MM is a 42-year-old African American woman admitted involuntarily to the psychiatric hospital due to expressing suicidal thoughts. She has a history of schizophrenia, major depressive disorder, and a previous suicide attempt. She is currently taking several medications including Risperidone, Trazodone, Sertraline, Klonopin, Latuda, Loratadine, Ativan, and Benadryl. Nursing care involves monitoring her mental status and side effects of the medications, restricting access to medications, and assessing for suicidal thoughts.
MM is a 42-year-old African American woman admitted involuntarily to the psychiatric hospital due to expressing suicidal thoughts. She has a history of schizophrenia, major depressive disorder, and a previous suicide attempt. She is currently taking several medications including Risperidone, Trazodone, Sertraline, Klonopin, Latuda, Loratadine, Ativan, and Benadryl. Nursing care involves monitoring her mental status and side effects of the medications, restricting access to medications, and assessing for suicidal thoughts.
MM is a 42-year-old African American woman admitted involuntarily to the psychiatric hospital due to expressing suicidal thoughts. She has a history of schizophrenia, major depressive disorder, and a previous suicide attempt. She is currently taking several medications including Risperidone, Trazodone, Sertraline, Klonopin, Latuda, Loratadine, Ativan, and Benadryl. Nursing care involves monitoring her mental status and side effects of the medications, restricting access to medications, and assessing for suicidal thoughts.
Nursing Units: Crescent Pine Psychiatric Center (Adult Unit B)
Pt.s Initials: MM____ Room_ Age 42yrs_______ Diagnosis: Schizophrenia and Major Depressive Disorder (NEC) ________________________________________________________
Presenting Problem and Pertinent Past Medical and Psychiatric History ( include prescribed, OTC or street medication(s) taken at home): Patient is a 42yrs old African American woman was Admitted involuntarily to the Crescent Pine Psychiatric hospital. She was brought from her Assisted Living Home by EMT in an ambulance for expressing suicidal thoughts of harming herself with no self injuring. She states I couldnt do it anymore not being able to do anything for myself, I want to go home. Pt. has a previous history of a suicide attempt by drug overdose for which she was hospitalized at Crescent Pine in last year December 2011. She states I hated spending my Christmas here last year and I hated spending my Easters here also. Pt. has a history of schizophrenia and MMD; a surgical history of Gastric Bypass (lost 125 lbs) and Breast reduction and tonsillectomy in 02/2010, and has medical Hx (Anemia). Denies suicidal, homicidal thoughts, auditory hallucination, alcohol, tobacco, and drugs abuse. She is feeling depressed because of conflicts with her adopted mother and sister mistreating her and not showing her any love. They states that she is stupid and sick in the head, and they does not care about her. She has been on some of these medications since her was last discharge from Crescent Pine and is currently taking them here. They include: : Trazodone (Desyrel)150mg tab PO at HS daily, Sertraline(Zoloft) 50mg tablet PO daily for (depression), Klonopin (Clonazepam)1mg PO BID for (anxiety, start 04/4/12-04/11/12 stop), Risperidone (Risperdal) 2mg tab PO daily to reduce psychosis and depression (Pt. refused Meds, she believes it makes her feels suicidal),Psyllium PKT(Metamucil) 2TBSP PO daily, Loratadine (Claritin/Alavert) 10mg tab PO for Allergy, Latuda(Lurasidone ) 80mg, daily for (depression), Ativan(Lorazepam)2mg Tab PO q 6hours Prn for agitation, and Benadryl 25mg PO q 6 hours for (Insomnia). VS: 04/10/12= Bp,162/96, Temp 97.9, P 70, RR 20. Will continue to monitor Pt.
DSM IV - TR Actions of Psychotropic Medications (Document Reference) Axis I (psychiatric clinical disorders)-Schizophrenia(paranoid type) Depressive Disorder NOS Risperidone (Risperdal) mood stabilizers 2 mg PO daily to reduce psychosis, but (Pt. refused meds she believes it makes her feels suicidal. It is an antipsychotic used to treat bipolar mania and manage psychotic disorders. It selectively blocks serotonin and dopamine receptors in the CNS to suppress psychotic symptoms.SE: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, aggressive behavior, dizziness, extrapyramidal reactions, headache, dreams, sleep duration, insomnia, sedation, fatigue, impaired temperature regulation, nervousness, Tardive Dyskinesia. Tablets: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Trazodone (Desyrel) 150mg tab PO at HS daily-antidepressant use to tx major depression and Insomnia and anxiety. It alters the effects of serotonin in the CNS; MAO inhibitors should be stopped at least 14 days before Trazodone therapy. Trazodone should be stopped at least 14 days before MAO inhibitor therapy. SE: SUICIDAL THOUGHTS, drowsiness, confusion, dizziness, fatigue, hallucinations, headache, insomnia, nightmares, slurred speech, syncope, weakness .Tablets (IR): 50 mg, 100 mg, 150 mg, 300 mg Tablets (ER) 150 mg, 300 mg
Axis II (personality & developmental disorders) -Deferred Sertraline (Zoloft) 50mg tablet PO daily for (depression), it is an antidepressant; Pt. is taking this meds for depressant and (social phobia). Inhibits neuronal uptake of serotonin in the CNS, thus potentiating the activity of serotonin. Has little effect on norepinephrine or dopamine. SE: NEUROLEPTIC MALIGNANT SYNDROME, SUICIDAL THOUGHTS, dizziness, drowsiness, fatigue, headache, insomnia, agitation, anxiety, confusion, emotional liability, impaired concentration, manic reaction, nervousness, weakness, yawning. Tablets: 25 mg, 50 mg, 100 mg
Klonopin (Clonazepam) 1mg PO BID for (anxiety, start 04/4/12-04/11/12 stop), anticonvulsant; pt. is taking this med for anxiety. Anticonvulsant effects may be due to presynaptic inhibition. Produces sedative effects in the CNS, probably by stimulating inhibitory GABA receptors. Prevention of seizures. Decreased manifestations of panic disorder. Adjunct management of acute mania, acute psychosis, or insomnia.SE: SUICIDAL THOUGHTS, behavioral changes, drowsiness, fatigue, slurred speech, ataxia, sedation, abnormal eye movements, diplopia, and nystagmus. Tablets: 0.5 mg, 1 mg, 2 mg. Axis III (general medical conditions) seasonal allergy rhinitiss, tachycardia, Anemia, and constipation, SP Gastric Bypass, Breast Reduction, and Tonsillectomy Psyllium PKT (Metamucil) 2TBSP PO (laxatives to relief and prevention of constipation) pt is taking this meds as a stool softener. Management of simple or chronic constipation, particularly if associated with a low-fiber diet. Useful in situations in which straining should be avoided (after MI, rectal surgery, and prolonged bed rest). Combines with water in the intestinal contents to form an emollient gel or viscous solution that promotes peristalsis and reduces transit time.SE Bronchospasm, cramps, intestinal or esophageal obstruction, nausea, vomiting. 2.53.5 and g/dose or packet .
Ativan (Lorazepam) 2mg Tab PO q 6hours Prn for agitation- Antianxiety, sedative/hypnotic, and analgesic adjuncts. Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter. Pt is taking this med PRN for agitation.SE: dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred speech, forgetfulness, confusion, mental depression, rhythmic myoclonic jerking in pre-term infants, paradoxical excitation. Tablets: 0.5 mg, 1 mg, 2 mg, and Injection: 2 mg/mL, 4 mg/mL Latuda (Lurasidone) 80mg, pt take daily for (depression and Psychosis), Treatment of schizophrenia, schizophrenic behavior. Its effect may mediated via effects on central dopamine Type 2 (D 2 ) and serotonin Type 2 (5HT 2A ) receptor antagonism.SE: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, akathisia, drowsiness, parkinsonism, agitation, anxiety, cognitive/motor impairment, dizziness, dystonia, tardive Dyskinesia, blurred vision, AGRANULOCYTOSIS, anemia, leukopenia. Loratadine (Claritin/Alavert) 10mg tab PO for Allergy-it is an antihistamines, pt is taking to relief of symptoms of seasonal allergies (Rhinitis). Blocks peripheral effects of histamine released during allergic reactions and decreased symptoms of allergic reactions (nasal stuffiness; red, swollen eyes, itching).SE: confusion, drowsiness (rare), paradoxical excitation, blurred vision, dry mouth, GI upset, photosensitivity, rash, weight gain. Tablets: 5 mg, 10 mg and Syrup: 5 mg/5 mL. Benadryl 25mg PO q 6 hours for (Insomnia). Benadryl (Diphenhydramine) PO PRN HS adult and children greater 12 yrs given at bedtime for nighttime sleep aid. It is an antihistamine, and antitussives use for mild nighttime sedation, Significant CNS depressant and anticholinergic properties, Antagonizes the effects of histamine at H 1 - receptor sites; does not bind to or inactivate histamine, Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal and ocular pruritus, ocular tearing and redness, urticaria).95% metabolized by the liver.SE: drowsiness, dizziness, headache, paradoxical excitation (increased in children), blurred vision, tinnitus, hypotension, palpitations, anorexia, dry mouth, constipation, nausea, Dysuria, frequency, urinary retention, photosensitivity, chest tightness. Nursing Assessments: assess for confusion, delirium, fall risk(Institute measures to prevent falls), Assess sleep patterns, when used for insomnia, administer 20 min before bedtime and schedule activities to minimize interruption of sleep, and may Administer with meals or milk to minimize GI irritation. Axis IV (psychosocial and environmental problems) - Family conflict with Mother and sister(Primary support system), non -compliance with meds, death of her brother
Axis V (global assessment of functioning) - On admission 20-30, but now 50. Signs & Symptoms of Physical and Psychiatric Problems Nursing Implications of Psychotropic Medications (Document Reference) S/I Past history of O.D. attempts Latuda (Lurasidone) 80mg: Monitor patient's mental status (orientation, mood, behavior) before and periodically during therapy; Assess weight and BMI initially and throughout therapy; Monitor mood changes. Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient; Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness). Notify health care professional immediately if these symptoms occur; Monitor CBC frequently during initial mo of therapy in patients with pre-existing or history of low WBC. May cause leukopenia, neutropenia, or agranulocytosis. Discontinue therapy if this occurs. Low Self- esteem and Despondent Agitation and Mood swings Ativan (Lorazepam) 2mg Tab PO- Conduct regular assessment of continued need for treatment; Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically throughout therapy; Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient; Assess geriatric patients carefully for CNS reactions as they are more sensitive to these effects. Assess falls risk
Insomnias Trazodone (Desyrel) 150mg tab PO at HS daily. Inform pt to inform prescriber if symptoms of priapism occur. Give medication shortly after the pt. has a meal or light snack to reduce nausea. Give larger portion of daily dose at bedtime if drowsiness occurs. Monitor depressed patients closely including children and teens, for suicidal thoughts and tendencies and notify the prescriber Feeling worthlessness, loneliness, Social Isolation Sertraline (Zoloft) 50mg tablet PO daily for (depression), Monitor appetite and nutritional intake. Weigh weekly. Notify health care professional of continued weight loss. Adjust diet as tolerated to support nutritional status; Monitor mood changes. Inform health care professional if patient demonstrates significant increase in anxiety, nervousness, or insomnia; Assess patient for feelings of fear, helplessness, and horror. Determine effect on social and occupational functioning; Assess patient for symptoms of social anxiety disorder (blushing, sweating, trembling, tachycardia during interactions with new people, people in authority, or groups) periodically during therapy. Rehospitalization Explain current condition, prognosis, and therapeutic regimen to patient, and the importance of medication (Risperidone (Risperdal) mood stabilizers 2 mg PO daily to reduce psychosis, because (Pt. refused meds she believes it makes her feels suicidal) compliance and ask her to consult Dr if they have any questions about medications. Paranoidal Klonopin (Clonazepam) 1mg PO BID- Monitor patient's mental status (orientation, mood, behavior) before and periodically during therapy. Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression; Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness). Notify health care professional immediately if these symptoms occur; Observe patient when administering medication to ensure medication is swallowed and not hoarded or cheeked; assessed pt for negative symptoms (social withdrawal, flat, blunted affects) of schizophrenia Significant Diagnostic Studies Nursing Responsibilities Related To Diagnostic Studies Normal Value Result of Test Implications WBCs Explain procedure to patient. Draw patients blood as ordered by physician. Blood specimen sent to lab 04/01/12 4.8-10.8 4.6 slightly low Low (leukopenia) decrease of white blood cells; great number of drugs and failure of the bone marrow may cause it; immunocompromised Notify MD. RBCs Explain procedure to patient. Draw patients blood as ordered by physician. Blood specimen sent to lab 04/01/12 4.20-5.40 3.83 low Low values for RBC lead to anemia; sign of poor oxygenation/ poor diet HGB Explain procedure to patient. Draw patients blood as ordered by physician. Blood specimen sent to lab 04/01/12 12.0-16,0 11.2 slightly low Low Hgb levels lead to anemia; sign of poor oxygenation. HCT Explain procedure to patient. Draw patients blood as ordered by physician. Blood specimen sent to lab 04/01/12 37.0-47.0 33.4 low Low HCT levels lead to anemia, sign of poor oxygenation.
Proposed Discharge Teaching: 1) Encourage pt to involve support system(mother and sister) in education of disease through family sessions 2) Explain the importance of follow up exam with the pts doctor(Dr. Hussein) and give all phone numbers needed for that 3) Teach pt the importance of medication compliance and ask her to consult Dr if they have any questions about medications. 4) Explain the pts condition, prognosis and therapeutic regimen and the importance of following that regimen 5) Encourage pt to participate in group therapy available here, at Pt. church or anywhere else that is assessable to Pt. 6) Encourage pt to talk about feelings with support system 7) Instruct patient and family members in disease process and to recognize and cope with relapse symptoms. 8) Instruct patient and family members about the uses, actions and adverse effects of prescribed drugs. 9) Provide instruction on when to notify primary care provider regarding drug adverse effects, or increase in symptoms. 10) Instruct patient and family about community resources, support groups, and possible use of outpatient community mental health centers. 11) For additional information and support refer patient and family to National Alliance for Research on Schizophrenia and Depression, www.narsad.org and www.schizophrenia.com. 12) Importance of continuing medication use probably for a lifetime. Do not stop taking these drugs abruptly or without Consulting with health care provider 13) Importance of maintaining a healthy lifestyle and balanced diet, minimal caffeine and no alcohol, regular adequate sleep patterns. 14) Provide the pt and family with 24hr 7 day a week crisis phone number to call whenever the need arises. 15) Provide pt. with Toll-free Depression Awareness, Recognition, and Treatment Help Hotline #: 1-800-421-4211. The toll-free suicidal hotline number is 1-800-784-2433
Jones & Barret Learing (2011) Nurses Drug Handbook (10 th edition)
Schultz & Videbeck (2009) Lippincotts Manual of Psychiatric Nursing Care Plans (8 th edition).
Mosbys (2009) Nursing Drug references (22 nd edition)
Karch, Amy (2011), 2011 Lippincotts Nursing Drug Guide. Mary C. Townsend, (2011), Lippincotts Manual of Psychiatric Nursing Care Plans (8th Ed)
Nursing Diagnosis (Number Each Problem) Scientific Basis for Nursing Diagnosis (Observations & Professional Sources) Short Term Goals Long Term Goals Nursing Interventions (Place* By Those Actually Done) Scientific Rationale For Nursing Intervention (Document Reference) Evaluation of Interventions Evaluation of Goals (Results, Patient behavior, Further Action) 1. 1) Risk for suicide related to disrupt family life and poor support system AEB pts feelings of hopelessness and helplessness. I couldnt do it anymore not being able to do anything for self and I want to go home Suicidal ideation is one of the common behaviors associated with depression (Townsend, M. C., 2011, p. 534). STG: Patient will make short-term verbal or written contract with nurse not to harm self while in the hospital.
LTG: Patient will identify (3) reasons to live before D/C 1)-Encourage the patient to verbalize feelings and emotional pain 1)Encouraging patient to verbalize feelings would relieve some stressors
2)Maintain low level stimuli in clients environment 2) Anxiety level rises in a stimulating environment. A suspicious agitated client may perceive individuals as threatening
3) Observe clients behavior every 15min and do this while carrying out routine activities 3) Close observation is necessary so that intervention can occur if required to ensure clients safety
4)Remove all dangerous object from clients environment 4)This is done so that when client is in agitated state she would not use them to harm self or others
5)Staff should maintain and convey a calm attitude behavior towards client 5)Anxiety is contagious and can be transferred from staff to client
6) Redirect the violent behavior with physical outlet for clients anxiety 6) Physical exercise is a safe and effective way to relieve pent up tension.
7). Reorient the patient person, place and time as indicated 7). Repeated Presentation of reality is concrete reinforcement for the patient
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Nursing Diagnosis (Number Each Problem) Scientific Basis for Nursing Diagnosis (Observations & Professional Sources) Short Term Goals Long Term Goals Nursing Interventions (Place* By Those Actually Done) Scientific Rationale For Nursing Intervention (Document Reference) Evaluation of Interventions Evaluation of Goals (Results, Patient behavior, Further Action) Knowledge deficit regarding treatment regimen r/t to altered thought process AEB by client inability to provide information about medical regimen Risperidone (Risperdal) mood stabilizers 2 mg PO daily to reduce psychosis, (Pt. refused meds she believes it makes her feels suicidal.
Following medical regimen can improve paranoia symptoms and anxiety. STG: Verbalize understanding of disorder and treatment before within the nxet 24 hours.
LTG: Assume responsibility for own learning within her abilities after and Participate in a process/treatment upon d/c. 1) Determine the current knowledge level of disorder and its management.
2) Instruct client/family about the disorder and management, its signs and symptoms and management of meds and ADLS.
3) Have individual verbalize/paraphrase knowledge gained.
4) Identify appropriate therapies and community support systems to meet individual needs.
5) Teach family members the facts about the clients illness, empathizing that it could strike any family.
*6) Stress to client how important it is to never stop therapy suddenly when taking Risperidone. 1) Knowledge base and readiness to learn.
2) Provides information and can promote independent behaviors within clients ability.
3) Evaluates clients comprehension of information regarding disorder.
4) Promotes trusting relationships and encourages further cooperation with treatment plan.
5) Educating the family helps to dispel myths and decrease stigma of mental illness.
6) The drug can precipitate rebounds Psychosis and anxiety
Nursing Diagnosis (Number Each Problem) Scientific Basis for Nursing Diagnosis (Observations & Professional Sources) Short Term Goals Long Term Goals Nursing Interventions (Place* By Those Actually Done) Scientific Rationale For Nursing Intervention (Document Reference) Evaluation of Interventions Evaluation of Goals (Results, Patient behavior, Further Action) 3). Social Isolation R/T expression of feeling of rejection of loneness, powerlessness imposed by others. Pt. states angrily I want to go home Im done with group therapy I have been in this place for twelve days now and these quack wont let me go home. Aloneness experience by individual and perceive as imposed by others as a negative / threatening state. STG: Clients willingly attend group therapy activities accompanied by trusted staff members within in the next 5 sessions.
LTG: client will voluntarily spend time with others client and staff members in group activities until d/c 1) Convey an accepting attitude by making brief, frequent contacts with Pt. 2) Show unconditional positive regard. 3). Be with the client to offer support during group activities that may be frightening or difficult for him or her. 4) Be honest and keep all promises. 5. Be cautions with touch. Allow client extra space and an avenue for exit if he or she becomes anxious. 6) Administer tranquilizing medications as ordered by physician. Monitor for effectiveness and for adverse side effects. 7) Discuss with client the signs of increasing anxiety and techniques to interrupt the response (e.g. Relaxation, exercises, thought stopping). 8) Give recognition and positive reinforcement for clients voluntary interactions with others. 2) An accepting attitude increases feeling of self-worth and facilitate trust. 2) This conveys your belief in the client as a worthwhile human being. 3) The presence of a trusted individual provides emotional security for the client. 4) Honest and dependability promote a trusting relationship. 5) A suspicious client may perceive touch as a threatening gesture. 6) Antipsychotic medications help to reduce psychotic symptoms in some individuals, thereby facilitating interactions with others. 7) Maladaptive behaviors such as withdrawal and suspiciousness are manifested during time of increased anxiety. 8) Positive reinforcement enhances self-esteem and encourages repetition of acceptable behaviors.