Level 1 Care Plan

Student: Samantha Wiederkehr Date: 11/08/19

Course: NSG-300CC Instructor: Ashley Hall

Clincial Site: Desert Haven Care Center Client Identifier: H.W. Age: 59

Reason for Admission: Schizophrenia

Medical Diagnoses: Clinical Manifestation(s):

Schizophrenia is a very difficult disease to completely understand the full
pathophysiology and how it is connected to body functions. With
schizophrenia there is an impairment in the functioning of dopaminergic
neurotransmission leading to dellusions and hallucinations. There is also a
disturbance in glutamatergic function (Aldawod, Alhawaj, Alsadah,
Alyaseen, Banjar, Fatani, Ghamri, & Slais, 2017, p. 2640). Some risk
factors include genetics, abuse of THC, and some autoimmune diseases.
Parkinson’s disease pathophysiology is a result of the loss of the main
input structure of the basal ganglia. Parkinson’s, “is a neurodegenerative
disorder caused by the loss of nigral dopaminergic neuronsinnervating the
striatum,” this loss causes, “an imbalance betweendopaminergic inputs
and cholinergic interneurons (ChIs) within the striatum” (Amalric &
Ztaou, 2019). Risk factors for Parkinson’s disease include age, genetics,
sex (men are more likely than women), and frequent exposure to toxins.
Schizophrenia presents with several defining signs and symptoms,
however, they can be controlled well with medication and H.W. did
not present with any at the time I was with him. Some
manifestations with schizophrenia include, “delusions,
hallucinations, grossly disorganized or catatonic behavior,
disorganized speech, and negative symptoms” (Aldawod, Alhawaj,
Alsadah, Alyaseen, Banjar, Fatani, Ghamri, & Slais, 2017, p.
2643).
Some manifestations with Parkinson’s include forward tilt in
posture, bradykinesia, and a short suffling gait. H.W. walks with
his chest slightly bent forward, relying on his walker to lean on. He
also tends to drag his feet in short incraments rather than picking
them up while walking. When walking with him he walks very
slow, and tends to perform other motor functions slowly as well.

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

Bipolar Disorder is a psychiatric disorder with a pathophysiology that is
composed of several different symptoms, but not fully understood.
Patients with Bipolar Disroder, “show a complex and integrated
pathophysiology that leads to cognitive, behavioral, and emotional
disturbances, immune, neuroendocrine and circadian dysfunctions,
neurodegeneration, severe impairments in social and healthrelated quality
of life and an average of 11 year reduction in life expectancy. Due to its
multifactorial profile, BD etiology, development, onset and progression
are still not well understood, even though genetic, environmental and life
style contributions are known” (Corrêa-Vellosoa, Gonçalvesb, Naaldijka,
Oliveira-Giacomellia, Pillata, & Ulrich, 2018, p. 35). Some risk factors of
Bipolar Disorder are genetics, family history, drug/alcohol abuse, and
high stress from a traumatic event.
Bipolar disorder manifestations can include periods of strong
emotional breakouts of both high and low emotional behaviors.
People who have Bipolar Disorder may feel very elated at one
moment talking quickly and being more active than normal and
then experience feelings of emptiness feeling tired and not wanting
to do activities they normally do. The patient showed signs of being
in a low mood being observed not eating much at breakfast and
skipping lunch to sleep instead.

Assessment Data

Subjective Data: H.W. greeted both myself and the other student nurse with me “good morning” as well as stating “I’m good,” after asking
how is morning was and returning the question by asking “how are you?” Later after breakfast he stated that “it was okay.” When asked how he
was feeling he stated “I feel good” and when asked if he was in any pain the patient said “no” denying any pain present.
VS: [11/8 @ 0700] Labs: N/A Diagnostics: N/A
T : 97°F
BP: 140/70
HR: 68 bpm
RR: 18 breaths/min
O2 Sat: 98% @ room air

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Assessment: Orders:
 Neuro: A&O x3 to person, place, and time. Speech is clear and  FULL CODE
patient is able to maintain a conversation that flows.  Regular diet: regular texture & thin consistency
 Skin: Color is appropriate for ethnicity presenting with no  Monthly vitals
lesions. Skin is clean, warm, dry, and intact.  Weekly skin assessment
 Respiratory: O2 Sat: 98% RA and respirations are 18 o Every day shift on Wednesdays for skin integrity
breaths/min.  Bowel monitor
 Cardiovascular: Pulse is 68 bpm, radial pulse is palpable 2+ o Every night shift
bilaterally and BP is 140/70.  Assess pain
 Hygiene: Patient is clean and well groomed. Presents with o Every shift
combed hair and clean clothes as well as maintaining a clean  Monitor legs/feet
room. Patient performs hygiene tasks independently. o For skin integrity
 GI: Abdomen is flat and client denies any pain or tenderness. o Every day shift Mon., Wed., & Fri.
Diet is regular, regular texture and thin consistency. Paient
o Every night shift Tue., Thu., Sat., & Sun.
consumed 25-50% of breakfast and 0% of lunch.
 Monitor behavior
 GU: Patient voids with no difficulty ot pain; urine is yellow and
o Every shift
clear.
o Sexual comments
 Pain: 0/10
o Verbally abusive
 Weight: 141 lbs.; patient has lost 20 lbs. since admission.
 RNA program for ROM
 Ambulation: patient ambulates with wheelchair or walker and
o Upper & lower extremities
shuffles his feet when walking.
 Behavior: Patient was calm and compliant during assessment o 5x per week as tolerated
and showed to be in a good mood throughout the morning. o For muscle strengthening
o Patient tended to walk around the halls frequently having
a difficult time sitting still except for when he took a nap
during lunch.

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 Medications
ALLERGIES: Invega (severe anaphylaxis), Penicillins (severe anaphylaxis & bronchospasms), Bees (environmental-mild)

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Lactulos Solution 30 mL PO BID Constipation Belching, cramps, Assess patient for
distention, flatulence, abdominal
diarrhea, & hyperglycemia distention, presence
(Vallerand, Sanoski, & of bowel sounds,
Delgin, 2017, p. 739). and normal pattern
of bowel function
(Vallerand,
Sanoski, & Delgin,
2017, p. 739).

Sinemet Tablet 1 tab PO TID Parkinsons Depression, involuntary Assess BP and

(Carbidopa/Levodopa) movements, orthostatic
hypotension, blurred
vision, & melanoma
(Vallerand, Sanoski, &
Delgin, 2017, p. 271).
pulse frequently
and monitor hepatic
and renal function
and CBC
periodically
(Vallerand,
Sanoski, & Delgin,
2017, p. 272).

Dulcolax Suppository 1 dose Rectally PRN Bowel care if NO BM for Abdominal cramps, Assess patient for
(Bisacodyl) 3 days nausea, hypokalemia, & abdominal
protein-losing enteropathy distention, presence
(Vallerand, Sanoski, & of bowel sounds,
Delgin, 2017, p. 220). and usual pattern of
bowel function
(Vallerand,
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 Sanoski, & Delgin,
2017, p. 221).

Milk of Magnesia 30 mL PO PRN Bowel care if NO BM for Diarrhea, flushing, & Assess for
2 days sweating (Vallerand, abdominal
Sanoski, & Delgin, 2017, distention, bwel
p. 794). sounds, and usual
bowel function
pattern (Vallerand,
Sanoski, & Delgin,
2017, p. 795).

Fleets Enema 1 dose Rectally PRN Bowel care if NO BM for Dizziness, headache, Assess for fever,
4 days cramping, abdominal pain, bowel sounds, &
& vomiting (Vallerand, abdominal
Sanoski, & Delgin, 2017, distention
p. 1014). (Vallerand,
Sanoski, & Delgin,
2017, p. 1014).

Ativan Tablet 1 tab PO q8h PRN Anxiety /aggitation Dizziness, drowsiness, Conduct a regular
(Lorazepam) blurred vision, & assessment for
respiratory depression continued need of
(Vallerand, Sanoski, & medicine, assess
Delgin, 2017, p. 786). carfully for CNS
reactions and fall
risk (Vallerand,
Sanoski, & Delgin,
2017, p. 786).

Seroquel Tablet 300 mg, PO At bedtime Schizophrenia, AEB, Neuroleptic malignant Monitor mental
(Quetiapine) 0.5 tab physical & verbal syndrome, seizures, status, assess for
aggression pancreatitis, anorexia, and suicidal tendencies,
rhabdomylosis (Vallerand, asess weight and
Sanoski, & Delgin, 2017, BMI, and monitor
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 p. 1063). BP and pulse
(Vallerand,
Sanoski, & Delgin,
2017, p. 1064).

Seroquel Tablet 50 mg, 1 PO TID Schizophrenia, AEB, Neuroleptic malignant Monitor mental
(Quetiapine) tab physical & verbal syndrome, seizures, status, assess for
aggression pancreatitis, anorexia, and suicidal tendencies,
rhabdomylosis (Vallerand, asess weight and
Sanoski, & Delgin, 2017, BMI, and monitor
p. 1063). BP and pulse
(Vallerand,
Sanoski, & Delgin,
2017, p. 1064).
Olanzaprine tablet 10 mg, 1 PO Qd Psychosis Neuroleptic malignant Assess mental
tab syndrome, agitation, status, monitor BP,
amblyopia, orthostatic ECG, pulse, and
hypotension, impotence, respiratory rate, and
agranulocytosis, assess fluid intake
photosensitivity, & fever and bowel function
(Vallerand, Sanoski, & (Vallerand,
Delgin, 2017, p. 919). Sanoski, & Delgin,
2017, p. 920).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family Measurable, time- Nursing or Provide reason why Was goal met? Revise the plan
focused. specific, reasonable, and interprofessional intervention is of care according the client’s
attainable. interventions. indicated/therapeutic. response to current plan of care.
Provide references.
Priority Nursing Diagnosis
Hopelessness related to Schizophrenia as evidenced by alteration in sleep pattern and decrease in appetite. This is my priority diagnosis because
if the patient has lost hope, they will not be motivated to involve themselves in their care and will be unable to progress in any pan of care.

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Patient will express H.W. will express 1. Assess patient for 1. Assessing the patient for 1. H.W talked about negative
feelings of negative feelings and self-destructive self-destructive behavior feelings instead of actinging
hoplessness. recognize the benefit of behavior is a priority in order to on them without expressing
positive social 2. Provide for reduce the risk for suicide them first
interactions by the end appropriate physical 2. Physical outlets help the 2. Patient identified ways to
of my shift (Phelps, outlets for expression patient release hostilities, express feelings that he
Ralph, & Taylor, 2017, of feelings reducing anxiety and enjoys (walking and listening
p. 154). 3. Help patient to tension to music) in order to reduce
participate in usual 3. Participating in activities anxiety.
activities as strength, helps maintain the 3. H.W. interacted with others
energy, and time patient’s sense of being and showed involvement in
permit (Phelps, connected to others life experiences (Phelps,
Ralph, & Taylor, (Phelps, Ralph, & Taylor, Ralph, & Taylor, 2017, p.
2017, p, 154). 2017, p. 154). 155).

Secondary Nursing Diagnosis:

Imbalanced nutrition: Less than body requirements related to Parkinson’s as evidenced by weakness of muscles required for mastication and
swallowing, as well as Bipolar Disorder as evidenced by insufficient interest in food during depressive stage.
Patient will show no H.W. will show no 1. Obtain and record the 1. Obtaining daily weights at 1. Patient’s weight
further evidence of further evidence of patients weight at the the same time every day measurements will show no
weight loss. weight loss and have a same time every day obtains an accurate change or an increase in
daily calorie intake of 2. Monitor fluid intake measure and can be used weight
2,000 calories by the and output daily to assess patients weight 2. Fluid intake and output will
end of the month 3. Educate patient on he gain/loss verify daily weight
(Phelps, Ralph, & importance of eating 2. Fluid intake and output measurements and ensure
Taylor, 2017, p. 232). a certain amount of may show a false increase weight gain isn’t due to fluid
calories daily in weight resulting from retention
(Phelps, Ralph, & fluid retention 3. H.W. will understand the
Taylor, 2017, p. 233). 3. Patient adherence importance of daily calorie
increases the chance of intake and adhere to the plan
compliance with the plan of 2,00 calories daily
of care (Phelps, Ralph, & (Phelps, Ralph, & Taylor,

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Taylor, 2017, P. 233). 2017, p. 233).

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 References

Aldawod, R., Alhawaj, F. A., Alsadah, S., Alyaseen, E. N., Banjar, J., Fatani, B. Z., Ghamri, A. S., & Slais, F. R. (2017).

Schizophrenia: Etiology, pathophysiology and management – A review. The Egyptian Journal of Hospital Medicine, 6, 2640-

2646. doi: 10.12816/0042241

Amalric, M. & Ztaou, S. (2019). Contribution of cholinergic interneurons to striatal pathophysiology in Parkinson's disease.

Neurochemistry International, 126, 1-10. https://doi.org/10.1016/j.neuint.2019.02.019

Corrêa-Vellosoa, J. C., Gonçalvesb, M. C., Naaldijka, Y., Oliveira-Giacomellia, Á., Pillata, M. M., & Ulrich, H. (2018).

Pathophysiology in the comorbidity of Bipolar Disorder and Alzheimer's Disease: Pharmacological and stem cell approaches.

Progress in Neuropsychopharmacology & Biological Psychiatry, 80, 34-53. https://doi.org/10.1016/j.pnpbp.2017.04.033

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylor’s nursing diagnosis reference manual. (10th ed.). Philadelphia, PA:

Wolters Kluwer.

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