: Monitor patient's mental status (orientation, mood,
behavior) before and periodically during therapy; Assess weight and BMI initially and
throughout therapy; Monitor mood changes. Assess for suicidal tendencies, especially
during early therapy. Restrict amount of drug available to patient; Monitor for
development of neuroleptic malignant syndrome (fever, respiratory distress,
tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness).
Notify health care professional immediately if these symptoms occur; Monitor CBC
frequently during initial mo of therapy in patients with pre-existing or history of low
WBC. May cause leukopenia, neutropenia, or agranulocytosis. Discontinue therapy
if this occurs.
Low Self- esteem and Despondent
Agitation and Mood swings Ativan (Lorazepam) 2mg Tab PO- Conduct regular assessment of continued need for
treatment; Assess degree and manifestations of anxiety and mental status (orientation,
mood, behavior) prior to and periodically throughout therapy; Prolonged high-dose
therapy may lead to psychological or physical dependence. Restrict amount of drug
available to patient; Assess geriatric patients carefully for CNS reactions as they are more
sensitive to these effects. Assess falls risk

Insomnias Trazodone (Desyrel) 150mg tab PO at HS daily. Inform pt to inform prescriber if
symptoms of priapism occur. Give medication shortly after the pt. has a meal or light
snack to reduce nausea. Give larger portion of daily dose at bedtime if drowsiness occurs.
Monitor depressed patients closely including children and teens, for suicidal thoughts and
tendencies and notify the prescriber
Feeling worthlessness, loneliness, Social Isolation Sertraline (Zoloft) 50mg tablet PO daily for (depression), Monitor appetite and
nutritional intake. Weigh weekly. Notify health care professional of continued weight loss.
Adjust diet as tolerated to support nutritional status; Monitor mood changes. Inform health
care professional if patient demonstrates significant increase in anxiety, nervousness, or
insomnia; Assess patient for feelings of fear, helplessness, and horror. Determine effect on
social and occupational functioning; Assess patient for symptoms of social anxiety
disorder (blushing, sweating, trembling, tachycardia during interactions with new people,
people in authority, or groups) periodically during therapy.
Rehospitalization Explain current condition, prognosis, and therapeutic regimen to patient, and the
importance of medication (Risperidone (Risperdal) mood stabilizers 2 mg PO daily to
reduce psychosis, because (Pt. refused meds she believes it makes her feels suicidal)
compliance and ask her to consult Dr if they have any questions about medications.
Paranoidal Klonopin (Clonazepam) 1mg PO BID- Monitor patient's mental status (orientation,
mood, behavior) before and periodically during therapy. Monitor closely for notable
changes in behavior that could indicate the emergence or worsening of suicidal thoughts
or behavior or depression; Monitor for development of neuroleptic malignant syndrome
(fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or
hypotension, pallor, tiredness). Notify health care professional immediately if these
symptoms occur; Observe patient when administering medication to ensure medication is
swallowed and not hoarded or cheeked; assessed pt for negative symptoms (social
withdrawal, flat, blunted affects) of schizophrenia
Significant Diagnostic Studies Nursing Responsibilities
Related To
Diagnostic Studies
Normal Value Result of Test Implications
WBCs Explain procedure to patient. Draw patients
blood as ordered by physician. Blood specimen
sent to lab 04/01/12
4.8-10.8 4.6 slightly low Low (leukopenia) decrease
of white blood cells; great
number of drugs and
failure of the bone marrow
may cause it;
immunocompromised
Notify MD.
RBCs Explain procedure to patient. Draw patients
blood as ordered by physician. Blood specimen
sent to lab 04/01/12
4.20-5.40 3.83 low Low values for RBC lead
to anemia; sign of poor
oxygenation/ poor diet
HGB Explain procedure to patient. Draw patients
blood as ordered by physician. Blood specimen
sent to lab 04/01/12
12.0-16,0 11.2 slightly low Low Hgb levels lead to
anemia; sign of poor
oxygenation.
HCT Explain procedure to patient. Draw patients
blood as ordered by physician. Blood specimen
sent to lab 04/01/12
37.0-47.0 33.4 low Low HCT levels lead to
anemia, sign of poor
oxygenation.


Proposed Discharge Teaching:
1) Encourage pt to involve support system(mother and sister) in education of disease through family sessions
2) Explain the importance of follow up exam with the pts doctor(Dr. Hussein) and give all phone numbers needed for that
3) Teach pt the importance of medication compliance and ask her to consult Dr if they have any questions about medications.
4) Explain the pts condition, prognosis and therapeutic regimen and the importance of following that regimen
5) Encourage pt to participate in group therapy available here, at Pt. church or anywhere else that is assessable to Pt.
6) Encourage pt to talk about feelings with support system
7) Instruct patient and family members in disease process and to recognize and cope with relapse symptoms.
8) Instruct patient and family members about the uses, actions and adverse effects of prescribed drugs.
9) Provide instruction on when to notify primary care provider regarding drug adverse effects, or increase in symptoms.
10) Instruct patient and family about community resources, support groups, and possible use of outpatient community mental health centers.
11) For additional information and support refer patient and family to National Alliance for Research on Schizophrenia and Depression,
www.narsad.org and www.schizophrenia.com.
12) Importance of continuing medication use probably for a lifetime. Do not stop taking these drugs abruptly or without Consulting with health care
provider
13) Importance of maintaining a healthy lifestyle and balanced diet, minimal caffeine and no alcohol, regular adequate sleep patterns.
14) Provide the pt and family with 24hr 7 day a week crisis phone number to call whenever the need arises.
15) Provide pt. with Toll-free Depression Awareness, Recognition, and Treatment Help Hotline #: 1-800-421-4211. The toll-free suicidal hotline number is 1-800-784-2433


References:
Doenges, Moorhouse, Murr (2007) Nursing Diagnosis Manual (2
nd
edition)

Jones & Barret Learing (2011) Nurses Drug Handbook (10
th
edition)

Schultz & Videbeck (2009) Lippincotts Manual of Psychiatric Nursing Care Plans (8
th
edition).

Mosbys (2009) Nursing Drug references (22
nd
edition)

Karch, Amy (2011), 2011 Lippincotts Nursing Drug Guide.
Mary C. Townsend, (2011), Lippincotts Manual of Psychiatric Nursing Care Plans (8th Ed)


Nursing Diagnosis
(Number Each Problem)
Scientific Basis
for
Nursing Diagnosis
(Observations & Professional Sources)
Short Term Goals
Long Term Goals
Nursing Interventions
(Place* By Those Actually Done)
Scientific Rationale
For Nursing
Intervention
(Document Reference)
Evaluation of
Interventions
Evaluation of
Goals
(Results, Patient behavior,
Further Action)
1. 1) Risk for suicide
related to disrupt
family life and poor
support system AEB
pts feelings of
hopelessness and
helplessness. I
couldnt do it anymore
not being able to do
anything for self and
I want to go home
Suicidal ideation is one of
the common behaviors
associated with depression
(Townsend, M. C., 2011, p.
534).
STG: Patient will
make short-term
verbal or written
contract with nurse
not to harm self
while in the hospital.

LTG: Patient will
identify (3) reasons to
live before D/C
1)-Encourage the patient
to verbalize feelings and
emotional pain
1)Encouraging patient
to verbalize feelings
would relieve some
stressors

2)Maintain low level
stimuli in clients
environment
2) Anxiety level rises in
a stimulating
environment. A
suspicious agitated
client may perceive
individuals as
threatening

3) Observe clients
behavior every 15min
and do this while
carrying out routine
activities
3) Close observation is
necessary so that
intervention can occur
if required to ensure
clients safety

4)Remove all dangerous
object from clients
environment
4)This is done so that
when client is in
agitated state she would
not use them to harm
self or others

5)Staff should maintain
and convey a calm
attitude behavior towards
client
5)Anxiety is contagious
and can be transferred
from staff to client

6) Redirect the violent
behavior with physical
outlet for clients anxiety
6) Physical exercise is a
safe and effective way
to relieve pent up
tension.


7). Reorient the
patient person, place
and time as indicated
7). Repeated
Presentation of
reality is concrete
reinforcement for
the patient











.


Nursing Diagnosis
(Number Each Problem)
Scientific Basis
for
Nursing Diagnosis
(Observations & Professional Sources)
Short Term Goals
Long Term Goals
Nursing Interventions
(Place* By Those Actually Done)
Scientific Rationale
For Nursing
Intervention
(Document Reference)
Evaluation of
Interventions
Evaluation of
Goals
(Results, Patient behavior,
Further Action)
Knowledge deficit
regarding treatment
regimen r/t to altered
thought process AEB by
client inability to
provide information
about medical regimen
Risperidone
(Risperdal) mood
stabilizers 2 mg PO
daily to reduce
psychosis, (Pt. refused
meds she believes it
makes her feels
suicidal.

Following medical regimen can
improve paranoia symptoms
and anxiety.
STG: Verbalize
understanding of
disorder and
treatment before
within the nxet 24
hours.

LTG: Assume
responsibility for
own learning within
her abilities after and
Participate in a
process/treatment
upon d/c.
1) Determine the current
knowledge level of
disorder and its
management.

2) Instruct client/family
about the disorder and
management, its signs
and symptoms and
management of meds
and ADLS.

3) Have individual
verbalize/paraphrase
knowledge gained.


4) Identify appropriate
therapies and community
support systems to meet
individual needs.


5) Teach family
members the facts about
the clients illness,
empathizing that it could
strike any family.

*6) Stress to client how
important it is to never
stop therapy suddenly
when taking
Risperidone.
1) Knowledge base and
readiness to learn.



2) Provides information
and can promote
independent behaviors
within clients ability.


3) Evaluates clients
comprehension of
information regarding
disorder.

4) Promotes trusting
relationships and
encourages further
cooperation with
treatment plan.

5) Educating the family
helps to dispel myths
and decrease stigma of
mental illness.


6) The drug can
precipitate rebounds
Psychosis and anxiety














Nursing Diagnosis
(Number Each Problem)
Scientific Basis
for
Nursing Diagnosis
(Observations & Professional Sources)
Short Term Goals
Long Term Goals
Nursing Interventions
(Place* By Those Actually Done)
Scientific Rationale
For Nursing
Intervention
(Document Reference)
Evaluation of
Interventions
Evaluation of
Goals
(Results, Patient behavior,
Further Action)
3). Social Isolation R/T
expression of feeling of
rejection of loneness,
powerlessness imposed
by others. Pt. states
angrily I want to go
home Im done with
group therapy I
have been in this place
for twelve days now
and these quack wont
let me go home.
Aloneness experience by
individual and perceive as
imposed by others as a
negative / threatening state.
STG: Clients
willingly attend
group therapy
activities
accompanied by
trusted staff
members within in
the next 5 sessions.

LTG: client will
voluntarily spend
time with others
client and staff
members in group
activities until d/c
1) Convey an accepting
attitude by making brief,
frequent contacts with
Pt.
2) Show unconditional
positive regard.
3). Be with the client to
offer support during
group activities that may
be frightening or
difficult for him or her.
4) Be honest and keep all
promises.
5. Be cautions with
touch. Allow client extra
space and an avenue for
exit if he or she becomes
anxious.
6) Administer
tranquilizing
medications as ordered
by physician. Monitor
for effectiveness and for
adverse side effects.
7) Discuss with client the
signs of increasing
anxiety and techniques
to interrupt the response
(e.g. Relaxation,
exercises, thought
stopping).
8) Give recognition and
positive reinforcement
for clients voluntary
interactions with others.
2) An accepting attitude
increases feeling of
self-worth and facilitate
trust.
2) This conveys your
belief in the client as a
worthwhile human
being.
3) The presence of a
trusted individual
provides emotional
security for the client.
4) Honest and
dependability promote a
trusting relationship.
5) A suspicious client
may perceive touch as a
threatening gesture.
6) Antipsychotic
medications help to
reduce psychotic
symptoms in some
individuals, thereby
facilitating interactions
with others.
7) Maladaptive
behaviors such as
withdrawal and
suspiciousness are
manifested during time
of increased anxiety.
8) Positive
reinforcement enhances
self-esteem and
encourages repetition of
acceptable behaviors.