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7/17/2019 Care Plan East Campus CORREGIDO
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University of Texas at Brownsville
Bachelor Science Nursing
Plan of Care (Based on Textbook
!oo" No# 1$ Student%s Na"e# Corte& 'itdsy )on&ale& !a"iro *s+inosa ,leana Saen& Sa"antha
Pt%s ,nitials# S- . / -ge# 0 2ate# 341541$
Patient%s .edical 2iagnosis# Psychosis
State a short ter" ob6ective for yourself during this nursing care ex+erience# 'earn and +ractice so"e of the skills that , learned the
last se"ester7 -lso +ractice the correct for" of charting and using the nursing care +lan7
2efine in your words the current diagnosis# ,t is the condition of the "ind involving loss of contact with reality7
Su""ary of diagnosis (*tiology and +athology according to textbook# - "ental disorder in which there is severe loss of contact withreality7 *videnced by delusions hallucinations disorgani&ed s+eech +atterns and bi&arre or catatonic behavior7 Psychotic disorders are
co""on features of schi&o+hrenia bi+olar disorders and so"e affective disorders7 They can also result fro" substance abuse (such as
hallucinogens substance withdrawal (such as deliriu" tre"ens or side effects of so"e +rescri+tion drugs7 *tiology# alterations in brain
structure and changes in do+a"ine neurotrans"ission7 The do+a"ine changes are directly related to hallucination and delusions7
Sy"+to"s according to textbook# ,n +sychotic states +atients "ay ex+ress unusual ideas (such as that they can read the "inds of
others send radio "essages directly to )od or inani"ate ob6ects travel to distant galaxies7 These ideas are called delusions7 Psychosis
is also "arked by +atients% re+orts of hearing voices (auditory hallucinations or seeing ob6ects or +ersons not visible to others (visual
hallucinations7 -uditory hallucinations are hall"arks of schi&o+hrenic and "anic states8 visual hallucinations are characteristic of drug
intoxication or withdrawal7 2isturbances in thought content and for" +erce+tion affect sense of self volition inter+ersonal relationshi+s
and +sycho"otor behavior occur7 Thorough +hysical and +sychiatric exa"inations rule out organic causes of the +atient sy"+to"s and
establish the diagnosis7
Textbook .edical .anage"ent (2x studies and treat"ent# Treat"ent goals focus on "eeting the +atient%s +hysical and
+sychosocial needs and usually co"bine drug thera+ies with behavioral thera+ies long9ter" +sychothera+y +sychosocial rehabilitation
and4or vocational counseling re:uiring use of co""unity resources7 Patients with +sychosis are treated effectively with neurole+tic drugs
(which a++ear to work by blocking +ostsyna+tic do+a"ine rece+tors such as halo+eridol ris+eridone or chlor+ro"a&ine7 Side effects of
so"e of these "edications include dystonic reactions and tardive dyskinesia7 The newer agents +roduce fewer of these extra+yra"idal
sy"+to"s7 Treat"ent drugs also have sedative anticholinergic and orthostatic hy+otension effects and about 1; of +atients taking these
agents ex+erience neurole+tic "alignant syndro"e (life9threatening fever "uscle rigidity and altered level of consciousness7
Textbook Nursing 2iagnosis
Based on .aslow%s <ierarchy
Procedures to be +erfor"ed by students
Based on Nursing 2iagnosis
1 Consti+ation 1 -ssess usual +attern of eli"ination and co"+ared with +resent +attern including si&e fre:uency color and :uality
= !isk for violence = -ssess +hysiological signs and external signs of anger7
> -nxiety > -ssess the client%s level of anxiety and +hysical reactions to anxiety7Using the <a"ilton -nxiety Scale7
0 !isk for suicide 0 -ssess for any changes in "ood or behavior every >? "in to 1 hour
$ 2isturbed sensory +erce+tion r4t bioche"ical i"balances
-*B violent behavior and nonco"+liances with taking"edications
$ -ssess and identify behavioral res+onse that "ay indicate "ental
+roble"s
!eferences (-uthor @ Page No7 Nursing central# Taber%s dictionary disease and disorders7
-d"ission
2ate#
341041$ Nu"ber of days in <os+ital# =
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G E N E R A L I N F O R M A T I O N
-d"itted Aia# .ode
-"b#
n4a .c
#
n4a ther
#
Court rdered
State"ent of Present Co"+laint# Psychosis exhibiting self +aranoia delusions @ auditory hallucinations
'ast <os+ital -d"ission 2ate# 4=04?5 !eason# drug overdose
,""uni&ation Current (y4n# y PP2# y Notes
#
,nfluen&a
.a6or ,llness +erations Blood Transfusions or Pregnancies#
1
7
Psychosis 37 n4a
=
7
Bi+olar disorder 7 n4a
>7
<y+erli+ide"ia 7 n4a
0
7
Suicidal ideation 1?
7
n4a
$7
2e+ressive disorder 117 n4a
5
7
Schi&o+hrenia 1=
7
n4a
<ealth .aintenance#
*xercise Ty+e# n4a /re:uency# n4a Duantity# n4a
<obbies if any#
Tobacco Ty+e# Cigarettes DTE4day x yrs7# 04day >1 years ,f :uit
date#
n4a
-lcohol
Ty+e#
Beer DTE4week# 1= cans4 week ,f :uit
date#
n4a
ther Ty+e# Cocaine DTE4week# $ gra"s4 week ,f :uit
date#
n4a
-llergies# ,bu+rofen na+roxen
.edication
(including ,As
2ose /re:9
uency
!oute Ti"e
to be
Classification 4 -ction 4 !ationale Nursing ,ntervention
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M E D I C
A T I O N
'ithiu" >??"g D2 P ?5??
10??==??
.ood stabili&er
-ction
-lters cation trans+ort in nerve and "uscle7
.ay also influence reu+take ofneurotrans"itters7
Thera+eutic *ffect(s#
Prevents4decreases incidence of acute "anice+isodes7
!ationale#
.anic e+isodes of bi+olar , disorder
(treat"ent "aintenance +ro+hylaxis7
-ssess "ental status(orientation "ood
behavior initially
and +eriodically7
,nitiate suicide +recautions if
indicated7
.onitor intake andout+ut ratios7 !e+ortsignificant changes
in totals7 Unless
contraindicated
fluid intake of atleast =???F>???
"'4day should be
"aintained7 Geight
should also be"onitored at least
every > "o7
'ab Test
Considerations#*valuate renal and
thyroid function
GBC withdifferential seru"
electrolytes and
glucose +eriodically
during thera+y7Toxicity verdose#
.onitor seru"
lithiu" levels twice
weekly duringinitiation of thera+y
and every = "o
during chronic
thera+y7 2raw bloodsa"+les in the
"orning
i""ediately before
next dose7Thera+eutic levels
range fro" ?7$ to 17$
"*:4' for acute
"ania and ?75F17="*:4' for long ter"
control7 Seru"
concentrations
should not exceed=7? "*:4'7
-ssess +atient for
signs and sy"+to"s
of lithiu" toxicity(vo"iting diarrhea
slurred s+eech
decreased
coordinationdrowsiness "uscle
weakness or
twitching7 ,f these
occur re+ort before
ad"inistering nextdose7
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Duetia+ine
S*!DU*'
>??"g -t
bedti"e
P ==?? -nti+sychotics "ood stabili&ers
-CT,NProbably acts by serving as an antagonist of
do+a"ine and serotonin7
-lso antagoni&es hista"ine <1 rece+tors
and al+ha19adrenergic rece+tors7
Thera+eutic *ffect(s#2ecreased "anifestations of +sychoses
de+ression or acute "ania7
!-T,N-'*
Schi&o+hrenia7
2e+ressive e+isodes with bi+olar disorder7
-cute "anic e+isodes associated with bi+olar , disorder (as "onothera+y Hfor
adults or adolescentsI or with lithiu" or
dival+roex Hadults onlyI7
.aintenance treat"ent of bi+olar , disorder(with lithiu" or dival+roex7
-d6unctive treat"ent of de+ression7
.onitor "entalstatus ("ood
orientation
behavior before and
+eriodically duringthera+y7
-ssess for suicidal
tendencieses+ecially duringearly thera+y7
!estrict a"ount of
drug available to
+atient7 !isk "ay beincreased in
children
adolescents and
adults J=0 yr7-ssess weight and
B., initially and
throughout thera+y7
.onitor BP (sittingstanding lying and
+ulse before and
fre:uently duringinitial dose titration7
,f hy+otension
occurs during dose
titration return tothe +revious dose7
bserve +atient
carefully when
ad"inistering toensure "edication is
swallowed and not
hoarded or cheeked7
.onitor for onset ofextra+yra"idal side
effects (akathisiaF
restlessnessdystonia
F "uscle s+as"s andtwisting "otions8 or
+seudo+arkinsonis"
F "ask9like faces
rigidity tre"orsdrooling shuffling
gait dys+hagia7
!e+ort these
sy"+to"s8 reductionof dose or
discontinuation "ay
be necessary7
Trihexy+henidyl or ben&tro+ine "ay be
used to control these
sy"+to"s7
.onitor for tardivedyskinesia
(involuntary
rhyth"ic "ove"ent
of "outh face and
extre"ities7 !e+orti""ediately8 "ay be
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'ora&e+a"
(-tivan
1"g +rn P-ntianxiety agentssedative4hy+notics
-CT,N
2e+resses the CNS +robably by +otentiating )-B- an inhibitory
neurotrans"itter7
Thera+eutic *ffect(s#Sedation72ecreased anxiety7
2ecreased sei&ures7
!-T,N-'*-nxiety disorder (oral7
Preo+erative sedation (in6ection7
2ecreases +reo+erative anxiety and
+rovides a"nesia7Unlabeled Use(s#
,A# -ntie"etic +rior to che"othera+y7
,nso"nia +anic disorder as an ad6unct with
acute "ania or acute +sychosis7
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Palla+eridone
,NA*)-
SUST*NN-
5"g D2 once
daily
P D2
???
-nti+sychotic-CT,N
.ay act by antagoni&ing do+a"ine and
serotonin in the CNS7 Pali+eridone is the
active "etabolite of ris+eridone7Thera+eutic *ffect(s#
2ecreased "anifestations of schi&o+hrenia7
2ecreased "anifestations of schi&oaffectivedisorder7
!-T,N-'*
-cute treat"ent of schi&oaffective disorder
(as "onothera+y or as ad6unct to "oodstabili&ers and4or antide+ressants7
.onitor +atientKs"ental status
(orientation "ood
behavior before and
+eriodically duringthera+y7 .onitor
closely for notable
changes in behaviorthat could indicatethe e"ergence or
worsening of
suicidal thoughts or
behavior orde+ression
es+ecially during
early thera+y7
!estrict a"ount ofdrug available to
+atient7
-ssess weight and
B., initially andthroughout thera+y7
.onitor BP (sitting
standing lyingdown and +ulse
before and
+eriodically during
thera+y7 .ay cause +rolonged DT
interval tachycardia
and orthostatic
hy+otension7bserve +atient
when ad"inistering
"edication to ensure
that "edication isactually swallowed
and not hoarded or
cheeked7
.onitor +atient foronset of
extra+yra"idal side
effects (akathisiaF
restlessnessdystonia F "uscle s+as"s and
twisting "otions8 or
+seudo+arkinsonis"
F "ask9like facerigidity tre"ors
drooling shuffling
gait dys+hagia7
!e+ort thesesy"+to"s8 reduction
of dose or
discontinuation of
"edication "ay benecessary7
.onitor for tardive
dyskinesia
(involuntary
rhyth"ic "ove"entof "outh face and
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2CUS-T* =0?"g +rn P +rn
:d
'axative stool softner
-CT,N
Pro"otes incor+oration of water into stool
resulting in softer fecal "ass7.ay also +ro"ote electrolyte and water
secretion into the colon7
Thera+eutic *ffect(s#Softening and +assage of stool7
!-T,N-'*
Prevention of consti+ation soften stool
-ssess forabdo"inal
distention +resence
of bowel sounds
and usual +attern of bowel function7
-ssess color
consistency anda"ount of stool
+roduced7
,A Solution !ate (dro+s4"inute Titration '.'4hr -ccess Port Pu"+4Ty+e
n4a n4a n4a n4a n4a
n4a n4a n4a n4a n4a
n4a n4a n4a n4a n4a
n4a n4a n4a n4a n4a
.ay use back for "ore s+aceLL
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N E U R O S E N S O R Y
Best !es+onse to -uditory <and )ri+# *ye .ove"ent# Pu+ils#
and4or Aisual Sti"ulus *:ual ✓ Nor"al ✓ !ight#
-ge over = years (child4adult Une:ual n4a Nystag"us n4a Si&e# >
rientation ($ ✓ Geakness n4a Strabis"us n4a !eaction# 1
Confused (0 n4a !ight n4a ther n4a
,na++ro+riate words (> ✓ 'eft n4a .ood4-ffect# 'eft#
,nco"+rehensible words (= n4a .uscle Tone# <a++y n4a Si&e# > None# (1 n4a Nor"al ✓ Content n4a !eaction# 1
-ge = years and under (infant -rching n4a Duiet n4a
S"iles 'istens /ollows ($ n4a S+astic n4a Githdrawn n4a C2*
Cries consolable (0 n4a /laccid n4a Sad n4a 3 ""
5 ""
$ ""
0 ""
> ""
= ""
1 ""
,na++ro+riate +ersistent cry (> n4a Geak n4a /lat n4a
-gitated restless (= n4a 2ecorticate n4a <ostile ✓
No !es+onse (1 n4a 2ecebrate n4a /ontanel4Gindow# n4a
*yes +en ther n4a (+ertaining to infant n4a
S+ontaneously (0 ✓ 'C# Soft n4a
To s+eech (> n4a -lert4riented n4a /lat n4a
To +ain (= n4a Slee+y n4a Sunken n4a
No res+onse (1 n4a ,rritable ✓ Tense n4aBest .otor !es+onse Co"atose n4a Bulging n4a
beys Co""ands (5 n4a 2isoriented n4a Closed n4a
'ocali&es +ain ($ n4a 'ethargic n4a ther n4a
/lexion Githdrawal (0 n4a -wake ✓
/lection -bnor"al (> n4a Slee+ing n4a
*xtension (= n4a 2rowsy n4a
None (1 n4a -gitated n4a
C.- SC-'* TT-'# 1=
!elated 2x7 Studies (lab work x9rays etc# n4a
Collaborative Care !eferral# n4a
!elated NS) 2x# Anxiety r/t unconscious conflict it! re"lity AE# i$%"ire& "ttention'
C A R D I O
( A S C U L A R
Skin Color# C..*NTS
n4a
*de"a# C..*NTS
M= +itting ede"a to right ar"7 Nor"al ✓ No n4a
/lushes n4a Ees ✓
Pale n4a Chest Pain#
Cyanotic n4a No ✓
<eart Sounds# Ees n4a
Nor"al ✓ P n4a
ther 2escribe n4a D n4a
-+ical Pulse !ate# n4a ! n4a
!egular n4a S n4a
,rregular n4a T n4a
Pace"aker# /a"ily Cardiac
Ty+e n4a <istory#
!ate n4a No ✓
Peri+heral Pulses# Ees n4a
Present ✓ Tele"etry .onitor
*:ual ✓ No ✓
Geak n4a Ees n4a
-bsent n4a !hyth" n4a
.onitor 'ines @ 2ata# n4a
!elated 2x7 Studies (lab work x9rays etc# <)B# 1>7 <CT# =$7> Platelets# =10???
!elated NS) 2x# nowledge deficit r4t lithiu" adverse effect -*B +atient re+orting unknown cause of +al+itations7
Collaborative Care !eferral# !C# hy+erli+ide"ia7
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) U L M O N A R Y
!es+irations#
Cough# = at ho"e No -uscultation# (clear, crackles, rhonchi
!ate 1 None ✓ Chest ex+ansion n4a wheezing -nterior Posterio
!egular ✓ Productive n4a Sy""etrical ✓
,rregular n4a Non+roductive n4a -sy""etrical n4a !t7 U++er 'obe n4a n4a
SB n4a 2escribe n4a *x+lain n4a 'eft U++er 'obe n4a n4a
2ys+nea on n4a !t7 'ower 'obe n4a n4a
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*xertion n4a 'eft 'ower 'obe n4a n4a
2evices# n4a
!elated 2x7 Studies (lab work x9rays etc# n4a
!elated NS) 2x# ,neffective breathing +attern r4t "edication regi"en -*B +atient taking Sero:uel
Collaborative Care !eferral# n4a
G A S T R O I N T E S T I N A L
-bdo"en# ST'# 2iarrhea# n4a Geight /luctuation
Soft n4a O B.s4day 1 Consti+ation# ✓ 'ast 5 "onths n4a
!igid n4a 'ast B. =4=41$ ther# bese n4a +ounds (M 9 n4a
Non9tender n4a -"ount n4a Thin n4a ,deal weight for
Tender n4a /or"ed ✓ *"aciated n4a sex and age# 10= or less
2istended ✓ 'oose n4a Nourished n4a Present weight 10
Bowel Sounds# 'i:uid n4a Nutrition# verweight 3 (lbs
Present HPI 4 P .ucus n4a Refer to dietician Underweight n4a (lbs
-bsent H-I n4a sto"y n4a if available
!UD P Ty+e
!'D P ,ncontinent n4a Tube feeding n4a
'UD P Stool Color# Chewing Proble" n4a
''D P Brown ✓ Swallowing n4a<y+oactive ✓ Black n4a Proble" n4a
<y+eractive n4a !ed Tinged n4a Nausea4Ao"iting n4a
Bloody n4a Poor -++etite n4a
2evices# n4a
!elated 2x7 Studies (lab work x9rays etc# n4a
Collaborative Care !eferral# !C# hy+erli+ide"ia7
!elated NS) 2x# Consti+ation r4t "edication regi"en -*B verbali&e fear of +ain while defecating inade:uate fluid intake and side effects oflora&e+a" and sero:uel
G E N I
T O U R I N A R Y / R E ) R O D U C T I ( E
Bladder <abits# n4a 'ast void '.P# n4a Pregnancies#
/re:uency# Color of urine Straw yellow ,f any +roble" n4a Pregnant n4a
2ysuria n4a -"ount Sufficient 2escribe n4a Geeks n4a
Nocturia n4a -++earance Clear n4a )ravida4Para n4a
Urgency n4a /luid @ *lectrolytes $ cu+s n4a 2ate of last#<e"aturia n4a Total Shift ,ntake $ cu+s 'ast Pa+ S"ear n4a Prostate *xa" n4a
!etention n4a Previous =0 hrs $ cu+s !esults n4a Testicular n4a
Burning n4a Total Shift ut+ut $ cu+s Breast self exa" n4a self9exa" n4a
,ncontinence Previous =0 hrs $ cu+s Use of n4a
2ayti"e n4a Catheter contrace+tives n4a
Nightti"e n4a ,nter"ittent n4a Ty+e n4a
Stress n4a ,ndwelling n4a Aaginal 2ischarge n4a
,ncontinence n4a Condo"9cath7 n4a 2escribe# n4a
ccasional n4a 2ialysis# n4a
ther
n4a -ccess Site n4a Bleeding# n4a
-"ount# n4a
Co""ents# n4a2evices# n4a
!elated 2x7 Studies (lab work x9rays etc# Urine culture 341041$ Negative for UT,7 No growth at Q1??? C/U4"'7 Na# 1>1 "*:4d' # >73
Cl# 1?5 BUN# 11 Creatinine# ?73
!elated NS) 2x# !isk for i"balanced fluid volu"e r4t he"atocrit =$7>; and sodiu" levels 1>1 "*:4'
Collaborative Care !eferral# n4a
DIET* 1?? calorie -2-
PU!PS*# to control the blood sugar and lose
weight or to lower the risk for heart +roble"s
!*ST!,CT,NS# carbohydrates fat and +rote
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M U S C U L O S + E L E T A L
.usculoskeletal /ull !.# n4a /unctional ,nde+endence .easure 'evels
Pain n4a Roint Stiffness n4a 'i"ited !.# n4a Total -ssist (sub6ect Q =$; effort n4a
Geakness n4a Cast n4a )ait# Steady ✓ .axi"al -ssist (sub6ect =$; effort M n4a
Contractures n4a -"+utation n4a Unsteady n4a .oderate -ssist (sub6ect $?; effort M n4a
Roint swelling n4a 2escribe n4a .obility in bed .ini"al -ssist (sub6ect 3$; effort M n4a
Paralysis n4a (able to turn self ✓ Su+ervision (stand9by assist verbal cues n4a
2efor"ity n4a .odified ,nde+endence (device needed n4a
Co"+lete inde+endence (ti"ely safety ✓
2evices# n4a
!elated 2x7 Studies (lab work x9rays etc7# n4a
Collaborative Care !eferral# n4a
!elated NS) 2x7# !isk for falls r4t "edication -*B +atient re+orted di&&iness after taking lora&e+a"
I N T E G U M E N T A R Y
Skin ,ntegrity# ,ndicate the location of any of the following on the chart to the right using the
designated letter#
n4a -7 rashes n4a *7 +ressure sores
✓ B7 lesions ✓ /7 recent scars
n4a C7 significant bruises 4 abrasions n4a )7 +resence of tubes 4 a++liances
n4a 27 burns n4a <7 other#
Pressure Sore Potential -ssess"entP-!-.*T*!S ? 1 = > Score
.ental Status -lter 'ethargic Se"i9Co"atose Co"atose ?
Count these conditions as doubleas 2UB'*
-ctivity -"bulatory Needs <el+ Chairfast Bedfast ?
.obility /ull 'i"ited Aery li"ited ,""obile ?
,ncontinence None ccasional Usually of
urine
Total of urine
and feces7
?
ral nutrition )ood /air Poor None ?
ral fluid intake )ood /air Poor None ?
Predis+osing
diseases
(diabetesneuro+athies
vascular
diseaseane"ias
-bsent Slight .oderate Severe 1
Patients with scores of 1? or above should beconsidered at risk7
TT-'
1
Skin Color# Skin Te"+erature# <x of skin
healing
n4a Teeth# GN' n4a
GN' ✓ GN' ✓ +roble"s# n4a ther describe "issing
Pale n4a Gar" n4a ther describe n4a teeths
Cyanotic n4a Cool n4a
-shen n4a Skin Turgor 2entures#
Raundice n4a Tight ✓ .outh# n4a U++er n4a
ther describe n4a 'oose n4a )u"s GN' ✓ 'ower# n4a
ther describe n4a Ghite Pla:ue n4a /ull# n4a
'esions n4a Partial# n4a
2evices#
!elated 2x7 Studies (lab work x9rays etc# n4a
!elated NS) 2x# !isk for infection r4t o+en lacerations on extre"ities -*B +atient touching and re"oving sutures with dirty hands7
Collaborative Care !eferral# n4a
C O M M E N T S n4a
n4a
n4a
n4a
C
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) S Y C , E M O T I O N S
.ental Status# Perce+tion -ffect <a++y ✓ ,ntellectual /unctioning
rientation Ti"e ✓ <allucination ✓ Sad ✓ -ble to Calculate n4a
Place ✓ 2elusion ✓ /lat ✓ -ble to -bstract n4a
Person ✓ ,llusion ✓ ther 2escribe Patient Rudg"ent n4a
Situation ✓ 2escribe# Patient verbali&ed is bi+olar !ational n4a
.e"ory of hearing voices7 n4a ,"+ulsive ✓,""ediate !ecall ✓ n4a n4a ,"+aired n4a
!ecent .e"ory n4a n4a n4a Suicidal E4N E
!e"ote .e"ory n4a n4a n4a Suicide !isk E4N E
2*A*'P.*NT-' ST-)* -CC!2,N) T *!,SN
Theoretically# Behaviorally# !ationale#
)enerativity vs7 stagnation Care Career and work are the "ost i"+ortantthings at this stage along with fa"ily7 .iddle
adulthood is also the ti"e wen +eo+le cantake on greater res+onsibilities and control7
.a6or Concerns !egarding <os+itali&ation 4 ,llness safety due to har" herself or others7
.a6or Change in 'ife in the Past Eear (Crisis 4 'oss 4 thers n4a
n4a
!elated 2x7 Studies (lab work x9rays etc7 n4aCollaborative Care !eferral# n4a
!elated NS)7 2x# Ris- for (iolence r/t !istory of %syc!otic sy$%to$"tolo.y "s ei&ence& 0y &istorte& t!in-in. t!"t ot!ers "re
tryin. to !"r$ !er
M I S C E L L A N E O U S
S'**P 4 !*ST P-TT*!N
<abits /eel !ested after Proble"s# None ✓ Use of Slee+
O hrs night $ Slee+# E4N E *arly Gaking n4a -ides# E4N N
-. Na+ E4N N Co""ent n4a ,nso"nia n4a 2escribe n4a
P. Na+ E4N N Night"ares n4a
!elated 2x7 Studies (lab work x9rays etc7 n4a
n4a
!elated NS) 2x# 2isturbed slee+ +attern r4t interru+tions -*B +atient states nurse was in her roo" every hour with a flashlight7
Collaborative Care !eferral# n4a
!'*S F !*'-T,NS<,P 4 <.* .-,NT*N-NC* P-TT*!N
ccu+ation Su++ort Syste" Private Pay n4a /a"ily Concerns !egarding
Patient states S+ouse n4a ,nsurance n4a <os+itali&ation n4a
history of engage"ent Neighbor 4 /riend n4a .2C!4 .2C2 n4a n4a
of +rostitution /a"ily in Sa"e No nown n4a n4a
*"+loyed E4N N !esidence n4a !esidence n4a n4a
!etired N ther /a"7 .e"b7 n4a Patient 'ives w4 n4a n4a
2isability N None n4a
S+ecial Concerns# n4a
!elated NS) 2x# Social isolation r4t alteration in "ental status -*B absence of su++ortive significant other7
Collaborative Care !eferral# n4a
A-'U*9B*',*/ P-TT*!N
Co""ents# n4a
!eligious 4 S+iritual Beliefs# n4a
Patient re:uest to contact "inister 4 +riest 4 rabbi# yes ✓ no
Na"e# n4a Phone Nu"ber# n4a
!elated 2x7 Studies (lab work x9rays etc7 n4a
n4a
!elated NS) 2x7 S+iritual distress r4t life changes -*B +atient stated that she is a living sacrifice7
Collaborative Care !eferral# n4a
,ntended 2estination Proble"s with self care +ost discharge# ✓ yes no
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E D U C A T I O N N E E D S / D I S C
, A R G E ) L A N N I N G Post 2ischarge# ,f yes ex+lain# Patient is +sychotic and is not able to take care
<o"e n4a of self
Undeter"ined n4a n4a
other ✓ -ssistant devices needed +ost9discharge# yes ✓ no
*x+lain# Patient will return to 6ail ,f yes ex+lain# n4a
n4a
n4a
Previous Utili&ation of Co""unity !esources# !eferral 2ate to 2ischarge#
<o"e <ealth n4a Coordinator n4a
<os+ice n4a <o"e <ealth n4a
-dult 2ay Care n4a Social Service n4a
Church )rou+ n4a N7N7-7 n4a
.eals on Gheels n4a ther n4a
<o"e -ide n4a *x+lain# Tro+ical Texas Behavioral <ealth will fund a three day
ther ✓ stay in facility u+on +atient status7
*x+lain# Tro+ical Texas Behavioral <ealth n4a
n4a n4a
n4a n4a
ther Co""ents# n4a
n4an4a
n4a
*ducational Needs# n4a
Barriers# Past *x+erience# n4a
!eading -bility n4a n4a
Sensory Proble"s n4a n4a
Physical State n4a 'earning !eadiness# .entally i"+aired
'anguage n4a
ther ✓
*x+lain# Patient is not "entally stable7
Su++ort Syste"s to be involved# Patient does not have a
Present nowledge# -ware of the chronic illness and the fa"ily su++ort syste"7
+ossible outco"es7 n4a
n4a
Teaching Plan and *x+ected utco"e# .edications co"+liance7 Teach the +atient about the i"+ortance of taking "edication and
understanding na"e of "edications what is for and side effects7 Teach the +atient cognitive9behavioral activities such as active +roble"
solving7 Teach the client to drink +lenty of fluids and to consu"e >90gr of sodiu"7 Teach the client to notice sti"uli that increase anxiety7
Teach the client skills of cognitive restructuring7 Teach the client there are agencies for counseling and su++ort grou+s for follow u+
assistance7 Teach the client relaxation techni:ues to decrease anxiety7
Collaborative Care !eferral#n4a
!elated NS) 2x# nowledge deficit r4t "ental status -*B reoccurring +sychotic e+isodes7
Assess$ent
1 ite$s
Su02ectie
3/or
O02ectie
Desi.n"te it!
4S5 or 4O5
An"lysis
St"te$ent
NANDA 6 %"rt
Nursin.
Di".nosis rel"te&
to As Ei&ence
0y
STG
LTG
)l"n it! 0rief
r"tion"le for e"c! one
7 in&ii&u"l %l"ns
869 Assess$ent
869 "ctiity
869 "ction
Nu$0er t!e$:
Interentions
Correl"tes it!
%l"n
)ut !ere !"t
"s &one
Nu$0er t!e$:
E"lu"tion
;"s it nor$"l
or "0nor$"l
Correl"te it!
interentions
Nu$0er t!e$:
<' 4S5
4I feel "nxious5
=' 4S5
4I feel &i>>y5
6' 4S5
4I "$ not sic-5
?' 4S5
4T( soun&
$"-es $e
"nxious5
@' 4S5
4I &ont nee&
$e&ic"tion5
1' 4S5
4I re"lly trust
you "n& I feel I
c"n tell you
"nyt!in.5
An"lysis
St"te$ent*
#ec"use t!e
clients $e&ic"l
&i".nosis is
%syc!osis' T!e
client
ex%eriences
seere "nxiety
e%iso&es'
NANDA 6 %"rt
nursin.
&i".nosis*
Anxiety r/t
unconscious
conflict it!
re"lity AE#
i$%"ire&
"ttention'
STG*
#y t!e en& of
s!ift %"tient ill
0e "0le to
er0"li>e
tec!niBues to
re&uce "nxiety
LTG*
#y &isc!"r.e
%"tient ill
re%ort "
re&uction in t!e
leel of "nxiety
<' Assess t!e clients
"nxiety leel it! t!e
,"$ilton Anxiety
Sc"le'T!is is "n i$%ort"nt tool to
"ssess "nxiety'
=' Assess si&e effects of
"nti"nxiety
$e&ic"tion)"tient nee&s to 0e ""re of
t!e %ossi0le si&e effects of t!e
%rescri0e& $e&ic"tion'
6' Assess clients
""reness of current
!e"lt! %ro0le$'T!is ill !el% to %re%"re t!e
%l"n of c"re "n& to set t!e
s!ort ter$ "n& lon. ter$
.o"ls'
?' Te"c! t!e client
s-ills of co.nitie
restructurin.'
Client c"n le"rn to control"nxious feelin.s r"t!er t!"n
0e controlle& 0y t!e$'
@' Te"c! t!e necessity
of "&!erence to t!e
%rescri0e $e&ic"tion')"tients nee& to -no t!e
i$%ort"nce of continuin.
tre"t$ent'
1' Te"c! t!e client to
notice sti$uli t!"t
incre"se sense of
"nxiety'Anxiety tri..ers c"n 0e si$%le
t!in.s 0ut it is i$%ort"nt t!"tt!e client reco.ni>e& t!e$'
' I$%le$ent "
su%%ortie t!er"%y
%ro.r"$'Su%%ort .rou%s !el%s to
control sy$%to$s'
' A&$inister
Lor">e%"$ <$. B1!
"s %rescri0e&'#en>o&i">e%ine is %rescri0e&
to control "nxiety &isor&ers
7' )roi&e client it!
" $e"ns to listen to
$usic of t!eir c!oiceMusic !el%s to rel"x "n&
control "nxiety'
<' ("li&"te
o0ser"tions 0y
"s-in. t!e client*
4Are you feelin.
"nxious no
=' Monitore&
si&e effects*
&rosiness
&i>>iness
&isorient"tion
&e%ression "rrest
6' As-e& t!e
client if is ""re
of current !e"lt!
%ro0le$
?' @ $in te"c!in.
session of
0re"t!in.
rel"x"tion
tec!niBues
@' @ $in te"c!in.
session of
%rescri0e&
$e&ic"tion "n&
si&e effects'
1' I$%le$ente&
" @ $in te"c!in.
session of "nxiety
tri..ers'
' H7HH )"tient
"ssiste& to co%in.
.rou% session'
' HHH
Lor">e%"$ )O
.ien "s %er
%!ysici"ns or&ers
7' )"tient
en2oye& cl"ssic"l
$usic &urin.
0re"-f"st'
<' Client "s
not "nxious
8Nor$"l9
=' Client felt
&i>>iness in t!e
$ornin.
8"0nor$"l9
6' Client "s
not ""re of
current !e"lt!
%ro0le$'
8"0nor$"l9
?' Client
er0"li>e& "n&
&e$onstr"te "
0re"t!in.
rel"x"tion
tec!niBue
8nor$"l9
@' Client
er0"li>e& t!e
i$%ort"nce of
t"-in.
$e&ic"tions'
8nor$"l9
1' Client
er0"li>e&
"nxiety
tri..ers'
8nor$"l9
' Client
en2oye& co%in.
.rou% session'
8nor$"l9
' Client
toler"te
$e&ic"tion
ell' 8nor$"l9
7' Client st"te&
to feel rel"xe&
"n& no "nxiety
tri..ers'
8nor$"l9
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RET,IN+ RE)LAN REDO
T"-e t!e )l"n on %reious %".e it! r"tion"le "n& tell future nurses !"t nee&s to 0e &one
<' Assess t!e clients "nxiety leel it! t!e ,"$ilton Anxiety Sc"le' Nurse continues it! %l"n of c"re to "ssess t!e "nxi
leel of t!e %"tient
=' Assess si&e effects of "nti"nxiety' Nurse continues to "ssess t!e si&e effects of "nti "nxiety $e&ic"tion'
6' Assess clients ""reness of current !e"lt! %ro0le$' Nurse continues it! "ssess$ent until %"tient er0"li>es t!e
correct un&erst"n&in. of illness'
?' Te"c! t!e client s-ills of co.nitie restructurin.' Nurse continues it! t!e te"c!in. sessions 0ec"use client li-e& t!e
&yn"$ic'
@' Te"c! t!e necessity of "&!erence to t!e %rescri0e $e&ic"tion' Nurse continues it! t!e te"c!in. session until %"tient
&isc!"r.e'
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1' Te"c! t!e client to notice sti$uli t!"t incre"se sense of "nxiety' Nurse continues it! t!e te"c!in. session until %"tien
is &isc!"r.e'
' I$%le$ent " su%%ortie t!er"%y %ro.r"$' Nurse continues it! su%%ortie t!er"%y until %"tient is &isc!"r.e "n& c"
$"n".er s!oul& refer %"tient'
' A&$inister Lor">e%"$ <$. B1! "s %rescri0e&' Nurse continues it! %rescri0e& $e&ic"tion until or&er is c!"n.e&'
7' )roi&e client it! " $e"ns to listen to $usic of t!eir c!oice' Nurse continues it! "ctiity until c!"n.e of c"re %l"n
410
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Assess$ent
1 ite$s
Su02ectie
3/or
O02ectie
Desi.n"te it!
4S5 or 4O5
An"lysis St"te$ent
NANDA 6 %"rt Nursin.
Di".nosis rel"te& to As
Ei&ence 0y
STG
LTG
)l"n it! 0rief r"tion"le for e"c!
one
7 in&ii&u"l %l"ns
869 Assess$ent
869 "ctiity
869 "ction
Nu$0er t!e$:
Interentions
Correl"tes it! %l"n
)ut !ere !"t "s &on
Nu$0er t!e$:
17
Patient locked in facility forsafety
=7 Patient diagnosis falls on
-xis ,
>7
Notice +atient +unching the
wall7
07 S
Patient stated to want to
+unch cafeteria staff7
$7
Patient was verbally
aggressive by cursing staff
57
Patient was seen +acing in
the hallway
An"lysis* #ec"use t!e %"tient is
%syc!otic "n& loc-e& in f"cility
for s"fety'
NANDA 6 %"rt nursin.
&i".nosis*
Ris- for In2ury r/t i$%"ire&
t!ou.!t %rocess iolent out
0urst "n& %rolon.e&
!"llucin"tions AE# client in
loc-e& f"cility for s"fety'
STG* #y t!e en& of s!ift t!e
%"tient ill re$"in free of
in2ury
LTG* #y &isc!"r.e t!e %"tient
ill reco.ni>e 0e!"iors t!"t
%l"ce self in %otenti"lly
&"n.erous situ"tions
<' Assess 2u&.$ent re."r&in.
%otenti"lly &"n.erous "ctiities'
Poor judgment and decision-making skills put
the client at risk for injury
=' Assess for %!ysic"l or co.nitie
function "lter"tions t!"t $i.!t le"&
to uns"fe 0e!"iors'!isk taking hy+ersexuality and decreased
ability to concentrate to racing thoughts +lace
the client at risk for in6ury7
6' Assess for suici&"l i&e"tion2e+ression can be associated with suicidal
ideation7
?' Te"c! %"tient to follo u% it!
)C) referr"l to out%"tient sericessuc! "s Tro%ic"l #e!"ior"l ,e"lt!
Soci"l ;or-er'Patient needs to obtain ongoing su++ort
syste"s for successful treat"ent +lan7
@' Te"c! t!e client "0out 0e!"iors
"n& res%onses to eniron$ent"l
sti$uli t!"t $"y 0e !"r$ful' To hel+ client to deal with l ife9long illness7 To
be aware of stressors that "ay be har"ful7
1' Te"c! %"tient effectie co%in.
0e!"iors',nterventions beyond the acute +hase address
lifestyle "anage"ent with an illness that alters 6udg"ent7
' )l"ce t!e client in " roo$ "s
close "s %ossi0le to t!e nurses
st"tion',n order to have a clear visual of the client
' S%e"- in s!ort si$%le sentencesCo""unicate so that the client understands
within his or her attention s+an7
7' )roi&e " s"fe structure&
eniron$entThe !N controls the environ"ent in the locked
facility to +revent in6ury7
<' Assesse& 2u&.$ent re."r
%otenti"lly &"n.erous "cti
0y "s-in. %"tient !o s!e
re"ct in &ifferent &"n.erou
scen"rios'
=' Assesse& "ttention s%"n
"0ility to concentr"te "n&
feelin.s of .r"n&iosity 0y
interiein. t!e %"tient
6' As-e& t!e %"tient &irect
!"e you t!ou.!t "0out
!"r$in. yourself
?' <H $in te"c!in. sessionon t!e i$%ort"nce of follo
it! out%"tient serices "n
intro&ucin. %"tient to soci"
or-er'
@' <H $in te"c!in. session
!o to "oi& confront"tion
re&irectin. "ttention to t!e
roo$ $"int"inin. %!ysic"l
&ist"nce fro$ ne."tie stre
1' <H $in te"c!in. session
!o to &e"l it! " stressfu
situ"tion 0y &oin. rel"x"tio
tec!niBues li-e &ee% 0re"t!
exercises'' Moe& client to " roo$ n
to t!e nurses st"tion'
' #e c"reful not to $oe i
%erson"l s%"ce 0y re$"ini
6 feet ""y "n& s%e"-in. s
"n& sloly'
7' )roi&e& t!e client it!
enou.! %erson"l s%"ce so &
not &isru%t ot!ers it!
0e!"iors s!e c"nnot contr
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RET,IN+ RE)LAN REDO
T"-e t!e )l"n on %reious %".e it! r"tion"le "n& tell future nurses !"t nee&s to 0e &one
<' Re.istere& nurse "ssesse& 2u&.$ent re."r&in. %otenti"lly &"n.erous "ctiities 0y "s-in. %"tient !o s!e
re"ct in &ifferent &"n.erous scen"rios' RN continues it! "ssess$ent until &isc!"r.e'
=' Re.istere& nurse "ssesse& "ttention s%"n "0ility to concentr"te "n& feelin.s of .r"n&iosity 0y interiein
t!e %"tient' RN continues it! "ssess$ent until &isc!"r.e'
6' Re.istere& nurse "s-e& t!e %"tient &irectly "0out t!ou.!t of !"r$in. yourself RN continue to "ssess for
suici&"l i&e"tions until %"tient is free of in2ury "n& suici&e'
?' Re.istere& nurse t"u.!t <H $in of t!e i$%ort"nce of folloin. it! out%"tient serices "n& intro&ucin.
%"tient to soci"l or-er' Soci"l or-er continues it! c"re "n& c"se $"n".e$ent %le"se "ssist it! referr"l'
@' Re.istere& nurse t"u.!t <H $in on !o to "oi& confront"tions 0y re&irectin. "ttention to t!e roo$
$"int"inin. %!ysic"l &ist"nce fro$ ne."tie stressors' RN continues it! follo u%'
1' Re.istere& nurse t"u.!t <H $in on !o to &e"l it! " stressful situ"tion 0y &oin. rel"x"tion tec!niBues li-
&ee% 0re"t!in. exercises' RN continues it! co$%li"nce'
' Re.istere& nurse $oe& client to " roo$ next to t!e nurses st"tion' RN $"int"in %"tient ne"r to nurses
st"tion'
' Re.istere& nurse "s c"reful not to $oe into %erson"l s%"ce 0y re$"inin. =6 feet ""y "n& s%e"-in.
softly "n& sloly' RN continues it! %l"n of c"re'
7' Re.istere& nurse %roi&e& t!e client it! enou.! %erson"l s%"ce so &oes not &isru%t ot!ers it! 0e!"iors
!e c"nnot control' RN continues it! %l"n of c"re'
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Plan of Care Sheets
Assess$ent
1 ite$s
Su02ectie
3/or
O02ectie
Desi.n"te it!
4S5 or 4O5
NANDA 6 %"rt Nursin. Di".nosis
rel"te& to As Ei&ence 0y
STG
LTG
)l"n 8Interention it! 0rief
r"tion"le9 for e"c! one
7 in&ii&u"l %l"ns
869 Assess$ent
869 "ctiity
869 "ction
Nu$0er t!e$:
Interentions 8"ctu"lly %e
Correl"tes it! %l"
)ut !ere !"t "s &
Nu$0er t!e$:
<'
4S5 )t st"tes 4T!ey "re
tryin. to turn $e into "
c"t'5
='4S5 )t st"tes no0o&y
un&erst"n&s !er'
6'
4S5 )t er0"li>es
!e"rin. oices to 0e "
s"crife'
?'4O5 l"cer"tions on
0ot! loer extre$ities
@'
4O5 )t s!os !ostile
0e!"ior 8scre"$in.
"n& cussin. &on t!e
!"ll9
An"lysis* #ec"use t!e
%"tient er0"li>e& t!"t
ot!ers "re tryin. to !"r$
!er'
NANDA 6 %"rt nursin.&i".nosis*
Ris- for (iolence r/t !istory
of %syc!otic
sy$%to$"tolo.y "s
ei&ence& 0y &istorte&
t!in-in. t!"t ot!ers "re
tryin. to !"r$ !er
STG* #y t!e en& of $y s!ift
%"tient ill 0e s"fe "n& free
fro$ in2ury'
LTG* #y &isc!"r.e )t ill
&is%l"y noniolent 0e!"ior
to"r& self "n& ot!ers in
<' Assess eniron$ent e"lu"te
situ"tions t!"t coul& 0eco$e
iolent
R"tion"le*Stressful environments can cause for pt
to get aggravated.
=' Assess t!e client for
%!ysiolo.ic"l si.ns "n& extern"l
si.ns of "n.er' Rationale !nger signs may indicate a violent
outburst.
6' Assess for t!e %resence of
!"llucin"tions' Rationale
"ommand hallucinations may direct theclient to behave violently.
?' A&$inister "n& $onitor &ru.
re.i$en'!ationale#,dentify drug side or adverse effects that
"ay cause or exacerbate sensory or +erce+tual +roble"s7
@'T"-e "ction to $ini$i>e %erson"l
ris-* Use nont!re"tenin. 0o&y
l"n.u".e' M"int"in "t le"st "n
"r$s len.t! &ist"nce fro$ t!e
client &o not touc! t!e client
it!out %er$ission' Do not "llo
client to 0loc- "ccess to "n exit' #e
""re of !ere ot!er st"ff is "t "ll
ti$es' Rationale
Safety of client and others.
1'Coll"0or"te it! ot!er !e"lt!
<'Assesse& eniron$ent "
surroun&in.s 8%"tients "n
"ctiities "roun& t!e$9
=' Assesse& t!e %t for %!ys
si.ns "n& extern"l si.ns of
Intern"l si.ns of "n.er inc
incre"se& %ulse r"te res%i
r"te "n& 0loo& %ressure c%ric-ly sens"tions n"use"
erti.o' Extern"l si.ns inc
incre"se $uscle tone c!"n
0o&y te$%er"ture eye c!"
li%s %resse& to.et!er flus!
%"llor .oose0u$%s titc!
se"tin.
6'Assesse& %"tient for %res
!"llucin"tions oer 0re"-f
?'A&$inistere&
Lit!iu$ 6HH $. B!
SeroBuel 6HH$. "t 0e&ti$
@' Too- "ction to $ini$i>e
%erson"l ris- 0y folloin.
"n& $"int"inin. "r$ len.&ist"nce fro$ client "n&
surroun&e& 0y st"ff "t "ll
1' Coll"0or"te it! st"ff to
encour".e %"tient to "ssist
' T"u.!t %"tient i$%ort"n
folloin. &ru. re.i$en "
"&erse effects of Lit!iu$'
"tc! for 0lurre& ision i
urin"tion &i"rr!e" o$it
tre$ors' M"&e cle"r t!e
i$%ort"nce of flui& int"-e
%er &"y9 "n& t!e i$%ort"n
so&u$ int"-e 86? ./&"y9'
' T"u.!t %"tient co.nitie
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1'
4O5 )T $e&ic"l !istory
s!o %"st of su0st"nce
"0use
t!e it! t!e "i& of
$e&ic"tions "n& nursin.
interentions 0y s!oin. no
si.ns of iolence'
te"$ $e$0ers in %roi&in.
t!er"%y "n sti$ul"tin. $o&"lities Rationale
#o achieve ma$imal gains tin functionand psychosocial well-being.
' Te"c! %"tient "0out $e&ic"tions
"ctions si&e effects t"r.et
sy$%to$s "n& toxic re"ctions' Rationale
#o avoid harmful interactions and%ordrug to$icity.
'Te"c! %"tient co.nitie
0e!"ior"l "ctiities Te"c! client
to confront on ne."tie t!ou.!t
%"tterns or unre"listic
ex%ect"tions' Rationale"ognitive-behavioral activities address
client&s assumptions, beliefs an attitudes
about their situations fosteringmodification of these elements to be as
realistic as possible, becoming more
aware of their cognitive choices ande$ercising greater control over their own
reactions.
7'Te"c! "n& encour".e t!e use of
"%%ro%ri"te e$er.ency co$$unity
resources' Rationale 't is necessary to get immediate help
when violence occurs .
0e!"ior"l "ctiities suc!
%ro0le$solin. "n& t!ou
sto%%in. to confront on n
t!ou.!t %"tterns'
7' Instructe& %"tient to con
Tro%ic"l !e"lt! or 7<< in
"n e$er.ency !en s!e fe
or stresse&'
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RETHINK, REPLAN, REDO
Take the Plan on previous pae !ith rationale an" tell future nurses !hat nee"s t
#e "one
<' Nurse continues to "ssess eniron$ent e"lu"te situ"tions t!"t coul& 0eco$e iolent
=' Nurse continues to "ssess t!e client for %!ysiolo.ic"l si.ns "n& extern"l si.ns of "n.er'
6' Nurse continues to "ssess for t!e %resence of !"llucin"tions
?' Nurse continues to A&$inister "n& $onitor &ru. re.i$en 8Lit!iu$ 6HH $. B! SeroBuel 6HH$. "t 0e&ti$
@' Nurse continues to t"-e "ction to $ini$i>e %erson"l ris-* Use nont!re"tenin. 0o&y l"n.u".e' M"int"in "t
le"st "n "r$s len.t! &ist"nce fro$ t!e client &o not touc! t!e client it!out %er$ission' Do not "llo client0loc- "ccess to "n exit' #e ""re of !ere ot!er st"ff is "t "ll ti$es'
1' Nurse continues to coll"0or"te it! ot!er !e"lt! te"$ $e$0ers in %roi&in. t!er"%y "n sti$ul"tin.
$o&"lities
' Nurse continues to te"c! %"tient "0out $e&ic"tions "ctions si&e effects t"r.et sy$%to$s "n& toxic
re"ctions'
' Nurse continues to te"c! %"tient co.nitie0e!"ior"l "ctiities Te"c! client to confront on ne."tie
t!ou.!t %"tterns or unre"listic ex%ect"tions'
7' Nurse continues to te"c! "n& encour".e t!e use of "%%ro%ri"te e$er.ency co$$unity resources'
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8/14
Assess$ent
1 ite$s
Su02ectie
3/or
O02ectie
Desi.n"te it!
4S5 or 4O5
NANDA 6 %"rt Nursin. Di".nosis
rel"te& to As Ei&ence 0y
STG
LTG
)l"n 8Interention it! 0rief r"tion"le9
for e"c! one
7 in&ii&u"l %l"ns
869 Assess$ent
869 "ctiity
869 "ction
Nu$0er t!e$:
Interentions 8"ctu"lly %erfo
Correl"tes it! %l"n
)ut !ere !"t "s &on
Nu$0er t!e$:
<' 4S5 )t yiel&s 4S"crifice isnee&e&5
=' 4O5 Multi%le l"cer"tion to
0il"ter"l rists "n& t!i.!s'
6' 4S5 )t yiel&s
4 I nee& to 0e Crucifie&5
?' 4O5 ,istory of %reious
suici&e "tte$%t
@' 4S5 )t st"tes
4I is! I ere &e"&5
1' 4O5 )syc!i"tric
illness/&isor&er' De%ression
Sc!i>o%!reni"
NANDA 6 %"rt nursin.&i".nosis*
Ris- for Suici&e r/t
sc!i>o%!reni" "fter
&e%ression "s ei&ence 0y
%reious "tte$%t to suici&e'
STG* #y t!e en& of $y s!ift
%"tient ill re$"in s"fe "n&
un!"r$e&'
LTG* #y &isc!"r.e )t ill
continue .rou% interentionst!"t c"n 0e useful to "&&ress
recurrent suici&e "tte$%ts''
<' Assess Ms' S'A' t!e "0ility toenter into " nosuici&e contr"ct'
Rational (iscussing feelings of self-harm
with a trusted person provides relief for the
client. ! contract gets the subject out in the
open and places some of the responsibility for
safety with the client.
=' Con&uct " t!orou.! %!ysic"l
"ssess$ent focusin. in
inte.u$ent"ry syste$' Rational )ew lacerations may indicatecontinue to self-mutilation and access to sharp
object.
6 . Assess for t!e influence of
cultur"l 0eliefs nor$s "n& "lues
on Ms' S'A's %erce%tions ofsuici&e'
Rational *hat the individual believes about
suicide may be based on cultural perceptions.
?' O0sere recor& "n& re%ort "ny
c!"n.es in $oo& or 0e!"ior t!"t
$"y si.nify incre"sin. suici&e ris-
"n& &ocu$ent results of re.ul"r
sureill"nce c!ec-s' Rational Suicidal ideation often is not
continuous+ it may decrease, then increase in
response to negative thinking or e$posure to
stressors.
@' Encour".e %"tient to
&e$onstr"te c"re to !erself @c!il&ren "n& sister' Rational #he familial characteristics of care
and support may be associated fosteringresiliency in families. Resilience is the ability
to e$perience adverse conditions and
successfully overcome them "alvert, /0.
1' Refer for !o$e$"-er or
%syc!i"tric !o$e !e"lt! c"re
serices for res%ite client
re"ssur"nce "n& i$%le$ent"tion
of " t!er"%eutic re.i$en' Rational #he (epression "are for Patients at 1ome (epression "!R2P!#10 program
provided assistance for medical and surgical
homebound clients as a routine part of clinical
<' If %ossi0le &urin. "&$ior !en r"%tor !"s 0een
st"0lis!e& it! %"tient "
suici&e contr"ct !"s to 0e
=' Durin. "&$ission " %!y
"ssess$ent !"s to 0e %erfo
est"0lis! " &"t" 0"se for
%ossi0le future selfin2urie
)!ysic"l "ssess$ent to 0e
tice " &"y "t *HH !rs "n&
=H*HH !rs'
6' Assess$ent of cultur"l0eliefs nor$s "n& "lues
s!oul& 0e %erfor$e& once
"t <6*HH "fter lunc! to i&e
uniBue cultur"l res%onses
stressors in &eter$inin.
sensitie interentions to
%reent suici&e'
?' Assess$ent for "ny c!"n
in $oo& or 0e!"ior "t *H
eery 6H $inutes to < !our
!ic! $"y si.nify incre"s
suici&e ris-'
@' To&"y "t H7*HH %"tient
consulte& t!e )!ycolo.ist
%"tient !"s 0een %roi&e&
encour".e$ent to selfc"r
!"s 0een %roi&e& "ccess t
f"orite %erfu$e "n& it !"
0een encour".e to see- !e
fro$ !er @ c!il&ren "n& si
for $or"l su%%ort'
1' #efore %"tient is &isc!"
!o$e %roi&e !o$e c"re
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practice 3ruce et al, 450
' Te"c! co.nitie0e!"ior"l
"ctiities suc! "s "ctie %ro0le$
solin. refr"$in. 8re"%%r"isin.
t!e situ"tion fro$ " &ifferent
%ers%ectie9 or t!ou.!t sto%%in.
8in res%onse to " ne."tie t!ou.!t%icturin. " l"r.e sto% si.n "n&
re%l"cin. t!e i$".e it! "
%re"rr"n.e& %ositie "ltern"tie9'
Te"c! t!e client to confront !is or
!er on ne."tie t!ou.!t %"tterns
8or co.nitie &istortions9 suc! "s
c"t"stro%!i>in. 8ex%ectin. t!e ery
orst9 &ic!oto$ous t!in-in.
8%erceiin. eents in only one of
to o%%osite c"te.ories9 or
$".nific"tion 8%l"cin. &istorte&
e$%!"sis on " sin.le eent9' Rational "ognitive-behavioral activities
address client&s assumptions, beliefs, andattitudes about their situations and foster
modification of these elements to be asrealistic and optimistic as possible.
' )roi&e t!e client it! %!one
nu$0ers of "%%ro%ri"te
co$$unity ".encies for t!er"%y
"n& counselin.' NAMI is "n
excellent resource for client "n&
f"$ily su%%ort' Rational "ontinuous follow-up care should beimplemented+ therefore, the method to access
this care must be given to the client Sun 6
7ong, 45580
7' Te"c! t!e %"tient !o to
reco.ni>e t!"t t!e client is "tincre"se& ris- for suici&e 8c!"n.es
in 0e!"ior "n& er0"l "n&
noner0"l co$$unic"tion
it!&r""l &e%ression or su&&en
liftin. of &e%ression9' Rational ! client may be at peace because a
suicide plan has been made and the client has
the energy to carry it out. #herefore, whendepression lifts, increased vigilance is
necessary Sun 6 7ong, 45580.
<H' A&$inister Ine." Sustenn"
8)"ll"%eri&one9 1 $. once " &"y
for tre"t$ent of sc!i>o"ffectie
&isor&er' Rational !ntipsychotic, !ction 9ay act by
antagonizing dopamine and serotoninin the
")S. Paliperidone is the active metabolite ofrisperidone.
"ssist"nce "s %"tient %refe
co$%"ny'
' At 7*HH !rs <?*HH !rs "
0efore 0e& <7*HH !rs it !"
continue it! te"c!in. Ms
co.nitie0e!"ior"l "cti
it! ill continue incre"sit! %ositie "n& o%ti$ist
"ttitu&e'
' #efore %"tient is 0een
&isc!"r.e !o$e it !"s 0ee
%roi&e& t!e %"tient it!
NAMI Rio Gr"n&e ("lley
8N"tion"l Alli"nce on Men
Illness9 su%%ort .rou% %!o
nu$0er 87@19 1=??71H'
7' Durin. te"$ conference
$eetin. to&"y "t <6*HH !r
client it !"s 0een %roi&e
te"c!in. on !o to reco.n
ris- for suici&e 0e!"iors'
<H' 1 $illi.r"$s of
)"li"%eri&one !"s 0een
"&$inistere& "t H*HH !rs
0re"-f"st once " &"y ee
&"y'
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RETHINK, REPLAN, REDO
Take the Plan on previous pae !ith rationale an" tell future nurses !hat nee"s t
#e "one
<' A nosuici&e contr"ct !"s 0een si.ne& 0y %"tient !ic! is -e%t in " secure %l"ce Re.istere& Nurse !"e e"
"ccess to contr"ct "s nee& it if Ms' S'A' 0eco$es suici&"l'
=' Re.istere& Nurse nee&s to continue it! %!ysic"l "ssess$ent tice " &"y "t H*HH "n& =H*HH "n& )"tient
C"re Tec!nici"n nee&s to re%ort "ny ne in2uries to Re.istere& Nurse if ne in2uries "%%e"r 0eteen
Re.istere& Nurse Assess$ents'
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6' Re.istere& Nurse nee&s to continue it! "ssess$ent of cultur"l 0eliefs nor$s "n& "lues once " &"y "t
<6*HH to o0t"in " 0etter un&erst"n&in. on %"tients %erce%tions of suici&e'
?' )"tient C"re Tec!nici"n nee&s to const"ntly "ssess for "ny c!"n.es in Ms' S'A' $oo& or 0e!"ior st"rtin.
fro$ H*HH t!e ti$e t!e %"tients "-es u% on freBuency of eery 6H $inutes to "n !our "n& %roi&e results t
Re.istere& Nurse'
@' Re.istere& Nurse "n& )!ycolo.ist s!oul& continue to encour".e to c"re to !erself !er c!il&ren "n& sister
it! t!e .o"l to cre"te " %ositie 0o&in. for f"ster %syc!olo.ic recu%er"tion'
1' Referr"l !"s 0een $"&e to %syc!i"tric !o$e !e"lt! Soci"l or-er ill -ee% follou% t!ree &"ys "fter
&isc!"r.e for %"tient co$%li"nce'
' )syc!i"tric Nurse continue it! co.nitie0e!"ior"l "ctiities &"ily "n& continue incre"sin. t!e leel "s
)syc!i"trics or&ers'
' Re.istere& Nurse "n& Soci"l or-er 0efore MS' S'A' is &isc!"r.e& !o$e %le"se re"ssure t!"t t!e %"tient !
t!e nu$0er for NAMI Rio Gr"n&e ("lley su%%ort .rou% 7@11=??71H'
7' )syc!i"tric Nurse %le"se reie te"c!in. it! Ms' S'A' "0out !o to reco.ni>e if s!e 0eco$es "t ris- for
suici&e "lso %roi&e t!is infor$"tion in ritin.'
<H' As %er )syc!i"trist $e&icine %rescri%tion continue it! )"li"%eri&one 1 $. 0y $out! &"ily' )"li"%eri&o
1$. %o B& J6H K = refills %rescri%tion !"s 0een sent to ;"l.reens FM H=' Me&ic"tion ill 0e re"&y to %ic- u
on H/=7/=H<@'