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UNRS 310Psychiatric Nursing Care Plan
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UNRS 310Psychiatric Nursing Care Plan
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UNRS 310Psychiatric Nursing Care PlanStudent Windy Laine Bondoc Date 11/23/2019
Instructor Gayane Avagimian Course NURS 223L
Patient Initials C.M. Date of Admission 11/19/2019 Legal Status Voluntary
5/16/1988 2 East (Vol, 5150, 5250,
Patient DOB Unit Conservatorship)
Chronological and 31 y/o Female Caucasian
Apparent Age Gender Ethnicity
Sulfa
Allergies
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
(location) (location, character,
onset)
5’4”, 122 lbs. 96.4 F oral 72 18 95% room air 126/74 Right arm No pain
Psychiatric Diagnosis and DSM 5 Diagnostic Criterion History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric
Admission / Outpatient Mental Health Services/5150
Advisement
Axis I: Psychosis due to stimulant use disorder, Alcohol use disorder, and Client has many inpatient hospitalizations and past outpatient
Opioid use disorder. treatment. Client has an extremely severe case of poly-
Axis II: Depressed. substance use disorder with bulimia nervosa and some
Axis III: Bulimia Nervosa, Possibly borderline personality traits, History of elements of borderline personality disorder vs. bipolar
Hypothyroidism. spectrum disorder. Client presents having used heroin and
Axis IV: Lack of job, lack of primary support system, financial issues, and substantial amounts of Methamphetamine and drinking of
legal issues. vodka daily, Client is in need of detox although stated she is
Axis V: N/A. not even really sure whether she has been taking other
things. Her brain is so cognitively impaired right now that
she is having a hard time giving a history.
Page 1 of 18
, Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Psychopathology of admitting and/or related psychiatric diagnosis Erickson’s Developmental Stage
Biophysical and/or related medical diagnosis Include Rationale Based on the Patient
Description of how this diagnosis relates to your patient With APA citations
With APA citations
Stimulant psychosis -is a mental disturbance caused by an overdose of Stage Seven – Generativity versus Stagnation
stimulants usually methamphetamine, methylphenidate, or cocaine, also
known as Ritalin. The symptoms of stimulant psychosis changes depending on Client C.M. is in stage 7 of Erickson’s developmental stage.
the drug ingested, but commonly involve the symptoms such as Stage 7 focuses on generativity vs stagnation. At this stage in
delusions, paranoia, hallucinations, and thought disorder. Other symptoms may life, people in this age range tend to look back and see if they
include erratic behavior, aggression, and mania which involves and typically have done enough to help younger or the less experienced, or
happen after an overdose on psychostimulants. The most common causative have they stayed stagnant in their own lives. Client C.M.
agents are substituted amphetamines such as substituted cathinones appears to have be in stagnation. Client is failing to find a
and dopamine reuptake inhibitors includes cocaine or methylphenidate way to contribute, and become stagnant and feel
(Recovery ways, 2018). unproductive. Client may feel disconnected or uninvolved
with her community and with society as a whole.
Alcohol use disorder -An alcohol use disorder (AUD) is drinking that causes
harm and distress. It is a medical condition in which a person drink alcohol (Mcleod, n.d)
compulsively and can't control how much alcohol intake, also feels anxious,
irritable, and stressed when there is no alcohol consumption. An AUD can
range from mild to severe, depends on the symptoms. Severe AUD is most
often called alcoholism or alcohol dependence (Mayoclinic, 2018).
Opioid use disorder –is a chronic lifelong disorder, with serious probable
consequences including disability, relapses, and death. Consuming larger
amounts of drugs over a longer period than intended. Opioids can lead to
physical dependence within a short time which is as little as 4 to 8 weeks. In
chronic users, the abruptly stop using of opioids can lead to severe symptoms
such as generalized pain, diarrhea, dilated pupils, chills, cramps, restlessness,
anxiety, insomnia, nausea, vomiting, and very intense cravings, because these
symptoms are severe it builds significant motivation to continue using opioids
Page 2 of 18
, Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
to prevent withdrawal (American Psychiatric Association, 2019).
Depression -is a mood disorder that is often referred to as clinical depression
or major depressive disorder. It’s defined by a persistent low mood, at the time
which the sufferer has feelings of sadness or low self-worth. Although periods
of sadness are usual in everyone, the symptoms of major depression become so
severe that they intervene with the social functioning, daily routines, and
personal relationships of the sufferer. In many cases, the symptoms become so
extensive that they threaten the integrity of employment, relationships,
financial well-being, and suicidal tendencies are not unusual among depression
sufferers (American Brain Society, 2019).
Bulimia Nervosa - Bulimia nervosa is a serious emotional eating disorder that
includes eating excessive amounts of food in a short period (binging) followed
by shame and guilt leading to extreme exercise, self-induced vomiting, or
laxative abuse (purging). Many refer to it as the binge and purge eating
disorder. There are many causes that can add to this disease and they can
contain neurochemical imbalances, genetic factors, and environmental
stressors such as abuse or exposure to trauma. Other emotional and
psychological issues such as an depression, anxiety disorder, and low self-
esteem are also known triggers in a person who is subject to having an eating
disorder (Center for Discovery, 2019).
Borderline Personality Disorder (BPD) - is a condition defined by problem
regulating emotion. People who experience BPD feel emotions intensely and
for long periods of time, and it is difficult for them to return to a stable
baseline following an emotionally triggering event. This difficulty can lead to
poor self-image, impulsivity, stormy relationships and intense emotional
responses to stressors. Struggling with self-regulation can also develop in
dangerous behaviors such as self-harm (NAMI, 2019).
Hypothyroidism - Hypothyroidism is an underactive thyroid gland.
Hypothyroidism means that the thyroid gland can’t produce enough thyroid
hormone to maintain the body running normally. People are hypothyroid if
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