Nursing Care Plan Problem List (5) & Teaching Needs (3)

First, review the health history, physical assessment, intake & output, medication records
for any problems your patient is having. List them below.
Second, assign them according to Maslow’s Hierarchy of Needs: A= Physiological,
B=Safety & Security, C=Love & Belonging, Self-Esteem, Self-Actualization, or
D=Knowledge.
Third, prioritize which problems in each category are the most important (1,2,3…)
Fourth, develop a nursing diagnosis to each problem (NANDA R/T etiology AEB)

3 actual; 1 risk; 1 wellness

Problem Maslow’s Priority Nursing Diagnosis

1. Ineffective Coping R/T situational
Situational crisis, AEB patient stating “I need
crisis, estranged C 2 to be in a safe place so I will not
daughter harm myself.”
making
derogatory
comments by
text to her
mother leading
to severe
anxiety

2. Severe Anxiety R/T fear AEB

Nervousness B 4 patient stating “ I don’t like to be
around large crowds of people
because I get paranoid.”

3. Risk for suicide AEB patient

Suicide ideation B 1 stating “I have attempted suicide
twice in the past by over dosing
on pills.”

4. Rape Trauma Syndrome R/T

Raped by B 3 having been the victim of sexual
cousin when assault AEB patient stating “ I
she was 8 can’t get the flashbacks of
years’ old trauma out of my thoughts.”

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 5. D 5 Readiness for enhanced Power
Self-control AEB patient stating “ I want to
learn how to gain self- control and
cope with my negative thoughts
and emotions, I don’t want to
have suicidal thoughts anymore.”

Identify 3 teaching needs

1.Teach the patient relaxation techniques such as deep breathing and guided
imagery to help shift negative thoughts to positive thoughts

2. Teach patient to join an exercise program such as aerobics or attend yoga

classes.

3.Teach patient to listen to you tube videos for positive affirmation, meditation for
mind body and spirit to enhance self-concept.

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 APPENDIX M
MEDICATION SHEET
Student Patient Diagnosis:
Name: Vivian Initials: JD Major
Fakhoury Depressiv
e Disorder
Allergies:
NKDA
Drug Dosage/ Route Admin Classification Purpose of Major Nursing
Frequency/Usual Times Drug/ Name Implications
Dosage Medical DX
Generic: Patient: 522 mg PO Once Daily Anti- Action: Side Effects:
buPROPion extended release Depressants Unknown, Drug Suicidal behavior
hydrochloride ERT tablet doesn’t inhibit Seizures
Brand: MAO, but it Agitation
Wellbutrin XL Usual: weakly inhibits Arrhythmias
174 mg norepinephrine, Blurred vison
348 mg dopamine, and Constipation
522 mg serotonin Increased coughing
reuptake. Weight loss
Rash
Usual: Decreased libido
Major Contraindications
Depressive
Disorder If taken MAO’s
Seasonal within the previous

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 Affective 14 days
Disorder Don’t take in
combination with
SSRI’s or
Patient/DX: methylene blue,
Major can cause
Depressive serotonin
Disorder syndrome

Precautions:
Don’t use with
other drugs
containing
Bupropion

Contraindicated in
patients abruptly
stopping use of
alcohol or
sedatives
(including
benzodiazepines).

Interactions:
Beta Blockers may
increase the levels
of these drugs and
adverse effects.
Use a reduced
dose with
Bupropion

Lab test
inferences:
May increase LFT

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 values.
May cause false-
positive results for
urine detection of
amphetamines.

Assess/Monitor:
Closely monitor
patient with history
of bipolar disorder.
Antidepressants
can cause manic
episodes during the
depressed phase
of bipolar disorder.
This may be less
likely to occur with
bupropion than with
other
antidepressants.
Teach:
Teach patient to
recognize and
immediately report
symptoms of
serotonin toxicity
(fever, mental
status changes,
muscle twitching,
excessive
sweating, shivering
or shaking
diarrhea, loss of
coordination).

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 Black Box
Waring:
Bupropion isn’t
approved for use in
children.
Use cautiously in
patients with recent
history of MI;
unstable heart
disease; renal or
hepatic impairment;
a history of
seizures, head
trauma, or other
predisposition to
seizures; and in
those being treated
with drugs that
lower seizure
threshold.

Tx of Overdose: No
Antedote listed
Reference: Lippincott Course Point Online

APPENDIX M
MEDICATION SHEET
Student Patient Diagnosis Major Depressive Disorder
Name:Vivian Initials:JD :
Fakhoury
Allergies:NKD

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A
Drug Dosage/ Route Admin Classification Purpose of Major Nursing
Frequency/Usual Times Drug/ Name Implications
Dosage Medical DX
Generic: Buspirone Patient:15 mg PO BID Anxiolytics Action: Side Effects:
Hydrochloride tablet May inhibit Headache, fatigue,
neuronal firing confusion, tachycardia,
Brand: Buspar Usual: 5mg, 7.5 mg and reduce blurred vision, nausea,
10 mg, 15 mg, 30 serotonin diarrhea, vomiting,
mg turnover in aches, pains, rash,
cortical, sweatiness,
amygdaloid,
and septo- Contraindications
hippocampal Not a dialyzable drug.
tissue. Drug isn’t
recommended for
patients with severe
Usual: hepatic or renal
Anxiety impairment.
Disorders
Precautions:
Patient/DX: Use in pregnant and
Severe Anxiety breast-feeding women
isn’t recommended.
Use during pregnancy
only if clearly needed.

Interactions:
Alcohol may increase
CNS depression
Grapefruit juice:
May increase drug
level. Give with other
than grapefruit.

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 Lab test inferences:
May interfere with
urinary
metanephrine/catechol
amine assay testing
for
pheochromocytoma,
resulting in a false-
positive result.

Assess/Monitor:
Monitor patient closely
for adverse CNS
reactions. Drug is less
sedating than other
anxiolytics, but CNS
effects may be
unpredictable.

Teach:
Warn patient not to
abruptly stop a
benzodiazepine
because of risk of
withdrawal symptoms.

Advise patient to take

consistently; that is,
always with or always
without food.

Black Box Waring:

None Listed
Tx of Overdose: No

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 Antedote Listed
Reference: Lippincott Course Point online

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 APPENDIX N

CARE PLAN TEMPLATE

NURSING
DIAGNOSIS EXPECTED NURSING RATIONALE EVALUATION
WITH OUTCOME INTERVENTIONS
SUPPORTING CRITERIA
DATA
Ineffective
Coping R/T Short Term: 1. Encourage patient 1.Describing Short Term Goal
situational crisis 1.The patient will to describe previous 1. Goal partially met:
Subjective: be able to identify previous stressors experiences
“I need to be in a at least 2 coping and the coping strengthens Patient has tried to use
safe place, so strategies to mechanisms used effective coping distraction techniques such
that I will not prevent a in the past that and helps eliminate as playing soft music. She
harm myself.” situational crisis were successful. ineffective coping prefers to speak with her
Objective: from forming mechanisms. psychiatrist, but she is not
Evidence by negative thoughts 2. Provide patient with always able to get in touch
patient’s posture such as suicide by additional support 2. This will promote when having a crisis.
& facial 2:30. groups such as adequate coping as 2. Goal partially met:
expression 2. Patient will be Mental Health part of the medical Patient had only her
(curling in her able to state at America Group on plan of care. doctor’s number, and a
shoulders, least two resources line (support group) number for mental health
squinting as she she has used in the Text MHA 741-741 from her insurance card.
was speaking) past for crisis National Suicide 3.Verbalization of 3. Goal Met:
intervention by Prevention Hotline 800 actual or perceived Patient was smiling, she
12:00 noon. 273-8255 threats can help was happy to be getting
3.Patient’s facial reduce anxiety and discharged in the afternoon
expression and 3. Use verbal and open doors for and she thanked me as
posture will change non- verbal ongoing she placed her hands in
after the working therapeutic communication & mine to show gratitude.
phase of communication Acknowledging and She was able to
therapeutic approaches empathizing continuously speak to me
communication by including empathy, creates a about her past, her crisis
11:00 am. active listening to supportive and triggers.

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 encourage the environment that
client to express enhances coping.
emotions such as
sadness, guilt and
anger. Long Term Goal
Long Term:
1.Patient will 1. Provide mental and 4.Interventions that 4. Goal Unmet:
remain free of physical activities improve body Patient is being discharged
self-inflicted harm within the client’s awareness such as and she acknowledged that
by end of shift. ability that will exercise, proper she will use diversional
divert focus to nutrition, and activities. She verbalizes
2.Patient will seek positive behaviors muscular relaxation  that she wants to do
help by a such as reading, may be helpful for whatever it takes to gain
mental/behavioral crafts, sports, treating anxiety self –control over her
health provider by games, exercise and depression. emotions and anxiety.
discharge. meditation.
2. Offer a referral to a 5.Intervention and 5. Goal Unmet:
cognitive behavioral close monitoring by Patient agreed to follow up
therapist to include mental health care with her Psychiatrist and
alternative coping providers and use the referral for
strategies for support of family or Behavioral therapy for
patient and spouse spouse will provide collaboration of care.
to assist in ongoing therapeutic healing
support and improve
outcome and
relationships.

Reference:
Lippincott Course Point online

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