Behavioral Health Care Plan

Student: Alexandria Casarez Date: 2/21/2020

Course: NSG-322-CC Instructor: Ryan McKenzie

Clincial Site: Banner Del Webb Client Identifier: FW Age: 65

Reason for Admission:

Worsening depression and suicidal ideations with plans to overdoes on medication.

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

FW primary diagnosis includes Major Depressive Disorder Clinical manifestations for this patient included apetite
(MDD) with reoccurent episodes. Secondary diagnosis include decrease, depressed mood, excessive fear, hopelessness,
anxiety disorder, hyperlipidemia, and external otitis. MDD impaired concentration, loss of energy, sleep disturbacnes,
pathophysiology is not very clear, some evidence points to a suicidal ideation, weightloss, fellings of worthlessness and
disturbance in seritonin levels (Halverson, 2019). Risk fackors for guilt.
MDD include history of depression, female gender, history of
suicide attempts, member of the LGBT communitry, substance
abuse, stressful life event, and chronic mental illness (Varcarolis,
2018).

Assessment Data
Subjective Data: Patient stated at admission he had fellings of being overwhelmed and stress with life events and work, patient had plans to
overdose with pills. Since spending time in the hospital and undergoing treatment patient had improved. Patient states “I am feeling a lot better,
I think after adjsuting my medicaiton and fixing the ratio, I can get back to my life again”.
VS: T : 36.5 °C Labs: Diagnostics:
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
 BP: 143/78 The following are abnormal lab values found in No studies were found in patients chart for diagnostic
HR: 57 bpm the patient charts. purposes.

RR: 18 Cholesterol- 254 mg/dL

O2 Sat: 98% room air LDL- 167 mg/dL

Non HDL- 197 mg/dL

Assessment: Orders/Safety Protocols:

Mental Status Exam: Patient was placed on a regular diet, activity as tollerated, FW was addmited to
inpatient, and had order for shower and shampoo.
Appearance (observed)
-Patient was a 65 year old male and appeared stated age, grooming and
hygiene fare. Patient has good eye contact, and no unusual manerism,
no psycomortor, agitation, or depression.
Behavior (observed)
-Patient’s behavior was mild.
Attitude (observed)
-Patient’s attittude was cooperative.
Level of Consciousness (observed)
-Patient was alert and oriented.
Orientation (inquired)
-Patient was oriented times three.
Speech and Language (observed)

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-Patient’s speech is clear, no slurring, with average content.
Mood (inquired)
-Patient mood was depressed.
Affect (observed)
-Patient’s affect was mood congruent.
Thought Process/Form (observed/inquired)
-Patient was logical, goal directed, no flight of of ideas or loose
associations
Thought Content (observed/inquired)
-Patient denies suicidal ideastions, homicidal ideations, delusions,
parania,hopelessness, and helplessness.
Suicidality and Homicidality (inquired)
-N/A, none
Insight and Judgment (observed/inquired)
-Patient states motvated for treatment.
Attention Span (observed/inquired)
-Patient’s attention span was fair.
Memory (observed/inquired)
-Patient’s immediate, recent, and remote memories were grossly intact
with minor deficits.
Intellectual Functioning (observed/inquired)

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-Patient’s intellectual funtioning was fair.

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 Medications
ALLERGIES: Wellbertin, Sellective seratonin reuptake inhibitors (SSRI’s), statins

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Acetic acid otic 3 drops R-ear QID Outer ear infection. Temporary stinging or burning Assess for allergic
of the ear reaction after
administration,
81 mg PO daily Blood thinner, and fever Heart burn, bleeding, Monitor hepatic
Asprin reducer. hepatotoxicity, and anaphylaxis function and serum
levels for drug toxicity.
Escitalopram (lexipro) 20 mg PO Daily Used for antidepressant action. Suicidal thoughts, seratonin Asses patient for
syndrom, and diarrhea suicidal tendencies, and
monitor for mood
changes and level of
anxiety.
Acetaminophen 650 mg PO PRN-Q4 Mild pain and fever reducer. Hepatotoxicity, uticaria, anxiety, Assess alcohol usage
HA, and constipation before administration,
due to an increased risk
of hepatotoxicity.
Bisacodyl 5 mg PO PRN Treatment of constipation. Nausea, abdominal cramping, Assess for abdominal
and hypokalemia distemtion, presence of
bowel sounds, and
unusal patters of bowel
function.
Calcium carbonate 500 mg PO-chew PRN Used as an antiacid. Bradycardia, cardiac arrest, Monitor patients vital
constipation, and arrhythmias signs, assess for
heartburn or
indigestion, and
abdominal pain.
Docusate 100 mg PO PRN Prevention of constipation. Throat irritation, mild cramps, PO administration with
and diarrhea a full glass of water or
juice.
10 drops Both ears PRN Treats earwax buildup. Allergic reaction When administering
Carbamide peroxide otic avoid touching the

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 dropper to ear.
Hydroxyzine 25 mg PO PRN-Q6 Treatment of anxiety Drowsiness, dry mouth, Assess mental status,
agitation, and wheezing level of sedation, and
monitor for agitation.
Ibuprophen 400 mg PO PRN-Q6 Mild to moderate pain reliver. Anaphylaxis, MI, stroke, HF, Assess for signs and
edema, and GI bleeding symptoms of GI
bleeding.
Magnesium hydroxide 30 mL PO PRN Used for GI complications and Diarrhea Asses for abdominal
constpation. distension and
prescence of bowel
sounds.
Ondanserton 4 mg PO PRN Prevention and treatment of Seatonin syndrome, HA, Assess patient for
nausea and vomiting. dizziness, constipation, and dry nasuea and vomitiong,
mouth. abdominal distention
and bowel sounds, prior
to and after
administration.
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: Risk for suicide related to MDD.

Encourage the client and family
members to get involves in
patients care. Have patient
discuss feelings and reasons for
attempt.
Patient envirionment will be
free from potential suicide
weapons, patient will recover
from sicidal episode, patient
will discuss feelings the
precipitated the suicide attempt,
patient will consult with mental
health professional, patient will
voice improvement of self-
worth.
Ask patient directly “Have you
had thoughts of killing yourself?”
and if so ask “What do you paln
to do?”.
Initiate proper safety protocols by
removing anything that can be
used to inflict harn.
Make appropriate referrals to
mental health professionals.
Asking patient directly what
their plan is important because if
there is a plan the risk increases.
Initiating safetey protocol
enurese the paitent’s safety.
Reffering patient to mental
health professionals helps the
patient work through suicidal
feelings and develop healthier
alternatives.
Patient won’t harm self in
hospital, patient states
reasons for suicide attempts,
patient identifies crisis
prevetion resources, and
patient expresses positive
feelings about self.

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Secondary Nursing Diagnosis: Ineffective coping related to inadequate opportunity to prepare for stressor.

Goal for patient is to develop Patient will express If possible assign primary nurse Assigning the primary nurse Patient will be able to identify
effective, healthy, coping understanding of the to the patient. Help the patient provides continuity of care and emotions triggered by illness or
mechanisms. relationship between emotional analyse the current situation and promotes development of personal crisis and usual coping
state and behavior, patient will evaluate the effectiveness of theraputic relationship. Helping behaviors. Patient identifies two
become actively involved in coping stradegie. the patient analyse and evaluate effective and two ineffective
planning of care, patient will coping stradegies fosters an coping bahaviors. Patient enlist
accept responsibility of objective outlook on the support from family and friends.
behavior, patient will identify situation.
effective and ineffective coping
techniques.
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.

Resources
Halverson, J. (2019, November 27). Depression. Retrieved from https://emedicine.medscape.com/article/286759-overview#a3

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Phelps, L. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD: Lippincott, Williams &

Wilkins/Wolters Kluwer. ISBN-13: 9781496347817

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). 

Philadelphia, PA: F.A. Davis.

Varcarolis, E. M. (2018). Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care.

[Pageburstls]. Retrieved from https://pageburstls.elsevier.com/#/books/9780323389655/