MENTAL HEALTH NURSING

NURSING CARE PLAN

I. Identification Data of Patient

Name: Trishna
Age: 37 year-old
Sex: Female
Religion: Hindu
Marital Status: Married
Educational Status:12th
Occupation: Housewife
Income Per Month:10,000
Languages Known: Hindi, punjabi
Ward: Psychiatric ward
Diagnosis: Depression
Address: Anand nagar patiala
Date of Admission:10 june 2021
Informant : Husband Relationship with Patient: Husband
Reliability of information : Yes/No
II. Presenting Chief Complaints
Patient: : Patient reports that when she was 19 years old, she cut her wrists because of a relationship with
her boyfriend.  The relationship ended because she moved to another state. She admitted it was an unwise
decision when she was taken to the hospital for treatment, but she was not hospitalized.  There is no
history of psychiatric hospitalization. At about 21years old, she saw a psychologist briefly due to some
issues in her life that were not fully revealed by the patient. She has used Cymbalta up to 60 mg and
Wellbutrin up to 200 mg twice daily at various times. The Cymbalta was slightly helpful; following
patient medication was changed to Wellbutrin by another physician to reduce her cigarette craving.  She
reports that the depression has been poorly controlled, but tobacco usage has been tapered down. She
denies any treatment with a psychiatrist or psychiatric nurse practitioner. The patient stated “I have been
feeling depressed, anxious and under stress” depression need to be considered as potential diagnosis, the
other diagnosis generalized anxiety and sleep apnea disorder due to excessive daytime sleepiness,
awakening, frequent arousals, and fatigue.

Informant:Husband told that she said, “I feel like killing myself.” She had lost her interest in life about
four months before. During that time, she reported depression every day for most of the day. Symptoms
had been getting worse for months. She had lost 14 pounds without dieting because she did not feel like
eating. She had trouble falling asleep almost every night and woke at 3:00 a.m. several mornings a week
(she normally woke at 6:30 a.m.). She had low energy, trouble staying focused and less ability to do her
office job at a dog food-processing plant. She was convinced that she had made a mistake that would lead
to the deaths of thousands of dogs. She expected that she would soon be arrested and would rather kill
herself than go to prison.
III. Present HistoryPatient’s depression started when she was a teenager. Patient reports being irritable
and having occasional crying spells. She frequently has a problem with motivation. She has trouble
remembering things and has low energy level. Appetite has been very poor without any weight
change. She has obstructive sleep apnea and a child who does not sleep at night due to the medical
condition. Patient reports going into “panic mode” where she feels that her whole body will explode.
During this period of panic mode, she becomes tachycardic, has difficulty taking a deep breath,
elevated blood pressure and sense of impending doom. She reports that these feelings may last about 3
hours and has on two occasions lasted about three days. This panic mode she communicates comes
after periods of not able to pay her monthly bills. She went to the clinic today because she is becoming
more irritable and anxious than usual.
 Treatment History
1. Drugs (name of the drug, dose, route, side effects, if any) : Medications:  Wellbutrin 200
mg(bupropion) b.i.d. (depression)

2. Cymbalta (duloxetine)30 mg PO daily (pain)

3. L-thyroxin 100mcg PO daily (hypothyroidism)

4. Lisinopril(zestril) 20mg PO daily (hypertension)

5. Hydrochlorothiazide 25mg PO daily (hypertension)

6. Metformin 800mg PO BID (Diabetes)

7. Zocor 20mg PO daily (cholesterol)

8. Ultram 75mg PO PRN q6hrs for pain

9. Prevacid 15mg PO daily for GERD

10. Over-the-counter: Multivitamins.

11. Herbal: Denied.

 ECT: Not given

 Psychotherapy: Cognitive behaviour therapy, interpersonal therapy, exercise and physical

activity, relaxation tharapy yoga etc given.

 Family therapy:Family therapy is given.

 Rehabilitation:

IV. Past Psychiatric and Medical History

 Allergies:  Penicillin,No known environmental or food allergies

 Childhood illness: Reports having usual childhood illnesses but cannot recall specific ones.
  Surgery:  Bilateral tubal ligation in 2007 and partial hysterectomy in 2004 for menorrhagia. 
The patient has had several miscarriages.

 Immunizations: All childhood immunizations were completed; including hepatitis A & B

series.

 Medical diagnoses: Hypertension, Obstructive Sleep Apnea, Gastric Esophageal Reflux

 Disease, Diabetes Mellitus, Chronic back pain, Obesity, Hypercholesterolemia.

 Psychiatric diagnosis: depression

 Treatment outcome:Good

 Substance use details:

 Caffeine: The patient has two or three drinks per day of coffee. She started drinking at age 14.
Still drinks coffee

 Tobacco: She consumes a pack of cigarettes a week given that she began Wellbutrin and before
that time she had been smoking one-half pack per day. Her first smoking experience was at age 15.

 Alcohol: Denied. It is essential to know if the patient drinks alcohol because a lot of psychoactive
medications can have an adverse interaction with alcohol.

V. Family History
Age at death
Name of Age/ Education Occupation Health Relationship and mode of
family Sex Status with patient death
member
 Trishna 37/F 12th Housewife Depression Patient
 Parkas 40/M B.A Shopkeeper Good Husband
h 15/F 10th Student Good Daughter
 Neena 12/M 8TH Student Good Son
 Angad

Genogram
(family of origin, three generations)
VI. Personal history

A. Perinatal history
 Antenatal period: No
 Intranatal Period: type of delivery- normal
 Birth: full term

 Birth Cry: immediate

 Birth Defects: No
 Postnatal complications: jaundice
B. Childhood history
 Primary caregiver:Mother
 Feeding: breastfed
 Age at weaning: 8month
 Developmental milestones: normal
 Behavior and emotional problems: thumb sucking, excessive temper tantrums, stuttering/
head- banging, nail biting.pica enuresis,
 Illness during childhood: malnutrition.

C. Educational History
 Age at beginning of formal education:6th
 Academic performance:Good
(specifically look for learning disability and attention deficit disorders)
 Extracurricular achievements, if any:No
 Relationship with peers and teachers:Good
 School phobia: yes
 Look for conduct disorders: No
(For e.g., truancy/ stealing)
Reason for termination of studies: Patient quit high school twice. Due to her depression. She stopped
before the last semester of her senior year. She got her GED after getting married.  The patient will
require learning a trade or continue education in adulthood if diagnoses are well managed.

D. Play history-Hockeyand kho kho with classmates

(at what stage and with whom)
 Relationship with Playmates:Good

E. Emotional Problems during Adolescence

Delinquency, smoking,drug taking.
F. Puberty
 Age at appearance of secondary sexual characteristics:16 Year
 Anxiety related to puberty changes:Yes
 Age at menarche:18year
 Reaction to menarche-anxiety
 Regularity of cycles, duration of flow:Regular,3-5 days
 Abnormalities, if any (menorrhagia, dysmenorrhea, etc.):Dysmenorrhea

G. Obstetrical History
 LMP:
 Number of children:2
 Any abnormalities associate with pregnancy, delivery, puerperium:No
 Termination of pregnancy, if any:No
 Menopause (including any associated problems):Night sweats,Anxiety

H. Occupational History
 Age at starting work:Housewife
 Job held in chronological order:
 Reasons for changes:
 Current job satisfaction:
(including relationship with authorities, colleagues, subordinates)
 Whether the job is appropriate to patient’s background: Yes/ No

I. Sexual and Marital History

 Types of marriage Arrange
 Duration of married life: 16 year
 Interpersonal and sexual relations: Satisfactory
 Extramarital relationship, if any, specify:No

J. Premorbid Personality
 Interpersonal relationship: Extrovert
 Family and Social relationship: Good
 Use of Leisure time Watching t.v,cooking
 Predominant mood: Optimistic fluctuating/
Desponent
 Usual reaction to stressful events: Depressed
 Attitude to self and others: Negative
 Attitude to work and responsibility:Responsible
 Religious beliefs and moral attitudes:Religious
 Habits
 Eating Pattern: Irregular
 Elimination: Regular
 Sleep: Irregular
 Use of drugs/ alcohol:Smoking
  Exercise Pattern: Nil
PHYSICAL EXAMINATION
 General Examination:
 Temperature:98.4f
 Pulse:82/beats/min
 Respiration:18/min
 Blood Pressure (BP):’ 142/88mm/hg
 Cardiovascular system:Hypertensive
 Respiratory System: : Normal
 Gastrointestinal System: : Normal
 Musculoskeletal System: Normal
 Lymph Nodes:Normal
 Breasts:Normal
 Pelvic Examination: Last Pap smear: June 2019. Result was negative
 Any other Signs:No

Summary:

MENTAL STATUS EXAMINATION

Mental Status Exam:

General appearance: Dressed appropriately for the season. Grooming is good. The patient appears
older than stated age.

Thinking Process: Patient dressed appropriately for the season

Behavior during the interview: Arrived on time. Cooperative, alert, and pleasant.

Thinking Process: During the interview, the patient was cooperative, alert, and pleasant.  The patient also
arrived on time

 Social skills: Had good eye contact. Reports reduced socialization.

Thinking process: patient maintained good eye contact.

Orientation:  Aware of person, place and time.

Thinking Process: Patient is within a reasonable range of self-aware

Memory: Memory was good for immediate recall of interviewer’s name.  Thinking process: Able to spell
the word “twitter” in forwarding and backward directions correctly. The patient can recall last four
presidents of the country.

Speech patterns: Very circumstantial and tangential with rate and tone.
Thinking Process:   Patient speech patterns seem normal.

Thought clarity: Clear

Thought content: She denies auditory or visual hallucinations. She denies suicidal and homicidal
ideation.

Thought process: No overt sign of psychosis, goal-directed.

Mood: Depressed, anxiety level is moderate.

Affect: Consistent with mood

Thinking process: Patient has clarity. Patient denies suicidal and homicidal ideation.

Insight and Judgment: Appropriate. Able to explain what she will do if when she gets to a stop sign
while driving, she responded: “I will stop”. She states that she needs help with her mental health.

Intellectual functioning: Intelligence is average.  The patient was able to complete initial interview and
consent forms.

Abstract thinking: She can interpret the proverb “make hay while the sun shines” means to work hard
while you can and save up for the future 

NURSING MANAGEMENT
Nursing Assessment
 Objective Data:

 Subjective Data:
  List of Nursing diagnosis according to the needs of the patients
1.Disturbed Thought Process related to biochemical/ neurophysical imbalance secondary to depression as
evidenced by impaired insight and judgment, poor decision-making skills, difficulty handling complex
tasks, confusion and disorientation, inability to do activities of daily living (ADLs) as normal.
2. Impaired Social Interaction related to social isolation secondary to clinical depression as evidenced by
withdrawal from group gatherings or social events, anxiety, impaired perception, inability to meet basic
needs and role expectations.
3.Risk for self-directed violence.
4.Self-Care Deficit
5. Grieving

-Disturbed The patient -Assess the patient’s level of -Patients level -To monitor
Thought will be able confusion. of confusion is effectiveness of
Process related to regain assessed. treatment and therapy.
to biochemical/ appropriate
neurophysical mental and -Assist the patient performing -Patient was -To maintain a good
imbalance physical activities of daily living. assisted in quality of life and
secondary to functioning. Consider one-to-one nursing. performing promote dignity by
depression as activities of allowing the patient to
evidenced by daily living. perform their ADLs
impaired while maintaining
insight and safety.
judgment, poor
decision- -Provide opportunities for the -Opportunities -To prevent feelings
making skills, patient to have meaningful are provided to of isolation. However,
difficulty social interaction, but never patient. forced interaction can
handling force any interaction. make the patient
complex tasks, agitated or hostile due
confusion and to confusion.
disorientation,
inability to do -Allow the patient to take Patient was -To help the patient
activities of time and think about what to allowed to take have enough time to
daily living say or do. time and think communication and
(ADLs) as about what to not feel rushed or
normal say or do. bothersome.

-Ensure that the patient takes -Ensured that -To ensure adherence
medications on time and as the patient takes to medical regimen.   
prescribed medications on
time and as
prescribed
-Impaired The patient -Explore the patient’s reasons -Patient’s -To establish a
Social will for social withdrawal without reasons for baseline observation
Interaction demonstrate judging or giving suggestions social of the anxiety level of
related to improved at first. Assess the anxiety withdrawal are the patient. Open-
social isolation social level of the patient, anxiety explored ended questions can
secondary to interaction by triggers and symptoms by without judging help explore the
clinical increased asking open-ended questions. or giving thoughts and feelings
depression as participation suggestions of the patient
evidenced by in social regarding social
withdrawal events. isolation.
from group
gatherings or -Initially, support the patient -Patient was -The patient can
social events, by meeting dependency needs supported by become more
anxiety, if deemed necessary. meeting confused, depressed or
impaired dependency anxious if the avenues
perception, needs for dependency are
inability to suddenly and/or
meet basic complete eliminated.
needs and role
expectations
-Encourage the patient to be -Patient was -To enhance the
independent and provide encouraged to patient’s self-esteem
positive reinforcement for be independent and encourage
 being able to do self-care and and provide him/her to repeat
other independent behaviors. positive desired behaviors. 
reinforcement
for being able to
do self-care.
-Support the patient’s efforts -The patient should
to verbalize and explore the -Patient’s efforts first recognize and
meaning behind each are supported to accept the presence of
ritualistic behavior or verbalize and ritualistic behavior or
tendency to become explore the tendency to become
withdrawn. meaning behind withdrawn before
each ritualistic change can happen.
behavior.
-Risk for self- -Identify the level -A client with a high-
directed of suicide precautions -Identified the risk will require a
violence needed. If there is a high-risk, level constant supervision
does a hospitalization of suicide preca and a safe
requires? Or if there is a low utions needed. environment.
risk, will the client be safe to
go home with supervision
from a family member or a
friend? For example, does
client:
 Admit
previous suicid
e attempts.
 Abuse any
substances.
 Have no
peers/friends.
 Have any
suicide plan.
-Check for the availability of -Normally, a suicidal
required supply of -Availability of client’s medical
medications needed. required supply supply should be
of medications limited to 3-5 days.
was checked.
-Encourage clients to express -Clients can learn
feelings (anger, sadness, -Clients are alternative ways of
guilt) and come up with encouraged to dealing with
alternative ways to handle express feelings overwhelming
feelings of anger and (anger, sadness, emotions and gain a
frustration. guilt) and use sense of control over
alternative ways his/her life.
to handle
-Contact the family, arrange feelings of anger
for crisis counseling. Activate and frustration. -Clients need a
links to self-help groups. network of resources
-Contacted with to help diminish
the family, personal feelings of
 arrange for helplessness,worthless
crisis ness, and isolation.
counseling.

-Implement a written no- -Reinforces action the

-Self-Care
suicide contract. client can take when
Deficit feeling suicidal.
-Written no-
suicide contract
-Encourage the use of soap, was -Being clean and well
washcloth, toothbrush, implemented. groomed can
shaving equipment, make-up temporarily increase
etc -Encourage the self-esteem.
use of soap,
washcloth,
toothbrush,
-Give step-by-step reminders shaving -Slowed thinking and
such as “Brush the teeth equipment, difficulty
“Clean the outer surfaces of make-up etc. concentrating make
your upper teeth, then your organizing simple
lower teeth. . .” tasks difficult.

-Monitor intake and output, -Most of the depressed

especially the bowel clients are constipated.
movements in case of If this problem is not
constipation. -Intake and addressed, it can lead
output, to fecal impaction.
especially the
bowel
movements in
-Encourage the intake of case of -Fluids can help
nonalcoholic and constipation are prevent constipation.
noncaffeinated fluids, 6 to 8 monitered.
glasses a day. -Patients was
encouraged to
-Encourage small, high- take fluids, 6 to -Minimize weight
calorie, and high-protein 8 glasses a day. loss, constipation,
snacks and fluids frequently and dehydration.
throughout the day and -Patients was
evening if weight loss is encouraged to
noted. take small, high-
calorie, and
-Assess the patient’s religious high-protein -Religious beliefs and
beliefs and cultural practices snacks. cultural practices
in terms of how they handle influence how people
their previous losses. -Patient’s express and accept
Grieving
religious beliefs the grieving process.
-Allow the patient to and cultural
recognize and express practices are -Expressing feelings
feelings and determine the assessed. in a nonthreatening
connection between the environment can aid
feelings and the event. -Patient was patients in handling
allowed to unresolved issues that
recognize and may be partly
express feelings responsible for the
and determine depression. It can also
the connection aids patient relate the
between the feeling to the event.
-Suggest alternative methods feelings and the
to determine and cope with event. -Allows individuals to
underlying feelings of anger, explore more ways in
hurt, and rejection. handling such
-Alternative situation.
methods to
determine and
cope with
-Assist the patient in underlying
recognizing early signs of feelings of -This actively
depression and identify anger, hurt, and involves the patient
methods to mitigate these rejection. and conveys the
signs. If the symptoms persist -Patient was message that the
or worsen, suggest other assisted in patient is not
professional support. recognizing powerless but rather
early signs of that options are
depression and available.
identify methods
to mitigate these
signs.