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Nursing Care Plan 1 risk for violence, self directed

Nursing Care Plan 1 risk for violence, self directed



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Published by dbryant0101
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Published by: dbryant0101 on Dec 08, 2008
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Case Scenario # 7Psychiatric Nursing CareINSTRUCTIONS
: For this case scenario, you will develop a Nursing Care Planusing SNL, the Standardized Nursing Languages ofNANDA,NOCandNIC(NNN). You will be completing the blank care plan that accompanies this scenario.
J.S. is a 19 year old college freshman, who was referred from the emergencyroom following an overdose of approximately 40 acetaminophen extra strength.He was cleared medically. He had been in outpatient counseling once a weeksince an initial overdose six months ago. Last night the patient was caught shoplifting and was charged with a crime, and now he has a court date pending. Hewas released to his family.
Shortly after his return home he ingested the tablets. He did not tell anyoneuntil he was discovered to be vomiting profusely and taken to the emergencyroom by his mother. He told the physician that when he took them he wanted todie. His mood and affect are depressed and blunted. He states his appetiteand sleep have been poor and he believes he has lost 10 pounds over the lastmonth. He is anhedonic and his grades are dropping due to inability toconcentrate. He is unable to describe any reason for this. He has thought ofsuicide in spite of intervention.
There is no evidence of psychosis or a thought disorder.
Functional Health Patterns
Nursing assessment data is organized inFunctional Health Patterns. FunctionalHealth Patterns can help direct the choice of Nursing Diagnoses. The elevenfunctional health patterns are
Health Perception-Health Management; Cognitive-Perceptual; Nutritional-Metabolic; Elimination; Activity-ExerciseSleep/Rest; Self-Perception/Self-Concept; Role/Relationship; Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief 
TheFunctional Health Patternthat is most relevant for J.S. is: 
Step 1. Choosing the Nursing Diagnosis (es)The following nursing diagnoses are appropriate for J.S In practice, you mayselect additional nursing diagnoses.Nursing Diagnosis:
Risk for violence, self-directed
Behaviors in which an individual demonstrates thathe/she can be physically, emotionally, or sexuallyharmful to self. 
Risk Factors:
Age 15- 19, single, mental health (severedepression
emotional status, suicidal ideation
Nursing Diagnosis: Ineffective individual copingDefinition: 
Inability to form a valid appraisal of the stressors,inadequate choices of practiced responses, and/orinability to use available resources
Defining Characteristics:
Lack of goal-directed behavior/resolution ofproblem including: sleep disturbance, abuse ofchemicals agents. Decreased use of social support;poor concentration, inadequate problem solving.
 Nursing Diagnosis: Altered nutrition, less than body requirementsDefinition
: The state in which an individual is experiencing anintake of nutrients insufficient to meet metabolicneeds. 
Defining Characteristics:
lack of interest in food 
Related Factors:
inability to ingest food due to psychologicalfactors
While all of these nursing diagnoses are appropriate, for purposes of thisexercise, let’s use
Risk for violence, self-directed
On the nursing care plan form, write in the nursing diagnosis, and check therisk factors (etiology) for J.S.
Step 2. Choosing the Nursing Outcomes (NOCs)
The next step is to select nursing outcomes that can best affect thisnursing diagnosis.
Listed below are two appropriate nursing outcomes for J.S.Nursing OutcomesSuicide Self-restraint
Seeks help when feeling self-destructive
Verbalizes control of impulses
Refrains from gathering means for suicide
Does not require treatment for suicide gestures or attempts.
Upholds suicide contract
Mood Equilibrium Indicators:
Exhibits impulse control
Reports adequate sleep
Exhibits concentration
Reports normal appetite
Absence of suicide ideation
Shows interest in surroundings
Select one of the above listednursing outcomesfor this care planexercise, go to the nursing care plan and check the indicators that youthink will best measure your patient’s progress towards the outcome that your have chosen.
You will need to
your patient’s current status for each indicator.
Now that you have chosen your outcome for J.S., you will need to selectthe interventions that will best meet this outcome.

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