SMITH- NURSE 223L
CARE PLAN
NURS 223L PSYCHIATRIC MENTAL HEALTH NURSING
Student Ashley Smith Date July 5, 2017
Instructor Gary Mittelberg Course NURS 223L
Patient Initials JV Date of 6-23-2017 Legal Status 5250
Admission (Vol, 5150, 5250,
Patient DOB 01/01/1993 Unit 3- Acute Conservatorship)
Chronological Chronological Age: 23 Female Hispanic/Vietnamese
and Apparent Apparent Age: younger
Age than 23. ~18 y/o Gender Ethnicity
Allergies NKA
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Blood Pressure Pain Scale 1-10
Sat) (location) (location, character,
onset)
4’ 11”/ 110 lbs 98.7F 72 18 99% O2 RA 99/69 0/10
(Orally) (Radial) (R Brachial) No Pain Reported
Psychiatric Diagnosis and Diagnostic Criteria History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission /
Outpatient Mental Health Services/5150 Advisement
Dx: unspecified schizophrenia spectrum versus bipolar disorder Patient was unable to provide a medical and mental history.
versus substance-induced psychosis. No known previous psychiatric admissions.
Patient presents with the following positive symptoms: delusions
Patient was diagnosed using guidelines from the DSM-5. According (magical thinking and ideas of reference), alteration in speech
to the American Psychological Association (2016), unspecified (pressured speech and flight of ideas), and bizarre behavior (hyper-
schizophrenia spectrum and other psychotic disorder 289.9 (F29) is sexuality).
a category that applies to presentation of symptoms Patient presents with the following negative symptoms: avolition.
characteristically similar to the schizophrenia spectrum (pg.120). Patient presents with the following cognitive and affective symptoms:
These symptoms cause clinically significant distress or impairment disordered thinking, inability to make decisions, poor problem solving
of a client’s social, occupational, or other important areas of their ability, difficulty performing tasks, memory deficits and suicidal
life. These symptoms however do not meet the full criteria for any ideation.
West Coast University Care Plan Template Page 1
Revision Date: Jan, 2013
,SMITH- NURSE 223L
of the disorders outlines within the schizophrenia spectrum. 5250 Advisement: you are here because you said you wanted to kill
Clinicians will us this disorder category when they choose not to yourself while attempting to harm yourself by walking in a busy street.
specify the reason that the criteria is not met for a specific spectrum
or other psychotic disorder.
Psychopathology of admitting and/or related psychiatric Erickson’s Developmental Stage
diagnosis Include Rationale Based on the Patient
Biophysical and/or related medical diagnosis With APA citations
Description of how this diagnosis relates to your patient
With APA citations
Schizophrenia- a patient who has been diagnosed with schizophrenia According to Halter (2014), patient JV is experiencing Erickson’s
has psychotic thinking or behavior that is present for at least 6 Stage of Early Adulthood (ages 20-35). A patient within this stage is
months. Areas of functioning are significantly impaired; including trying to establish intimate bonds of love and friendship (pg. 23). This
school or work, self-care, and interpersonal relationships (Sommer, particular stage is called Intimacy versus Isolation. Successful
2016). According to the American Psychiatric Association (2016), resolution of this crisis results in a patient’s ability to love deeply and
unspecified schizophrenia spectrum is a new DSM-5 diagnosis that commit oneself. Unsuccessful resolution of this crisis results in
is characterized by gross deficits in reality testing. The patient is emotional isolation and egocentricity. Patient JV is currently
experiencing a rift in perception of objective reality and while in experiencing a false assumption of intimacy via hypersexuality.
psychosis typically centered on a grandiose, persecutory, or somatic According to Montaldi (2003), hypersexuality can be categorized as an
theme. The patient may experience fear, confusion, panic, and will obsessive compulsive disorder, impulse control disorders, and/or a
be distracted and preoccupied by their internal dialogue. They will chemical dependency/addiction (pg. 2). Hypersexual behaviors can
also be unable to complete tasks required of daily living. It is also eventually persist so much so that they harden into a pattern that
suggested that medical professionals look at other plausible acquires more generalized attributes such as regulation of internal
diagnoses such as methamphetamine abuse, manic state of bipolar mental states, such as reducing anxiety or enhancing excitement. Due
disorder, and/or brief psychotic disorder. According to Marini to the unknown mental health history of patient JV, we cannot attribute
(2016), the biopsychosocial perspective of schizophrenia allows for any specific time frame for her hyper sexuality. Therefore we cannot
medical professionals to look at chemical imbalances and accurately assume that her hypersexual nature is due to an internal
medication management in order to accurately treat biological regulation of mental state.
concerns as well as address potential stressors that attribute to However, we can attribute her substance abuse as an isolative reaction.
disabling effective psychosocial coping skills. Garski (2015) Individuals who have not successfully resolved intimate bonds are
continues, every human body has a unique brain with particular unable to trust others and feel isolated. The feeling of isolation may
capacities. These capacities can be reached through learning and contribute to substance abuse behaviors as well as feed promiscuous
productive work or wasted through unhealthy habits and/or sexual attitudes.
intellectual inactivity. A persistent biologically based mental
disorder can interfere with not only social functioning but be
West Coast University Care Plan Template Page 2
Revision Date: Jan, 2013
, SMITH- NURSE 223L
severely disabling thereby affecting primary aspects of life and can
be disrupted with occasional hospital or crisis care.
The diagnosis was unclear as to which specific psychosis the patient
may be undergoing. However, the DSM-5 explains that medical
professionals must look at a variety of psychosis inducing diagnoses
that could also be contributing to the current mental status of the
patient. The patient is currently expressing many signs and
symptoms of unspecified schizophrenia as well as a manic episode
of bipolar disorder, methamphetamine abuse, and/or a brief
psychotic disorder. Due to the lack of medical and psychological
history it is appropriate to monitor the ever changing signs and
symptoms of this patient and adjust the treatment plan as the
psychosis further develops.
MENTAL STATUS EXAMINATION
Appearance
Presenting Appearance Gait and Motor Coordination Level of Participation in the
(nutritional status, physical deformities, (awkward, staggering, shuffling, rigid, Program/Activity
hearing impaired, glasses, injuries, cane) trembling with intentional movement or at (Group attendance and milieu participation,
Basic Grooming and Hygiene rest), exercise)
(clean, disheveled and whether it is posture
appropriate attire for the weather) (slouched, erect),
any noticeable mannerisms or gestures
Patient presented without physical Patient presented with restless movements. Patient attempted to join several groups
deformities. Her nutritional status seemed Her gait was appropriate, but her coordination throughout the day. She was unable to sit still
adequate. Patient has facial tattoos. during group physical activity was for more than a few seconds at any time. She
Patient presented with sexually provocative uncoordinated. The patient was unable to would remark in group with inappropriate
clothing. She was wearing a red lace shirt effectively keep her balance during basic statements such as “I’m horny” and “I just
where you could see the full detail of her lunge and single leg stretches. want some meth”. The patient was also
bra. She was also wearing form fitting jeans Patient presented with erect posture while unable to focus during exercise group. She
that she continued to pull up due to her walking around, and would purposefully would leave group to put down her jacket
undergarments showing. Patient’s hair was remove pieces of clothing in front of male “because it’s couture” and then return after
pulled back into a pony tail, but she kept patients. She would also look around before being redirected by staff. She was incapable
West Coast University Care Plan Template Page 3
Revision Date: Jan, 2013
CARE PLAN
NURS 223L PSYCHIATRIC MENTAL HEALTH NURSING
Student Ashley Smith Date July 5, 2017
Instructor Gary Mittelberg Course NURS 223L
Patient Initials JV Date of 6-23-2017 Legal Status 5250
Admission (Vol, 5150, 5250,
Patient DOB 01/01/1993 Unit 3- Acute Conservatorship)
Chronological Chronological Age: 23 Female Hispanic/Vietnamese
and Apparent Apparent Age: younger
Age than 23. ~18 y/o Gender Ethnicity
Allergies NKA
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Blood Pressure Pain Scale 1-10
Sat) (location) (location, character,
onset)
4’ 11”/ 110 lbs 98.7F 72 18 99% O2 RA 99/69 0/10
(Orally) (Radial) (R Brachial) No Pain Reported
Psychiatric Diagnosis and Diagnostic Criteria History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission /
Outpatient Mental Health Services/5150 Advisement
Dx: unspecified schizophrenia spectrum versus bipolar disorder Patient was unable to provide a medical and mental history.
versus substance-induced psychosis. No known previous psychiatric admissions.
Patient presents with the following positive symptoms: delusions
Patient was diagnosed using guidelines from the DSM-5. According (magical thinking and ideas of reference), alteration in speech
to the American Psychological Association (2016), unspecified (pressured speech and flight of ideas), and bizarre behavior (hyper-
schizophrenia spectrum and other psychotic disorder 289.9 (F29) is sexuality).
a category that applies to presentation of symptoms Patient presents with the following negative symptoms: avolition.
characteristically similar to the schizophrenia spectrum (pg.120). Patient presents with the following cognitive and affective symptoms:
These symptoms cause clinically significant distress or impairment disordered thinking, inability to make decisions, poor problem solving
of a client’s social, occupational, or other important areas of their ability, difficulty performing tasks, memory deficits and suicidal
life. These symptoms however do not meet the full criteria for any ideation.
West Coast University Care Plan Template Page 1
Revision Date: Jan, 2013
,SMITH- NURSE 223L
of the disorders outlines within the schizophrenia spectrum. 5250 Advisement: you are here because you said you wanted to kill
Clinicians will us this disorder category when they choose not to yourself while attempting to harm yourself by walking in a busy street.
specify the reason that the criteria is not met for a specific spectrum
or other psychotic disorder.
Psychopathology of admitting and/or related psychiatric Erickson’s Developmental Stage
diagnosis Include Rationale Based on the Patient
Biophysical and/or related medical diagnosis With APA citations
Description of how this diagnosis relates to your patient
With APA citations
Schizophrenia- a patient who has been diagnosed with schizophrenia According to Halter (2014), patient JV is experiencing Erickson’s
has psychotic thinking or behavior that is present for at least 6 Stage of Early Adulthood (ages 20-35). A patient within this stage is
months. Areas of functioning are significantly impaired; including trying to establish intimate bonds of love and friendship (pg. 23). This
school or work, self-care, and interpersonal relationships (Sommer, particular stage is called Intimacy versus Isolation. Successful
2016). According to the American Psychiatric Association (2016), resolution of this crisis results in a patient’s ability to love deeply and
unspecified schizophrenia spectrum is a new DSM-5 diagnosis that commit oneself. Unsuccessful resolution of this crisis results in
is characterized by gross deficits in reality testing. The patient is emotional isolation and egocentricity. Patient JV is currently
experiencing a rift in perception of objective reality and while in experiencing a false assumption of intimacy via hypersexuality.
psychosis typically centered on a grandiose, persecutory, or somatic According to Montaldi (2003), hypersexuality can be categorized as an
theme. The patient may experience fear, confusion, panic, and will obsessive compulsive disorder, impulse control disorders, and/or a
be distracted and preoccupied by their internal dialogue. They will chemical dependency/addiction (pg. 2). Hypersexual behaviors can
also be unable to complete tasks required of daily living. It is also eventually persist so much so that they harden into a pattern that
suggested that medical professionals look at other plausible acquires more generalized attributes such as regulation of internal
diagnoses such as methamphetamine abuse, manic state of bipolar mental states, such as reducing anxiety or enhancing excitement. Due
disorder, and/or brief psychotic disorder. According to Marini to the unknown mental health history of patient JV, we cannot attribute
(2016), the biopsychosocial perspective of schizophrenia allows for any specific time frame for her hyper sexuality. Therefore we cannot
medical professionals to look at chemical imbalances and accurately assume that her hypersexual nature is due to an internal
medication management in order to accurately treat biological regulation of mental state.
concerns as well as address potential stressors that attribute to However, we can attribute her substance abuse as an isolative reaction.
disabling effective psychosocial coping skills. Garski (2015) Individuals who have not successfully resolved intimate bonds are
continues, every human body has a unique brain with particular unable to trust others and feel isolated. The feeling of isolation may
capacities. These capacities can be reached through learning and contribute to substance abuse behaviors as well as feed promiscuous
productive work or wasted through unhealthy habits and/or sexual attitudes.
intellectual inactivity. A persistent biologically based mental
disorder can interfere with not only social functioning but be
West Coast University Care Plan Template Page 2
Revision Date: Jan, 2013
, SMITH- NURSE 223L
severely disabling thereby affecting primary aspects of life and can
be disrupted with occasional hospital or crisis care.
The diagnosis was unclear as to which specific psychosis the patient
may be undergoing. However, the DSM-5 explains that medical
professionals must look at a variety of psychosis inducing diagnoses
that could also be contributing to the current mental status of the
patient. The patient is currently expressing many signs and
symptoms of unspecified schizophrenia as well as a manic episode
of bipolar disorder, methamphetamine abuse, and/or a brief
psychotic disorder. Due to the lack of medical and psychological
history it is appropriate to monitor the ever changing signs and
symptoms of this patient and adjust the treatment plan as the
psychosis further develops.
MENTAL STATUS EXAMINATION
Appearance
Presenting Appearance Gait and Motor Coordination Level of Participation in the
(nutritional status, physical deformities, (awkward, staggering, shuffling, rigid, Program/Activity
hearing impaired, glasses, injuries, cane) trembling with intentional movement or at (Group attendance and milieu participation,
Basic Grooming and Hygiene rest), exercise)
(clean, disheveled and whether it is posture
appropriate attire for the weather) (slouched, erect),
any noticeable mannerisms or gestures
Patient presented without physical Patient presented with restless movements. Patient attempted to join several groups
deformities. Her nutritional status seemed Her gait was appropriate, but her coordination throughout the day. She was unable to sit still
adequate. Patient has facial tattoos. during group physical activity was for more than a few seconds at any time. She
Patient presented with sexually provocative uncoordinated. The patient was unable to would remark in group with inappropriate
clothing. She was wearing a red lace shirt effectively keep her balance during basic statements such as “I’m horny” and “I just
where you could see the full detail of her lunge and single leg stretches. want some meth”. The patient was also
bra. She was also wearing form fitting jeans Patient presented with erect posture while unable to focus during exercise group. She
that she continued to pull up due to her walking around, and would purposefully would leave group to put down her jacket
undergarments showing. Patient’s hair was remove pieces of clothing in front of male “because it’s couture” and then return after
pulled back into a pony tail, but she kept patients. She would also look around before being redirected by staff. She was incapable
West Coast University Care Plan Template Page 3
Revision Date: Jan, 2013
