CJSim Mental Health Care Plan – Managing
Aggression & Psychosis (Bipolar & Substance-
Induced) | Chamberlain|CJSim Care Plan for
Client DH Managing Aggression and Psychosis.
DH care plan-mental - CJSim care plan
Mental-Health Nursing (Chamberlain University)
, Relearning: Clinical Judgment Plan of Care Template
Student Name: Ryan Glasgow Date of Admission: 10/18
Client Initials: DH Date of Care: 10/18
Age/DOB: 39 Admitting Diagnosis: Bipolar disorder, substance-induced
Allergies: Unknown psychosis (cocaine mixed with alcohol and cocaine alone)
BSA/BMI: 23.7 Code Status: Full Comorbidities: Bipolar disorder, history of substance use
(cocaine and alcohol)
Planned Treatments/Procedures:
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions,
and
provider orders
Cultural/Spiritual : N/A Health Promotion/Development: Encourage participation
in coping skills group and other therapeutic interventions.
Neurological/Cognition/Coping/Adaptation/Function:
Oppositional and irritable, pacing, talking to himself, refuses Infection/Immunity/Inflammation : N/A
intake questions, requesting alcohol. Exhibits aggression
towards staff and security, with threatening statements.
Exhibiting depressive symptoms as aggression subsides. Mobility: Pacing up and down the hallway, becoming
increasingly aggressive.
Nutrition/Elimination : N/A
Pain/Comfort/Tissue Integrity: Unknown physical pain but
experiencing psychological discomfort.
Fluid/Electrolytes/Acid-Base: Client refused
Safety: High priority: Client threatening self-harm and
Gas Exchange/Perfusion: N/A harm to others. Security present; seclusion and IM
medications utilized for de-escalation.
Glucose Regulation: N/A
Other: Family support system, housing, occupation are
unknown.
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase
1/Question 1 section)
Generate Solutions &
Recognize & Analyze Prioritize Hypotheses Take Evaluate Outcomes
Cues
Actions
Priority Hypotheses for Priority Priority
Priority
Assessments/Cues Nursing Care Interventions/Actions Teaching/Discharge
Needs
1. Psychiatric instability 1. Stabilization of
1. Administer medications
1. Aggression psychiatric symptoms
2. Substance -
2. Ensure safety of client
2. Refusal to cooperate induced 2. Continued
and staff
psychosis medication
3. Threats of violence compliance
3. Maintain observation
3. Agitation linked to
mental health 3. Psychosocial support
conditions
Priority Laboratory Priority Actual & Priority
Tests/ Priority Medications
Potential Collaborati
Diagnostic Cues Complications/Cues ve Actions
1. Toxicity levels 1. Risk of harm to self/others 1. Haloperidol 1. Psychiatric evaluation
2. Mental health assessment 2. Psychiatric decline 2. Lorazepam 2. Social worker
3. Electrolyte panel 3. Isolation/ 3. Olanzapine 3. Consult with a Psychiatrist
aggressive
©
1
Aggression & Psychosis (Bipolar & Substance-
Induced) | Chamberlain|CJSim Care Plan for
Client DH Managing Aggression and Psychosis.
DH care plan-mental - CJSim care plan
Mental-Health Nursing (Chamberlain University)
, Relearning: Clinical Judgment Plan of Care Template
Student Name: Ryan Glasgow Date of Admission: 10/18
Client Initials: DH Date of Care: 10/18
Age/DOB: 39 Admitting Diagnosis: Bipolar disorder, substance-induced
Allergies: Unknown psychosis (cocaine mixed with alcohol and cocaine alone)
BSA/BMI: 23.7 Code Status: Full Comorbidities: Bipolar disorder, history of substance use
(cocaine and alcohol)
Planned Treatments/Procedures:
Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions,
and
provider orders
Cultural/Spiritual : N/A Health Promotion/Development: Encourage participation
in coping skills group and other therapeutic interventions.
Neurological/Cognition/Coping/Adaptation/Function:
Oppositional and irritable, pacing, talking to himself, refuses Infection/Immunity/Inflammation : N/A
intake questions, requesting alcohol. Exhibits aggression
towards staff and security, with threatening statements.
Exhibiting depressive symptoms as aggression subsides. Mobility: Pacing up and down the hallway, becoming
increasingly aggressive.
Nutrition/Elimination : N/A
Pain/Comfort/Tissue Integrity: Unknown physical pain but
experiencing psychological discomfort.
Fluid/Electrolytes/Acid-Base: Client refused
Safety: High priority: Client threatening self-harm and
Gas Exchange/Perfusion: N/A harm to others. Security present; seclusion and IM
medications utilized for de-escalation.
Glucose Regulation: N/A
Other: Family support system, housing, occupation are
unknown.
START of Shift (CJSim™) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase
1/Question 1 section)
Generate Solutions &
Recognize & Analyze Prioritize Hypotheses Take Evaluate Outcomes
Cues
Actions
Priority Hypotheses for Priority Priority
Priority
Assessments/Cues Nursing Care Interventions/Actions Teaching/Discharge
Needs
1. Psychiatric instability 1. Stabilization of
1. Administer medications
1. Aggression psychiatric symptoms
2. Substance -
2. Ensure safety of client
2. Refusal to cooperate induced 2. Continued
and staff
psychosis medication
3. Threats of violence compliance
3. Maintain observation
3. Agitation linked to
mental health 3. Psychosocial support
conditions
Priority Laboratory Priority Actual & Priority
Tests/ Priority Medications
Potential Collaborati
Diagnostic Cues Complications/Cues ve Actions
1. Toxicity levels 1. Risk of harm to self/others 1. Haloperidol 1. Psychiatric evaluation
2. Mental health assessment 2. Psychiatric decline 2. Lorazepam 2. Social worker
3. Electrolyte panel 3. Isolation/ 3. Olanzapine 3. Consult with a Psychiatrist
aggressive
©
1
