WORKING PLAN OF CARE

Subjective Findings: Client verbalizes her life is worth living, and is grateful that she knew when to seek help.
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Legal Status:__VOL___________ Age___61_______ Sex___F___ Employment Status__Unemployed_______________
DSM-5 Diagnosis

Current Stressors/Reason For Hospitalization

Bipolar

Severe Depression Apathetic dont care about anything anymore

AssessmentTools Utilized

RelevantMedications

1. Physical Assessment
2.
3.
4.
5.

1. Lamotrigine (mood
stabilizer/anti-convulsent)
2. Clonazepam (Klonopin)
3. Trazadone
4. Prozac
5.

CulturalNeeds

1.NURSINGDIAGNOSIS R/TAEB Readiness for Enhanced Coping r/t behavioral efforts AEB asking for help when
needed.

INTERVENTIONS
1. Encourage expression of positive thoughts and emotions.
2. Empower the client to set realistic goals and to engage in
problem solving.
3. Assess and support positive psychological strengths (hope,
optimism, self-efficacy, resiliency, and social support)

RATIONALES
1. Communication skills contribute to the well-being of
clients and minimize psychosocial problems. (Duff et al,
2010)
2. These are techniques to improve self-management and
coping for clients with chronic conditions (Battersby el al,
2011)
3. Hope, optimism, and resilience have been identified as
positive psychological characteristics that can be enhanced
for health and wellness in individuals as well s for public
health. (Kobau et al, 2011)

EVALUATION/CLIENTRESPONSE/PROGRESS Client has verbally stated that she is ready to get on track with her
life.

2.NURSINGDIAGNOSISR/TAEB Ineffective self-help management r/t non-therapeutic regimen AEB history of failing to
adhere to medical regimen.

INTERVENTIONS
1. Help the client identify and modify barriers to effective
self-management.
2. Involve family members in knowledge development,
planning for self-management, and shared decision making.
3. Explore the meaning of the persons illness experience and
identify uncertainties and needs through open-ended
questions.

RATIONALES
1. Self-management education helps achieve positive health
outcomes. (Govil et al, 2011)
2. Interviews of clients suffering from illnesses and their
family members illuminated themes associated with lack of
knowledge about health promotion and community
resources, which were identified as barriers to self-health
management. (Caress, Luker, & Chalmers, 2010)
3. Understanding the meaning of subjective data as
perveived by clients experiencing the symptom contributed
to their ability to self-manage and develop coping strategies.
(Schulman-Green et al, 2011)

EVALUATION/CLIENTRESPONSE/PROGRESS

3.NURSINGDIAGNOSIS R/TAEB Risk for hopelessness r/t bipolar depression AEB a history of recurrent depressive
episodes.

INTERVENTIONS

RATIONALES
1. Hopelessness is a potential predictor for depressive
symptoms. (Brothers &Andersen, 2010)