Mental Health Care Plan
I need a care plan for the mental health patient in this video
- Review Care plan patient: https://de.ryerson.ca/games/nursing/hospital/area.html#2
Enclosed is an example of a care plan and a blank care plan template
Name: EXAMPLE Date: Client (INITALS ONLY) Room #
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DIAGNOSIS: |
R/T |
AEB: · |
PREVENTIONS (Level):
1.
2.
3.
4.
5.
6.
RATIONALE
1.
2.
3.
4.
5.
6.
OUTCOMES/GOALS
1.
2.
3.
4.
5.
6.
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EVALUATION AND REVISIONS: |
DIAGNOSIS:
R/T
AEB:
·
PREVENTIONS (Level):
7.
8.
9.
10.
11.
12.
7.
8.
9.
10.
11.
12.
7.
8.
9.
10.
11.
12.
EVALUATION AND REVISIONS:
DIAGNOSIS:
R/T
AEB:
·
|
PREVENTIONS (Level):
13. 14. 15. 16. 17. 18. |
RATIONALE 13. 14. 15. 16. 17. 18. |
OUTCOMES/GOALS 13. 14. 15. 16. 17. 18. |
EVALUATION AND REVISIONS:
DIAGNOSIS:
R/T
AEB:
·
|
PREVENTIONS (Level):
19. 20. 21. 22. 23. 24. |
RATIONALE 19. 20. 21. 22. 23. 24. |
OUTCOMES/GOALS 19. 20. 21. 22. 23. 24. |
EVALUATION AND REVISIONS:
DIAGNOSIS:
R/T
AEB:
·
|
PREVENTIONS (Level):
25. 26. 27. 28. 29. 30. |
RATIONALE 25. 26. 27. 28. 29. 30. |
OUTCOMES/GOALS 25. 26. 27. 28. 29. 30. |
EVALUATION AND REVISIONS:
Potential, actual, and wellness diagnoses (ATLEAST 10)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
References
Name: EXAMPLE Date: September 30th, 2015 Client: J. B Room #: 2
NORMAL LINE OF DEFENSE/REQUIRED DATA STRESSORS (TYPE) RESPONSES TO STRESSORS
· J.B is a 68 year-old male patient.
· He lives with his wife in Wauwatosa, Wisconsin and is well known to Froedtert hospital he was admitted for PAD, PVD 09/16/2015.
· J.B has a past medical history of: erectile dysfunction, inguinal hernia, coronary artery disease, hypercalcemia, pedal edema, colonic polyps, carpal tunnel syndrome, stasis edema, normocytic anemia, atherosclerosis, atrial fibrillation, atherosclerosis, obstruction sleep apnea, carotid disease, chronic kidney disease, anemia and pulmonary hypertension.
· He also has a surgical history of left and right leg bypass and 2nd toe amputation.
· He has no known allergies and is a full code.
· He believes in God and he sometimes attends church at assembly of God.
· His father died of lung cancer and his mom died due to emphysema.
· He is married and have six children, two girls and four boys.
· He is on a carbohydrate consistent diet and fluid restriction of 2000mL.
· The patient is bed rest with bathroom privileges to prevent further trauma to his infected wound.
· Pt has difficulty having a bowel movement. At home he usually has a BM 3 times a week and uses medications daily to help him have a bowel movement,
· He is frustrated that he cannot do the things he used to do such as go to family events, church, exercise and walk independently.
· The patient currently walks with a walker and one assistant.
· Pt states health, “is able to feel good and carry on with normal activities”. Pt states he is not healthy because, “I do not have enough blood flow in my legs”.
· V.S: Temp: 98.0 HR:62 RR:17 BP:130/62 02: 98 % on room air
· Pt used to run every morning prior to being in the hospital July 2014.
· Leisure activities: works as a lawyer
· Pt states his sleep, rest, relaxation is not normal and he does not have enough energy
· Pt uses CPAP machine nightly.
· Pt states his his image is so-so and he has a general sense of worth.
· Pt states is unable to have sexual activity due to erticle dysfunction.
· Pt does not have the ability to cope, he uses drugs to cope
1. Physiological
1A J.B. is uncomfortable when he stands and tries to ambulate for long periods of time due pain in his legs
1B. It is difficult for J.B to move around because of all of the drains and IV lines.
2. Psychological
2A. “My health status makes me depressed and I feel that my body is declining” J.B feels that he is not getting healthy and it is taking an emotional toll on his body.
2B. “I feel really depressed and lonely at the hospital”
3. Sociocultural
3A. He misses out on social interaction and working.
3B. At risk for loss of independence
4. Developmental
4A. “I feel dependent on others; I can’t do the things I used to do.”
4B. “It is difficult for me to do my daily AM cares and toilet”.
5. Spiritual
5A. He has the potential for spiritual distress
5B. He has the potential to lack purpose and meaning in life.
1. Physiological
1A. J.B complains of the soreness in his incision sites
1B. J.B has multiple JP drains and IV infusing.
2. Psychological
2A. “I am not healthy”
2B. “My wife works too much.”
3. Sociocultural
3A. J.B does not get to do many activities that he once was able to do.
3B. He may not be able to go back home due his wife having difficulty handling his mobility and care.
4. Developmental
4A. J.B needs help with a lot of personal cares
4B. It is getting harder for him to bend with age
5. Spiritual
5A. “I haven’t been to church in months
Due to my legs”
5B. “My kids do not want anything to do with me”
DIAGNOSIS:
Ineffective coping
R/T
· Inadequate coping skills
· Inadequate level of confidence inability to cope
· Inadequate resources available
AEB:
· Substance abuse
· Low self-esteem
Interventions
1. The nurse will observe for contributing factors of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, recent change in life situation, or gender differences in coping strategies.
2. The nurse will use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client and family to express emotions such as sadness, guilt, and anger; verbalize fears and concerns; and set goals.
3. The nurse will encourage the client to describe previous stressor and the coping mechanisms used.
1. “ Ineffective coping strategies such as disengagement with others have been found to be predictors of greater distress in a sample (Desbiens & Fillion, 2007).”
2. “Clinicians communication skills contribute to well-being of clients and minimizes psychosocial problems (Duff et al, 2009).”
3. “A psychoeducational intervention that included the clients identification of symptoms, types of coping strategies used before and after the event, and ways to select alternative strategies was accompanied by mediation intervention statistically significantly improved PTSD and depression (Oflaz, Haitpoglu, & Ayan, 2008).”
4. “The supportive relationship the nurse has with the clien may be essential to individuals coping with a threatening process (Giske & Gjengedal, 2007).”
OUTCOMES/GOALS (always have a date)
1. Patient will be not exhibit signs of behavioral problems during shift of care.
2. Patient will participate in group one group activity once per shift.
3. Patient will express feelings associated with substance abuse as a coping with stress.
4. Patient will verbalize adapt coping mechanism used.
5. Patient will verbalize concerns of harming self.
Patient will be honest with self, staff, and family members about feelings of sadness or hurt.
EVALUATION AND REVISIONS:
The patient was able to meet majority of the goal. Patient did participate in group activity with the student nurses. He tried to participate in group but left early due to fatigue. He patient understands mediation use and its side effects and is willing to take Geodon. Patient is still reluctant to take Haldol but is considering it. Patient verbalized the need for help with substance abuse of THC and would like more information regarding it. Overall the goals were met and patient seems to be improving.
DIAGNOSIS:
Activity intolerance
R/T
Imbalance between peripheral oxygen supply and demand
Congestive heart failure
AEB:
· Abnormal blood pressure response to activity
· Exertion dyspnea
· Verbal report of fatigue
· Verbal report of weakness
Interventions
1. Allow for periods of rest before and after planned exertion periods such as meals, bath, treatment, and physical activity.
2. If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an up right position several times daily if possible.
3. If the client is able to walk and has heat failure, consider use of the 6-minute heart failure test to determine physical ability
4. When the client is up observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, impaired consciousness, as well as changes in vital signs.
5. Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. If present refer to physical therapy.
RATIONALE
1. “Both physical and emotional rest help lower arterial pressure and reduce the workload of the myocardium” (Fauci et al, 2011).
2. “Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake and increased resting heart rate” (fauci et al, 2011).
3. The 6-minute walk test is a safe, simple exercise test that predicts functional capacity (Du et al, 2010).
4. When an adult rise to the standing position about 350- 800mL of blood pools in the lower extremities. As a results hypoperfusion may occur, including feelings of weakness, nausea, headache, lightheadedness, dizziness, blurred vision, and fatigue. (Bradley & Davis, 2012).
5. Fear of falling and repeat falling is common in the elderly. Balance rehabilitation provides individualized treatment for person with various deficits (Ebell, 2010).
OUTCOMES/GOALS (always has a date)
1. The client will demonstrate increased tolerance to activity by end of shift 09/30/2015.
2. The client will participate in prescribed physical activity by lunch time 09/30/2015.
3. The client will complete the 6-minute walk test by end of shift 09/30/2015.
4. The client will state the symptoms and adverse effects of exercise and report onset of symptoms immediately by end of shift 09/30/2015.
EVALUATION AND REVISIONS:
The patient was able to demonstrate increased tolerance to activity by end of shift verbally. The patient participated in prescribed physical activity at 10:00 AM. The patient tolerated physical therapy well and will continue the prescribed regimen. The client was not able to complete the 6-minute walk test with physical therapy on my shift, but it completed prior to me taking care of this patient. Maybe this can be done again to see if there is any improvement. The patient was able to states the symptoms of adverse effects and reported if he had any other changes or felt different. All other goals were met by my client in the stated time frame.
DIAGNOSIS:
Impaired mobility
R/T
Chronic limb ischemic and Post-surgical patient
AEB:
· Inability to move purposefully within physical environment, including bed mobility, transfers and ambulation.
Intervention
1. The nurse will perform range of motion exercises at least twice a day unless contraindicated; repeat each maneuver three times.
2. The nurse will obtain any assistive devices needed for activity, such as gait belt, walker and scooter
3. The nurse will achieve mobility by having the P.G. start walking with a walker as soon as possible.
4. The nurse will consult with physical therapy for sit to stand exercises, strength training, gait training and a development of mobility plan.
RATIONALE
1. “Inactivity rapidly contributes to muscle shortening and changes in joint structure” (Fletcher, 2015).
2. Assistive devices can help increase mobility (Yeom, Keller & Fleury, 2011)
3. “Early ambulation improves level of independence with assistive devices” (Radawiec et al, 2010). “Early ambulation for acute limb injuries generally resulted in improved function, less plan and earlier return to work” (Ebell, 2005).
4. “Functional decline from associated deconditioning is common in elderly, and acute impatient rehabilitation can be effective in preventing immobility and activity intolerance (Yeom, Keller, &Fleury, 2011).
OUTCOMES/GOALS (always have dates)
1. The patient will verbalize the feeling of increased strength and ability to move by discharge.
2. The patent will use assistive devices demonstrate the use of adaptive equipment when ambulating from chair to bed by the end of the shift.
3. The patient will walk around the unit one time by the end of shift.
4. The patient will increase muscle strengthening activities with physical therapy by discharge.
EVALUATION AND REVISIONS:
The patient was able to demonstrate increased tolerance to activity by end of shift verbally. The patient participated in prescribed physical activity at 10:00 AM. The patient tolerated physical therapy well and will continue the prescribed regimen. The client was not able to complete the 6-minute walk test with physical therapy on my shift, but it completed prior to me taking care of this patient. Maybe this can be done again to see if there is any improvement. The patient was able to states the symptoms of adverse effects and reported if he had any other changes or felt different. All other goals were met by my client in the stated time frame.
References
Bradley JG, Davis KA: Orthostatic hypertension, Am Fam Physician 68 (12): 283-289, 2012.
Du H, Newton PJ, Salamonson Y et al: A review of the six-minute walk test: its implication as a self administered assessment tool, Eur J Cardiovasc Nurs 8 (1): 2-8,2010.
Ebell M: Early mobilization better for acute limb injuries, Am Family Physician 71 (4): 776, 2010
Fauci A, Braunwalk E, Kasper DL et al: Harrison’s principles of internal medicine, ed 17, New York, 2011, McGraw-Hill.
Fletcher K: Immobility; geriatric self- learning module, Medsurg Nurs 14(1):35, 2015
Radawiec SM, Howe C, Gonzalez CM et al: Safe ambulation of an orthopedic patient, Orthop Nurs 28(2):24-27, 2010
Yeom HA, Keller C, Fleury J: Interventions for promoting mobility in community- dwelling older adults, I am Acad Nurse Prac 21 (2): 95-100, 2011
Potential, actual, and wellness diagnoses
1. Activity intolerance related to poor blood flow to lower extremities
2. Ineffective health maintenance r/t to smoking and lack of information about disease management
3. Risk for impaired skin integrity r/t to ischemic tissues of legs and feet
4. Risk for peripheral neurovascular dysfunction r/t impaired peripheral blood flow to lower extremities
5. Activity intolerance r/ t imbalance between peripheral oxygen supply and demand aeb dyspnea with activity, abnormal blood pressure response
6. Ineffective Health maintenance r/ t deficient knowledge regarding self- care and treatment of disease
7. Chronic Pain: intermittent claudication r/ t ischemia aeb patient states he is in pain
8. Ineffective peripheral tissue Perfusion r/ t disease process
9. Risk for Falls r/t altered mobility
10. Risk for Injury r/t tissue hypoxia, altered mobility, altered sensation
11. Risk for Peripheral neurovascular dysfunction r/t possible vascular obstruction
12. Risk for impaired Skin integrity r/t altered circulation or sensation
13. Readiness for enhanced Self Health management r/t self- care and treatment of disease
14. Ineffective tissue perfusion r/t obstructed blood flow in peripheral arteries aeb pulses that are not palpable in lower extremities, patient history of intermittent claudication, decreased sensation perception in patient’s feet
15. Impaired mobility r/t chronic limb ischemia aeb Inability to move purposefully within physical environment, including bed mobility, transfers and ambulation.