Behavioral Health Care Plan

Student: Ahsan Arca Date: 10/30/19

Course: NSG-322CC Instructor: Paula Hoover

Clincial Site: Banner University: Behavioral Health Unit Client Identifier: C.A. Age: 19

Reason for Admission: Suicide attempt was made on 10/23/19, ingesting 18 tablets of Depakote.

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). Some risk factors
of suicidal thoughts include: feeling hopelessness, previous suicide
attempts, family history of mental disorders, and a recent stressful life
event (“Mayo Clinic”, 2017).
C.A. manifestations: withdrawing from family contact prior to
attempt, great feelings of being trapped/hopelessness, and an
increase in anxiety (“Mayo Clinic”, 2017).
Other manifestations: volatile mood, constantly occupied with
thoughts of death, saying goodbye to people like they will never
see them again, changing normal routines, and giving away
belongings for no reason (“Mayo Clinic”, 2017)

Assessment Data

Subjective Data: “My fiance recently broke up with me, 3 weeks ago. This was not the only thing that triggered my attempt, a bunch of
other things just built up.”. When asked if client felt safe on the unit, or had any thoughts of harming self/others, client claimed, “I do not
feel suicidal right now and have none of those thoughts”.

VS: Taken at 0700 Labs: taken on 10/25/19 on 0704 Diagnostics:

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
T : 35.6 C BUN: 7.6 mg/dL (normal 6-20) Anxiety, borderline personality disorder, major
depressive disorder, and OCD.
BP: 126/80 HDL: 36mg/dL (normal 40-59)
HR: 90 bpm Normal values reference (Lewis, Bucher,
Heitkemper, Harding, Kwong, & Roberts, 2017).
RR: 16 bpm
O2 Sat: 96% on RA
Taken at 1100
T: 36.9 C
BP: 126/82
HR: 85 bpm
RR: 16 bpm
O2 sat: 98% on RA

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Assessment: Orders/Safety Protocols:

Height: 173 cm  Full code

 Suicide precautions: SP1
Weight: 72.7kg
 Suicide precautions
PMH: epilepsy and nocturnal enuresis.  Fal precautions
 Regular diet
Mental Status Exam:
Appearance (observed): client is dressed appropriately, well-groomed,
and his hair is dyed red.
Behavior (observed): appropriate and client is cooperative. He is
respectful to others.
Attitude (observed): client is motivated to get better and participates
in his plan to get better.
Level of Consciousness (observed): client is conscious.
Orientation (inquired): client is alert and oriented x3, to person, place,
and time.
Speech and Language (observed): client’s speech is well articulated and
able to express feelings clearly.
Mood (inquired): client’s mood is appropriate to content.
Affect (observed): client is bright and happy.
Thought Process/Form (observed/inquired): no disturbances in
thought process.
Thought Content (observed/inquired): appropriate. No hallucinations
or delusions present.
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Suicidality and Homicidality (inquired): Attempted suicide prior to visit.
Currently has no suicidal thoughts or thoughts of harming others.
Insight and Judgment (observed/inquired). Good insight and
judgement.
Attention Span (observed/inquired): client is attentive and aware of
situation.
Memory (observed/inquired): memory intact. He is able to remember
a lot of things that escalated prior to visit.
Intellectual Functioning (observed/inquired): Appears smart, but
cannot seem to put himself first, but rather attempts to fix others
before himself.
Anxiety level: 6//10
Depression level: 4/10

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 Medications
ALLERGIES: NKA

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Divalproex sodium 500mg, 1 PO BID Used as a monotherapy Suicidal thoughts, Assess client’s
(Depakote) tab and adjunctive therapy hepatotoxicity, and suicidal ideations.
for “simple and complex hypothermia (Vallerand & Monitor hepatic
absence seizures” Sanoski, 2017). functions, as drug
(Vallerand & Sanoski, can cause
2017, p.1238). hepatotoxicity.
Therapeutic effect: Teach client to take
supresses seizures by drug as ordered,
increases GABA levels in and take missed
the brain (Vallerand & doses as soon as
Sanoski, 2017). they remember.
Some s.e. include
drowsiness,
agitation, and
dizziness (Vallerand
& Sanoski, 2017).
Escitalopram (Lexapro) 10 mg, 1 PO daily Used for major depressive Neuroleptic malignant Monitor client’s
tab disorder (Vallerand & syndrome, suicidal mood changes.
Sanoski, 2017). thoughts, and serotonin Assess for
Therapeutic effect: syndrome (Vallerand & serotonin
“antidepressant action” Sanoski, 2017). syndrome,
by inhibiting serotonin including
uptake in CNS (Vallerand tachycardia, labile

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 & Sanoski, 2017).
400mg, 1 PO Q6h PRN Used for mild to
Ibuprofen (Advil) tab pain- mild moderate pain and fever.
(Vallerand & Sanoski,
2017).
Therapeutic effect:
“decreased pain and
inflammation” by
inhibiting prostaglandin
synthesis (Vallerand &
Sanoski, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s)
Client- or family-focused. Measurable, time- Nursing or interprofessional
specific, reasonable, and interventions.
Myoccardial infarction, GI
bleed, and hepatitis
(Vallerand & Sanoski,
2017).
Rationale
Provide reason why Was goal met? Revise
intervention is
BP, and vomiting.
Caution pt. about
driving and
activities that
require
attentiveness, as
drug causes
drowsiness. Some
s.e. include:
insomnia, diarrhea,
and nausea
(Vallerand &
Sanoski, 2017).
Assess for signs of
GI bleed, such as
tarry stools. Assess
patient’s pain every
2 hrs. Advise client
to take medication
with water and
remain upright for
15-30min after.
Common s.e.
include: headache,
constipation, and
vomiting (Vallerand
& Sanoski, 2017).
Evaluation
the plan of care
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 attainable.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Ineffective coping r/t situational crisis, AEB inability to cope with breakup. This was chosen the priority, as it essentially plays role in client’s
safety, a component found on the second tier of Maslow’s Hierarchy of needs (Friberg & Creasia, 2016).
“Patient will become Client will express 1. “Encourage
involved in planning of motivation in getting expression of
own care” (Phelps, Ralph, better and express 3 feelings, and accept
& Taylor, 2017, p.76). coping mechanisms to what the patient
incorporate during a says” (Phelps, Ralph,
crisis, by the end of the & Taylor, 2017,
shift. p.77).
2. “Identify and reduce
unnecessary stimuli
in environment”
(Phelps, Ralph, &
Taylor, 2017, p.77).
3. “Request feedback
from patient about
behaviors that seem
to work” (Phelps,
Ralph, & Taylor,
2017, p.77).
Secondary Nursing Diagnosis:
Anxiety r/t situational crises, AEB a recent breakup with fiance.
indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
1. “Devoting time to The goal was partially
listening helps met.
patients express 1. Therapeutic
emotions, grasp communication was
situations, and utilized to build
cope effectively” rapport with client.
(Phelps, Ralph, & 2. Interaction with
Taylor, 2017, p.77). client occurred in
2. “To avoid the milieu, as
subjecting patient students are
to sensory or prohibited to go in
perceptual clients’ rooms.
overload” (Phelps, 3. Client was asked
Ralph, & Taylor, what coping
2017, p.77). mechanisms has
3. “To encourage worked for him and
patient to evaluate what has not.
effect of these
behaviors” (Phelps,
Ralph, & Taylor,
2017, p.77).
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 Client will state a 1. “Accept the 1. “Forcing the The goal was met.
reduction in anxiety level, patient as is” patient to change 1. Client was
rating anxiety level (Phelps, Ralph, & before the patient approached in a
Client will be less anxious
between 3-5 on a scale of Taylor, 2017, is ready causes nonjudgemental
about current life
0/10 by the end of the p.735). panic” (Phelps, manner and
stressors.
shift. 2. “Reassure the Ralph, & Taylor, acceptted despite
patient about 2017, p.735). his flaws.
being safe” 2. “The patient may 2. Client was
(Phelps, Ralph, & perceive being at reminded that
Taylor, 2017, risk, which may everyone in the
p.735). increase the unit is here to help
3. “Teach relaxation patient’s level of him and that he is
techniques” anxiety” (Phelps, safe here.
(Phelps, Ralph, & Ralph, & Taylor, 3. Client was shown
Taylor, 2017, 2017, p.735). deep-breathing
p.735). 3. “To counteract exercises.
fight-or-flight
response” (Phelps,
Ralph, & Taylor,
2017, p.735).
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.