Nursing Care Plan 1

Assessment: Nursing Diagnosis: Outcome:

Impaired Social Interaction: Impaired social interaction ● The patient will
Insufficient or excessive related to lack of support identify feelings that
quantity or ineffective quality system as evidenced by lead to poor social
of social exchange dysfunctional interactions interactions by the
(Varcarolis & Halter, 2018). with family and peers.
end of day three of
● Patient reports: inpatient therapy
“Few close friends” (7/30/20 @ 0000).
● Patient states: “Has ● The patient will
been isolating from interact with
friends and family family/friends by the
over the last two end of day one of
days” inpatient therapy
● Lives with her (7/27/20 @ 0000).
mother
● Parents divorced 12
years ago
● Father lives out of
state
Interventions: Rationales: Evaluation:
● When the Jenna is ● Maximizes the ● Outcome met; the
at the most potential for patient was able to
depressed state, the interactions while identify feelings that
nurse will Involve minimizing anxiety lead to poor social
interaction by the end
the client in one-to- levels (Doenges &
of 7/30/20 2300. Will
one activity. et al, 2016). follow up with this
● The nurse will ● Socialization care plan tomorrow,
eventually involve minimizes feelings as Jenna is at risk for
the client in group of isolation. future decreased
activities (e.g., Genuine regard for interactions with
group discussions, others can increase family/friends,
art therapy, dance feelings of self- evaluate during next
therapy). worth (Gulanick & shift.
● The nurse will help Myers, 2016). ● Outcome partially
Jenna to solve the ● Anticipatory met, Jenna was able
to meet with her
problem of isolation planning can ease
mother, however, she
for short-term the sense of was unable to provide
solutions, such as isolation and meaningful
acute inpatient loneliness that can communication. Will
hospitalization due accompany this continue current care
to SU attempt. situation (Varcarolis plan and reassess
● Refer Jenna and & Halter, 2018). tomorrow (7/28/20)
her family to self- ● Jenna and the after further
help groups in the family can gain assessment

1
 community. tremendous support -----------S. N. S.
and insight from Zerbst 7/27/20 0000.
people sharing their
experiences
(Gulanick & Myers,
2016).

Nursing Care Plan 2

Assessment: Nursing Diagnosis: Outcome:
The diagnosis Disturbed Disturbed thought process ● The patient maintains
Thought Processes related to Adderall overdose reality orientation and
describes an individual secondary to depression as communicates clearly
with altered perception and evidenced by an inaccurate with others at the end
interpretation of stimuli of this shift (7/27/20
cognition that interferes
including auditory @ 2300).
with daily living. Causes hallucinations. ● The patient
are biochemical or
recognizes and
psychological disturbances
clarifies possible
like depression and
misinterpretations of
personality disorders
the behaviors and
(Varcarolis & Halter, 2018).
verbalization of
● The patient
others by inpatient
informed her mother
hospitalization day
that she took a
three, 7/30/20 @
“handful” of Adderall
0000.
this morning.
● The patient’s
mother reports
Jenna took
approximately 20
tabs of Adderall
● Complaining she’s
hearing voices;
denies visual
hallucinations
o Command
hallucinations
in nature
● Jenna states: “the
devil is in the place!
I can feel it! The
voices are telling
me that I am going
to hell forever!”
● Appears fearful and
anxious

2
 ● Little to no eye
contact
● Appears to be
looking through you
when she does look
at you.
Interventions: Rationales: Evaluation:
● The nurse will assist ● Cognition/thinking ● Outcome partially
with treatment for often improves with met; the patient was
underlying treatment/correction able to maintain
problems-- correct of occasional orientation
throughout the day.
Jenna’s overdose medical/psychiatric
○ The nurse will
on Adderall. problems (Doenges recognize and
● The nurse will & et al, 2016). support the
provide safety ● It is always patient’s
measures (e.g., side necessary to accomplishme
rails, padding, as consider the safety nts including
necessary; close of the patient those with
supervision, seizure (Gulanick & Myers, projects,
precautions), as 2016). responsibility
indicated. ● The patient may feel fulfillment and
● The nurse will threatened and may social
interactions
refrain from forcing withdraw or rebel
(Gulanick &
activities and (Gulanick & Myers,
communications. 2016). Myers, 2016).
Will re-assess
● The nurse will ● This is to avoid outcome
reduce provocative triggering fight/flight 8/2/20 @
stimuli, negative responses 0000. SN. S.
criticism, (Gulanick & Myers, Zerbst 8/2/20.
arguments, and 2016). ● Outcome met, Jenna
confrontations. was able to clarify
misinterpretations of
her behaviors. SN. S.
S. Zerbst 7/30/20
0000.

3
 Nursing Care Plan 3
Assessment: Nursing Diagnosis: Outcome:
Ineffective Coping: Ineffective coping related to ● The patient
Inability to form a valid inadequate preparation for describes and
appraisal of the stressors, stressors and inadequate initiates effective
inadequate choices of support system secondary to coping strategies by
destructive behavior toward
practiced responses, the end of inpatient
self, as evidenced by
and/or inability to use overdose on Adderall.
stay day 3 (7/30/20
available resources @ 0000).
(Varcarolis & Halter, 2018). ● The patient
● According to identifies personal
Jenna’s Mother she strengths and
took approximately accepts support
20 tabs of Adderall through the nursing
● Complaining she’s relationship by the
hearing voices; end of this shift
denies visual (7/28/20 @ 2300).
hallucinations Will continue to re-
o Command assess this care
hallucinations plan, as the patient
in nature may regress to
● States: “the devil is ineffective coping
in the place! I can mechanism after
feel it! The voices every shift
are telling me that I throughout her
am going to hell inpatient
forever!” hospitalization.
● Appears fearful and
anxious
● Little to no eye
contact
● Appears to be
looking through you
when she does look
at you.
● Hospitalized three
weeks ago
o Diagnosed
with
depression
o Diagnosed
with suicidal
ideations
o Discharged
ten days ago

4
 ● Lives with her
mother
● Parents divorced 12
years ago
● Graduated from
high school
● Few close friends
● No current plans for
her future
Interventions: Rationales: Evaluation:
● The nurse well set a ● An ongoing ● Outcome met, Jenna
working relationship relationship was able to identify
with Jenna through establishes trust, positive coping
continuity of care. reduces the feeling mechanism. SN S.
Zerbst 7/30/20 0000
● The nurse will assist of isolation, and
● Outcome partially
Jenna with set may facilitate coping met, Jenna was able
realistic goals and (Gulanick & Myers, to identify personal
identify personal 2016). strengths, however, is
skills and ● Involving the patient unable to accept
knowledge. in decision making support. Will
● The nurse will helps them move reassess her ability to
provide chances to toward accept support for her
express concerns, independence strengths by 8/1/20
fears, feelings, and (Varcarolis & Halter, 0000.
expectations, while 2018).
using empathetic ● Verbalization of
communication. actual or perceived
● The nurse will threats can help
educate Jenna on reduce anxiety and
different coping open doors for
mechanisms for her ongoing
to be able to better communication
cope with life (Varcarolis & Halter,
stressors. 2018).

5
 References:

Alexis, I. (2019). Adderall overdose signs and symptoms. Retrieved:

https://www.addictioncampuses.com/adderall/overdose/

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide:

Diagnoses, prioritized interventions, and rationales. FA Davis

Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and

Outcomes. Elsevier Health Sciences

Healthline. (2020). Low creatine. What need to know. Retrieved:

https://www.healthline.com/health/low-creatinine

Keltner, N. L. (2013). Psychiatric nursing. Elsevier Health Sciences

Varcarolis, E. M., & Halter, M. J. (2018). Depressive Disorders. In Foundations of

psychiatric mental health nursing: A clinical approach (pp. 242-269). St. Louis,

MO: Saunders Elsevier