NURS 223L
CARE PLAN
NURS 223L PSYCHIATRIC MENTAL HEALTH NURSING
Student S.G Date 5/10/18
Instructor G. Mit Course NURS 223 L Mental Health
Patient Initials B.K Date of Admission 4/23/18 Legal Status Vol
(Vol, 5150, 5250,
Patient DOB 02/02/1961 Unit Briar Conservatorship)
Chronological and 57 Female Caucasian
Apparent Age Gender Ethnicity
Allergies None
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
(location) (location, character,
onset)
125 lb 98 (Temporal) 86 (right radial) 18 98% 120/82 (Left arm, 3 (upper back, aches,
brachial) occasionally dull)
Psychiatric Diagnosis and Diagnostic Criteria History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement
Nursing Diagnosis: Ineffective coping related to alcohol use as Patient presents with the following symptoms: There is a persistent
evidenced by increased alcohol use and impairment in life desire or unsuccessful efforts to cut down or control alcohol use.
functioning. Craving or a strong desire or urge to use alcohol. Recurrent alcohol use
resulting in a failure to fulfill major role obligations at work, school, or
Patient was diagnosed using guidelines from the DSM-5. A home. Important social, occupational, or recreational activities are
problematic pattern of alcohol use as manifested by at least (2) of given up or reduced because of alcohol use. Alcohol use is continued
the following occurring within a 12-month period. 1)Alcohol is often despite knowledge of having a persistent or recurrent physical or
taken in larger amounts or over a longer period than was intended. psychological problem that is likely to have been caused or
2) There is a persistent desire or successful efforts to cut down or exacerbated by alcohol.
control alcohol use. 3.) A great deal of time is spent in activities
necessary to obtain alcohol, use alcohol, or recover from its Patient was admitted voluntarily with the help of her friends, patient
effects.4) Craving or a strong desire or urge to use alcohol. was drinking about (3) bottles of wine a day.
8)Recurrent alcohol use in situations in which it is physically Previous psychiatric admission: Patient stated that prior to being
hazardous. 9) Alcohol use is continued despite knowledge of having hospitalized, she was in a rehab facility in 2010 for about 3 months
West Coast University Care Plan Template Page 1
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erRevision Date: Month, Year January 2017) Page 1
, NURS 223L
a persistent or recurrent physical or psychological problem that is where she remained sober for 5 years.
likely to have been caused or exacerbated by alcohol. 10) Tolerance, Outpatient mental health services: none
as defined by either of the following: A) A need for markedly
increased amounts of alcohol to achieve intoxication or desired
effect. B) A markedly diminished effect with continued use of the
same amount of alcohol. 11) Withdrawal, as manifested by either of
the following C) The characteristic withdrawal syndrome for
alcohol. D) Alcohol (or a closely related substance such as a
benzodiazepine) is taken to relieve or avoid withdrawal problems
(Halter,2018)
Psychopathology of admitting and/or related psychiatric diagnosis Erickson’s Developmental Stage
Biophysical and/or related medical diagnosis Include Rationale Based on the Patient
Description of how this diagnosis relates to your patient With APA citations
With APA citations
Alcoholism also known as Alcohol Use Disorder, is a broad term that Middle Adults (35 to 65 years) Generativity vs. Stagnation
defines excessive drinking that results in mental or physical health In this stage of development middle adults strive for generativity
problems. Amounts of alcohol that are considered safe vary which include: Using life as an opportunity for creativity and
depending upon individual factors and can range from mild (two to productivity, having concern for others, consider parenting an
three symptoms), moderate (four or five symptoms, and severe important task, contribute to the well-being of the next generation,
(presence of six or more symptoms). Patient presents with strive to do well in one's own environment, adjust to changes in
moderate alcoholism which according to the DSM-5 patient exhibits physical appearance and abilities (Halter, 2017)
(four or five symptoms) from the Criteria for Alcohol use Disorder. Patient is leaning more towards the stagnation side of this
Symptoms include: patient exhibits a persistent desire and developmental stage by not fulfilling life goals that involve family,
successful effort to cut down or control alcohol use, possesses a career and society, and concerns for future generations. She
craving or a strong desire/ urge to use alcohol, important social, mentioned having a son but only spoke two phrases about her son,
occupational, or recreational activities are given up or reduced which consisted of, "he's doing good, he's old enough", and "he is all
because of alcohol use, and alcohol use is continued despite grown up now". She didn’t elaborate more about her son, she quickly
knowledge of having a persistent or recurrent physical or changed the topic to talking about her boyfriend. She seems very
psychological problem that is likely to have been caused or attached to her boyfriend, she mentioned that she started drinking
exacerbated by alcohol. Patient stated that she started drinking because she missed him so much (due to their long-distance
once she started dating a man with whom she was having a long- relationship). Patient stated that she feels depressed and lonely when
distance relationship with. She started feeling depressed because she doesn't see her boyfriend (she sees her boyfriend every 6 months
she would hardly see him. The patient began drinking every other or so), and drinking helps her relax. She doesn't seem concerned for
day, but after feeling really stressed, she later found herself drinking others such as her son, friends, and family, she is very invested in her
West Coast University Care Plan Template Page 1
Revision Date: January 2017
erRevision Date: Month, Year January 2017) Page 2
, NURS 223L
about 1-2 bottles of wine a night. This led to her missing days at boyfriend which comes off as self-absorbed. In addition, she stated
work and isolating herself. Her close friends noticed she was that once she started drinking, she didn't see friends or family often,
changing for the worst, and encouraged her to get the appropriate she just didn’t have the energy to be around people.
help.
West Coast University Care Plan Template Page 1
Revision Date: January 2017
erRevision Date: Month, Year January 2017) Page 3
CARE PLAN
NURS 223L PSYCHIATRIC MENTAL HEALTH NURSING
Student S.G Date 5/10/18
Instructor G. Mit Course NURS 223 L Mental Health
Patient Initials B.K Date of Admission 4/23/18 Legal Status Vol
(Vol, 5150, 5250,
Patient DOB 02/02/1961 Unit Briar Conservatorship)
Chronological and 57 Female Caucasian
Apparent Age Gender Ethnicity
Allergies None
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
(location) (location, character,
onset)
125 lb 98 (Temporal) 86 (right radial) 18 98% 120/82 (Left arm, 3 (upper back, aches,
brachial) occasionally dull)
Psychiatric Diagnosis and Diagnostic Criteria History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement
Nursing Diagnosis: Ineffective coping related to alcohol use as Patient presents with the following symptoms: There is a persistent
evidenced by increased alcohol use and impairment in life desire or unsuccessful efforts to cut down or control alcohol use.
functioning. Craving or a strong desire or urge to use alcohol. Recurrent alcohol use
resulting in a failure to fulfill major role obligations at work, school, or
Patient was diagnosed using guidelines from the DSM-5. A home. Important social, occupational, or recreational activities are
problematic pattern of alcohol use as manifested by at least (2) of given up or reduced because of alcohol use. Alcohol use is continued
the following occurring within a 12-month period. 1)Alcohol is often despite knowledge of having a persistent or recurrent physical or
taken in larger amounts or over a longer period than was intended. psychological problem that is likely to have been caused or
2) There is a persistent desire or successful efforts to cut down or exacerbated by alcohol.
control alcohol use. 3.) A great deal of time is spent in activities
necessary to obtain alcohol, use alcohol, or recover from its Patient was admitted voluntarily with the help of her friends, patient
effects.4) Craving or a strong desire or urge to use alcohol. was drinking about (3) bottles of wine a day.
8)Recurrent alcohol use in situations in which it is physically Previous psychiatric admission: Patient stated that prior to being
hazardous. 9) Alcohol use is continued despite knowledge of having hospitalized, she was in a rehab facility in 2010 for about 3 months
West Coast University Care Plan Template Page 1
Revision Date: January 2017
erRevision Date: Month, Year January 2017) Page 1
, NURS 223L
a persistent or recurrent physical or psychological problem that is where she remained sober for 5 years.
likely to have been caused or exacerbated by alcohol. 10) Tolerance, Outpatient mental health services: none
as defined by either of the following: A) A need for markedly
increased amounts of alcohol to achieve intoxication or desired
effect. B) A markedly diminished effect with continued use of the
same amount of alcohol. 11) Withdrawal, as manifested by either of
the following C) The characteristic withdrawal syndrome for
alcohol. D) Alcohol (or a closely related substance such as a
benzodiazepine) is taken to relieve or avoid withdrawal problems
(Halter,2018)
Psychopathology of admitting and/or related psychiatric diagnosis Erickson’s Developmental Stage
Biophysical and/or related medical diagnosis Include Rationale Based on the Patient
Description of how this diagnosis relates to your patient With APA citations
With APA citations
Alcoholism also known as Alcohol Use Disorder, is a broad term that Middle Adults (35 to 65 years) Generativity vs. Stagnation
defines excessive drinking that results in mental or physical health In this stage of development middle adults strive for generativity
problems. Amounts of alcohol that are considered safe vary which include: Using life as an opportunity for creativity and
depending upon individual factors and can range from mild (two to productivity, having concern for others, consider parenting an
three symptoms), moderate (four or five symptoms, and severe important task, contribute to the well-being of the next generation,
(presence of six or more symptoms). Patient presents with strive to do well in one's own environment, adjust to changes in
moderate alcoholism which according to the DSM-5 patient exhibits physical appearance and abilities (Halter, 2017)
(four or five symptoms) from the Criteria for Alcohol use Disorder. Patient is leaning more towards the stagnation side of this
Symptoms include: patient exhibits a persistent desire and developmental stage by not fulfilling life goals that involve family,
successful effort to cut down or control alcohol use, possesses a career and society, and concerns for future generations. She
craving or a strong desire/ urge to use alcohol, important social, mentioned having a son but only spoke two phrases about her son,
occupational, or recreational activities are given up or reduced which consisted of, "he's doing good, he's old enough", and "he is all
because of alcohol use, and alcohol use is continued despite grown up now". She didn’t elaborate more about her son, she quickly
knowledge of having a persistent or recurrent physical or changed the topic to talking about her boyfriend. She seems very
psychological problem that is likely to have been caused or attached to her boyfriend, she mentioned that she started drinking
exacerbated by alcohol. Patient stated that she started drinking because she missed him so much (due to their long-distance
once she started dating a man with whom she was having a long- relationship). Patient stated that she feels depressed and lonely when
distance relationship with. She started feeling depressed because she doesn't see her boyfriend (she sees her boyfriend every 6 months
she would hardly see him. The patient began drinking every other or so), and drinking helps her relax. She doesn't seem concerned for
day, but after feeling really stressed, she later found herself drinking others such as her son, friends, and family, she is very invested in her
West Coast University Care Plan Template Page 1
Revision Date: January 2017
erRevision Date: Month, Year January 2017) Page 2
, NURS 223L
about 1-2 bottles of wine a night. This led to her missing days at boyfriend which comes off as self-absorbed. In addition, she stated
work and isolating herself. Her close friends noticed she was that once she started drinking, she didn't see friends or family often,
changing for the worst, and encouraged her to get the appropriate she just didn’t have the energy to be around people.
help.
West Coast University Care Plan Template Page 1
Revision Date: January 2017
erRevision Date: Month, Year January 2017) Page 3
