NURS 223L Psychiatric Nursing Care Plan

NURS 223L Psychiatric Nursing Care PlanNURS 223L Psychiatric Nursing Care PlanORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS I’m working on a nursing case study and need an explanation to help me learn. i have at the case study with the example of the template and the bank template need to just fill it out 3 attachmentsSlide 1 of 3attachment_1attachment_1attachment_2attachment_2attachment_3attachment_3Student DateInstructor CoursePatient Initials Date of Admission Legal Status(Vol, 5150, 5250, Conservatorship)Patient DOB UnitChronological and Apparent Age Gender Ethnicity. NURS 223L Psychiatric Nursing Care PlanAllergiesHeight/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure (location) Pain Scale 1-10 (location, character, onset)Psychiatric Diagnosis and DSM 5 Diagnostic CriterionHistory of Present Psychiatric Illness:Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 AdvisementPsychopathology of admitting and/or related psychiatric diagnosisBiophysical and/or related medical diagnosisDescription of how this diagnosis relates to your patientWith APA citations Erickson’s Developmental StageInclude Rationale Based on the PatientWith APA citationsMENTAL STATUS EXAMINATIONAppearancePresenting Appearance(nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)Basic Grooming and Hygiene(clean, disheveled and whether it is appropriate attire for the weather) Gait and Motor Coordination(awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),posture(slouched, erect),any noticeable mannerisms or gestures Level of Participation in the Program/Activity(Group attendance and milieu participation, exercise)Manner and ApproachInterpersonal Characteristics andApproach to Evaluation(oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)Behavioral Approach(distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing).Coping and stress tolerance.Speech(normal rate and volume, pressured, slow, loud, quiet, impoverished). NURS 223L Psychiatric Nursing Care PlanExpressive Language(no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling)Receptive Language(normal, able to comprehend questions, difficulty understanding questions)Orientation, Alertness, and Thought ProcessRecall and Memory(recalls recent and past events in their personal history). Recalls three words (e.g., Cadillac, zebra, and purple)Orientation(person, place, time, presidents, your name) Alertness(sleepy, alert, dull and uninterested, highly distractible)Coherence(responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow) Concentration and Attention(naming the days of the week or months of the year in reverse order, spelling the word “world”, their own last name, or the ABC’s backwards) Thought Processes(loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).Values and belief system Hallucinations and Delusions(presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications) Judgment and Insight(based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)Mood and Affect:Mood or how they feel most days(happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry).Affect or how they felt at a given moment(comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation. Rapport(easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset). NURS 223L Psychiatric Nursing Care PlanFacial and Emotional Expressions(relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic) Response to Failure on Test Items(unaware, frustrated, anxious, obsessed, unaffected)Impulsivity(poor, effected by substance use)Anxiety(note level of anxiety, any behaviors that indicated anxiety, ways they handled it)Risk Assessment:Suicidal and Homicidal Ideation(ideation but no plan or intent, clear/unclear plan but no intent)Self-Injurious Behavior(cutting, burning)Hypersexual, Elopement, Non-adherence to treatment Discharge Plans and Instruction:Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program Teaching Assessment and Client / Family Education:(Disease process, medication, coping, relaxation, diet, exercise, hygiene)Include barriers to learning and preferred learning stylesPertinent Lab Tests Results(normal ranges in parentheses)Rationale for AbnormalsValproic Acid (50 – 120 mcg/mL)Lithium (0.5 – 1.2 mEq/L)Carbamazepine (5 – 12 mcg/mL)CBC (WBC with diff, ANC, RBC)Urine Drug ScreenThyroid PanelLiver Function (AST/ALT, LHD, Albumin, Bilirubin)Kidney Function (BUN, creatinine)Blood Alcohol LevelDiagnostic Test Results(with dates)Rationale for AbnormalsSubstance Abuse and other Addictions(gambling, sex, shopping, smoking)Type:Amount / Frequency:Duration:Last Used:Withdrawal Symptoms: Type:Amount / Frequency:Duration:Last Used:Withdrawal Symptoms:C.A.G.E. QuestionnaireHave you ever felt you should cut down on your drinking? Yes / NoHave people annoyed you by criticizing your drinking? Yes / NoHave you ever felt bad or guilty about your drinking? Yes / NoHave you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? Yes / NoAbnormal Involuntary MovementsCode: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = SevereI: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)0 1 2 3 4II: Extremity Movements:Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot0 1 2 3 4III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)0 1 2 3 4IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)0 1 2 3 4V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)Yes No   DiagnosisMinimum of 2 NANDA – actual and/or potential.Include etiology and signs and symptoms.*Includedefinition of the nursing diagnoses with APA citations PlanningOutcome CriteriaMinimum of 2 measureablegoal per diagnosis related to the nursing diagnosis ImplementationMinimum of 4independent and collaborative nursing intervention include further assessment, intervention, and teaching that is related to the outcome criteriaRationales for interventions(With APA citations ) EvaluationGoal MetGoal not Met(If not met, what revisions would you make?) How did the patient respond to your interventions1.Nursing Diagnosis Definition: 1. 2. 1.2.3.4. 1.2.3.4. 1. 2.2.Nursing Diagnosis Definition: 1. 2. 1.2.3.4. 1.2.3.4. 1. 2.MEDICATION LISTMedicationsGeneric / Trade Class/Rationale for the patient Dose/Route/ Time (Frequency) Range / Therapeutic Levels Mechanism of action / Onset of action Common side effects / Food and drug interaction Nursing considerations specific to this patient     REFERENCES            Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10 Order NowjQuery(document).ready(function($) { $.post(‘https://nursingpaperessays.com/wp-admin/admin-ajax.php’, {action: ‘wpt_view_count’, id: ‘62034’});});jQuery(document).ready(function($) { $.post(‘https://nursingpaperessays.com/wp-admin/admin-ajax.php’, {action: ‘mts_view_count’, id: ‘62034’});});