Behavioral Health Care Plan

Student: Ahsan Arca Date: 10/20/19

Course: NSG-322CC Instructor: Paula Hoover

Clincial Site: Banner University Medical Center: Behavioral Client Identifier: T.A. Age: 28
Health Unit

Reason for Admission: Suicide attempt was made when he was in jail.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Suicidal thoughts: thinking of taking one’s own life, which is a “tragic
reaction to stressful life situations (“Mayo Clinic”, 2017, para. 1). For
individuals thinking of taking their own lives, it may seem like there is no
other way out of their situation (“Mayo Clinic”, 2017).
T.A. manifestations: talking about suicide, “withdrawing from
social contact”, increasing substance abuse (“Mayo Clinic”, 2017).
Other manifestations: volatile mood, constantly occupied with
thoughts of death, saying goodbye to people like they will never
see them again, and giving away belongings for no reason (“Mayo
Clinic”, 2017).

Assessment Data

Subjective Data: “I use drugs everyday, have anxiety, depression, and suicidality”. When asked to rate his anxiety/depression level, he rated
it “7/10” on numerical scale.

VS: Taken at 0900 Labs: Taken 10/17/19 at 0631 Diagnostics:

T : 37.2 C  WBC: 8.8K/mm3 (normal 4,000- MDD, Anxiety, and suicide attempt.

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 BP: 134/86 11,000/mcL)
HR: 69bpm  RBC: 4.83M/MM3 (normal 3,800,000-
5,000,000/mcL)
RR: 18 breaths/min  Hgb: 14.2g/dL (normal: 11.7-17.3 g/dL)
O2 Sat: 98% on RA  Hct: 42.6% (normal 35-50%)
 Platelet: 282K/mm3 (normal 150,000-
Taken at 1015
400,000)
T: 37.9 C  TSH: 0.04 ulU/mL
BP: 138/90  Benzodiazepine screen: positive
 Cannaboid (THC) screen UR: positive
HR: 72bpm  Fentanyl screen, UR: positive
RR: 20 breaths/min  Methadone screen, UR: positive
O2 sat: 98% on RA Normal values reference (Lewis, Bucher,
Heitkemper, Harding, Kwong, & Roberts, 2017).

Assessment: Orders/Safety Protocols:

PMH: seizures and chicken pox, Hx of alcohol use disorder and opioid  MSAS for alcohol withdrawal
use disorder.  BeH precautions: minimum suicide, danger to self
 Regular diet
Mental Status Exam:
 Consult to social services
Appearance (observed): appropriate. Dressed appropriately.  COWS and MSAS for methadone and Xanax were “0” scored.

Behavior (observed): guarded and shy.

Attitude (observed): Reserved. Showed interest in conversation.
Level of Consciousness (observed). A&O x 4- to person, place, time,
and situation. Client is aware of how he got to this unit, but does not
remember how he arrived in jail (place of being prior to admission).

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Orientation (inquired): aware of self and surroundings.
Speech and Language (observed): speaks clearly, but quiet. Able to
express feelings well.
Mood (inquired): Calm, a little bit anxious.
Affect (observed): has a flat affect when not being talked to. Appears
depressed and slightly smiles during interaction.
Thought Process/Form (observed/inquired): able to think clearly, may
have pessimistic thoughts.
Thought Content (observed/inquired): thinks about getting out of the
unit a lot and going back to work in order to make money for his
family.
Suicidality and Homicidality (inquired): attempted suicide prior to visit.
Was not able to ask if he was currently suicidal.
Insight and Judgment (observed/inquired): appropriate. Judgment is
intact.
Attention Span (observed/inquired): able to give attention to one
thing. He was able to keep up with a game of cards. When observing
client in the milieu, he seemed to stare into places quite often- seems
to have a lot in his mind.
Memory (observed/inquired): remembers well, except the time fram
from when he was taken from his hotel room by the cops to jail. He
claimed to have been “high on drugs”.
Intellectual Functioning (observed/inquired): able to reason and
problem solve. However, he claimed to be “stupid” when it comes to

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work and drugs; T.A. claimed that he spends $100 on drugs prior to
going to work, just to make $200 at work and that he “need(s)” drugs
to be able to cope with a 12-hour shift.

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 Medications
ALLERGIES:
NKA

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
METHadone 30mg, PO daily Use for moderate-severe Respiratory depression, Assess patient’s
(Dolophine) 3tab chronic pain for opiod- bradycardia, and urinary pain every 2hrs.
tolerant patients. retention (Vallerand & Monitor client’s BP
Therapeutic effect: Sanoski, 2017). and respirations
decreases pain sensation during
by binding to the CNS administration.
(Vallerand & Sanoski, Inform client that
2017). drowsiness and
dizziness may
occur, so stand up
slowly.
Common s.e.
include
constipation and
hypotension
(Vallerand &
Sanoski, 2017).
Mirtazapine (Remeron) 15mg, 1 PO QBedtime used for major depressive Suicidal thoughts, Assess for suicidal
tab disorder. agranulocytosis, and thoughts and
Theapeutic effect: serotonin syndrome mental status.
potentiates (Vallerand & Sanoski, Monitor changes in
norepinephrine and 2017). mood and
serotonin, producing increased suicidal

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 antidepressant effects thoughts.
(Vallerand & Sanoski, Advise client to
2017). refrain from
alcohol, as it
interacts with drug.
Common s.e.
include drowsiness,
dizziness, and
constipation
(Vallerand &
Sanoski, 2017).
150mg, 1 PO Daily For major depressive Seizures, suicidal thoughts, Assess client’s
Venlafaxine (Effexor cap disorder. and serotonin syndrome mood and mental
XR) Therapeutic effect: (Vallerand & Sanoski, status; monitor for
inhibits norepinephrine 2017). increased anxiety,
and serotonin reuptake, nervousness,
decreasing effects of insomnia.
depression (Vallerand & Assess for suicidal
Sanoski, 2017). thoughts.
Assess serotonin
syndrome including
hallucinations,
increased BP.
Common s.e.
include abnormal
dreams, anxiety,
and abdominal pain
(Vallerand &
Sanoski, 2017).
Ondansentron (Zofran) 4mg, 1 tab PO Q4h, PRN For prevention of N/V. Serotonin syndrome, Instruct client to
N/V Therapeutic effect: Steven’s-Johnson report
“blocks the effects of syndrome, and diarrhea. hypersensitivity
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 serotonin at 5-HT3- reactions. Monitor
receptor sites located in client’s bowel
vagal nerve terminals function- CDAD
(Vallerand & Sanoski, may occur with
2017, p.933). drug. Instruct client
to report diarrhea
that does not go
away with
antidiarrheals,
accompanied by a
fever. Common s.e.
include headache,
constipation, and
dry mouth
(Vallerand &
Sanoski, 2017).
1mg, 1tab PO TID PRN Used for anxiety Blurred vision, Assess degree of
Alprazolam (Xanax) anxiety associated with dependence, and mental anxiety.
depression. depression (Vallerand & Advise client to
Therapeutic effects: Sanoski, 2017). avoid grapefruit
produces anxiolytic effect juice, as it may
in the CNS (Vallerand & interact with the
Sanoski, 2017). drug.
Common s.e.
include dizziness,
drowsiness, and
lethargy (Vallerand
& Sanoski, 2017).
1mg, 1tab PO Q1h PRN For alcohol withdrawal Paralytic ileus, Assess for
Dicyclomine (Bentyl) alcohol symptoms. anaphylaxis, and abdominal
withdrawa Therapeutic effect: palpitation (Vallerand & distention. Advise
l decreases GI motility Sanoski, 2017). client to stay in
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 symptoms (Vallerand & Sanoski, “temperature-
2017). controlled rooms”.
Instruct client to
rise slowly as
hypotension
occurs. Common
s.e. include
confusion,
constipation, and
heartburn
(Vallerand &
Sanoski, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client- or family-focused. Measurable, time- Nursing or interprofessional Provide reason why Was goal met? Revise
specific, reasonable, and interventions. intervention is the plan of care
attainable. indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for suicide r/t vulnerability to self-inflicted harm (Phelps, Ralph, & Taylor, 2017). This has been chosen the priority nursing diagnosis, as
patient’s safety is threatened, a characteristic of which is found under Maslow’s hierarchy of needs in the second tier (Friberg & Creasia,
2016).
Patient will state an 1. “Suicide risk The goal was partially
improvement in suicidal 1. Directly ask the increases if the met.
Patient will feel safe in a thoughts, rating his patient if he thinks patient has a 1. Pateint was not
therapeutic milieu. suicidal thoughts 0/10 on about killing himself definite plan” asked if he had
a numerical scale (0 being (Phelps, Ralph, & (Phelps, Ralph, & suicidal
the least risk for Taylor, 2017). Taylor, 2017, thoughts/plans.
attempting suicide) by the 2. “Initiate appropriate p.814). 2. Patient’s
end of the shift. safety protocols by 2. “To help ensure belongings were
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 removing from the patient’s safety” collected upon
patient’s (Phelps, Ralph, & admission.
environment Taylor, 2017, 3. Therapeutic
anything that could p.814). communication
be used to inflict 3. “To show was
further self injury” inconditional demonstrated
(Phelps, Ralph, & positive regard” during
Taylor, 2017, p.814). (Phelps, Ralph, & interaction with
3. “Use warm, caring, Taylor, 2017, the patient.
nonjudgmental p.814).
manner” (Phelps,
Ralph, & Taylor,
2017, p.814).

Secondary Nursing Diagnosis:

Social isolation r/t inability to engage in satisfying personal relationships (Phelps, Ralph, & Taylor, 2017), AEB claiming to have “lost all friends
and family” due to drug addiction.
Client will agree to spend Client will socialize with 1. Spend time with 1. “To establish a The goal was met.
time socializing with other patients, therapists, the patient and trusting 1. Interaction with
others in the milieu, as and nurses throughout engage him in relationship” client was
well as loved ones in the the day, communicating conversations (Phelps, Ralph, & implemented
past. with at least 10 people by 2. “Encourage patient Taylor, 2017, intermittently
the end of the shift. Client to begin relating to p.807). through the day.
will also verbalize reaching others through 2. “To help patient 2. Client was
out to loved ones, once participation in practice newly enforced to play
discharged. unit activities” acquired social games with other
(Phelps, Ralph, & skills” (Phelps, patients on the
Taylor, 2017, Ralph, & Taylor, unit.
p.807). 2017, p.807). 3. Client’s feelings
3. “Encourage the 3. “To let patient was heard of,
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 patient to know that the providing
articulate feelings. patient’s ideas are therapeutic
Listen valued” (Phelps, responses and
nonjudgmentally” Ralph, & Taylor, projecting positive
(Phelps, Ralph, & 2017, p.807). body language to
Taylor, 2017, show care towards
p.807). client.
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socioeconomic
status, and cultural and spiritual preferences of the individual and focused on providing safe, evidence-based care for the achievement
of quality client outcomes.

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 References

Friberg, E. E., & Creasia, J. L. (2016). Conceptual foundations: The bridge to professional nursing practice (6th ed.). St. Louis, MO.

Lewis, S., Bucher, L., Heitkemper, M., & Harding, M. (2017). Medical-surgical nursing (10th ed.). St. Louis, MO.

Mayo Clinic. (2018). Suicide and suicidal thoughts. Retrieved from https://www.mayoclinic.org/diseases-

conditions/suicide/symptoms-causes/syc-20378048

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD.

Vallerand, A., & Sanoski, C. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA.

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