CARE PLAN
NURS 223L PSYCHIATRIC MENTAL HEALTH NURSING
Student S.G Date 5/10/18
Instructor G. Mit Course NURS 223 L Mental Health
Patient Initials B.K
... [Show More] Date of Admission 4/23/18 Legal Status
(Vol, 5150, 5250,
Conservatorship)
Vol
Patient DOB 02/02/1961 Unit Briar
Chronological and
Apparent Age
57
Gender
Female
Ethnicity
Caucasian
Allergies None
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure
(location)
Pain Scale 1-10
(location, character,
onset)
125 lb 98 (Temporal) 86 (right radial) 18 98% 120/82 (Left arm,
brachial)
3 (upper back, aches,
occasionally dull)
Psychiatric Diagnosis and Diagnostic Criteria History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement
Nursing Diagnosis: Ineffective coping related to alcohol use as
evidenced by increased alcohol use and impairment in life
functioning.
Patient was diagnosed using guidelines from the DSM-5. A
problematic pattern of alcohol use as manifested by at least (2) of
the following occurring within a 12-month period. 1)Alcohol is often
taken in larger amounts or over a longer period than was intended.
2) There is a persistent desire or successful efforts to cut down or
control alcohol use. 3.) A great deal of time is spent in activities
necessary to obtain alcohol, use alcohol, or recover from its
effects.4) Craving or a strong desire or urge to use alcohol.
8)Recurrent alcohol use in situations in which it is physically
hazardous. 9) Alcohol use is continued despite knowledge of having
Patient presents with the following symptoms: There is a persistent
desire or unsuccessful efforts to cut down or control alcohol use.
Craving or a strong desire or urge to use alcohol. Recurrent alcohol use
resulting in a failure to fulfill major role obligations at work, school, or
home. Important social, occupational, or recreational activities are
given up or reduced because of alcohol use. Alcohol use is continued
despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or
exacerbated by alcohol.
Patient was admitted voluntarily with the help of her friends, patient
was drinking about (3) bottles of wine a day.
Previous psychiatric admission: Patient stated that prior to being
hospitalized, she was in a rehab facility in 2010 for about 3 months
erRevision Date: Month, Year January 2017) Page 1 [Show Less]