MENTAL HEALTH CLINICAL CARE PLAN

RNSG 2160 Clinical Care Plan

Student's Name: Roberto Buezo Date: 09/29/2023

Patient's initials: J.M Unit: 3B
Legal Status: Voluntary X or Involuntary ______________
Date of Admission: 07/19/2023
Highest Level of Education Completed: Graduated college
Instructions: Initial information should be taken from the Client’s Medical Record. This
information can be used to complete the rest of the care plan.
Introduction of patient: Patient J. M is a 26 years old White female who admitted herself
voluntarily due to acute manic behavior, agitation, behavioral problems, sleep disturbance,
homicidal thoughts, and suicidal ideas. Her DSM-5 diagnosis is unspecified mood(affective)
disorder, with a previous history of bipolar disorder. The patient exhibits an elevated, hyper-
verbal, grandiose, and paranoid mood with signs of nervousness and anxiety.
Chief Complaint: Patient is 26 years old female who presented with unspecified mood (affective
disorder).
Chief Complaint (in the patient’s own words): “I am fucking going manic.”
History of Present Admission: Ms. J.M came here voluntarily to the facility. Ms. J.M is 28
years old white female with a psychiatric history of bipolar disorder. Medical history includes
Type 2 diabetes. Today is her 5th admission here at this facility for the patient. This patient was
last admitted at this facility from 6/12/2023 to 6/15/2023. At the time of discharge this patient
was prescribed the following medications:
Eskalith 900mg PO at bedtime.
Metformin 500 mg PO BID.
Latuda 40mg PO daily with breakfast.
Trazodone 50 mg PO at bedtime PRN.

Client’s stated understanding of diagnosis: Ms. J.M states that she is here because she is
“fucking manic!” and “going insane in the membrane”. She stated that she feels her mood has
been “very elated manic”. She says that it is been like that for around 4 weeks. She mentions
that her medications were "changed" while she was at a local ER three weeks ago. She describes
the medication change as having a significant negative impact on her, stating that it had adverse
effects. She reports that her lithium medication was continued, but her Latuda prescription was
discontinued. She stated that she feels like a “rock star”. She says that she is a Doctor and a
Lawyer. She mentioned that she has been experiencing poor sleep quality for the past three
weeks. She says that she does not know how many hours she has been sleeping. She says that

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she will make sure that she writes her own prescriptions here at this facility because she feels
that she has “all the answers”. She discloses that she is experiencing thoughts of both suicidal
and homicidal. She says that she is ready to buy a gun and shoot ”everyone”.

When asked for more information about any psychosis-like symptoms, J.M. denies experiencing
visual or auditory hallucinations—meaning she doesn't see or hear things that others can't.
However, she does express feeling paranoid and believes that someone is plotting to harm her.
Says that she feels like shooting people but she doesn’t know who.

When asked about her substance or alcohol use/abuse, Ms. J.M. mentioned that she occasionally
smokes marijuana and drinks tequila, but she did not provide any additional details.

Ms. J.M was asked to provide more information regarding any medication she is currently on.
Says that she was switched to Seroquel, but it does not help her. She mentioned that she has
been taking her Lithium at night but admitted to skipping some doses. She also stated that she
stopped taking her trazodone, although it used to be helpful for her. Additionally, she claimed to
have started taking Klonopin during the last week, but this information could not be verified.

Laboratory (only identify problem areas):

Test Date Results Interpretation Nursing Implication(s)

MCH 6/13/2023 25.7 (L) Consuming foods rich in

iron or additional iron
supplements.
MCHC 6/13/2023 31.3 (L) Add more fiber to diet,
take vitamin B6, include
iron supplements,
increase iron in diet.
Lymphs 6/12/2023 3.2 (H) Antibiotic treatment or
(Absolute) immunosuppressants may
be administered upon
order from HCP

Physical assessment: (Not a formal head-to-toe assessment)

From chart:
Vital signs: Temperature: 98.6F Pulse: 84 Respirations: 22 BP:136/87
Integumentary: Negative
Cardiovascular:
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Rate and rhythm: Tachycardia present.

Pulses: Normal pulses bilaterally
Heart sounds: Normal heart sounds

Muscular-Skeletal:
General: Normal range of motion.
Cervical back: Normal range of motion
MSE: psychomotor agitation

Respiratory: Negative

Gastrointestinal: Negative

Genitourinary: Negative

Psychiatric Medications:

Name Dosage Route Specific use Side Effects Nursing Client

for this Food/Drug Interactions Implications Learning
Client Needs &
Understanding
Trazodone 50 mg PO Sleep CNS: drowsiness, dizziness, Administer prn May make
nervousness, fatigue, confusion, at bedtime patient drowsy.
decreased concentration, (may repeat x1 report if there’s
malaise, if not effective) any sleep
tremor, headache, insomnia, sy disturbances
ncope, disorientation,
incoordination.
CV: orthostatic hypotension,
HTN, edema.
EENT: blurred vision, red or
itchy eyes, tinnitus, dry mouth,
nasal congestion.
GI: constipation, nausea, vomit
ing, anorexia, diarrhea.
Hematologic: anemia.
Metabolic: weight gain or loss.
Musculoskeletal: aches, pains.
Skin: rash, urticaria, diaphoresi
s.

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Anticoagulants (aspirin,
clopidogrel, dabigatran,
NSAIDs, rivaroxaban), antiplat
elet agents: May increase risk
of bleeding. Monitor patient
closely.
Antihypertensives: May
increase hypotensive effect
of trazodone.
Alcohol use: May enhance
CNS depression. Discourage
use together.
Olanzapine 2.5 mg PO Agitation CNS: somnolence, insomnia, Administer Report agitation
parkinsonism, dizziness, NMS, q6h prn for levels and any
suicide attempt, abnormal gait, agitation. signs of side
asthenia, personality disorder, monitor effects that has
auditory hallucinations, agitation not been
restlessness, fatigue, levels. present.
akathisia, headache, tremor, Give drug
articulation impairment, tardive without regard
dyskinesia, fever, for food.
extrapyramidal events (IM), Don’t push
hypertonia. tablet through
CV: prolonged QT foil backing;
interval, orthostatic remove foil
hypotension, tachycardia, chest from package,
pain, HTN, ecchymosis, then remove
peripheral tablet.
edema, hypotension (IM). Place ODT on
EENT: amblyopia, conjunctivit patient’s
is, rhinitis, nasal tongue
congestion, pharyngitis, sore immediately
throat. after opening
GI: constipation, dry package.
mouth, dyspepsia, increased ODT may be
appetite, increased given without
salivation, vomiting, water.
thirst, flatulence.
GU: hematuria,
metrorrhagia, urinary
incontinence,
UTI, amenorrhea, vaginitis, vag
inal discharge.
Hematologic: leukopenia.
Hepatic: increased liver
enzyme levels.
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Metabolic: hyperglycemia,
dyslipidemia, weight gain.
Musculoskeletal: joint pain,
extremity pain, back pain, neck
rigidity, twitching, muscle
spasm, stiffness.
Respiratory: increased
cough, dyspnea, URI.
Skin: diaphoresis, ecchymosis,
acne, injection-site reaction,
injection-site pain (IM).
Other: flulike syndrome, viral
infection, injury.

Drug to drug interactions may

be monitored for increase of
olanzapine levels or may need
to reduce medication. may be
used cautiously and limit
dosage for desired effect.
Lithium 300mg PO Manic CNS: fatigue, Administer - Needs to report
lethargy, coma, seizures, tremo TID. Monitor any signs of
rs, for lithium complications or
drowsiness, headache, confusio toxicity levels side effects of
n, stupor, tongue and any medications.
movements, tics, change in - Tell patient to
restlessness, dizziness, vertigo, take drug with
mental status.
psychomotor retardation, plenty of water
blackouts, EEG changes, and after meals to
worsened organic mental minimize GI
syndrome, impaired upset.
speech, ataxia, incoordination, - Explain the
hypertonicity, fever, chore importance of
athetotic movements, having regular
extrapyramidal symptoms, blood tests to
hallucinations, poor memory, determine drug
dysgeusia. levels and to
CV: arrhythmias (including monitor therapy;
Brugada even slightly high
syndrome), bradycardia, revers values can be
ible ECG dangerous.
changes, severe bradycardia, h - Warn patient and
ypotension, SA node caregivers to
dysfunction. expect
transient nausea,

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EENT: blurred large amounts of

vision, exophthalmos, nystagm urine, thirst, and
us, tinnitus, dry mouth, salivary discomfort during
gland swelling, hypersalivation, first few days and
dental caries. to watch for
GI: vomiting, anorexia, diarrhe evidence of
a, toxicity.
thirst, nausea, gastritis, abdomi - Instruct patient
nal pain, flatulence, to withhold one
indigestion, fecal incontinence. dose and call
GU: polyuria, renal toxicity prescriber
with long-term use, oliguria, immediately if
glycosuria, decreased CrCl, signs and
albuminuria, urinary symptoms of
incontinence, erectile toxicity appear,
dysfunction. but not to stop
Hematologic: leukocytosis. drug abruptly.
Metabolic: transient - Warn patient to
hyperglycemia, goiter, hypothy avoid hazardous
roidism, hyponatremia, thirst. activities that
Musculoskeletal: muscle require alertness
weakness, muscle and good
hyperirritability, polyarthralgia. psychomotor
Skin: pruritus, rash, diminished coordination until
or absent sensation, drying and CNS effects are
thinning of hair, psoriasis, known.
acne, alopecia, folliculitis, - Tell patient not
DRESS syndrome. to switch brands
Other: ankle and wrist edema. or take other
prescription or
Interactions OTC drugs
Drug-drug without
ACE inhibitors, ARBs: May prescriber’s
increase lithium level. guidance.
Monitor lithium level; - Advise patient to
adjust lithium dosage, as immediately seek
needed. emergency
Antiarrhythmics and other assistance if
drugs that prolong QT fainting, light-
interval: May increase risk of headedness,
life-threatening arrhythmias. abnormal
Avoid use together. heartbeat, or
Antipsychotics shortness of
(clozapine, haloperidol, risperi breath occurs
done, thioridazine): May because these
increase risk of neurotoxic signs and

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reactions. Monitor patient symptoms are

closely. associated with a
potentially life-
threatening heart
disorder known as
Brugada
syndrome.

Latuda 20mg PO Depressive CNS: somnolence, akathisia, Administer Patient must eat
episodes with extrapyramidal daily with with
bipolar symptoms, agitation, dystonia, breakfast. medication.
dizziness, insomnia, abnormal Give with food
dreams, anxiety, Patient must
containing at
restlessness, fatigue. understand side
least 350
CV: tachycardia. effects and drug
calories.
EENT: blurred vision, to drug
nasopharyngitis, rhinitis, interactions as
oropharyngeal pain, dry mouth, well as alcohol
increased salivation. and cannabis
GI: nausea, vomiting, dyspepsi use may
a, abdominal
interfere with
pain, diarrhea, dysphagia,
usage of this
increased appetite.
GU: UTI, increased creatinine medication.
level.
Metabolic: dyslipidemia,
hyperglycemia, weight gain.
Musculoskeletal: back pain.
Respiratory: URI.
Skin: rash, pruritus.
Other: flu-like symptoms.

Interactions
Drug-drug
Antihypertensives: May
increase risk of hypotension.
Monitor orthostatic vital signs
and adjust antihypertensive
dosage as needed.
Food-food
Alcohol use, cannabis,
grapefruit, grape juice, St.
John’s wort

Other Medications:

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Name Dosage Route Specific use Side Effects Nursing Client

for this Food/Drug Interactions Implications Learning
Client Needs &
Understanding
Metformin 500 mg PO Type 2 CNS: asthenia, headache, dizziness, chills, Administer Adhere to
diabetes light-headedness, taste disorder. BID. Check medication
mellitus CV: chest discomfort, palpitations, Glucose level regimen as
flushing. before prescribed.
EENT: rhinitis. administering.
GI: diarrhea, nausea, vomiting,
indigestion, abdominal bloating, Watch for
abdominal medication
discomfort, flatulence, anorexia, abnormal compliance
stools, constipation, dyspepsia, weight
loss.
Metabolic: vitamin
B12 deficiency, hypoglycemia.
Musculoskeletal: myalgia, limb pain.
Respiratory: URI, dyspnea.
Skin: nail disorder, diaphoresis.
Other: accidental injury, infection.
Boxed Warning: Alcohol use: May
increase drug effects and potentiate
metformin’s effect on lactate
metabolism. Discourage use together
Mylanta 15ML PO GI upset Non-significant Administer May cause gas
q6h after each relief or
meal and/or bloating,
bedtime. fullness, any
discomfort of
GI gas. Ma
Milk of 15 ML PO Constipation GI: abdominal Administer Understand that
Magnesia cramping, diarrhea, nausea. q4h it may impair
Metabolic: fluid and electrolyte absorption of
disturbances with daily use. other drugs.
Other: laxative dependence with long-
term or excessive use.
May impair absorption. Separate doses
by 1 to 6 hours, depending on
individual competing drug.

Clinical presentation (textbook description) of Psychiatric admitting diagnosis.

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1. Deficient knowledge related to Unfamiliarity with the causes, signs, and symptoms, and
management of depression secondary to mania as evidenced by verbalizing inaccurate
information, inaccurate follow-through of instruction, inappropriate behaviors (ex.
agitated, apathetic, hysterical, hostile), questioning members of the healthcare team.)

2. Risk for suicide, not attempt to harm self as evidenced by patient won’t verbalize
hurting herself due to family problems.

3. Disturbed thought processes related to biological/medical factors, biochemical

imbalances, persistent feelings of extreme guilt, fear or anxiety, and prolonged grief
reaction secondary to mania as evidenced by decreased problem-solving abilities,
hypervigilance, impaired ability to grasp ideas or orders thoughts, impaired attention
span/easily distracted, impaired insight.

4. Risk for self-directed violence related to anhedonia, helplessness, hopelessness, and

social isolation secondary to mania as evidenced by previous attempts of violence, and
suicidal plans.

5. Risk for injury related to extreme hyperactivity, destructive behaviors.

6. Imbalanced nutrition, less than body requirements related to refusal or inability to sit
still long enough to eat meals.

Mental Status on day of care: Provide evidence (examples) for each category and
indicate any change from admission Mental Status Exam (MSE).

Appearance: Alert, attitude is cooperative/ flirtatious, disheveled and unkept, hyper, fair eye
contact, odd behavior/mannerisms
Mood & Affect (give data and note if congruent with Affect):
Mood: Elated, Patient was positive for agitation (rolling eyes), suicidal, grandiose,
Affect: incongruent with stated mood., patient is experiencing persistent thoughts of suicide and
exhibit hyperverbal behavior, grandiose thoughts, and paranoia.

Memory Recent & Remote (evaluate and provide verifiable examples):

Memory: impaired. Example, mother is her stepmom and her sister is her niece.
Remote: impaired. Example, I have been to the ER in and out in the past month.
Thought Process & Content (provide examples of each to support findings):
Thought process: Flight of ideas: grandiose thoughts for example, stated that Lady Gaga
(television celebrity) is related to her. She states she is a doctor and a lawyer. rapid speech.

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Insight & Judgment (provide examples of each to support findings):

Insight: fair
Judgment: fair
Developmental Level: Identify developmental levels for the following theorists, then choose
one other theorist from your textbook that you think most appropriately defines your client’s
developmental level. You must describe the client’s current behavioral developmental level not
their chorological developmental level.
Theorist Level Supporting Data
Maslow: Safety needs Becomes manic, tries to throw chair at
peers and is not aware of the increased
stimuli, her room needs to be blocked
off for some time for safety for others.
Monitoring every hour.
Erikson: Intimacy vs. O.O can not stay at home alone and
isolation feels that her thoughts will go manic or
“off the wall” she can not control
herself without having someone there.

How does the client's culture impact his or her mental health needs currently? (It
always does) The patient identifies with white culture and mentions having a YouTube channel.
She claims a familial connection to Lady Gaga, a well-known pop celebrity, and believes that
her channel has a substantial following eagerly awaiting her content as an influencer.
Spirituality group: patients’ awareness of her feelings that contribute to values formation to help
patient cope with life such as the patient stating” I see tweaking and stuff moving like laundry
and dead bugs”.

How does the client’s spirituality impact his or her mental health needs currently? (May be
formal religion, or simply sense of meaning and hope).
The client expresses a lack of spiritual beliefs and mentions, "I follow what Lady Gaga
follows." Lady Gaga's beliefs encompass aspects of being a gypsy and a Christian. The client
identifies with the glamorous side of Lady Gaga by incorporating elements like silver
eyeshadow and bold red lipstick into her appearance. She shares that she feels the need to
consistently wear makeup because it gives her a sense of glamour.

How is the client participating in Treatment Plan? (List all that apply)
Patient is in group therapy ‘management of emotions and medication with restarting lithium for
bipolar. She also is offered an alternate activity, reading material as well as one on one sessions
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with the health care providers with adjusting medications and Psychologist going through her
emotions and how to deal with them.
Nursing Process: Refer to your text for essential elements of documentation. Include mood,
affect, and behavior as well as physiologic data in the assessment.
Problem List: (Include all current problems for this client.) Prioritize the list before completing
the plan of care.
Client Problem Priority Assessment Data- Subjective and/or Objective
data
1.Risk for suicide Safety Not attempting to harm self. Patient verbalizes self-
harm due to her family problems. Needs interaction
daily to assist with identifying strategies to manage
sad emotions. Reported mood “ I feel good.” Patient
feels settled. Patient was visibly interacting
appropriately with others and attended group.
Safety Exhibit improving manic symptoms as evidenced by
the patient will be calm in groups and not state “I am
2. Elevated mood
fucking manic and going insane. I am a rock star, a
/Mania mood
doctor and a lawyer, I will write my orders. I will buy
a gun and shoot everyone.”. Patient was combative,
violent, hyper manic, agitated, angry, verbally
aggressive, threatening staff and peers. Patient was
noted with inappropriate sexual behavior. Patient was
intrusive, loud, screaming, yelling, and very
disruptive. Patient poured some hot coffee on a
female psych tech. spilled the floor with some coffee,
and threw some sugar meant fo patient’s coffee on the
floor.
Guided Patient thoughts process is impaired and needs
imagery and reframing and guided imagery and relaxation
3. Poor coping skills
reframing techniques. No roommate allowed for safety concerns
of others and herself. Patient options of reading and
group therapy.

Highest Level Nursing Diagnosis:

Diagnosis (Problem R/T, Etiology or Human Response R/T Stressor)/ Data supporting Problem
As Evidenced by; (AEB):

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1. Deficient knowledge related to Unfamiliarity with the causes, signs, and symptoms, and
management of depression secondary to mania as evidenced by verbalizing inaccurate
information, inaccurate follow-through of instruction, inappropriate behaviors (ex.
agitated, apathetic, hysterical, hostile), questioning members of the healthcare team.)

2. Risk for suicide, not attempt to harm self as evidenced by patient won’t verbalize
hurting herself due to family problems.

3. Disturbed thought processes related to biological/medical factors, biochemical

imbalances, persistent feelings of extreme guilt, fear or anxiety, and prolonged grief
reaction secondary to mania as evidenced by decreased problem-solving abilities,
hypervigilance, impaired ability to grasp ideas or orders thoughts, impaired attention
span/easily distracted, impaired insight.

4. Risk for self-directed violence related to anhedonia, helplessness, hopelessness, and

social isolation secondary to mania as evidenced by previous attempts of violence, and
suicidal plans.

5. Risk for injury related to extreme hyperactivity, destructive behaviors.

6. Imbalanced nutrition, less than body requirements related to refusal or inability to sit
still long enough to eat meals.

Expected Outcomes (include short term objectives that demonstrate measurable progress
to major goal(s):

Short term Goals:

Patient will continue to engage in group and explore healthier ways to manage her emotions
Patient will not attempt to self-harm as evidence by patient won’t verbalize hurting self-due to
family problems.

Long term goals:

adhere to medication regimen.
Patient will continue lithium capsule 300 mg PO TID.
Patient Will restart Latuda but at 20 mg PO daily with breakfast.

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Nursing Interventions (make specific to individual and useful to nurses that come after to you to
care for patient; w/ Rationale):

Plan:
a) Immediate plan:
Scheduled PRN medication, group sessions, precautions and/or special observations ordered,
lab tests and or previous results reviewed. Patient is offered alternate activity such as reading
materials. Encourages participants to utilize decision making skills and share thought process
for choices made.
b) Discharge planning and use of community resources:
Voluntary admission to inpatient psychiatry to stabilize symptoms and monitor for safety PRN.
Facilitated group therapy of management of emotions.

c) Actual Outcomes (how is the client different from morning report base on your
intervention)
The client remains calm, tries not to act out in behavior, controlled emotions with lack of
Aggression and thoughts of suicide. Patient is happy and not upset or sad. Patient is
more engaged in group than in the morning. For example, in the morning she was very
distant and wanted to stay in her room until medication was given.

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References:

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).
Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO:
Elsevier

Lippincott CoursePoint (2023, July 10) Lippincott Advisor for Education. Retrieved August 5,
2023,https://advisor.lww.com/lna/document.do?bid=6&did=1232393
&searchTerm

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INSTRUCTOR'S COMMENTS:

Your instructor will be looking for evidence of learning, growth and increased
observational
skills. You may be asked to redo sections of this worksheet to ensure you meet the
learning
objectives.
Evaluation (To be completed by instructor)

Score:

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