Nursing Care Plan Fall 2023 Mental Health

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School

Old Dominion University *

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Course

201C

Subject

Chemistry

Date

Feb 20, 2024

Type

docx

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Uploaded by ProfessorSkunk1845

Recognize Cues (Assessment) Analyze Cues (Diagnosis) Prioritize the Hypothesis and Generate Solutions (Goals) Take Action (include rationales) (Implementation) Evaluate the Actions (Evaluation) RG 45 y.o Caucasian Male FULL CODE Subjective:  Allergies: NKA  Feels depressed.  Has been consuming alcohol since 16 y.o.  Has a suicide plan Objective:  AA&O: x4  Normal Posture  Cooperative attitude  Anxious Medical DX: Suicidal Ideation and Alcohol use disorder Risk for suicide r/t reports of desire to die or kill self. 1. Prior to discharge, Patient will agree to treatment plan to reduce risk for suicidal behaviors. 2. During therapy, Patient will address feelings of suicide. 1. Assess for risk factors that may increase the potential for a suicide attempt. Rationale: It is a myth that suicide occurs without forewarning. People contemplating suicide may exhibit verbal and behavioral cues about their intent to end their life. (Independent) (pg.252) 2. Assess all support resources available to the patient. Rationale: Patients who are depressed and whose lives are pervaded with a sense of hopeless may isolate themselves or be unable to access available supports. 1. Prior to discharge, Patient stated, “I do not want to shoot myself anymore.” Goal Met. 2. During group therapy, Patient address reasons for wanting to self- harm. Goal Met.

Nonadherence to treatment program r/t complex treatment regimen evidenced by missed appointments for treatment. 3. 1-week post- discharge, Patient will express impulses to harm self and when to talk to staff. 1. On 11/10/2023, Patient will have completed 2 treatments. 2. During follow- up visits, Patient’s substance screens will remain negative. (Independent) (pg.252) 3. Assess decision making and problem-solving ability. Rationale: Suicide seems an acceptable solution when an individual is no longer able to effectively solve problems or make decisions. The patient may need guidance in decision-making (Independent) (pg.252) 1. Perform random substance screens. Rationale: Support and rewards for compliance are important for the patient’s recovery. (Collaborative)(pg.241) 2. Assess any secondary gains from substance use. Rationale: Perceived gains (friends, income) promote relapse behaviors and continued 3. On 11/10/2023, Patient had not been discharged. Goal is unmet. Goal Continued. 1. On 11/10/2023, Patient completed daily group therapy in the facility. Goal Met. 2. On 11/10/2023, Patient had not completed a follow-up visit. He is currently still at Northlake. Goal is unmet. Goal Continued.

3. In the event of a relapse, Patient will return to center for treatment. substance use. (Independent)(pg.241) 3. Plan for small, steady improvements. Rationale: It is realistic to expect patients to refrain from alcohol and drugs 1 day at a time. (Independent)(pg.241) 3. On 11/10/2023, Patient was still at Northlake. Goal is unmet. Goal Continued.

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