Behavioral Health Care Plan

Student: Christine Foley Date: February 27, 2020

Course: NSG-322CC Instructor: Professor Susan Joseste

Clincial Site: Valley Hospital Client Identifier: B.M. Age: 39 years

Reason for Admission: Pt experiencing delusions

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Pyschosis not due to a substance or known physiological condition Observed
 Pathophysiology: It is commonly accepted that there is a  Delusions
neuropathic change related to psychosis. There is often a decrease  Social withdrawal
in the white and gray matter of the brain. The C-4 gene has been  Sucidial ideation
recently discovered and researchers have discovered that this gene  Perceptions not based in reality
causes “synaptic pruning”. Synaptic pruning is the destruction of  Memory loss
repeated neural connections in the frontal lobes. In addition, many  Disorganized behvior
people who suffer from pyschosis have abnormalities of the frontal  Inability to problem solve
lobes. Some people have atrophied frontal lobes, others have lower
brain volume, increased amounts of CSF and slower blood Expected
flow/glucose metabolism in the brain. Another theory is that the  Visual hallucinations
prefrontal cortex and the thalamus have difficultly communicating  Auditory hallucinations
with each other. This creates difficulty with cognitive functioning
 Olfactory hallucinations
such as planning, memory, social skills, decision making, and
 Gustatory hallucinations
abstract thinking (Varcarolis, p. 245).
 Paranoia
 Risk Factors: patient is at a greater risk or psychosis if they have
the C-4 gene, or family history of schizophrenia. Prenatals are at  Poverty of thought
risk if they have a lack of oxygen at birth, have poor nutirition or  loss of motivation
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 are starving. Stress is another risk factor as is the use of street  inability to experience pleasure or joy
drugs (marijuana, methamphetamines, and LSD) (Varcarolis, p.  feelings of emptiness
245).  blunted affect
 Trouble focusing
 Depression
 Dysphoria
 Demoralization (Varcarolis, p. 247).

Assessment Data
Subjective Data:
“I‘m here because I didn’t know how to get home”
VS: T : 97.2ºF Labs: Diagnostics:
BP: 107/74 mmHg abnormal values: Tuberculiln skin test- pending
HR: 62 bpm hemoglobin: 11g/dL (norma1 12-18 g/dL)
RR: 18 resp/min BUN: 25 mg/dL (10-20 mg/dL)
O2: 100% RA

Assessment: Orders/Safety Protocols:

Patient is short in stature and missing a few teeth otherwise dentation is  Check every 15 min
intact.  Regular diet
 Activity therapy
Past medical history is unknown
 Admission height
Past psychiatric history is unknown  Admit to RS
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Patient states that he was a social drinker  Berlin questionnaire
 Group therapy
Mental Status Exam:
 History & physical
 Affect/Mood/Behaviors: pt affect is euphoric and states that mood  Medical consult- pt. request for burn on left leg
is good, pt displays unusual body movement with tongue  Non-adherent dry dressing on left leg
fasiculations, lateral eye movement, foot tapping, and twidling of  Shower and BM documentation
the thumbs.  Urine drug screen
 Vital signs every shift
 Appearance/Psychomotor activity: appearance is is unkepmt,
 Weight as available
wears an oversized long sleeved button down, with jeans ripped at
the bottom and pinned back together. Patient paces up and down the  Suicide precaution
halls for the majority of shift and refrains from socializing with
other patients.
 Thought process/content/speech pattern: patient’s thoughts are
disorganized, some difficulty focusing on conversation, does not
answer all questions appropriately.
 Perceptual disturbances (AH, VH, other): patient denies AH and
VH disturbances, patient experiences delusions believes he is a
“Navy pilot”, “works for the senate”, and believes he has a wife in
Tuscon. Pt does not realize he is experiencing delusions.
 Cognition/memory (3 word recall, proverb, etc.): patient’s
cognition is impaired, unable to recall past events
 Judgment/Insight: judgment and insight is poor, however he
knows he is being treated because he did not know how to get
home.
 Current SI/HI - suicidal ideation is passive, denies homicidal
ideation
 Other comorbidity/ abnormal physical findings: no other
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 comorbidies, has a second degree burn on the left lower leg
 Intellectual Functioning (observed/inquired): below average for
stated age

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 Medications
ALLERGIES: diphenhydramine, haloperidol

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations

Olanzapine 5 mg PO BID I: To treat schizophrenia Parkinsonism, NMS, suicidality, Assess for development
Class: antipsychotic abnormal gait, personality of EPS, draw labs:
Te: AH, VA, olfactory and disorder, tremors, EPS, AST, ALT, GGT, CK,
gustatory distrubances will orthostatic hypotension, glucose, triglycerides,
decrease and patient will ecchmosis, peripheral edema, bilirubin, and WBC.
experience less delusions constipation, dry mouth, Assess mental status.
(Vallerand, Sanoski, & Delgin, increased salivation, vomiting, Watch for changes in
2017). increased thrist, hematuria, behvaior that could
urinary incontinence, dyspnea indicate worsening in
(Vallerand, Sanoski, & Delgin, suicidality. Teach
2017). patient to get up slowly
after taking medication
and to peel the package
open and not pop it
through the backing
(Vallerand, Sanoski, &
Delgin, 2017).
Silver sulfadiazine 1% one Topical BID I: Topical cream to treat Exfoliateive dermatitis, Stevens- Assess burned tissue for
Class: antibacterial application infection in 2nd-3rd degree Johnson, toxic epidermal, infection, assess for
over entire burns. necrolysis, burning, itching, skin rash. Teach patient
wound bed Te: infection will disappear pain, rash, skin discoloration, purpose of medication,
and burn will heal (Vallerand, skin necrosis, leukopenia and to tell health care
Sanoski, & Delgin, 2017). (Vallerand, Sanoski, & Delgin, provider if a rash
2017). develops (Vallerand,
Sanoski, & Delgin,
2017).
Trazodone 50mg PO PRN I: Anti-depressant Lactation, suicidal ideation, Assess for serotonin
Class: antidepressant bedtime drowsiness, hypotension, syndrome, autonomic
Te: patient will be able to sleep nightmares, dry mouth instability,

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Hydroxyzone pamoate 50mg
Class: antihistamine
throughout the night
(Vallerand, Sanoski, & Delgin,
2017).
PO Q6h I: anxiety/agitation
Te: patient’s level of anxiety
will decrease and agitation and
agitated behavior will decrease
(Vallerand, Sanoski, & Delgin,
2017).
(Vallerand, Sanoski, & Delgin,
2017).
Drowsiness, dizziness, fatigue,
involuntary motor aactivity, dry
mouth, respiratory depression,
involuntary urinary activities
(Vallerand, Sanoski, & Delgin,
2017).
neurotransmitter
aberrations, GI
symptoms, and suicidal
tendencies. Teach
patient about possible
sexual dysunction
(Vallerand, Sanoski, &
Delgin, 2017).
Assess for profound
sedation, assess mental
status. Teach patient to
not drink alcohol,
encourage patient that
freuqent mouth rinses,
good oral hygiene or
sugarless gum/candy
may decrease dry
mouth (Vallerand,
Sanoski, & Delgin,
2017).
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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client- or family-focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for self-directed violence r/t suicidal ideation as evidenced by patient stating so in admission interview. This is a
priority nursing diagnosis because it relates to the safety of the patient
Patient will be able to Pt will report feelings of 1) Listen carefully while pt 1) This communicates that 1) Goal met: nurse and
identify triggers that increased self-worth by is speaking. Engage in caring, support and student nurse engaged in
stimulate desire to hurt self the end of shift active listening and do not understanding without conversation and
during stay at hospital challenge what pt is saying asking for denial of utilized active listening
(Sparks et al., p. 426). feelings (Sparks et al., p. while patient was
2) Supervise medication 426). speaking (Sparks et al.,
adminstration and be aware 2) Medications can be p. 426).
of side effects/adverse hoarded and some 2) Goal met: Nurse
effects (Sparks et al., p. medications can increase managed medication
426). sucidial ideation (Sparks et adminstration while
3) Encourage pt to set goal al., p. 426). student nurse looked up
of cooperating with 3)Refusal to participate in medications in drug
psychiatric intervention psychiatric care indicates guide (Sparks et al., p.
(Sparks et al., p. 426). that pt is suppressing 426).
feelings thus impairing 3) pending: patient
healing (Sparks et al., p. engaged in group
426). therapy with therapist
during shift (Sparks et
al., p. 426).
Secondary Nursing Diagnosis:
Impaired social interaction related to impaired thought process as evidenced by delusions
Patient will interact with Patient will maintain 1)Determine if medication 1) Many positive 1) Pending: awaiting labs
peers and nurses interaction with another has reached a therapeutic symptoms with (Phelps et al., p. 773).
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appropriately by the end of client while engaging in an level (Phelps et al., p.
hospital stay. activity (i.e. broadgame, 773).
drawing) during shift.
2) Provide client with
simple activties to engage
in such as looking at
pictures or painting
(Phelps et al., p. 309).
3) Acknowledge the
patient when they make
positive steps toward
increasing social skills and
appropriate interactions
with others (Phelps et al.,
p. 309).
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socioeconomic
status, and cultural and spiritual preferences of the individual and focused on providing safe, evidence-based care for the achievement
of quality client outcomes.
References
schizophrenia subside with
medication (Phelps et al., 2) Goal met: Recreational
p. 773). therapy provided drawing
and painting activities
2) Simple activities (Phelps et al., p. 309).
distract from delusions and
helps the patient focus on 3) Goal not met: nurse
reality (Phelps et al., p. neglected to acknowledge
309). positive social interactions
(Phelps et al., p. 309).
3) Recognition goes a long
way to support a behavior
(Phelps et al., p. 309).
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Phelps, L., Ralph, S.S., & Taylor C.M. (2017). Sparks and taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD:

Lippincott, Williams & Wilkins/Wolters Kluwer.

Vallerand, A. H., Sanoski, C. A., & Delgin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia, PA: F. A. Davis.

Varcarolis, E. M. (2017). Essentials of psychiatric mental health nursing: A communication approach to evidence-based care.

Elsevier Inc.