PSYCHIATRIC NURSING CARE PLAN-
CASE STUDY
Ms. Janet Steel is a 26-year-old female with a History of HTN, Anxiety, Asthma, Hypochondria and PCOS. She was admitted to Millwood Hospital due to a Panic Attack she experienced 1 month ago. She was initially admitted to JPS psych unit, was discharged home but she is still unstable at this time. The patient has been complaining of having a wound and pain (level 6) under her left foot, but there is no wound under her left foot. The patient’s mother is her support system and Responsible Party. When the charge nurse entered the room to ask the reason for admission, the patient stated “I have severe anxiety and I had a panic attack last month. I am having pain under my left foot because I have a wound”. The charge nurse did a head to toe assessment, but there is no wound under her left foot. The family indicated that the patient will often complain of having something wrong with her all the time. She has been going to the hospital every week for the last 6 months and the physicians diagnosed her with Hypochondria. The patient has been very restless and anxious. She has been very uncooperative with care because she thinks everyone is going to hurt the wound on her left foot, that does not exist. She has a flat affect and is very anxious. She has very soft speech and a medium tone. She denies having any homicidal, suicidal, visual or auditory hallucinations. She is having delusions about the wound on her left foot, that does not exist. Her perception is that she is in lots of pain due to a wound that does not exist per the charge nurse assessment. Her thought processes are illogical. She is alert and oriented x 2, has moderate insight and judgement, is independently ambulatory and is able to toilet herself. She is continent of bowel and bladder. She is non-denominational and does not attend church regularly. She is on a Regular diet with thin liquids. She has good dentition. She has good health and sleeps for 6 hours every night. She does not attend group activities; she has abused marijuana in the past 3 months. She finished Highschool. She plans to go home with her mother upon discharge.
Medication List:
Seroquel 25mg 1 tab PO BID
Xanax 1 mg 1 tab PO q12 hours PRN
Lisinopril 10mg 1 tab PO QD
Acetaminophen 325mg 1 tab PO q4 hours PRN
Metformin 500mg 1 tab PO QD
Vital signs:
VS: 98.6°, 110/74, 72, 18, 99% ra
Objective Data
Alert and Oriented X 2
Normal Dentition
Height 5ft 10in; Weight 135lb.
Cardiovascular: S1, S2, S3 present; all peripheral pulses palpable
Respiratory: Normal lung sounds in all lobes
Gastrointestinal: BS present in all 4 quadrants.
Labs:
Test Results Ref. Range Units
Sodium 139 137-145 mmol/L
Potassium 3.7 3.5-5.3 mmol/L
Chloride 101 98-107 mmol/L
Carbon dioxide 24 22-30 mmol/L
Anion gap 13.0 7.0-16.0 mmol/L
Creatinine 1.20 0.66-1.25 mg/dL
Estimated GFR Non AFR American 100 >60 ml/min/1.73m2
Anion gap 12 7.0- 16.0 mmol/L
Blood Urea Nitrogen (BUN) 28 9-20 mg/dL
WBC: 8.0 3.4 -10.8 x10E3/ul
Student
Date
Instructor
Course
Patient Initials
Date of Admission
Legal Status
(Vol, 5150, 5250, Conservatorship)
Patient DOB
Unit
Chronological and Apparent Age
Gender
Ethnicity
Allergies
Height/Weight
Temp (location)
Pulse (location)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure (location)
Pain Scale 1-10 (location, character, onset)
Psychiatric Diagnosis and DSM 5 Diagnostic Criterion
History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement
Psychopathology of admitting and/or related psychiatric diagnosis
Biophysical and/or related medical diagnosis
Description of how this diagnosis relates to your patient
With APA citations
Erickson’s Developmental Stage
Include Rationale Based on the Patient
With APA citations
MENTAL STATUS EXAMINATION
Appearance
Presenting Appearance
(nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)
Basic Grooming and Hygiene
(clean, disheveled and whether it is appropriate attire for the weather)
Gait and Motor Coordination
(awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),
posture
(slouched, erect),
any noticeable mannerisms or gestures
Level of Participation in the Program/Activity
(Group attendance and milieu participation, exercise)
Manner and Approach
Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)
Behavioral Approach
(distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing).
Coping and stress tolerance.
Speech
(normal rate and volume, pressured, slow, loud, quiet, impoverished)
Expressive Language
(no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling)
Receptive Language
(normal, able to comprehend questions, difficulty understanding questions)
Orientation, Alertness, and Thought Process
Recall and Memory
(recalls recent and past events in their personal history). Recalls three words (e.g., Cadillac, zebra, and purple)
Orientation
(person, place, time, presidents, your name)
Alertness
(sleepy, alert, dull and uninterested, highly distractible)
Coherence
(responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)
Concentration and Attention
(naming the days of the week or months of the year in reverse order, spelling the word “world”, their own last name, or the ABC’s backwards)
Thought Processes
(loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).
Values and belief system
Hallucinations and Delusions
(presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)
Judgment and Insight
(based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)
Mood and Affect:
Mood or how they feel most days
(happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry).
Affect or how they felt at a given moment
(comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation.
Rapport
(easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions
(relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)
Response to Failure on Test Items
(unaware, frustrated, anxious, obsessed, unaffected)
Impulsivity
(poor, effected by substance use)
Anxiety
(note level of anxiety, any behaviors that indicated anxiety, ways they handled it)
Risk Assessment:
Suicidal and Homicidal Ideation
(ideation but no plan or intent, clear/unclear plan but no intent)
Self-Injurious Behavior
(cutting, burning)
Hypersexual, Elopement, Non-adherence to treatment
Discharge Plans and Instruction:
Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program
Teaching Assessment and Client / Family Education:
(Disease process, medication, coping, relaxation, diet, exercise, hygiene)
Include barriers to learning and preferred learning styles
Pertinent Lab Tests Results
(normal ranges in parentheses)
Rationale for Abnormals
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
CBC (WBC with diff, ANC, RBC)
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results
(with dates)
Rationale for Abnormals
Substance Abuse and other Addictions
(gambling, sex, shopping, smoking)
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
C.A.G.E. Questionnaire
Have you ever felt you should cut down on your drinking?
Yes / No
Have people annoyed you by criticizing your drinking?
Yes / No
Have you ever felt bad or guilty about your drinking?
Yes / No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Yes / No
Abnormal Involuntary Movements
Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe
I: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,
grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)
0 1 2 3 4
II: Extremity Movements:
Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.
Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot
0 1 2 3 4
III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)
0 1 2 3 4
IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)
0 1 2 3 4
V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)
Yes No
Diagnostic
Label
As evidenced by
Contributing
Factors
Related to
Signs and
Symptoms
Diagnosis
Minimum of 2 NANDA – actual and/or potential.
Include etiology and signs and…
