Psych Care Plan

 

Vermont Technical College Associate Degree Nursing Program Care Plan Form  NUR 2030/2040 2030/2040 Student Name: Courtney Warrington

(CVS 8/13) Date: 12/5/13

Nursing Unit: Brattleboro Retreat

My client is a 27 year old Caucasian female who was admitted March 2012. She has the following DSM IV diagnoses: Axis I- Psychosis with PTSD Axis II- Borderline personality disorder Medicationss include: Modafinil, Fluphenazine, Lyrica, Fluoxetine, Atorvastatin, Clonazepam, Benztropine, Clonidine, and Medication Chlorpromazine.

Nursing Diagnosis

1.  Risk for self- or other- directed violence r/t  psychosis  psychos is AEB self-inflicted wounds and angry outbursts of aggression towards staff

Expected Client Outcome (Goal) and Criteria

Nursing Interventions

Underlying Scientifi Scientificc Principle(s) of Nursing Interventions

Evaluation

Short term goal:

Maintain a low stimuli environment with few  people, ambient ambient lighting, low noise

A high stimulus environment increases anxiety (Townsend 2012,  p. 531)

Client has decreased selfviolence and decreased violence towards others with interventions in place

Maintain a 1:1 with client, with constant observation for escalating behavior

Close observation allows quick intervention to self or other directed anger,  preventing a dangero dangerous us situation before it can  begin (Townsend (Townsend 201 2012, 2, p. 531)

Meets expected outcome criteria of no harm to self or others in next 14 days, and reporting feelings of anger to staff within the next 2 days

Client will not harm self or other in the next 8 hours Within the next 2 days client will recognize signs of escalating anger and report them to staff for intervention Long term goal: Client will not harm self or others within the next 14 days

Allow client some control over her situation by offering choices to de-escalate  behavior Ensure enough staff

Giving client some control over her situation may decrease her anxiety (Townsend 2012, p. 531)

 

available quickly for a show of support if necessary

 

Sufficient staff support shows the client there is control over the situation, ensures staff and client safety (Townsend 2012 p. 531)

Remove dangerous objects from the client’s environment

2. Risk for suicide related to psychosis AEB client stating “I have to kill myself or when I die I will have no soul” soul”, and recent suicide attempt (11/2013)

Short term goal: Client will not harm herself in next 8 hours Long term goal: Will not harm self in the next 14

Reduce the client’s ability to use objects to harm herself and others in an altered mental state

Only when other interventions have been exhausted and client continues to dangerously

Exhausting other methods ensures least restrictive alternative is being used

escalate, proving a harm to herself or others,  physical or mechanica mechanicall restraints may be necessary

Reduces risk of harm to  patient and staff when client cannot be talked down (Townsend 2012, p. 531)

Removal of dangerous object from client environment Provide constant observation and 1:1 support to client

Client safety is first  priority (Townsend (Townsend 201 2012, 2,  p. 313)

Client has no attempts of self-harm Able to communicate feelings of self-harm to staff for assistance and

 

 

days.

Decreased episodes of  psychosis resulting in  psychosis suicidal ideations within 30 days

Use caution when administering medications

Constant observation  prevents client client from selfharm

Encourage client to express feelings r/t

Suicidal client may store medication to attempt overdose (Townsend 2012,

desire to commit suicide

 p. 314)

Client will remain medication compliant (court order)

“…suicidal behaviors may  be viewed as as anger turned turned inward on the self. If this anger can be verbalized in a non-threatening environment, the client may be able to eventually resolve these feelings”

Maintain honesty and consistency in interactions

(Townsend 2012, p. 314). Consistently taking medication will decrease episodes of psychosis, thereby decreasing suicidal ideation Building a rapport with client will allow her to more easily express negative feelings and thoughts of self-harm to trusted staff

early intervention Consistent compliance with medication results in decrease of psychotic symptoms