Behavioral Health Care Plan

Student: Samantha Wiederkehr Date: 02-09-20

Course: 322CC Instructor: Professor Banke

Clincial Site: Banner Del. E Webb Client Identifier: L.M. Age: 69

Reason for Admission:

Psychiatrist sent L.M. here once he indicated that he has been having increased auditory hallucinations.

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

Unspescified Schizophrenia Spectrum Disorder: Observed:
 Pathophysiology: Schizophrenia is characterized by an abnormal  Staring into space
reality in which individuals may experience hallucinations or  Tapping ones feet
delusions. This disorder impairs people ability to function daily,  Messing with hands frequently
and can potentially influence the way the act and make decisions.  Innability to sit still
The cause is not known, but theories have shown that it has  Auditory hallucination (subjective)
something to do with an individuals genetics as well as the
environment around them. Other theories believe it may have to do Expected:
with issues in the brains neurotransmitters (Schizophrenia, 2020).  Delusions or hallucinations
 Risk factors: Risk factors may include family histor, issues with  Abnormal behavior (inappropriate or talking to oneself)
preganncy as a neonate and its affect on the brains development,  Breathing quickly and heavily
and using drugs that may alter the brains ability to function at a  Sweating
young age (Schizophrenia, 2020).  Fatigue
Unspecified Anxiety Disorder:  Difficulty sleeping
 Pathophysiology: Unspecified anxiety disorder is in theory thought

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 to be caused by a combination of biological, environmental, and
psychological components. It is a sense of being overly alert and
worried about everyday things that causes impaired functioning
and posibily an innability to function (Varcarolis, 2017).
 Risk factors: Some risk factors may include traits of remaining
reserved to ones self in child hood, traum or exposure to stress, a
family history of anxiety, or chronic health conditions that may
produce or worsen anxiety symptoms (Anxiety Disorders, 2020).

Assessment Data
Subjective Data: “I was having bad auditory hallucinations, paranoia, and depression.”
VS: Labs: Diagnostics:
T : 36.1 Abnormal values: CT head/brain without contrast – for intractable headache
and dizziness
BP: 131/96 WBC: 11.4 K/MM3 (high)
Results: age related atrophy
HR: 75 HMG: 5.9% (high)
RR: 16
O2 Sat: 98% RA

Assessment: Orders/Safety Protocols:

PMH: unspecified psychosis and major depression FULL CODE

Mental Status Exam: BeH Acknowledgement of presence

Appearance: appropriate for circumstances and environment, well- Activity as tolerated

groomed Regular diet
Behavior/mood/attitude: cooperative, talkative, positive, anxious
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Level of Consciousness/orientation: A&O x4 Risk for falls
Speech and Language: no problems identified, speaks clearly
Affect: alert, calm; congruent with mood
Thought Process/Form: appropriat for circumstances; no delusions;
verbalizes auditory halucinations; thought content is coherent
Suicidality and Homicidality: client denies
Insight/Judgment: understands the need for treatment; capable of
reality based thinking
Attention Span: able to focus on conversation
Memory: intact
Intellectual Functioning: no problems identified
Hallucinations: auditoy (“you’re worthless” “you deserve to die”
Pain: 7/10 (shoulder and knee)
Current depression: 0/10
Current anxiety: 5/10

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 Medications
ALLERGIES:
Halopuridol and Plavix

Name Dose Route Frequenc Indication/Therapeutic Adverse Effects Nursing

y Effect Considerations
Aspirin 81mg PO Daily Treatment of EENT: tinnitus Assess pain and
inflammatory disorders , GI: GI bleeding, limitation of
pain, fever, and dyspepsia,epigastric movement, assess
prohylaxis of TIAs and distress, nausea, abdominal fever and note
MI. reduces inflammation pain, anorexia, associated signs,
and fever, decreases hepatotoxicity, vomiting monitor hepatic
incidence of TIAs and Hemat: anemia, hemolysis function before
MI, and analgesia. Derm: rash, urticaria antirheumatic
(Vallerand, Sanoski, & Misc: allergic reasctions therapy, monitor
Deglin, 2017). including anaphylaxis and serum salycilate
laryngeal edema levels, and monitor
(Vallerand, Sanoski, & for signs of toxicity
Deglin, 2017). (Vallerand,
Sanoski, & Deglin,
2017).
Atorvastatin 20mg PO Before bed Adjunctive management CNS: amnesia, confusion, Assess patients diet
of primary dizziness, headache, history, evaluate
hypercholesterolemia and insomnia, memory loss, serum cholesterol
mixed dyslipidemia. weakness and triglyceride
Lowers total and LDL EENT: rhinitis levels, onitor liver
cholesterol and Resp: bronchitis function tests,
triglycerides (Vallerand, CV: chest pain,peripheral monitor patients
Sanoski, & Deglin, 2017). edema CPK levels if they
GI: abdominal cramps, develop muscle
constipation, diarrhea, tenderness during
flatus, heartburn therapy (Vallerand,

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 GU: erectile dysfunction Sanoski, & Deglin,
Derm: rashes and pruritus 2017).
MS: rhabdomylosis,
arthralgia, arthritis
(Vallerand, Sanoski, &
Deglin, 2017).
Pantoprazole 40mg PO Daily Erosive esophagitis CNS: headache Assess patient for
associated with GERD. GI: CDAD, abdominal epigastric or
Maintainence of healing pain, diarrhea, eructation, abdominal pain as
of erosive esophagitis. flatulence well as for frank or
Diminishes accumulation Endo: hyperglycemia occult blood in
of acidin the gastric F&E: hypomagnesemia stool, assess liver
lumen, lessening acid GU: acute interstitial function tests, and
reflux. Heals duodenal nephritis monitor bowel
ulcers and esophagitis Hemat: vitamin B12 function
(Vallerand, Sanoski, & deficiency (Vallerand,
Deglin, 2017). MS: bone fracture Sanoski, & Deglin,
(Vallerand, Sanoski, & 2017).
Deglin, 2017).
Risperidone 0.5mg PO Daily Treatment for CNS: neuroleptic malignant Monitor patients
schizophrenia in adults syndrome, suicidal mental status and
and adolescents (ages 13- thoughts, aggressive mood, assess
17). May act by behavior, dizziness, weight and BMI,
antagonizing dopamine extrapyramidal reactions, monitor BP,
and serotonin in the CNS, headache, increased dreams observe patient
decreasing symptoms of and sleep duration, during
psychoses, bipolar mania, insomnia, sedation, fatigue administration to
or autism (Vallerand, EENT: pharyngitis, rhinitis, ensure medication
Sanoski, & Deglin, 2017). visual disturbances was swallowed,
Resp: cough dyspnea monitor for onset
GU: decreased libido, extrapyramidal
dysmenorrhea/menorrhagia, side effects,
difficulty urinating, monitor for

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 polyuria development of
Derm: itching/skin rash neuroleptic
malignant
syndrome and
notify HCP
immediately if
symptoms occur
(Vallerand,
Sanoski, & Deglin,
2017).
Sertraline 150mg PO Daily Treatment for major CNS: Neuroleptic Assess for suicidal
depressive disorder. malignant syndrome, tendencies.
Inhibits neuronal uptake suicidal thoughts, agitation, Monitor appetite
of serotonin in the CNS and confusion and nutritional
potentiating the activity EENT: pharyngitis, intake. Assess for
of serotonin and having tinnitus, and visual serotonin
an antidepressent action abnormalities syndrome. Monitor
(Vallerand, Sanoski, & CV: palpitations mood changes and
Deglin, 2017). GI: dry mouth, dyspepsia, inform health care
flatulence, and vommiting professional if
GU: sexual dysfunction and patient
urinary frequency demonstrates
Derm: hot flashes and rash significant increase
Endo: diabetes in anxiety,
F&E: hyponatremia nervousness, or
MS: back pain and myalgia insomnia
Neuro: paresthesia and (Vallerand,
twitching Sanoski, & Deglin,
Misc: serotonin syndrome 2017).
(Vallerand, Sanoski, &
Deglin, 2017).
Trazadone 25mg PO Prn sleep Treatment for major CNS: suicidal thoughts, Monitor BP and
depression, insomnia, drowsiness, confusion, pulse before and

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 chronic pain, and anxiety.dizziness, fatigue, during therapy,
Alters the effects of hallucinations, headache, assess dor
serotonin on the CNS insomnia, nightmares, serotonin
causing an antidepressant slurred speech, syncope, syndrome, assess
action (Vallerand, weakness mental status
Sanoski, & Deglin, 2017). EENT: blurred vision, frequently, assess
tinnitus suicidal tendencies,
CV: dry mouth, altered asses pain, and
taste, constipation, diarrhea, assess CBC and
excess salivation, renal and hepatic
flatulence, nausea, functions before
vomiting and throughout
GU: hematuria, erectile therapy (Vallerand,
dysfunction, priapism Sanoski, & Deglin,
Derm: rash 2017).
Hemat: anemia, leukopenia
MS: myalgia
Neuro: tremor
(Vallerand, Sanoski, &
Deglin, 2017).
Acetaminophen 650mg PO Q4h prn Treatment of mild to CNS: agitation, anxiety, Assess overall
moderate pain and fever. headache, fatigue, insomnia health status and
Inhibits the synthesis of Resp: atelectasis, dyspnea alcohol usage
prostaglandins causing CV: hypertension, before
analgesia (Vallerand, hypotension administering
Sanoski, & Deglin, 2017). GI: hepatotoxicity, acetaminophen,
constipation, increased liver assess amount,
enzymes, nausea, vomiting frequency, and
F&E: hypokalemia type of drugs taken
GU: renal failure in patients self-
Hemat: neutropenia, medicating, asses
panytopenia pain, and evaluate
MS: muscle spasms, hepatic and renal
trismus function
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 (Vallerand, Sanoski, &
Deglin, 2017).
Ibuprofen 400mg PO Q6h prn Treatment of mild to CNS: headache, dizziness,
moderate pain and fever. drowsiness, intraventricular
Inhibits prostaglandin hemorrhage, psychic
synthesis decreasing paindisturbances
and inflammation and EENT: amblyopia, blurred
reducing fever vision, tinnitus
(Vallerand, Sanoski, & CV: arrythmias, edema,
Deglin, 2017). hypertension
GI: GI bleeding, hepatitis,
constipation, dyspepsia,
nausea, necrotizing
enterocolitis, vomiting,
abdominal discomfort
GU: cystitis, hematuria,
renal failure
Derm: expoliative
dermatitis, steven-johnson
syndrome, toxic epidermal
necrolysis, rashes, injection
site reaction
Hemat: anemia, prolonged
bleeding time
(Vallerand, Sanoski, &
Deglin, 2017).
Hydroxyzine 25mg PO Q6h prn Treatment of anxiety. CNS: drowsiness, agitation,
Sedation. Decreased ataxia, dizziness, headache,
nausea and vomiting. weakness
Decreased allergic Resp.: wheezing
symptoms associated with GI: dry mouth, bitter taste,
release of histamine, constipation, nausea
(Vallerand,
Sanoski, & Deglin,
2017).
Assess for signs
and symptoms of
GI bleeding, assess
patient for skin
rash frequently,
assess pain prior to
and during
treatment, monitor
BUN, serum
creatinine, CBC,
and liver function
tests (Vallerand,
Sanoski, & Deglin,
2017).
Assess patient for
profound sedation
and provide safety
precautions, assess
mental status, and
assess degree of
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Nicotine 21mg Transdermal Daily
patch
Nursing Diagnoses and Plan of Care
Goal Expected Outcome
Client- or family-focused. Measurable, time-specific,
reasonable, and attainable.
including pruritus GU: urinary retention nausea and
(Vallerand, Sanoski, & Derm: flushing rash frequency
Deglin, 2017). (Vallerand, Sanoski, & (Vallerand,
Deglin, 2017). Sanoski, & Deglin,
2017).
Adjunct therapy in the CNS: headache, insomnia, Assess smoking
management of nicotine abnormal dreams, history prior
withdrawal in patients dizziness, drowsiness, totherapy, assess
desiring to give up impaired concentration, patient for smoking
cigarette smoking. nervousness, weakness withdrawal
Lessens symptoms of Resp: dyspnea symptoms
nicotine with drawal CV: tachycardia, chest throughout therapy,
including irritability, pain, hypertension and evaluate
insomnia, somnolence, GI: abdominal pain, progress in
headache, and increased constipation, diarrhea, dry smoking cessation
appetite (Vallerand, mouth, dyspepsia throughout therapy
Sanoski, & Deglin, 2017). Derm: burning at site, (Vallerand,
erythema, pruritus, Sanoski, & Deglin,
cutaneous hypersensitivity, 2017).
rash, sweating
Endo: dysmenorrhea
MS: arthralgia, back pain
(Vallerand, Sanoski, &
Deglin, 2017).
Intervention(s) Rationale Evaluation
Nursing or interprofessional Provide reason why Was goal met? Revise
interventions. intervention is the plan of care
indicated/therapeutic. according the client’s
Provide references. response to current plan
of care.
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Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Hopelessness related to expression of not being able to get better as evidenced by despondent verbal cues.
The client will maintain a Patient will develop copin 1. Encourage positive 1. Positive thinking will 1. Client gave
sense of hope and mechanisms to deal with thinking and convey a help the client to examples of positvie
demonstrate an increase in their feelings of sense of confidence in develop an optimistic thinking and showed
motivation and purpose. hoplessness. the patients ability to point of view. a sense of
cope. 2. Giving the patient a confidence after
2. Convey belief in sense of being able to do so.
patients ability to encouragement and 2. The patient showed
develop and use coping belief will increase an increase in
skills. their self esteem and confidence and
3. Identify and point out reduce feeling of wanted to begin
patients strengths and dependence. forming coping
encourage putting those 3. Pointing out the mechanisms.
strengths to use. patients strengths will 3. Client identified
encourage him to use their own strengths
(Phelps, Ralph, & Taylor, them more and cause and was motivated
2017) him to maintain to try to use them in
optimal functioning. developing new
coping mechanisms.
(Phelps, Ralph, & Taylor,
2017)
Secondary Nursing Diagnosis:
Ineffective coping related to aurditory hallucinations as evidenced by alteration in concentration.
Client will be able to Patient will identify 1. Help patient recognize 1. An increase in self- 1. Pointing out positive
express feelings of coping effective and ineffective positive personal esteem wil help patient qualities allowed the
difficulties associated with coping techniques by the qualities. feel more inclined to patient to feel more
auidtory hallucinations. end of shift. 2. Help patient analyze choose effective confident in making
current situation and coping behaviors. effective coping
use effective coping 2. This will help the decisions.
techniques. client build an 2. Working with the
3. Encourage the patient objective point of client to identify

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 to use support systems. view. current coping
3. Having a support techniques built a
system will help stepping stone for what
(Phelps, Ralph, & Taylor,
encourage the patient to do in the future
2017)
to maintian effective when identifying
coping skills. coping mechanisms.
3. Creating a support
system encouraged the
(Phelps, Ralph, & Taylor,
client to continue
2017)
making effective
coping choices now
and in the future.
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

Anxiety Disorders. (2020). Retrieved from https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

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

Kluwer.

Schizophrenia. (2020). Retrieved from https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-

20354443

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

Varcarolis, E. M. (2017). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care (3rd ed.

Revised reprint). St. Louis, MO: Elsevier-Saunders. ISBN-13: 9780323389655 (Available as print text only)

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