NURS 406 Nursing Care Plan_Updated | Psychiatric/Mental Health Concept Map Care Plan

NURS 406 Nursing Care Plan Psychiatric/Mental Health Concept Map Care Plan Name: Linetelle Liondo Date: February 24, 2020 Clinical Group/Instructor: Professor Crissey Patient Initials: L.L I. Nursing Assessment: Admission Information: Admission Date: 2/03/20 Age: 38 yrs old Gender: Female Reason for hospitalization: Patient is a 38-year-old woman with repeated history of depression. Patient now being admitted for evaluation and treatment of anxiety and psychotic symptoms. Surgical procedures: The patient has never had any surgical procedures Medical diagnoses: (medical and psychiatric; past and present) Patient has major depressive disorder, recurrent, severe with psychotic symptoms. Advance Directives: Living will: Patient does not have a living will Power of Attorney: Patient does not have a power of attorney DNR: Patient does not have a DNR Laboratory Data: Test: Normal values: On Admission: Current values: Interpretation: WBC: 4.5-11.0 5.8 6.5 Within normal level Differential: 3.7-5.5 Hemoglobin: 11.7-15.0 12.8 12.4 Within normal level Hematocrit: 34.0-47.0 39.0 38.1 Within normal level Platelets: 150-450 286 283 Within normal level Prothrombin time(PT): N/A INR: N/A PPT: N/A Blood glucose: 70-110 85 93 Within normal 1 Sf2015 NURS 406/258- 2015 level Na+: 135-145 136 141 Within normal level K+: 3.5-5 3.6 3.9 Within normal level Cl- : 98-110 100 102 Within normal level Ca+: 9-10.5 9.2 9.6 Within normal level BUN: 7-22 18 22 Within normal level OTHERS: DIAGNOSTIC TESTS: CXR: NONE EKG: NONE OTHER: MEDICATIONS: List all meds in proper MD order format: NAME, DOSAGE, ROUTE: RATIONALE: ASSESSMENT/CONSIDERATIONS: Magnesium Hydroxide (Simethicone) 30 mL PO, liquid q6hr PRN Used for dyspepsia Patient should be assessed for heartburn and indigestion when taking this medication. Make sure to monitor calcium and potassium levels while on this medication. (Townsend, 2015). Ibuprofen 600 mg PO, q6hr PRN Used for pain Patient must be assessed for pain and skin rash. Stop taking when the first sign of a skin rash is noted. (Townsend, 2015). Trazodone 50 mg PO, PRN Used for Insomnia Patient must be given Trazodone in the evening due to the drowsiness effect of this medication. (Kluwer, 2016). Hydroxyzine 50 mg PO, q8hr PRN Used for anxiety Patient must be watched for intense sedation. Implications such as keeping the side rails up and keeping the bed in a low position are recommended. (Townsend, 2015). Sertraline (Zoloft) 100 mg daily Used for depression Patient should be assessed for suicidal behaviors. Nutritional intake should also be monitored. (Townsend, 2015) OTC MEDS/HERBALS: Patient does not take any OTC meds/herbals ALLERGIES: List all: Patient is allergic to Penicillin PAIN ASSESSMENT: LOCATION: Patient reports pain in her lower back DESCRIBE PAIN: (INTENSITY, DURATION, FREQUENCY) Patient reports that she feels pain in her lower back everyday for the entire day. PAIN PERCEPTION ON SCALE 0-10: 6; Patient reports that her pain level is a 6 out of 10 PAIN MEDS USED: Ibuprofen 600 mg PO, PRN LAST TIME PAIN MED USED: 2/17/17 TREATMENTS: MEDICAL TREATMENTS: Patient did not receive any medical treatments. PSYCHIATRIC THERAPIES: Individual therapy SUPPORT SERVICES: Patient does not have any support services. NUTRITION: DIET: Patient consumes a regular diet 3 times daily. RESTRICTIONS: Patient does not have any food restrictions FLUID INTAKE (24HRS): Patient has an adequate amount of fluid intake daily. GAG REFLUX INTACT: Patient’s gag reflux is present. APPETITE: BREAKFAST: Patient consumes 100% of breakfast LUNCH: Patient consumes 100% of lunch DINNER: Patient consumes 100% of dinner OTHER INTAKE ISSUES: Patient does not have any other intake issues. ELIMINATION: LAST BM: Patient’s last bowel movement was on 1/27/17. Patient has a bowel movement everyday that is soft and easy to pass. 8-hr URINE OUTPUT: Patient’s 8-hour urine output is normal. 24-hr URINE OUTPUT: Patient’s 24-hour urine output is normal. FOLEY/CONDOM CATHETER: Patient does not have a foley/condom catheter present.