Behavioral Health Care Plan

Student: Nicole Kretkowski Date: 1/26/19

Course: NSG-322CC Instructor: Dustin Gorsky

Clincial Site: Banner University Behavioral Health Unit Client Identifier: NM Age: 24

Reason for Admission: Suicide attempt. An excessive intak of BP medications and antipsychotic medications. (40 tablets of lisinopril and 20
tablets of prothenazine)

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

Schizoeffective disorder Generalized Anxiety Disorder
Generalized Anxiety Disorder -Persistent worrying/anxiety about situations that are out of
Patho: Excessive ongoing anxiety and worry that are difficult to control proportion
and interfere with everyday activities. A person may develop this as a -Overthinking plans and solutions to all possible worst-case
child or as an adult. Generalized anxiety disorder can improve with outcomes
psychotherapy, medications, coping skills, and relaxation skills.
-Difficulty trying to let go of worry
Risk factors: Personality (a person whose temperament is timid, negatice
or avoids anything dangerous may be more prone to this disorder than -Inability to relax
others), genetics, or certain experiences that occurred in one’s life. -Difficulty concentrating
PTSD -Muscle tension or aches
Patho: PTSD is a mental health condition that is triggered by a terrifying PTSD
event (either witnessing it or experiencing it). People who go through
traumatic events may have diffulty adjusting or coping. Symptoms may -Intrusive memories
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
include flashbacks, nightmares, and severe anxiety. Uncontrollable -Avoidance
thoughts about the specific event commonly occur in an idividual who has -Easily being startled or frightened
PTSD.
-Negative thoughts about oneself, or other people
Risk factors: Experiencing intense or long-lasting trauma, having
experienced trauma earlier in life such as childhood or sexual abuse, -Memory problems
having a job that increases the risk of being exposed to traumatic events -Difficulty maintaining close relationships
(military personnel and first responders), and having blood relatives with
mental health problems are all factors that can make one more likely to ADHD
develop PTSD. The most common events leading to the development of -Hyperactive-impulsive behavior
PTSD include sexual violence, physical abuse, physical assault, an
accident, being treatened with a weapon, or combat exposure -Inattention

ADHD -Talks too much

Patho: A chronic condition that affects children and often continues into -Fidgets with or taps his or her hands or feet/squirms in the seat
adulthood. A person who has ADHD can have difficult sustaining -Easily distracted
attention, hyperactivity, and impulsive behavior. Children can also have
-Trouble paying attention
poor performance in school and have a hard time with relationships.
Symptoms sometimes lessen with age but some individuals never Borderline Personality Disorder
completely outgrow ADHD symptoms. Treatment will not cure ADHD, -Intense fear of abandonment
but it can help dramatically. Treatment includes medications and
behavioral interventions. The exact cause of ADHD is not clear. However, -Rapid changes in self-identity and self-image
factors involved in the development include genetics, environment, and -Periods of stress-related paranoia
central nervous system development.
-Impulsive or risky behavior (gambling, reckless driving, spending
Risk factors: Blood relatives, exposure to environmental toxins, maternal sprees, binge eating, or drug abuse.
drug use (alcohol or smoking during pregnancy), or premature birth.
Sugar is a possible suspect in causing hyperactivity, but there is no -Ongoing feelings of emptiness
reliable proof. -Inappropriate, intense anger (losing temper)
Borderline Personality Disorder Client Manifestations
Patho: A mental health disorder that impacts one’s way of thinking and - Difficulty trying to let go of worry
feeling about themselves. This can cause problems in functioning in
-Inability to relax
everyday life and usually includes a pattern or unstable intense
relationships, distorted self-image, and extreme emotions and -Intrusive memories
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impulsiveness. A person with this disorder will usually have an intense -Negative thoughts about oneself, or other people
fear of abandonment or instability and may have difficulty tolerating -Hyperactive-impulsive behavior
being alone. This disorder usually begins by early adulthood and seems to
be worse in young adulthood. -Inattention
Risk factors: Hereditary predisposition or a stressful childhood (Mayo -Talks too much
Clinic, n.d.). -Fidgets with or taps his or her hands or feet/squirms in the seat
-Easily distracted
-Trouble paying attention
-Impulsive or risky behavior (gambling, reckless driving, spending
sprees, binge eating, or drug abuse.

Assessment Data
Subjective Data: NM states she took BP medications as a suicide attempt.

VS: T : 36.8 C Labs: 1/24/19 at 08:30 Diagnostics:

BP: 162/100 CBC 1/9/19 at 14:45
HR: 83 bpm WBC: 10.0 K/MM3 -Chest PA + Lat
RR: 20 RBC: 4.86 M/MM3 1/15/19 15:55

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HGB: 13.0 g/dL -Chest Single View Portable
HCT: 41.0 %
Platelets: 268 K/MM3
Chem General
Glucose: 97 mg/dL
BUN: 14.1 mg/dL
Creatine: 0.67 mg/dL
BUN/Creat Ratio: 21
Sodium: 135 mmol/L
Potassium: 4.6 mmol/L
Chlorid: 99 mool/L
CO2: 13
Magnesium: 1.8 mg/dL
Calcium: 9.5 mg/dL
Liver Enzymes
AST: 21 U/L
ALT: 27 U/L
Bilirubin: 0.2 mg/dL
*Labs within normal range.

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Assessment: Orders/Safety Protocols:

Mental Status Exam: - Full code

Appearance - Regular diet

Eye contact is present while communicating, darts around at times. - Vital signs
Apparel is appropriate to the occasion, wearing jeans with fashionable - Belt precations: Danger to self
holes in them and a white jacket. Female patient who wears men’s
clothing. Hair is short, clean, and brushed. Client is showered, - Activity as tolerated
fingernails are maintained and not dirty, and patient wears no make-up.
Three tattoos are noted- (Three green dots on the right between thumb
and index finger. Client’s age agrees with overall look. Size is
appropriate for age.
Behavior
Shakes hands and feet while communicating. Gait pattern is normal.
Psycho-motor agitation is noted. Patient rocks in chair and is fidgeting.
Attitude
Positive attitude about other people. Low-self esteem when talking
about self. States she can easily give advice to others but hard for her to
take own advice.
Level of Consciousness
Alert and responsive to questions.
Orientation
Alert and oriented x3- can identify who she is, where she is, and what
time it is. Is aware of conversation going on and answers questions
appropriately.

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Speech and Language
Words come tumbling out with pressured speech. Volume is high
pitched. Flow of speech is rapid.
Mood
Patient appears anxious as evidenced by fidgeting and rapid speech.
When asked her mood she states she is happy that nursing students are
here visiting and talking with her.
Affect
Bright, outward expression of happiness. Congruent with situation and
mood. No random bursts of anger are noted.
Thought Process/Form
No disturbances noted with logical thought process. No rumination,
loosening associations, neoligisms, or clang associations are noted.
Thought Content
Auditory, command, olfactory, and gustatory hallucinations are noted.
Patient explains that she hears demonic voices telling her to kill her
family or self. Smells burning like a fire or heavy smoke and can taske
heavy smoke. Delusions are noted. Patient thinks men are out to get her.
Gets along better with women. Wants to fight men if they make her feel
uncomfortable.
Suicidality and Homicidality
No current suicidal/homicidal thoughts are noted. Patient denies when
asked. Patient states this is the last SA and she is moving on with her
life.

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Insight and Judgment
Emotional and fair insight focus as evidenced by knowing what her
illness entails but not fully aware of limitations or consequences of
actions. Judgement is fair as evidenced by inabilty to set goals for
discharge. Patient states she wants to “smoke a cig” when asked about
current goals. Patient then focuses back to coping skills she can identify
to help with discharge such as deep breathing.
Attention Span
Attention is 7/10. Patient appears to switch subjects or gaze out the
window.
Memory
Long term memory is intact. Poor short-term memory. Not able to recall
any three words (Ball, tree, flag). Not able to count backwards by serial
7’s. Recalls the month and year.
Intellectual Functioning
Fair. Patient needs further assistance with making decisions and setting
out goals for her future.

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 Medications
ALLERGIES:
Abilify, Clozaril, Zyprexa, Seroquel, Cogentin
*Used for all medications: Vallerand, Sanoski, & Deglin, 2017).
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Haloperidol (Haldol) 5 mg PO Q Bedtime -Alters the effects of dopamine -Seizures, agranulocytosis, -Assess mental status
in the CNS. Also has neuroleptic malignant syndrome, prior to and periodically
choinergic and alpha- constipation, dry mouth, blurred during therapy.
adrenergic blocking activity. vision, extrapyramidal reactions. -Assess positive
-Used for acute and psychotic (hallucination,
disorders including delusions) and negative
schizophrenia, manic stages, (social isolation)
and drug-induced psychoses. symptoms of
-Useful in managing aggressive schizophrenia.
patients . -Monitor BP (sitting,
standing, lying down)
and pulse prior to and
frequently during the
period of dose
adjustment. May cause
QT interval changes on
ECG.
-Observe patient
carefully when
administering the
medication, to ensure
that it is actualy taken
and not hoarded.
-Monitor for
developnment of
neuroleptic malignant
syndrome- fever,
respiratory distress,
tachycardia, seizures,
diaphoresis,
hypertension or
hypotension, pallor,

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 tiredness, severe muscle
stiffness, loss of bladder
control.
-Monitor CBC with
differential and liver
function tests
periodically during
therapy.
Nicotine 21 mg Transdermal Daily -Provides a source of nicotine -Headache, insomnia, abnormal -Prior to therapy, assess
during controlled withdrawal dreams, dizziness, drowsiness, smoking history
from cigarette smoking. nasopharyngeal irritation, (number of packs per
-Used for adjunct therapy (with sneezing, increased appetite, oral day, smoking patterns,
behavior modification) in the injury, trandermal burning at the nicotine content of
management of nicotine patch site, erythema, pruritus, preferred brand, degree
withdrawal patients desiring to and dysmenorrhea. to in which patients
give up cigarette smoking. inhale smoke).
-Assess patient for
symptoms of smoking
wwithdrawal during
nicotine replacement
therapy.
-Monitor for toxicity
and overdose: nausea,
vomiting, diarrhea,
increased salivation
abdominal pain,
headahce, dizziness,
auditory and visual
disturbances, weakness,
dyspnea, hypotension,
and irregular pulse.

Diphenhydramine 50 mg IM PRN -Antagonizes the effecgt of -Drowsiness, dizziness, -Determine why the
(Benadryl) agitation histamine at H1-receptor sites; headache, paradoxical medication was ordered
does not bind to or inactivate excitation, blurred vision and assess symptoms
histamine. Significant CNS tinnitus, hypotension, nausea, that apply to the
depressant and anticholinergic anorexia, dry mouth, dysuria, individual patient.
properties. photosensitivity, urinary -Assess for urticaria
-Used for relief of allergic retention, thickened bronchial and for ptency or
symptoms caused by histamine airway.

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 release including: anaphylaxis, secretions, wheezing, and chest -May decrease skin
seasonal and perennial allergic tightness. response to allergy
rhinitis, allergic dermatoses. tests.
-Used to prevent motion -Assess sleep patterns.
sickness and a mild nighttime -Assess degree or nasal
sedation. stuffiness, rhinorhea,
and sneezing.
-Caution patients to
avoid OTC cough and
cold products while
breast feeding or to
children less than 4 yrs.
Hydroxyzine 25 mg PO Q6H PRN -Acts as a CNS depressant at -Drowsiness, agitation, ataxia, -Assess patient for
anxiety the subcortical level of the dizziness, heache, weakness, profound sedation and
CNS. Has anticholinergic, wheezing, dry mouth, urinary provide safety
antihistamine, and antiemetics retention, pain at IM site, chest precautions as indicated
properties. Blocks histamine 1 tightness, constipation, nausea, (side rails up, bed in
receptors. abscesses at IM sitees. low position, call light
-Used for treatment of anxiety. within reach,
Preoperative sedation. supervision of
Antiemetic. Antipruritic. (may ambulation and
be combined with other transfer).
opioids). -Older adults are more
sensitive to CNS and
anticholinergic effects.
-Assess mental status.
-May cause false-
negative skin test using
allergen extracts.
Discontinue the drug at
least 72 hrs before test.
-Assess degree of
vomiting/nausea.
-Assess degree of
itching and character of
involved skin.
Ondansetron (Zotran) 4 mg PO Q6H, PRN T3-receptor sites (selective -Sedation, dry mouth, transient -Monitor fluid and
nausea and antagonist) located in the vagal increases in liver electrolyte status.
vomitting nerve terminals and the aminotransferases and bilirubin, Diarrhea, which may
cause fluid and

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 chemoreceptor trigger zone in hypersensitivity reactions, electrolyte imbalance is
the CNS diarrhea, headache. a potential adverse
-Prevents nausea and vomiting effect of this drug.
associated with cancer
chemotherapy and anesthesia.
Lorazepam 2 mg=1 mL IM PRN -Most potent of the available -Anterograde amnesia, -Have equipment for
agitation benzodiazepines. drowsiness, sedation, dizziness, maintaining patent
-Effects are mediated by the weakness, disorientation, sleep airway immediately
inhibitory neurotransmitter disturbance, hallucinations, available before starting
GABA. Action sites: thalamic, hypertension or hypotension, IV administration.
hypothalamic,, and limbic blurred vision, diplopia, -Supervise ambulation
levels of the CNS. decreased hearing, abdominal of older adult patients
-Used for the management of discomfort, and anorexia. for at least 8 hours after
anxiety disorders and for short- injection to prevent
term relief of symptoms of falling and injury.
anxiety. Also used for -Assess CBC and liver
preanesthetic medication to function tests
produce sedation and the periodically for patients
reduce anxiety and recall of on long-term therapy.
events related to day or surgery. -Inform the client not to
-Also used for management of self-medicate with OTC
status epilepticus. drugs and seek
physician guidance.
-Drug should be
gradually decreased.

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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 Was goal met? Revise the
reasonable, and attainable. interventions. intervention is plan of care according the
indicated/therapeutic. client’s response to current
Provide references. plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Risk for suicide related to life-threatening situation as evidenced by attempting to overdose.
-Patient will be able to - Identifies healthy ways - Assess suicide risk and -To identify patient’s -Goal is ongoing.
focus on positive ways to to deal with and express protective factors using safety in regards to Patient continues to
cope in order to maintain anxiety within two weeks. approved risk assessment harming self. have outbreaks due to
the quality of life. - Identifies positive scale/tool. anxiety and yells at
coping strategies within staff. Needs to be able to
two weeks. respond to anxiety in a
- Demonstrates ability to - Discuss benefits and -Each patient needs healthier manner.
manage suicidal impulses values of psychotherapy communication -Goal is met. Patient
within two weeks. treatment. interventions tailored to the identifies positive
- Discloses posession of patient’s situation. coping strategies such as
and surrenders harmful deep breathing, listening
objects within two weeks. - Encourage constructive to music, and drawing.
-Identifies available expression of fears, -To reduce anxiety. -Goal is ongoing.
community resources and anxieties, and anger. Patient states she is not
support systems within suicidal but needs to
two weeks. continue to be stable
unil discharge and
- Establish trusting -To stimulate throughout.
therapeutic relationship nonthreatening two-way -Goal is met. Patient
does not carry any
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 using nonjudgemental conversation (Phelps, harmful objects and
approach. Ralph & Taylor, 2017). does not attempt to harm
self.
-Goal is met. Patient
identifies community
resources such as
“Cheers” group that she
will attend outside of the
hospital.

Secondary Nursing Diagnosis:

Ineffective coping related to inadequate opportunity to prepare for stressors as evidenced by risk-taking behavior.
-Patient will be able to -Patient will express -Spend consistent, -An open environment will -Goal is ongoing. Patient
form a valid appraisal of understanding of the uninterrupted time with help the patient ventilate is working on expressing
stressors and use available relationship between the patient. Encourage intense emotion. Through understanding of inner
resources to help cope. emotional state and open expression of discussion, you can help emotions related to
behavior within two feelings. the patient understand the behaviors.
weeks. personal meaning attached -Goal is met. Patient is
-Patient will become to recent events and foster actively involved in
actively involved in a realistic assessment of planning care as evidenced
planning own care. the situation. by using adequate
-Patient will accept resources such as group
responsibility for behavior therapy, communicating
within two weeks. -Help the patient recognize with health care
and accept responsibility professionals, and using
-Patient will identify -Developing a sense of
for own actions. deep breathing techniques.
effective and ineffective responsibility is necessary
coping techniques within Discourage the patient -Goal is met. Patient
before change can occur.
two weeks. from unfairly placing accepts responsibility for
blame on others. behavior and states she
-Patient will use available
will not try to kill self
support systems, such as
again.
family, friends, and
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 psychotherapist, to -Help the patient analyze -Goal is ongoing. Patient
develop and maintain the current situation and identifies effective coping
-To foster an objective
effective coping skills evaluate the effectiveness techniques but needs more
outlook.
within two weeks. of coping strategies. time identifying
ineffective coping
strategies.
-Goal is met. Patient uses
-Praise the patient for -To reinforce appropriate available support systems.
identifying and using behavior. She relies on her sister,
effective coping
(Phelps, Ralph & Taylor, friends, and support
techniques.
2017). groups to help cope.

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.
Phelps, L., Ralph, S., & Taylor, C. (2017). Spark’s & Taylor’s Nursing Diagnosis Reference Manual (10th ed.). Riverwood, IL:

Wolters Kluwer. ISBN: 9781496347817

Mayo Clinic. (n.d.). Retrieved from https://www.mayoclinic.org/

Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s Drug Guide for Nurses (15th ed.). Philadelphia, PA: F:A. Davis Company.

ISBN: 9780803657052

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