Behavioral Health Care Plan

Student: Sareece Guerrero Date: 02/22/20

Course: NSG-322CC Instructor: Mbeng

Clincial Site: Banner Del Webb Client Identifier: D. R. Age: 70

Reason for Admission: Client D. R. was admitted 02/21/20 voluntarily in private car from daughter worrying about recent abnormal isolation
and hearing him say, “Maybe swallow some cleaning fluid, that would do it” in admitting suicidal ideation.

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

Medical History: hypertension, high cholesterol, depression, tobacco user,
cut wrists in the past (date unknown)
Suicidal Ideation: This occurs when a person undergoes a complex and
intense range of emotions and altered thought processes that leads them to
think of ways to self-inflict death. It is said that 90% of suicide
completions were done by those who had a diagnosable psychiactric
disorder, such as depressive disorders, psychosis, substance abuse, and
personality disorders. Neurobiologically, those with abnormalities in their
serotonin system, overactivity of the noradrenergic system, and with
hypothalmic-pituitary-adrenal abnormalities have been linked to those
with suicidal ideations. Other chronic conditions with a poor prognosis
such as cancer also make a person at risk. Medications like
benzodiazepines, antihypertensives, and calcium channel blockers may
cause suicidal thoughts as well. Life situations that may put someone in
immense emotional distress are socioeconomic problems, legal issues,
Social isolation: “Risk factors to be assessed among older adults
include social isolation, solitary living arrangements, widowhood,
lack of financial resources, poor health, and feelings of
hopelessness” (Varcarolis, E. M., 2017, p. 365). The client’s
daughter claimed he was isolating himself, and he admitted to
pushing his family away and feeling lonely. At the facility, he spent
most of his time alone if he was not in group or eating meals.
Hopelessness: “According to Brendel and colleagues (2016),
extreme hopelessness appears to be a key predictor of suicide.
Often this type of thinking is precipitated or intensified by a
negative and overwhelming event. In other words, people may
contemplate suicide when they feel trapped and that “there is no
way out” (Varcarolis, E. M., 2017, p. 364). The client’s statements
suggest that he believes there is nothing else to live for, and no
other way for him to take his pain away.

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

bullying history, problematic relations, childhood maltreatment, and a
family history of suicide (Varcarolis, E. M., 2017, p. 362-364).

Assessment Data
Subjective Data: Statements made by the client include: “I feel like my life doesn’t amount to anything”, “Tired of living the routine life.
Days flipped by, then comes the holidays again”, “I have been pushing my family away”, “I just don’t see the point of living anymore because a
lot of my friends are dead and the ones that are still alive don’t care to know me anymore”, “Today is going to be my last day on earth”, and “I
have no control over anything in life.” He reports having no strengths or hobbies. These claims that were made expressed the opposite when he
rated his anxiety and depression at a 1/10, which is a sudden behavioral change that makes it more suspicious that his sucidality is being
intentionally masked.
VS: T : 36.4 C Labs: Diagnostics:
BP: 147/74 No abnormal lab values noted Urinalysis: 2/21/20
HR: 75 Amber and hazy
RR: 16 50(small) glucose
O2 Sat: 97 RA 20(small) ketones
100(moderate) protein
Positive bilirubin
0.03(small) blood, 3-10 RBC
11-20 WBC
There were no follow up comments or interventions for
these abnormal results, which raises concern. Although the
lab values were normal, this makes me question things
like kidney dysfunction and infection.

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Assessment: Orders/Safety Protocols:

Mental Status Exam: Code Status: Full Code

Appearance (observed)- Wearing facility clothing of provided purple Q15 minute observation/safety checks
scrubs, no odor sensed, and had slightly dry skin, bald, rash in the groin Routine Vitals
area
Ambulation: independent
Behavior (observed)- Appropriate, cooperative, withdrawn. Attended
groups and meals but layed in bed for the rest of the time Education: depression, HTN, cholesterol, and tobacco use

Attitude (observed)- Willing to participate and get better and is Diet: Regular
appreciative of our service. Could possibly be decieving in claims of
Medication Administration mentioned below
anxiety and deppresion.
Discharge: estimated to be in 7 days, unspecified location
Level of Consciousness (observed)- Intact, fully alert and responsive
(I would ask for another urinalysis a few days later to see if there are
Orientation (inquired)- Fully oriented x4
still abnormal substances in it.)
Speech and Language (observed)- Low, monotone, and clear speech.
Did not speak much, repsonded in few words.
Mood (inquired)- Feels hopeless, lonely, left behind by family and
friends
Affect (observed)- Flat, only smiled once
Thought Process/Form (observed/inquired)- Claims to have no control
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over SI thoughts, and they can last up to 4-8 hours a day. The reasons
for ideation are because he wants to “completely end pain, can’t live on
with pain or feelings”.
Thought Content (observed/inquired)- Seems to be determined to get
better, although deception is assumed because his anxiety and
depression rating went from a 7 to a 1 overnight.
Suicidality and Homicidality (inquired)- Claims to have no intentions or
desire to harm himself or others, but does admit to having SI.
Insight and Judgment (observed/inquired)- Seems to be functioning
when observing his interaction in the Rec group
Attention Span (observed/inquired)- Able to focus
Memory (observed/inquired)- No memory problems
Intellectual Functioning (observed/inquired)- No impairments, received
education at a high school level

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 Medications
ALLERGIES: No known allergies

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
nicotine 21 mg = 1 transdermal Daily Reduce smoking withdrawal Nausea, dizziness, headache, The client is a smoker,
patch symptoms, aids in quitting heartburn, flushing, mood but did not want the
changes (RxList, 2020). nicotine patch. If the
client presents with
symptoms of smoking
withdrawals, then I
would want to let the
client know that this
could help him while
not forcing him to take
it. These side effects are
not very common or
severe, although the
nurse can let the client
know about them if he
chooses to have it.
hydrOXYzine 25 mg = 1 PO Q6H PRN Relieves anxiety QT prolongation, tremors, This client is not on
tablet anxiety headache, dry mouth (RxList, cardiac monitoring or
2020). getting their heart
sounds routinely
checked, so that would
be something to look
into if he did choose to
take it. The nurse
should monitor and
offer alternate relief
from other side effects.
The client should be
educated about the
indications and side
effects if he chooses to
have it.
traZODone 50 mg = 1 PO QBedtime Treats major depressive Serotonin syndrome, suicidal These side effects are

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 tablet PRN sleep disorder, can be used to help thoughts, cardiac arrhythmias, severe and require close
this client sleep orthostatic hypotension, risk for observation of the
bleeding, hyponatremia, client. There are
priapism, headache, asssessments being
nervousness, dry mouth, made about suicidality
constipation (RxList, 2020). and blood pressure,
although there should
also be ones to detect
hyponatremia and
cardiac arrhythmias if
he takes it. The nurse
should hold the
medication and notify
the provider if severe
symptoms occur. The
client should be
educated about the
indications and side
effects if he chooses to
have it.
acetaminophen 650 mg = 2 PO Q4H PRN Pain reliever Nausea, appetite loss, headache, This medication does
tablets pain dark urine, clay-colored stools not have serious or
(RxList, 2020). common side effects, so
the only thing that the
nurse should really
consider is the client’s
pain level and to follow
dosing orders if he
requests it so that no
overdose occurs. The
client should be
educated about the
indications and side
effects if he chooses to
have it.
ibuprofen 400 mg = 1 PO Q6H PRN Pain reliever Stomach pain and ulcers, With long term use, this
tablet pain constipation, diarrhea, bloating, has the potential to
gas, heartburn, nausea, vomiting, disrupt the lining of the
dizziness, headache (RxList, stomach and cause
2020). gastric ulcers and

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 bleeding, which is the
main thing to be
monitoring. The nurse
should monitor and
offer alternate relief
from other side effects.
The client should be
educated about the
indications and side
effects if he chooses to
have it.
bisacodyl 5 mg = 1 PO Daily PRN Treats constipation (stimulant) Abdominal cramping, nausea, The client does not have
tablet constipation vomiting, diarrhea (RxList, constipation, although
2020). there are three PRN
medications for it if he
does. If this medication
is causing undesirable
side effects, then he can
switch to an alternative
drug if he wants. The
nurse should monitor
and offer alternate relief
from other side effects.
The client should be
educated about the
indications and side
effects if he chooses to
have it.
docusate 100 mg = 1 PO BID PRN Treats constipation (softner) Abdominal cramping, diarrhea, The client will not be
capsule constipation low electrolyte levels and using this long-term and
dependence with excessive use is not at risk for
(RxList, 2020). dependence or major
electrolyte imbalances,
so if the medication is
causing any other upset
to the client, an
alternative treatment
can be used. The client
should be educated
about the indications

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 and side effects if he
chooses to have it.
calcium carbonate 500 mg = 1 PO TID PRN Relieves indigestion Milk-alkali syndrome, The nurse must monitor
tablet indigestion Hypercalcemia, signs of these
hypophosphatemia, appetite loss, electrolyte imbalances
nausea, constipation (RxList, that can have serious
2020). effects of metabolic
alkalosis if left
untreated. The nurse
should monitor and
offer alternate relief
from other side effects.
The client should be
educated about the
indications and side
effects if he chooses to
have it.
magnesium hydroxide 30 mL PO Daily PRN Treats constipation Muscle weakness, respiratory The client’s vital sign
constipation depression, hypotension, are being monitored, so
electrolyte imbalance, diarrhea it would be necessary to
(RxList, 2020). be aware of the effects
it can have on blood
pressure and respiratory
rate. The nurse must
monitor signs of these
electrolyte imbalances
that can have serious
effects of on the body if
left untreated. The nurse
should monitor and
offer alternate relief
from other side effects
such as diarrhea. The
client should be
educated about the
indications and side
effects if he chooses to
have it.
Nursing Diagnoses and Plan of Care
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 Goal Expected Outcome Intervention(s)
Client- or family-focused. Measurable, time-specific, Nursing or interprofessional
reasonable, and attainable. interventions.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for suicide, related to hopelessness, as evidenced by claims such as, “I just don’t see the point of living anymore”,
“Maybe swallow some cleaning fluid, that would do it”, and “Today is going to be my last day on earth.”
This is priority because it has a direct effect on the client’s safety when he makes claims of wanting to kill himself.
Client will remian safe and The client will report and The nurse will perform ordered
return to baseline mental state. display no signs of suicidality suicide precautions such as Q15
and report a scale of anxiety minute observations and limiting
and depression lower than 2/10 access to potentially harmful
upon discharge. objects.
Create a professional and
tustworthy relationship with the
client to help him open up about
his true feelings. When his real
feelings are expressed, they can
be treated.
The client could benefit from
making a suicide contract so that
he is encouraged to not harm
himself.
Rationale
Provide reason why intervention
is indicated/therapeutic.
Provide references.
“Follow institutional protocol for
suicide regarding creating a safe
environment (taking away
potential weapons—belts, sharp
objects; checking what visitors
bring into patient’s room)”
(Varcarolis, E. M., 2017, p.
369).
“Encourage patients to talk
about their feelings and problem
solve alternatives” (Varcarolis,
E. M., 2017, p. 369).
“If accepted at your institution,
construct a no-suicide contract
with the suicidal patient. Use
clear, simple language. When
contract expires, it is
renegotiated” (Varcarolis, E. M.,
2017, p. 369).
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
The nurse was able to
maintain Q15 minute
observationsof the client to
ensure safety.
The nurse was able to show
the client genuine care for
them and establish rapport. I
was not personally able to
gather information of his real
feelings, although he was
able to share beforehand.
The client did not make a
suicide contract, as the health
care professionals did not
offer it to him.
Overall, the client was able to
claim no signs of suicidality
and remain safe, although his
appearance and behavior
suggest that he may still be
suffering. This goal is to be
awaited for his actual time of
discharge
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Secondary Nursing Diagnosis:
Risk for infection, related to substance in the urinary tract, as evidenced by urinalysis results containing WBCs and other
abnormalities.
This is secondary because the urinalysis had no confirmation of the presence of bacteria, so this would just be something to
monitor.
Client will remain free from The client will show no signs of The nurse will perform proper “Wash your hands frequently, The nurse was able to perform
infection infection and maintain practices hand hygeine and encourage the hand washing is the single most proper hand hygeine and
to reduce the risk of infection client to wash their hands often important thing you can do to encourage hand hygeine in the
throughout his stay. before and after bathroom use prevent infection” (Harding, M., client.
and before and after eating or Roberts, D., Reinisch, C.,
interacting in the public area. Hagler, D., & Kwong, J., 2020,
p. 215).
The client was able to drink
Encourage fluid intake to adequate fluids to dilute his
further dilute urine and prevent “Management: uncomplicated amber urine.
statsis and UTI. UTI, adequate fluid intake”
(Harding, M., et. al, 2020, p.
1027). The client and nurse were able
The nurse will teach the client to work together to ensure his
the importance of perineal care perineal area was clean.
and the proper technique. “Perineal care after each bowel
movement are important for
comfort and to prevent Overall, the client had remained
infection” (Harding, M., et. al, free from infection, showed no
2020, p. 1265). signs of infection, and
maintained practices to reduce
the risk of infection thorughout
his stay.
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.
References
Harding, M., Roberts, D., Reinisch, C., Hagler, D., & Kwong, J. (2020). Lewis's Medical-Surgical Nursing. VitalSource Bookshelf.

(11th ed.). Retrieved from https://online.vitalsource.com/#/books/9780323551496/

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

VitalSource Bookshelf. (3rd ed.). Retrieved from https://online.vitalsource.com/#/books/9780323389655/

RxList. (2020). Drugs A-Z list. Retrieved from https://www.rxlist.com/script/main/hp.asp

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