NURS 406 Nursing Care Plan
Psychiatric/Mental Health Concept Map Care Plan
Name: Linetelle Liondo Date: February 24, 2020
Clinical Group/Instructo
... [Show More] r: Professor Crissey Patient Initials: L.L
I. Nursing Assessment:
Admission Information:
Admission Date: 2/03/20
Age: 38 yrs old
Gender: Female
Reason for hospitalization:
Patient is a 38-year-old woman with repeated history of depression. Patient now being admitted for evaluation and treatment of anxiety and psychotic symptoms.
Surgical procedures:
The patient has never had any surgical procedures
Medical diagnoses: (medical and psychiatric; past and present)
Patient has major depressive disorder, recurrent, severe with psychotic symptoms.
Advance Directives:
Living will: Patient does not have a living will
Power of Attorney: Patient does not have a power of
attorney
DNR: Patient does not have a DNR
Laboratory Data:
Test:
Normal values:
On
Admission:
Current
values:
Interpretation:
WBC:
4.5-11.0
5.8
6.5
Within normal
level
Differential:
3.7-5.5
Hemoglobin:
11.7-15.0
12.8
12.4
Within normal
level
Hematocrit:
34.0-47.0
39.0
38.1
Within normal
level
Platelets:
150-450
286
283
Within normal
level
Prothrombin time(PT):
N/A
INR:
N/A
PPT:
N/A
Blood glucose:
70-110
85
93
Within normal
1
Sf2015
NURS 406/258- 2015
level
Na+:
135-145
136
141
Within normal
level
K+:
3.5-5
3.6
3.9
Within normal
level
Cl- :
98-110
100
102
Within normal
level
Ca+:
9-10.5
9.2
9.6
Within normal
level
BUN:
7-22
18
22
Within normal
level
OTHERS:
DIAGNOSTIC TESTS:
CXR: NONE
EKG: NONE
OTHER:
MEDICATIONS: List all meds in proper MD order format:
NAME, DOSAGE, ROUTE:
RATIONALE:
ASSESSMENT/CONSIDERATIONS:
Magnesium Hydroxide (Simethicone) 30 mL PO, liquid q6hr PRN
Used for dyspepsia
Patient should be assessed for heartburn and indigestion when taking this medication. Make sure to monitor calcium and potassium levels while on
this medication. (Townsend, 2015).
Ibuprofen 600 mg PO, q6hr PRN
Used for pain
Patient must be assessed for pain and skin rash. Stop taking when the first sign
of a skin rash is noted. (Townsend, 2015).
Trazodone 50 mg PO, PRN
Used for Insomnia
Patient must be given Trazodone in the evening due to the drowsiness effect of
this medication. (Kluwer, 2016).
Hydroxyzine 50 mg PO, q8hr PRN
Used for anxiety
Patient must be watched for intense sedation. Implications such as keeping the side rails up and keeping the bed in a low position are recommended.
(Townsend, 2015).
Sertraline (Zoloft) 100 mg daily
Used for depression
Patient should be assessed for suicidal behaviors. Nutritional intake should also
be monitored. (Townsend, 2015)
OTC MEDS/HERBALS:
Patient does not take any OTC meds/herbals
ALLERGIES: List all:
Patient is allergic to Penicillin
PAIN ASSESSMENT:
LOCATION:
Patient reports pain in her lower back
DESCRIBE PAIN: (INTENSITY, DURATION, FREQUENCY)
Patient reports that she feels pain in her lower back
everyday for the entire day.
PAIN PERCEPTION ON SCALE 0-10:
6; Patient reports that her pain level is a 6 out
of 10
PAIN MEDS USED:
Ibuprofen 600 mg PO, PRN
LAST TIME PAIN MED USED: 2/17/17
TREATMENTS:
MEDICAL TREATMENTS: Patient did not receive any medical treatments.
PSYCHIATRIC THERAPIES:
Individual therapy
SUPPORT SERVICES:
Patient does not have
any support services.
NUTRITION:
DIET:
Patient consumes a regular diet 3 times daily.
RESTRICTIONS:
Patient does not have any food restrictions
FLUID INTAKE (24HRS):
Patient has an adequate amount
of fluid intake daily.
GAG REFLUX INTACT:
Patient’s gag reflux is present.
APPETITE:
BREAKFAST: Patient consumes 100% of breakfast
LUNCH: Patient consumes 100% of lunch
DINNER: Patient consumes 100% of dinner
OTHER INTAKE ISSUES:
Patient does not have any other
intake issues.
ELIMINATION:
LAST BM:
Patient’s last bowel movement was on 1/27/17. Patient has a bowel movement everyday that is soft and easy to pass.
8-hr URINE OUTPUT:
Patient’s 8-hour urine output is normal.
24-hr URINE OUTPUT:
Patient’s 24-hour urine
output is normal.
FOLEY/CONDOM CATHETER:
Patient does not have a foley/condom catheter present. [Show Less]