Case Scenario # 7 Psychiatric Nursing Care INSTRUCTIONS: For this case scenario, you will develop a Nursing Care

Plan using SNL, the Standardized Nursing Languages of NANDA, NOC and NIC (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 emergency room following an overdose of approximately 40 acetaminophen extra strength. He was cleared medically. He had been in outpatient counseling once a week since an initial overdose six months ago. Last night the patient was caught shop lifting and was charged with a crime, and now he has a court date pending. He was released to his family. Shortly after his return home he ingested the tablets. He did not tell anyone until he was discovered to be vomiting profusely and taken to the emergency room by his mother. He told the physician that when he took them he wanted to die. His mood and affect are depressed and blunted. He states his appetite and sleep have been poor and he believes he has lost 10 pounds over the last month. He is anhedonic and his grades are dropping due to inability to concentrate. He is unable to describe any reason for this. He has thought of suicide in spite of intervention. There is no evidence of psychosis or a thought disorder. Functional Health Patterns • Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help direct the choice of Nursing Diagnoses. The eleven functional health patterns are Health Perception-Health Management; Cognitive-Perceptual; Nutritional-Metabolic; Elimination; Activity-Exercise; Sleep/Rest; Self-Perception/Self-Concept; Role/Relationship; Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief. The Functional Health Pattern that is most relevant for J.S. is:

Role/Relationship

Step 1. Choosing the Nursing Diagnosis (es) The following nursing diagnoses are appropriate for J.S In practice, you may select additional nursing diagnoses. Nursing Diagnosis: Risk for violence, self-directed Definition: Behaviors in which an individual demonstrates that he/she can be physically, emotionally, or sexually harmful to self. Risk Factors: Age 15- 19, single, mental health (severe depression), emotional status, suicidal ideation Nursing Diagnosis: Ineffective individual coping Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources Defining Characteristics: Lack of goal-directed behavior/resolution of problem including: sleep disturbance, abuse of chemicals agents. Decreased use of social support; poor concentration, inadequate problem solving. Nursing Diagnosis: Altered nutrition, less than body requirements Definition: The state in which an individual is experiencing an intake of nutrients insufficient to meet metabolic needs. Defining Characteristics: lack of interest in food Related Factors: inability to ingest food due to psychological factors • While all of these nursing diagnoses are appropriate, for purposes of this exercise, let’s use

Risk for violence, self-directed

• On the nursing care plan form, write in the nursing diagnosis, and check the risk factors (etiology) for J.S.

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Step 2. Choosing the Nursing Outcomes (NOCs) • The next step is to select nursing outcomes that can best affect this nursing diagnosis. • Listed below are two appropriate nursing outcomes for J.S. Nursing Outcomes Suicide Self-restraint Indicators: • 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 listed nursing outcomes for this care plan exercise, go to the nursing care plan and check the indicators that you think will best measure your patient’s progress towards the outcome that your have chosen. • You will need to RATE your patient’s current status for each indicator. • Now that you have chosen your outcome for J.S., you will need to select the interventions that will best meet this outcome.

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Step 3. Choosing the Nursing Interventions • If you have chosen the NOC, Suicide Self-Restraint, continue below to select your interventions and activities. If you have chosen the NOC, Mood Equilibrium, continue to that section to select your interventions and activities. ______________________________________________________________ •

NOC – Suicide Self-Restraint The following two Nursing Interventions: Suicide Prevention and Surveillance –Safety are appropriate for J.S. Review the activities listed
below each NIC and select 5. Write these five activities on the care plan. NIC – Suicide Prevention - Activities (NIC3
• Determine whether patient has specific suicide plan identified •
pg. 620)

Encourage the person to make a verbal nosuicide contract Protect patient from harming self Remove dangerous items from the patient’s environment Instruct patient and significant other in signs, symptoms, and basic physiology of depression Escort patient during off-ward activities, as appropriate Instruct family on possible warning signs or pleas for help patient may use

• •

Determine history of • suicide attempts Demonstrate concern • about patient’s welfare Facilitate discussion of • factors or events that precipitated the suicidal thoughts Observe closely during suicidal crisis Facilitate support of patient by family and friends •

• •

Place patient in least restrictive environment that allows for necessary level of observation Refrain from negatively criticizing Place patient in room with protective window coverings, as appropriate Instruct family that suicidal risk increases for severely depressed patients as they begin to feel better Provide psychiatric counseling, as appropriate Refer patient to psychiatrist, as needed.

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NIC – Surveillance - Safety
• Monitor patient for alterations in physical or cognitive function that might lead to unsafe behavior Place patient in least restrictive environment that allows for necessary level of observation Monitor environment for potential safety hazards •

Activities (NIC3 pg. 635)
• Provide appropriate level of supervision/surveillance to monitor patient and to allow therapeutic actions, as needed Communicate information about the patient’s risk to other nursing staff

Determine degree of surveillance required by patient, based on level of functioning and the hazards present in environment Initiate and maintain precaution status for patient at high risk for dangers specific to the care setting

NOC, Mood Equilibrium NIC, Mood Management
• Select 5 nursing activities that are appropriate for this patient and write them on the care plan in the activity column for Mood Management.

Mood Management - Activities (NIC3 pg.457)
Monitor self care activities Monitor cognitive functioning Administer moodstabilizing medications Monitor fluid & nutritional intake Encourage pt to take an active role in treatment Assist pt to maintain a normal cycle of sleep/wakefulness Teach new coping & problemsolving skills

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The second NIC for the NOC, Mood Equilibrium is Medication Management Again, select 5 nursing activities that are appropriate for J.S. and write them on the care plan in the activity column for Medication Management Medication Management - Activities (NIC 3,
Monitor pt for the therapeutic effect of the medication Teach pt/family the effects & side effects of the medication Instruct pt/family when to seek medical care Monitor for adverse effects of the drug Teach pt/family the method of medication administration
pg.451)

Monitor for nontherapeutic drug interactions Provide pt/family with written information to enhance self administration

Congratulations!
You have successfully completed your first nursing care plan using the standardized nursing language vocabularies of NANDA, NOC, and NIC. 1. If you wish to received CE for this educational activity, please complete the evaluation form and return along with $10 to: Carol Williams, MS, RN, C Educational Services for Nursing University of Michigan Health System 300 North Ingalls , 6B12 Ann Arbor, Michigan 48109-0436 2. If you are working with a coordinator please give your quiz, evaluation and completed nursing care plan to your coordinator.

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Psychiatric Care NURSING DIAGNOSIS: Patient Name
❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏ ❏

Defining Characteristics (Signs & Symptoms) ❏ ❏ ❏ Related Factors (Etiology) ❏ ❏ ❏

NOCs (Outcomes)

Suicide: Self Restraint

Measurement Scale Score: 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated ❏ 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 DATE/TIME INITIALS

Mood Equilibrium

Measurement Scale Score: 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated ❑ Exhibits impulse control ❑ Reports adequate sleep ❏ Reports normal appetite ❑ Exhibits concentration ❏ Shows interest in surroundings DATE/TIME INITIALS

NICs (interventions) ACTIVITIES:

MODIFICATIONS:

Suicide Prevention

DATE/TIME

ACTIVITIES:

MODIFICATIONS:

❑:

Surveillance Safety

DATE/TIME

ACTIVITIES:

MODIFICATIONS:

Mood Management

DATE/TIME

ACTIVITIES:

MODIFICATIONS:

Medication Management

DATE/TIME

OTHER INTERVENTIONS:
• •

SIGNATURE BOXES:

• •

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