CONCEPT MAP N140

DSM-IV-TR DIAGNOSIS
Axis I - _Schizoaffective Disorder, Bipolar Type_______
Axis II - _Deffered_________________________________
Axis III - _History of Systemic Lupus Erythematosus___

DIAGNOSTIC TEST & RESULTS

ECG- probably normal variant, sinus rhythm, RSR in V1
High: RBC 9.7 (limits 4.0-10.5)
Low: WBC 3.72 (limits 3.80 -5.10)
High: MCV 102 lt (limit 80-98)
High: MCH 3.5 lt (limits 27.0-34.0)
Low: Protein Total serum 5.9L (limits 6.0-8.5)

Axis IV - _Problem with primary support group, problems r/t social

environment, housing problems____________________
Axis V - _GAF=30_________________________________
BIOPSYCHOSOCIAL ASSESSMENT:
Eriksons (see short assessment)
Maslow (see short assessment)
Limited to no family support
Non-compliance with Medication and follow-up care
Chemical dependencies
No job skills

CURRENT MEDICATIONS/TREATMENTS:

See Medication sheets

TEACHING NEEDS:
1-Medication
2- Hygiene
3-Anger Management
4- Coping Skills
D/C PLANNING:
Discuss with Lisa plans for group home placement

PATIENT STRENGTHS:
Can communicate, Motivated, Positive self-image, Supportive
boyfriend/common law husband

NURSING DIAGNOSIS / PROBLEM

NURSING CARE

OUTCOME

1)
Therapeutic Regimen Management,
ineffective related to lack of relief of
symptoms of Schizophrenia and Bipolar
Disease as evidenced by labile mood,
pressured speech, disorganized
thoughts

Interventions: Assess for Medicine

effectiveness
Report any noted untoward side effects
or APRs to MD for further orders
Coordinate any Lab work or diagnostic
test ordered

Demonstrates the ability to organize

small tasks without assistance or
conflict within one month
Demonstrates more stable moods
starting in 6 weeks or within
medications therapeutic range
Communicates ability to organize
thoughts and verbalize needs within 6
wks or within medications therapeutic
range

2) Knowledge deficient, ineffective

related to Medication Regimen as
evidenced by demanding certain
medications and refusing the
medications ordered

Interventions:
Educate Lisa regarding medications,
uses, dosages, as well as any side
effects or ADRLs to report
Document progress in Patients report

Demonstrate compliance with

medications by taking the medications
daily without complaints 50% of the time
Demonstrate compliance with
medications by taking the medications
daily without complaints 65% of the time
Communicates understanding of the
new drug regimen by less focus on old
medication regimen 50% of the time

3) Therapeutic Regimen Management,

ineffective related to Group Therapy as
evidenced by disruptive and demanding
behavior

Encourage Lisa to Participate in all

groups and activities
Teach Lisa stress relieving techniques
such as taking a deep breath before
interrupting another patient or group
leader

Patient will participate in groups without

being disruptive 50% of the time
Patient will participate in groups without
being disruptive 65% of the time
Patient will participate without
interrupting speakers 50% of the time

NURSING DIAGNOSIS / PROBLEM

NURSING CARE

OUTCOME

4)
Ineffective Coping/decisional Conflict
related to mental illness, memory loss,
impaired adaptive and social behaviors
and problem-solving skills as evidenced
by inability to perform daily hygiene,
inability to understand extent of illness,
inability to perform self-care

Educate Lisa on personal hygiene, such

as washing hair instead of applying
lotions and wearing appropriate fitting
and clean clothes
Educate Lisa on why she has been
institutionalized and the behaviors that
will allow her to be accepted into a less
restricted mileu

Demonstrates the ability to perform

hygiene (ADLs) without assistance or
conflict 1 x a week
Demonstrates the ability to perform
hygiene such as brushing teeth and
washing hair 3 x a week
Communicates what she needs to do to
be released to a less restrictive
environment 50% of the time she is
asked.

5)Health Maintenance, ineffective related

to patients medical diagnoses of SLE,
COPD, Asthma, Chronic Bronchitis,
History of DVT, History of
Hypothyroidism, as evidenced by
continuing to smoke, resistance to
taking medications, and remaining
immobile for long periods of time

Observe for symptoms of medical

problems and report to MD for treatment
orders
Educate Lisa regarding environmental
allergies to avoid
Educate Lisa regarding hazards of
cigarette smoking as related to COPD
Educated Lisa regarding symptoms of
DVT and techniques to avoid developing
it.
Assess for presence of s/s of COPD,
SLE & DVT

Patient reports to RN/MD any known

symptoms of her medical problems
which may exacerbate in a normal tone
50% of the time
Patient demonstrates compliance with
medications by taking her medications
every day without complaints as ordered
Demonstrates compliance with all
medical appointments starting
immediately after teaching
Demonstrates an understanding of the
dangers of cigarette smoking and shows
an attempt to cut down within one week