PATIENT DEMOGRAPHICS:
MENTAL HEALTH
ASSESSMENT AND CARE PLAN
Student Name: Gabriel EdwardsRoberson
Patient Initials: J.S Admission Date:
9/9/23
Age: 62
Gender: Male
Clinical Date: 10/9
DSM – 5 Classification: F25.0
Pain: scale usedNo pain
Characteristics:
Rating:
Duration:
Non-verbal:
Location:
Class I:
Class II:
Class III:
Religion:
How does it affect their care?
Clinical Faculty Name: McLeod
Allergies/Reactions to: NKA
LMP: NA
(Mark NA if not applicable)
Height: 5’10
Weight: 230 lbs
BMI: 33
Religion not specified.
Cultural Considerations:
Information Unknown
PAST MEDICAL HISTORY:
Hyperlipidemia, BPH, and diabetes
Drug and Alcohol History:
Unknown
Past Psychiatric History:
Multiple inpatient psychiatric admissions
Current Situation that Lead to Psychiatric Hospitalization:
Patient was TDO. Went missing on 9/8 and was found 6 hours later. He was having auditory hallucinations
and delusions and believes people are out to get him. He has been diagnosed with schizoaffective disorder,
bipolar type and antisocial personality disorder.
FAMILY HISTORY:
(medical and psychiatric history of family as it pertains to clients psychiatric health)
Family history is not pertinent to the presenting problem.
1
010422
ASSESSMENT:
VITAL SIGNS:
TIME
0800
BP
TEMP
118/69
97.9
HR
101
RESP
17
PHYSICAL ASSESSMENT:
(WNL is not accepted. Normal is not acceptable. Please be specific.)
General Assessment and Motor Behavior:
(Hygiene and grooming; appropriate dress; posture; eye contact; unusual movements or
mannerisms; speech, look for signs of EPS, tardive dyskinesia, and Parkinson’s characteristics).
Patient was well groomed and was dress appropriately, but pants kept falling. He was a well-nourished
individual and made poor eye contact. He had a shuffling gait and was a fall risk due to this.
Mood and Affect: (expressed emotions; facial expressions).
Patient cooperated while getting vitals, but his speech was very monotone. He was flat and blunted.
Thought Process and Content:
(content: what the client is thinking: Process: how the client is thinking; clarity of ideas, self-harm or suicidal
urges, ability to contract for safety).
Patient was confused and disoriented.
Sensorium and Intellectual Processes:
(orientation to person, place, time, and situation; confusion, memory, use mini mental exam as
appropriate, assess concentration, abstract thinking abilities and abnormal sensory experiences or misperceptions like hallucinations or delusions)
Orientation to person only. He was confused and his LOC was somnolent.
Judgment and Insight:
(judgment: interpretation of the environment, decision making ability; insight: understanding one’s own part in his/her
current situation).
Patient had poor insight and judgement. He didn’t understand why he was in the facility and proceeded
to tell me that “ someone was out to get him”.
Self-Concept: (personal view of self, description of physical self, personal qualities or attributes).
Patient stated his goal was to “Live long and prosper”.
Roles and Relationships:
(current roles including roles in the family, at work, and at social activities, satisfaction with roles, success at roles;
significant relationships, support systems).
Patient is not employed. He served in the military and FBI and was honorably discharged. He is not
married and lives with his brother and niece.
Physiologic and Self-Care Issues:
(eating habits, sleep patterns, health problems, document compliance and/or reason for noncompliance
with medications, ability to perform ADLs).
2
010422
Patient has insomnia and sleep disturbances, usually only gets 4 hours of sleep. He is a diabetic but has
no problems with diet or appetite.
Cultural and Spiritual Beliefs:
(what is clients stated religion? Where is client from? Ethnicity, customs, traditions, and background; how does
their cultural and spiritual belief effect nursing care).
Patient reported “The religion that Keanu Reeves hold from Lebanon” is his religion.
MEDICATIONS:
**Don’t copy & paste**
(Include ALL medications patient is currently taking unless otherwise advised by instructor)
Trade Name:
divalproex
sodium
Generic Name:
Depakote
Class:
Mood stabilizer
Dose:
500 mg
Is dose safe?
Yes
PO
Route:
Form:
Tablet
Mechanism of
Action
Its mechanism of
action has not
been established,
but divalproex
sodium use is
thought to cause
an increase in
brain
concentrations of
GABA.
(Wilkins, L.W. &.
(2021).
Condition That
Patient is
Receiving
Medication
For
Patient is anxious
Potential Adverse
Effects
Dizziness
Headache
Insomnia
Hypotension
Diarrhea
Patient education:
Tell patient and
caregivers that
drug may increase
risk of suicidal
thoughts and
behaviors. Warn
patient and
parents not to stop
drug therapy
abruptly
Frequency:
Daily
Trade Name:
Haloperidol
Mechanism of
Action
Generic Name:
Haldol
Class:
Antipsychotic
Dose:
10mg
Nursing
Implications &
Patient Education
Nursing
Implications:
Monitor liver
function tests, be
aware that this
medication can
cause suicidal
thoughts, and
hepatotoxicity.
Condition That
Patient is
Receiving
Agitated
psychosis
Medication
For
A butyrophenone
that exerts
antipsychotic
effects by
blocking
3
Potential Adverse
Effects
Extrapyramidal
reactions
Dystonia
Tardive dyskinesia
Sedation
Seizures
Dry mouth
Nursing
Implications &
Patient Education
Nursing
implications:
Monitor for signs
or hypersensitivity
reactions. Watch
for signs of NMS.
010422
Is dose safe?
Yes
Route:
PO
Form:
Tablet
postsynaptic
dopamine
receptors in the
brain.
Constipation
Leukopenia
Patient education:
Adherence to
regime. Increase
liquids and eat
sugar free candy
for dry mouth.
Increase fiber and
exercise for
constipation. If
missed dose occurs
take does within 4
hours of usual
time.
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Nursing
Implications:
Avoid using MAOI.
Anticholinergic
effects.
(Wilkins, L.W. &.
(2021).
Frequency:
BID
Trade Name:
Diphenhydrami
ne
Generic Name:
Benadryl
Class:
Antihistamines
Dose:
50mg
Is dose safe?
Yes
PO
Route:
Form:
Capsules
Mechanism of
Action
Competes with
histamine for H1receptor sites.
Prevents, but
doesn't reverse,
histaminemediated
responses,
particularly those
of the bronchial
tubes, GI tract,
uterus, and blood
vessels.
Condition That
Patient is
Receiving
Medication
Agitated
or For
anxious.
Sedation
Seizures
Drowsiness
Constipation
Vomiting
Dry mouth
Agranulocytosis
Patient education:
Take with food.
Avoid alcohol and
hazardous
activities that
require alertness.
Possible
photosensitivity
reactions.
Frequency:
PRN Q6H
(Wilkins, L.W. &.
(2021).
4
010422
Trade Name:
Metformin
Mechanism of
Action
Generic Name:
Glucophage
Class:
Antidiabetics
Dose:
1,000 mg
Is dose safe?
Yes
PO
Route:
Form:
Tablet
Frequency:
Condition That
Patient is
Receiving
Patient
Medication
is a For
diabetic.
Decreases hepatic
glucose
production and
intestinal
absorption of
glucose and
improves insulin
sensitivity
(increases
peripheral glucose
uptake and use).
Potential Adverse
Effects
Dizziness
Nausea
Headache
Hypoglycemia
Dyspepsia
Nursing
Implications &
Patient Education
Nursing
implications:
Not indicated for
use in patients with
type 1 diabetes.
Monitor patient’s
glucose levels
regularly.
Patient education:
Take with meals to
reduce GI issues.
Take daily and do
not stop abruptly.
(Wilkins, L.W. &.
(2021).
BID
5
010422
Trade Name:
Lorazepam
Generic Name:
Ativan
Class:
Anxiolytics
Dose:
2mg
Is dose safe?
Yes
PO
Route:
Mechanism of
Action
Potentiates the
effects of GABA,
depresses the
CNS, and
suppresses the
spread of seizure
activity.
Condition That
Patient is
Receiving
Medication For
Anxious
Potential Adverse
Effects
Physical and
psychological
dependency
CND depression
Sedation
Hangover effect
Respiratory
depression
(Wilkins, L.W. &.
(2021).
Form:
Patient education:
Avoid alcohol while
taking drug.
Never stop
abruptly.
Tablets
Frequency:
PRN Q6H
Trade Name:
NA
Generic Name:
Nursing
Implications &
Patient Education
Nursing
implications:
Monitor hepatic,
renal, and
hematopoietic
function
periodically in
patients receiving
repeated or
prolonged therapy.
Drug can lead to
abuse.
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Class:
Dose:
Is dose safe?
Route:
Form:
6
010422
Frequency:
7
010422
Trade Name:
NA
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Mechanism of
Action
Condition That
Patient is
Receiving
Medication For
Potential Adverse
Effects
Nursing
Implications &
Patient Education
Generic Name:
Class:
Dose:
Is dose safe?
Route:
Form:
Frequency:
Trade Name:
NA
Generic Name:
Class:
Dose:
Is dose safe?
Route:
Form:
Frequency:
8
010422
LAB DATA & DIAGNOSTIC EVALUATION:
If the patient does not have recent labs/diagnostic tests,
Write what would be indicated for a patient with this diagnosis
Include diagnostic test like X-rays, CTs, and MRIs
Lab Data
Date
9/8/23
LAB Ordered:
Reason for lab:
Normal Values
Client Results
Baseline test
Negative
result
Positive for
Benzodiazepines
Reason for lab:
Normal Values
Client Results
Reason for abnormal
results (or n/a if
normal)
Reason for lab:
Normal Values
Client Results
Reason for abnormal
results (or n/a if
normal)
Urine drug
screen
Date
LAB Ordered:
Date
LAB Ordered:
9
Reason for abnormal
results (or n/a if
normal)
Patient is taking
Lorazepam.
010422
PSYCHIATRIC MANAGEMENT:
PSYCHIATRIC DIAGNOSIS
Define
Etiology
Pathophysiology
PRIMARY
SECONDARY
Schizoaffective disorder, Bipolar
type
Antisocial personality disorder
Schizoaffective disorder is a
mental health disorder that
has a combination of
psychotic and mood
symptoms. The signs and
symptoms include of both
schizophrenia and mood
disorders like bipolar. (Ackley,
B. J, 2021)
Antisocial Personality Disorder (ASPD) is a
mental health disorder characterized by a
persistent pattern of disregard for the rights
of others, lack of empathy, and violation of
societal norms and rules.
(Ackley, B. J, 2021)
The exact cause of
schizoaffective disorder isn't
known, but it's believed to
involve a combination of genetic,
biological, and environmental
factors. Genetics play a role, as
the disorder tends to run in
families. Some researchers also
point to abnormalities in brain
structure or neurotransmitter
function, Environmental factors,
such as stress or trauma during
early childhood, may contribute.
(Ackley, B. J, 2021)
The etiology of antisocial personality
disorder is complex and involves a
combination of genetic, neurobiological, and
environmental factors.
The pathophysiology of
schizoaffective disorder is
multifactorial, involving a
combination of genetic
predisposition,
neurobiological factors, and
environmental influences.
The pathophysiology of antisocial personality
disorder is multifaceted, and not all
individuals with the disorder will share the
same neurobiological or environmental
factors. Additionally, the interaction
between genetic predisposition and
environmental influences is complex and
varies among individuals.
(Ackley, B. J, 2021)
Ackley, B. J, 2021)
(Ackley, B. J, 2021)
Clinical Manifestations
(textbook)
Delusions
Hallucinations
Disorganized thinking, speech,
and behavior
Social withdrawal
Erratic or dramatic behavior
(Ackley, B. J, 2021)
(Ackley, B. J, 2021)
10
010422
Clinical Manifestations
(actual)
Hallucinations
Delusions
Manic episodes
Cognitive impairment
Disorganized thinking
(National Alliance on Mental
Illness)
Impulsivity
Hostility
Manipulating others
Not accepting responsibility
(Antisocial personality disorder: Beyond
keeping to yourself)
PRIORITIZED LIST OF RELEVANT NURSING DIAGNOSIS:
List all nursing diagnosis relevant to patient condition & based on assessment
1. Impaired physical mobility
2. Fear
3. Impaired social interactions
4. Impaired memory
5. Sleep deprivation
11
010422
NURSING CARE PLAN
Student Name: _____________________________________________ Date: ____________________Class: ________________ Patient Initials: _______________
A care plan should start with the major issues for that client. Write the top three priority nursing diagnosis for this client, with the highest priority first. Be sure to include “related
to”, “as evidenced by”, or “risk factors” (if at risk diagnosis) for each medical diagnosis. Write at least one short term and one long term (“expected outcome”) measurable goal per
nursing diagnosis stated in terms of client achievement (“the client will…”). List at least 3 specific nursing actions (interventions) for each nursing diagnosis and give the scientific
rationale for selecting the action you will use to work toward that goal, along with the cited reference of that rationale. Evaluate if goal was met and list specific assessment data to
support it (How did you know goal was met?)
NURSING DIAGNOSIS
(NANDA APPROVED)
EXPECTED OUTCOME
(Measurable Goal with dates)
ST: within time frame of
clinical
LT: can be outside of time
frame of clinical
1. Impaired physical
mobility
R/T
Cognitive impairment
AEB
Shuffling gait
ST:
Demonstrate use of
adaptive equipment to
increase mobility by the
end of shift.
NURSING
INTERVENTIONS
RATIONALE
(Why are you doing this?)
(What do you plan to do for
the client to accomplish the
goal? Be specific and include
time frames)
(Citation for each rationale)
1. Obtain any assistive
devices needed for
activity, such as gait belt,
weighted vest, walker,
cane, crutches, or
wheelchair, ergonomic
shower chairs; ceiling and
floor-based lifts; and airassisted lateral transfer
devices.
1.Promoting
independence and
improve mobility with the
use of walkers,
wheelchairs, grab bars,
commodes, adaptive
equipment, prostheses,
and other devices.
2.Monitor and record the
client's response to
activity, such as pulse
rate, blood
2. Use valid and reliable
screening procedures and
tools to assess the client's
preparticipation in
12
(Ackley et al., 2022)
EVALUATION
(If goal not met, need to evaluate why?
And what to do to meet goal?)
ST: Goal met. Patient was given a
walker during the shift.
pressure, dyspnea, skin
color, subjective report.
exercise health screening
and risk stratification for
exercise testing (low,
moderate, or high risk)
(Ackley et al., 2022)
3. Ensure the safety of the 3. Obstacles in the room
LT: Describe feeling
can impede activities,
stronger and more mobile environment.
especially transferring
by discharge.
and ambulating.
(Ackley et al., 2022)
4. Consider patient's selfreported fear of falling.
5.Medicate for pain.
4. Self-reported fear of
falling has been shown to
be a sensitive predictor
for fall risk.
(Ackley et al., 2022)
5.Pain limits mobility and
if exacerbated by specific
movements should be
temporarily avoided.
(Ackley et al., 2022)
2. Fear
ST: The patient will use
coping strategies to deal
1. Provide safety.
1. Safety is always the #1
priority, especially when a
13
LT: Goal not met. Patient is
progressing towards goal.
R/T
Altered contact with
reality
effectively with
hallucinations/delusions
by end of shift.
patient is mentally and
emotionally unstable.
(Ackley et al., 2022)
2.Monitor for increasing
agitation or anxiety.
AEB
Delusions and
hallucinations.
ST: Goal not met. Patient was
hallucinating and became very
fearful.
2. Keeping a close eye on
the patient's thoughts
and actions for signs of
escalating agitation or
anxiety, and act promptly
to intervene to stop any
harm to the patient or
other people.
(Ackley et al., 2022)
LT: The patient will
express delusional
material less frequently.
3.Remove the client from
chaotic environments.
3. Reduce stimulus that
LT: Goal not met. Patient is
might make hallucinations progressing towards goal.
worse.
(Ackley et al., 2022)
4. Use therapeutic touch
and healing touch
techniques.
4. Therapeutic touch
reduced anxiety and
agitation.
(Ackley et al., 2022)
5. Stay with clients when
they express fear; provide
verbal and nonverbal
14
5. Patients' anxiety levels
decreased when nurses
reassurances of safety if
safety is within control.
stayed with patients to
offer comfort and
confidence. Anxiety or
agitation was recognized
and managed based on
the clients' capacity to
interact with their
environment.
(Ackley et al., 2022)
3. Impaired social
interactions
R/T
ST: Use available
opportunities to practice
interactions by the end of
shift.
1.Observe speech,
nonverbal gestures, and
body language.
Impaired
communication
AEB
1. Assessing the patient's ST: Goal not met. Patient stayed to
speech, body language, or himself and didn’t attend group
even the patient's lack of therapy.
eye contact,
acknowledgment, or
response can reveal
information about the
causes of their impaired
social interaction.
(Ackley et al., 2022)
Flat affect
2.Encourage group
activities.
15
2. Offering patients the
chance to engage may
help with any bad
symptoms they may be
going through, such as the
inability to communicate
their emotions. Patients
should never be forced to
socialize.
(Ackley et al., 2022)
LT: Use successful social
interaction behaviors by
discharge.
3. Give positive verbal and 3. Recognize and
nonverbal feedback for
encourage patients when
appropriate behavior.
they take steps to
increase social
engagement.
(Ackley et al., 2022)
4. Consider use of animalassisted therapy (AAT).
4. An AAT-treatment group
showed improvement in
negative symptoms of
schizophrenia such as
apathy, a sociality,
anhedonia, and alogia.
(Ackley et al., 2022)
5.Develop a trusting
relationship.
5. Patients could have a
mistrust of other people.
The nurse is developing
rapport and establishing
trust by attentively.
(Ackley et al., 2022)
listening to the patient's
thoughts.
16
LT: Goal not met. Patient is
progressing towards goal.
REFERENCES:
(APA format)
Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2021). Nursing
Diagnosis Handbook, Revised Reprint with 2021-2023 NANDA-I® Updates-E-Book. Elsevier
Health Sciences.
Antisocial personality disorder: Beyond keeping to yourself. Cleveland Clinic. (n.d.).
https://my.clevelandclinic.org/health/diseases/9657-antisocial-personalitydisorder#symptoms-and-causes.
National Alliance on Mental Illness. (n.d.). Schizoaffective disorder. https://www.nami.org/learnmore/mental-health-conditions/schizoaffective-disorder. Accessed October 10, 2023.
Videbeck, S. L. (2022). Lippincott CoursePoint Enhanced for Videobeck’s Psychiatric-Mental Health
Nursing (9th ed.). Wolters Kluwer
Health. https://coursepoint.vitalsource.com/books/9781975205867.
Wilkins, L.W. &. (2021). Nursing 2022 Drug Handbook (42nd ed.). Wolters Kluwer
Health. https://coursepoint.vitalsource.com/books/9781975160166.
17
Care Plan Grading Matrix:
Section
Score
Demographic Data
Possible Points
10
Physical Assessment
25
Medications
10
18
Lab & Diagnostic Evaluation
5
Medical Diagnosis
5
List of Prioritized Nursing
Diagnosis One-part statements
Nursing Care Plan
• (3) 3 part nursing diagnoses
• (1) Short Term goal with
Evaluation
• (1) Long Term goal with
Evaluation
• (5) Nursing interventions for
each nursing diagnosis
Citations, References & APA
format
5
30
10
100%
Total
Comments:
19