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Presenting Problem:

This is a 28 year-old Caucasian female who was admitted to Doctors Hospital Psychiatric Unit 4 South due to an overdose on multiple medications. The patient was found by the police on January 13th picking through garbage near the hospital. Patient overdosed on approximately 30 Alprazolam, Venlafaxine, Trazadone, Benadryl, and Nyquil. She stated she remembered taking the all of the drugs, but does not remember anything after that. Patient believes that the stressors in her life are what caused to overdose on medication. Patient also states that the main reason she overdosed was because she was raped three days prior.

Patients Perception of Stressors/Illness:

Patient states that she is aware of her diagnosis. Patient believes that the stressors in her life are what caused to her overdose on medication. These stressors included financial issues, overwhelmed by school, and her job at a plastic factory where she has conflict with her boss.

MENTAL STATUS EXAM

Behavior: Patient was dress appropriately for the weather. The patient appears her stated age of 28. Patient’s weight was appropriate to height. She was not well groomed and did not practice proper hygiene. Patient sat stiff in the chair, often drifted during the conversation, and did not give consistent eye contact throughout the interview or at group therapy. Facial expressions were flat and she showed no emotion. Patient did not participate in group activities unless she was called upon by the social worker, and she would vaguely share her insight.

Speech: Patient’s speech was organized and clear. She spoke at an extremely slow rate with a very soft volume.

Attitude: Patient’s attitude was positive about getting treatment. She stated that she wants to “go home and get better so that I can care for my three children”. She comes to group activity, which shows cooperation and progress towards her treatment.

Mood: Patient’s mood is anhedonic. She shows no interest in activities or in other patients.

Affect: Patient’s affect was flat and she did not show much emotion throughout interview or ingroup activities.

Page 2 Nursing concept map for mental health Essay

Thought Content: Patient did not speak unless spoken to. However, while conversing with the patient I noticed that her thoughts were appropriate to the conversation.

Orientation: Patient is alert and oriented to person, place, time, event, and oriented to the significance of the circumstances of beingin the hospital.

Insight/Judgment: Patient exhibits fair insight and unstable judgment decisions. Although she understands that she has a mental illness, she is led to believe that suicide is the only option for her. Patient needs to improve on judgment skills.

PSYCHIATRIC HISTORY

Patient was first hospitalized in 2000 due to her first suicide attempt of overdose on vitamins. She was hospitalized again in 2011 when she overdosed on Tylenol. Patient has a history of anxiety attacks and depression that she has battled her whole life, with multiple outpatient treatments.

PSYCHOSOCIAL ADAPTATIONS

Ideas of Harm to Self/Others: Patient denies suicide or homicidal ideations at the present time. However, a history of multiple suicide attempts ultimately puts the patient at a danger to herself and possibly others.

Ego Defense Mechanisms (describe how used by the patient): One defense mechanism noted from the patient was dissociation. Patient stated that she had a bad childhood, and finds it hard to trust people. I notice that now she is dissociating herself from the world and feels disconnected from reality. Another defense mechanism used by the patient was rationalization. Patient states that she has trouble at work because her boss does not like her. Lastly, patient uses suppression when dealing with stressors. She feels that if she ignores them, they will go away (Varcarolis, Hlater, 2011, p. 216-217)

Level of Self Esteem: Patient shows signs of chronic low self-esteem. Patient stated that “I have always been self conscious, I always feel like I am not good looking enough, especially the fat on my legs”. According to Maslow’s hierarchy of needs, when self-esteem is compromised, we feel inferior, worthless, and helpless (Varcarolis, Halter, 2011, p. 39)

Communication/Interaction Patterns (nonverbal communication): Patient did not exhibit many body movements when communicating with health care staff, other patients, or myself. Patient sat still in her chair and did not show any emotion with her thought process. Patient did not make eye contact with anyone she communicated with.

Sexual Patterns (consider roles, identity, lifestyle): Patient states that she is heterosexual. Patient is not currently in a relationship nor is she sexually active. She used to have multiple sex partners in the past.

Psychosomatic Responses (describe somatic complaints that may be stress related): Patient states that she has a lot of trouble sleeping. Other than insomnia, patient did not complain of any other somatic responses that could be stress related.

Use of Alcohol or other Drugs: Patient denies the use of drugs and alcohol.

Degree of Participation in Care/Groups: Patient was part of the Blue Group (Lower functioning). Patient did not exhibit interest in any group activities or care from the staff members. Patient would only answer a question if she was called on, but she never was the first to initiate a response during group activities. However, she is aware that group therapy, activities, and adhering to the medication regimen are all part of the program to be released from the psychiatric unit.

Adjustment to Illness/Disorder: Patient has been battling mental illness from as long as she can remember. She has never formally “adjusted” to her illness. She is aware that she has a problem, however she is unable to see results in any treatment she received in the past.

Previous Patterns of Coping with Stress: Patient uses suppression when coping with stress. She states that she “pushes things to the side and ignores them instead of dealing with them”. Patient states that she does not know how to properly cope with stress.

CULTURAL, SOCIAL AND ECONOMIC INFLUENCES

Environmental Factors: Patient’s financial situation is one of the greatest stressors in her life. She is a single mother with three small children. The father is not in the picture, so she has to care for her children alone without help from anyone. Patient also does not have health care insurance, making it difficult for her to get access to healthcare.

Religious Beliefs/Practices: Patient does not obtain a specific religion. Patient states that she is an atheist.

Education: Patient currently attends Oakland Community College for Landscaping. She is only four credits away from earning an associates degree.

Peer/Social Relationships: Throughout the shift, I noticed that the patient did not interact with peers. When asked, she stated that she does not have friends. One patient took a liking to H.C., however she did not seem to show much interest in him.

Support System: Patient mentioned that she does not have much of a support system. Her children are currently with her aunt, and that is one of the only people she can count on for help if needed. Patient states that she is independent and would rather do things herself rather than rely on others as most people have disappointed her in the past.

Occupational History: Patient states that she has had many different jobs in the past. Her most recent job was at a Plastic Factory working on the line. She believes that the job will not be available to her when she gets discharged from the hospital as she did not call the facility to let them know she is unable to come to work.

Avenues of Productivity/Contribution (current job status, role contributions, and responsibility for others): Patient is employed at a Plastic Factory and is responsible for herself as well as her three young kids. Patient does not receive aid from the government, nor does she receive help from the father of her children.

Health Beliefs and Practices: Patient believes that most health conditions (including mental illness) can be partially treated with proper nutrition. Healthy eating and exercise are important to the patient.

Other Lifestyle Factors Contributing to Present Adaptation: None other than stated above.

PHYSICAL HEALTH STATUS

Co-existing Medical Conditions (need for medical management): None.

Vital Signs: Blood pressure: 99/69, Heart rate: 133, Temperature: 98.2 F, Respirations: 16, No pain.

Lab Results:
Sodium: 141 mmol/L
Potassium: 4.1 mmol/L
Chloride: 110 mmo/L
CO2: 28 mmol/L
Anion Gap: 3
Glucose: 98 mg/dL
BUN: 11 mg/dL
Creatinine: 0.80 mg/dL
NON-AA GFR: 91
APR AMER GFR: 110
Calcium: 8.2 mg/dL
WBC: 4.10 K/ uL
RBC: 3.00 M/ uL
Hematocrit: 32.1%
Hemoglobin: 12 g/dL
Platelets: 162 k/uL
Urine Specific Gravity: 1.02

Results of other Diagnostic Tests: None.

Client Strengths: Patient states that she is a good mother. She stated that “Even after everything, I still try my hardest to give my kids a great life”. She also states that she is very artistic.

Current Medications including Dosage and Frequency. Use the MAR form, Appendix D (Include what these medications are for and why ordered for this client. Use multiple pages, as necessary. Refer to MAR.

DIAGNOSIS, PLANNING, INTERVENTIONS, EVALUATION

DSM IV-TR Axis (List from patient record):

Axis IBipolar Disorder Type 2, Acute Psychosis, Major Depression

Axis IINone.

Axis IIINone.

Axis IVSupport group, occupational problems, economic problems, access to health care.

Axis V 10-20.

Nursing Diagnosis #1 (highest priority): Risk For Suicide

RT: History of Prior Suicide Attempts (2000, 2011, 2013)

AEB: Suicidal Ideations

Short-term Goals/Objective (in measurable terms, with timeframe stated)

1. Patient will remain safe while in the hospital, with the aid of nursing intervention and support (Varcarolis, 2011, p. 483). 2. Patient will name two people she can call if thoughts of suicide recur before discharge (Varcarolis, 2011, p. 483). 3. State one positive thought everyday and why that positive thought makes her want to continue to live (Varcarolis, 2011, p. 483). 4. Make a no-suicide contract with the nurse covering the next 24 hours, then renegotiate the terms at that time (Varcarolis, 2011, p. 483).

Nursing Interventions with scientific rationales:
Identify one scholarly research reference for at least one nursing intervention from the priority diagnosis (provide copy.)

1. During the crisis period, health care workers will continue to emphasize the following four points: the crisis is temporary, unbearable pain can be survived, help is available, and you are not alone. Rationale: Because of “tunnel vision,” patients do not have perspective on their lives. These statements give perspective to the patient and help offer hope for the future (Varcarolis, 2011, p. 483).

2. Follow unit protocol for suicide regarding creating a safe environment. Rationale: Provide safe environment during time patient is actively suicidal and impulsive; self destructive acts are perceived as the only way out of an intolerable situation (Varcarolis, 2011, p. 484).

3. Keep accurate records of patient’s verbal and physical behaviors and all nursing/physician actions. Rationale: These might become court documents. If patient checks and attention to patient’s need or request are not documented, they do not exist in the court of law (Varcarolis, 2011, p. 484).

4. Put on either suicide precautions or suicide observation. Rationale: Protection of all patient’s life at all costs during crisis is part of medical and nursing staff responsibility. Follow hospital protocol (Varcarolis, 2011, p. 484).

5. Keep accurate and timely records, document patient’s activity, usually every 15 minutes (follow hospital protocol. Rationale: Accurate documentation is vital. The chart is a legal document as to patient’s ongoing status, interventions taken, and by whom (Varcarolis, 2011, p. 484).

6. Construct a no-suicide contract between the suicidal patient and nurse. Use clear, simple launguage. When contract is up, it is renegotiated. Rationale: The no-suicide contract helps patients know what to do when they begin to feel overwhelmed by pain (Varcarolis, 2011, p. 484).

Patient Outcome/Evaluation Criteria (Evaluate the patient’s progress toward their goals).

1. MET: Patient stayed safe while in the hospital and was recently
discharged. 2. PARTIALLY MET: Patient states that she will call her aunt if she has thoughts of suicide. 3. MET: Patient states she wants to live because she has three young children at home. 4. NOT MET: Patient did not make a no-suicide contract with the nurse.

Nursing Diagnosis #2: Rape Trauma Syndrome

RT: Sexual Assault

AEB: Suicide Attempt

Short-term Goals/Objective (in measurable terms, with timeframe stated)

1. Patient will express reactions and feelings about the assault before discharge (Varcarolis, 2011, p. 472). 2. Patient will have a short-term plan for handling immediate situational needs before discharge (Varcarolis, 2011, p. 472). 3. List common physical, social, and emotional reactions that often follow a sexual assault by the end of the day (Varcarolis, 2011, p. 472). 4. Patient will have access to information on obtaining competent legal council (Varcarolis, 2011, p. 472).

Nursing Interventions with scientific rationales:

1. Approach victim in a nonjudgmental manner. Rationale: Nurses’ attitudes can have an important therapeutic impact. Displays of shock, horror, disgust, or disbelief are not appropriate (Varcarolis, 2011, p. 473).

2. Confidentiality is crucial. Rationale: The client’s situation is not to be discussed with anyone other than medical personnel involved unless victim gives consent (Varcarolis, 2011, p. 473).

3. Explain to victim the signs and symptoms many people experience during the long-term phase, like nightmares, anxiety, depression, and insomnia. Rationale: Many individuals think they are going crazy as time goes on and are not aware that this is a process that many people in their situation have experienced (Varcarolis, 2011, p. 473).

4. Listen and let the victim talk. Do not press the patient to talk. Rationale: When people feel understood, they feel more in control of their situation (Varcarolis, 2011, p. 473).

5. Stress that they did the right thing to save their life. Rationale: Rape victims might feel guilt or shame. Reinforcing that they did what they had to do to stay alive can reduce guilt and maintain self-esteem (Varcarolis, 2011, p. 473). 6. Do not use judgmental language. Rationale: Use the words: reported not alleged, declined not refused, and penetration not intercourse (Varcarolis, 2011, p. 473).

Patient Outcome/Evaluation Criteria (Evaluate the patient’s progress toward their goals).

1. PARTIALLY MET: Patient expressed a few feelings about the incident, but nothing in depth. 2. NOT MET: Patient does not have a short-term plan for handling immediate situational needs. 3. NOT MET: Patient did not list common physical, social, or emotional factors following a sexual assault. 4. MET: Patient will have access to information on obtaining competent legal council.

Additional Data Needed: I would like to receive more information on her past psychiatric history, as well as the details regarding the recent sexual assault. Patient did not answer questions in detail when asked.

Learning Needs of Client to be addressed through Teaching: Patient needs more information regarding coping skills. Patient seems to be making the same mistakes (suicide attempt) over and over again.

Client’s Perception of Progress: Patient believes that she is starting to feel better, and believes that she is on her way to recovery. She understands that she will need an intense outpatient therapy once she is discharged.

Student Reflection:

It is always interesting to talk to different patient’s and to understand the reasoning behind

their mental illness. From my experience, I notice that stress is usually the cause of

exacerbated symptoms of a latent mental illness. As with H.C., multiple life

stressors are what caused her to feel the need to attempt suicide for the third time. As

always, speaking with H.C. has helped me with my communication techniques. Although

she was not as verbal as other patient’s that I have had in the past, it was a nice change

that ultimately challenged me to take charge and ask open-ended questions to be able to

fully understand her more in detail. It will be a long road to recovery, but I see hope in the

future for H.C. if she receives extensive outpatient treatment.

References

Varcarolis, E.M. (2011). Manual of psychiatric nursing care planning: assessment guides,

diagnoses, psychopharmacology (fourth edition). St. Louis, MO: Saunders.

Varcarolis, E.M., Halter, M.J. (2011). Foundations of psychiatric mental health nursing, a

clinical approach. (sixth edition). St. Louis, MO: Saunders.a

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