NURS 360

Capstone Project
PMH Care Plan
Student Nurse Reporting Form
SN: _Stephanie Wong___________ Date: 10/10/15_____________
Pt.: Sex: _M__ Age: __40______
Date of Admission:_08/18/15__________
Transferred? _X__No ___Yes:
(Reason/Date)___________________________________
Income source: Non-employed________________
Legal Status: ______MH5______________________
Expiration Date: _______N/A______
DSM Diagnosis:
I
Major Depression Disorder
_________________________________________________________________
II
Deferred
__________________________________________________________________
III
GI Ulcer
_____________________________________________________
IV
Unemployed, dysfunctional family support
______________________________________________________________________
V
GAF 50-41
_________________________________________________________________
What brought patient to the hospital?
Patient was brought in for suicidal ideation and history of major depression.

Patients description of illness/issues:

Patient states feeling my heart is heavy in combination of anxiety, depression

and suicidal ideation. C/O chest pain, SOB. He endorsed suicidal ideation and
relieves anxiety by stabbing his abdomen with acupuncture needles repeatedly.
Efforts to reaching out to family were met with disdain. He stated, They just get
mad at me for being a failure. I dont see the point in living like this. Patient
describes depression and anxiety since childhood that resulted in suicide
attempt in the 6th grade by hanging. He did not receive any psychiatric care until
ED visit despite multiple requests by his family. He states continued flashbacks
and anxiety from childhood physical trauma by his stepfather growing up and
notes majority of his headaches originate from these recurrent memories.
Spirituality: Jehovah witness
Considerations r/t ethnicity or religion:
N/A
Patients Strengths:
College Education
Patients Limitations:
Not able to maintain relationships, dysfunctional family and friend support.
Medications
Order: Aripiprazole (Abilify) 15mg PO Daily
Drug class: Atypical Antipsychotic
Pts target sx: MDD
Total 24h dose: 15 mg
Recommended range: 2-15 mg
L M H Max: Max
Current Side effects: Depression, suicide ideation, headache, anxiety, insomnia,
dizziness, fatigue
Order: Clonazepam (Klonopin) 1mg tab PO BID
Drug class: Benzodiazepine
Pts target sx: Anxiety, Insomnia, lethargic
2

Total 24h dose: 2mg

Recommended range: 0.25-0.5 mg BID-TID or 4mg/ day
L M H Max: M
Current Side effects: Depression, fatigue, and drowsiness
Order: Methylphenidate 5 mg tab oral BID
Drug class: Psycho stimulant
Pts target sx: Narcolepsy
Total 24h dose: 10mg
Recommended range: 5-15 mg PO BID/TID
L M H Max: M
Current Side effects: Nervousness, insomnia, headache, and dizziness.

Order: Prazosin 2mg PO at Bedtime

Drug class: Anti-hypertension/ Alpha Blockers
Pts target sx: Anxiety, Nightmares
Total 24h dose: 4 mg
Recommended range: 6-15 mg/day
L M H Max: L
Current Side effects: dizziness, headache
Order: Sertraline (Zoloft) 200 mg tab PO Daily
Drug class: SSRI
Pts target sx: Depression/Anxiety
Total 24h dose: 200mg
Recommended range: 50-200 mg/day
L M H Max: Max
Current Side effects: suicide ideation, headache, insomnia, anxiety, nervousness
PRN Medications
Order: Acetaminophen (Tylenol) 650 mg tab PO Q4hr
Drug class: Analgesic
Pts target sx: Fever/Pain
Total 24 hr dose: N/A
Recommended range: 325-1000 mg/day
L M H Max: M
Current side effects: N/A
Order: Lorazepam (Ativan) 1mg tab PO Q2hr
Drug class: Benzodiazepine
Pts target sx: Agitation, Anxiety, and insomnia
Total 24hr dose: N/A
Recommended range: 2-6 mg/day
3

L M H Max: L
Current side effects: N/A
Order: Meclizine (Antivert) 25 mg tab PO BID
Drug class: Antihistamine
Pts target sx: Vertigo
Recommended range: 25-100 mg/day
LMH Max: L
Current side effects: N/A
Order: Melatonin 3 mg tab PO Bedtime
Drug class:
Pts target sx: Insomnia
Total 24 hr dose: N/A
Recommended range: 0.3 5 mg
LMH Max: M
Current side effects: N/A
Order: Nitroglycerin (Nitro-BID) 2% Ointment Packets 1.5 inch Apply to chest wall
Q30 min PRN (B/P >160)
Drug class: Nitrates Vasodilators
Pts target sx: HTN, Angina
Recommended range: 0.5-5 inch
L M H Max: L
Current side effects: N/A
AXIS III: List all conditions even if they are not listed in multi-axial diagnoses or
on chart. (Particularly note any unstable conditions & all non-medication
interventions.)
1. GI Ulcer
BMI: 23.62

Category: Normal

Height: 165 cm

Weight: 141.2 lbs

Food & fluid intake: Regular Diet

Bladder & bowel status: Regular
Sleep pattern: Poor sleep
Total sleep/24 hrs: 10.5/ 24 hrs
(Circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning
awakening
Number of hrs of disruption: 5 hrs

Naps: When? Late afternoon

Total naptime: 1 hr

Lab & studies

Date/Panels in which all values were normal:
08/18/15 UA Reflex to C&S
08/31/15 TSH Reflex FT4
09/09/15 CBC w Diff
09/09/15 Lipids
09/09/15 BMP
09/09/15 Hepatic Panel
09/09/15 Lipase
Date/Any abnormal labs:
09/09/15 CBC w Diff- ABS Neutrophils 7.09 (H)
09/09/15 Triglycerides 205 (H)
Labs you would expect but were not ordered:
All labs expected to be drawn.
Glucose readings x 24h for all diabetic pts.: N/A
All drug screen findings:
08/18/15 Urine Drugs Screen #2 (Negative)
08/18/15 Ethanol Plasma/ Serum (Negative)

MENTAL STATUS ASSESSMENT:

Behavior:
Appearance: Groomed appropriately, hygiene appropriate, cooperative in
activities and discussions, motor activity: psychomotor depression, speech: soft,
non-pressured.
Affect:
Affect appropriate, Mood: Depressed, sad, displays to be anxious and tearful
during conversation.
Sensorium:
Patient A/O X3 to person, place and time.
Imagery:
Patient denies currently having any nightmares and hallucinations. Able to
describe past history and recall on events experienced.
Cognition:
Thought content: linear thought process, patient able to remote memory, suicidal
ideation active with thoughts of hopelessness, failure, and worthlessness.
Association: intact, Insight: fair, not fully able to perceive and understand causes
and situations of his mental illness. Judgment: not able to make rational
decisions during stressful events, understands consequences of behaviors.

Interpersonal relationships:
Only has supportive relationship with sister from Chicago
No other outside support.

Developmental level: (Assets & barriers)

Ericksons Intimacy vs. Love

Patient displays isolation, loneliness and depression with results having no

committed relationships.
Relationships with brother, mother and stepfather are dysfunctional.
Drugs: Substance abuse or dependence: (Include nicotine & any alcohol &
drugs. List by drug: Last date of use/Current acute intoxication or withdrawal
signs and symptoms when SN caring for pt./Used how long/Route/Usual
amount/Negative consequences)
Drug class

Last Use

N/A
N/A
N/A

N/A
N/A
N/A

Acute intox or
Length of
Route
withdrawal sx? Time Used
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

Usual amt. Negative Consequences

N/A
N/A
N/A

N/A
N/A
N/A

Problems Identified In Hospitals Master Treatment Plan:

1. MDD
2. GAD
3. Anxiety
4. PTSD
Current Discharge Plan: N/A
Nursing interventions you performed this shift (Include safety and teaching!):
Performed one to one assessment.
Provided safe unit measures and built trusting relationship.
Explored patient history of family and support.
Assessed suicidal thoughts and plan.
Explored MDD by using Burns Assessment tool sheet and identifying stressors.
Educated coping mechanism for stress management using breathing and guided
meditation.
Evaluated patients learning outcomes regarding attending social support groups,
coping and management in seeking help during suicidal ideation.

Patient-centered Care Analysis

PRIORITIZED PATIENT NEEDS
What are the patients 4 highest needs/problems?
(Use your best nursing judgment! It will be different than the master treatment
plan.) P=Problem, E= Evidence, S= Solution.
1. P: Risk for Suicide
E: Patient states having history of suicidal attempt since childhood by
attempting to hang self. First time now medical attention for treatment. Prior to
admission attempted to stab abdomen with acupuncture needles. Currently
experiencing active suicidal thoughts x 2 in a day. States he still wants to attempt
suicide after discharge by drifting away in the ocean. Patient states having
anxiety, feelings of failure, hopelessness and worthlessness the past week. He
doesnt want to live or feel this way anymore d/t abusive family history and
limited social support.
S: Patient will not harm self, expresses decreased anxiety, expresses feelings
appropriately, obtains and yields from harmful objects.

ST Goal: Patient will be able to notify for help when having suicidal ideation for
the next two days of hospitalization.
LT Goal: Patient will have no suicidal ideation, obtain coping and management
skills by discharge.

2. P: Ineffective coping
E: Patient states having anxiety, insomnia, fatigue, headaches, and tightness
of chest. No previous medical attention given until this past admission. Has lack
of goal directed behavior, decreased social support, only has sister but is offisland, inability to cope and ask for help, and states having active suicidal
ideation.
S: Patient able to verbalize ability to cope and asks for help when needed,
demonstrates ability to solve problems, remain free of suicidal ideation, able to
discuss and identify life stressors, and properly cope when stressors occur.

ST Goal: Patient will be able to obtain and use one 1 coping skill in two days of
hospitalization.
LT Goal: Patient will be able to obtain three coping skills by discharge.

3. P: Knowledge Deficit
E: Patient has long history of depression with suicidal attempt since
childhood. Never received medical attention until now. Patient has no knowledge
or able to identify harmful medication side effects, displays not able to use
coping techniques with stressors.
S: Patient will have increased knowledge of medications, food or drug
interactions and side effects, able to state understanding of symptoms with his
condition of MDD, able to state and obtain how to cope with MDD, patient will be
able to report sign and symptoms of drugs, call for crisis management, and
identify social support groups to attend.
ST Goal: Patient will be able to state and understand symptoms of MDD the next
day in hospitalization.
LT Goal: Patient will be able to understand symptoms of MDD, use coping
techniques for stressors, report a crisis and scheduled social support group by
discharge.
4. P: Social Isolation
E: Patients sister in Chicago is only family support available. Relationship
with brother, mother and stepfather are not involved with care or supportive.
Patient states having no friends that he can count on. Not aware of social support
groups available outside of hospital, feeling worthless and active suicidal
ideation.
S: Patient will be able to communicate feelings of isolation, increase patient
trusting relationships with staff and social groups, and positively interact with
other patients.
ST Goal: Patient will attempt to build social relationships and attend activities
within the next two days of hospitalization.
LT Goal: Patient will continue attending social support groups and have
scheduled meetings by discharge.

10

Care Plan
Nursing Diagnosis: Risk for suicide related to feelings of anxiety, failure, low self-esteem, hopelessness, worthlessness, hx of suicidal
ideation and dysfunctional social support.
P: Risk for Suicide
E: Patient states having history of suicide since childhood by attempting to hang self. Prior to admission attempted to stab abdomen
with acupuncture needles. No previous treatment for MDD prior to admission. Currently experiencing active suicidal thoughts x 2 in a
day. States he still wants to attempt suicide after discharge by drifting away in the ocean. Patient states having anxiety, feelings of
failure, hopelessness and worthlessness the past week. He doesnt want to live or feel this way anymore d/t abusive family history and
limited social support.
S: Patient will not harm self, expresses decreased anxiety, expresses feelings appropriately, obtains and yields from harmful objects.
ST Goal: Patient will be able to notify for help when having suicidal ideation for the next two days of hospitalization.
LT Goal: Patient will have no suicidal ideation, obtained coping and management skills if suicidal ideation reoccurs by discharge.

11

Intervention & Frequency

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including page number)
1.)

1.) Provide a safe unit

environment. Establish a positive therapeutic
relationship with patient.
Frequency x1
2.) Assess for suicidal ideation with history
of attempted suicide, family risk of suicide,
depression, triggers from previous stressful
life events, childhood abuse and lack of
social support. Frequency x 1
3.) Assess by using screening tools such as
Burns Checklist and Suicide Self-Harm Risk
assessment. Frequency x1
4.) Assist patient in making realistic goals by
developing coping skills to help patient
handle stressful situations. Explore different
styles such as self-soothing senses,
breathing, and guided meditation.
Frequency x 1
5.) Educate patient about crisis management
and referral to support groups available.
Frequency x1
6.) Evaluate patient learning outcomes of
coping techniques, manage crisis
management and maintaining social support
groups. Frequency x 1

1.) Providing a safe environment and building trust will increase the nursepatient relationship. (Ackly & Ladwig, p. 285) It is very important to
inform the patient whatever information communicated will only be
discussed amongst medical staff involved. (Ackley & Ladwig, p. 797) The
nurse-patient relationship gives the patient support, someone to talk to, and
prevents self-harm. (Coping with Suicidal, 2015)
2.) Assessing history helps the nurse understand the patients risk factors such
as family history of suicide and depression. Research shows that the risk
for suicide is associated with changes in brain chemicals called
neurotransmitters, including serotonin. (OCHPA, 2015)
3.) Assessment of Burns and Suicidal demonstrates strengths as a part of
protocol in evaluating suicidal risks. It decreases assessment errors of
suicide risk when brief assessment tools were used. (Ackley & Ladwig, p.
797)
4.) Coping by using self-soothing senses of vision, smell, hearing, taste, and
touch. Writing a journal and using distractions may help. Most important
notify for help and talking with someone can reduce the pain of suicide.
Improve and maintaining relationships are part of coping long term. Taking
each goal one step at a time to prevents disappointment and getting the
patient overwhelmed. (OCHPA, 2015)
5.) Patients experiencing suicide often feel alienated and benefit from actions
that facilitate social support. Patient should have resources for crisis to receive
evaluation and help. (Ackly & Ladwig, p.799) National Suicide
Prevention Lifeline, a service available to anyone. You may call
for yourself or for someone you care about. All calls are
confidential. (OCHPA, 2015)
6.) This helps the nurse and patient evaluate mastery and
understanding of new learned skills. (Ackly & Ladwig, p.799)

2.)

3.)

4.)

5.)

Evaluation
Patient remained safe in unit.
Established positive therapeutic
relationship. Patient displayed comfort
and was trusting during conversation.
Able to retrieve rapport on history and
current problems such as history of
suicidal attempt during childhood, high
family risk of suicide, unable to
maintain stable life, stepfather was
abusive, and lack of family and friend
support. Experiences anxiety, tightness
of chest, insomnia, low self esteem,
hopelessness. Patient discussed having
a plan after discharge to drift away in
the ocean. Information was noted and
reported to assigned RN.
Used Burns and Suicidal Self- harm
assessment tools to see where patient
stands with depression and suicide
ideation. Patient scored for Burns 31
and Suicide 9.
Patient was able to develop one coping
mechanism for stress management by
using deep breathing technique. Patient
states it helped relieve anxiety and
improve relaxation.
Informed patient of available resources
such as crisis referral line and outside
support groups after discharge.
Discussed with RN that social worker
will provide information prior to
discharge.

12

6.) Patient was able to retain one coping

mechanism, expressed when feeling
suicidal to talk to someone, and
continue group activities.

Scholarly Journal Article review, Source and Implications:

Orange County Health and Psychology Associates. (2015). Coping with suicidal thoughts. Retrieved from

13

https://ochpa.com/coping-with-suicidal-thoughts

Assessment Tool(s):
Burns Depression Checklist Tool
Suicide Self-Harm Risk Assessment Tool

14

Nursing diagnosis: Ineffective coping r/t MDD as evidenced by anxiety, hopelessness, low confidence, insomnia, fatigue, HA, and
tightness of chest.
P: Ineffective coping
E: Patient states having anxiety, insomnia, fatigue, headaches, and tightness of chest. No previous medical attention given until
this past admission. Has lack of goal directed behavior, decreased social support, only has sister but is off-island, inability to cope and
ask for help, and states having active suicidal ideation.
S: Patient able to verbalize ability to cope and asks for help when needed, demonstrates ability to solve problems, remain free of
suicidal ideation, able to discuss and identify life stressors, and properly cope when stressors occur.
ST Goal: Patient will be able to state and use one coping skill in two days of hospitalization.
LT Goal: Patient will be able to obtain three coping skills by discharge

Scientific Rationale
Intervention & Frequency
1.) Provide safe unit environment. Establish
therapeutic relationship with patient.
Frequency x 1
2.) Use active listening and acceptance to help
client express emotions such as crying, guilt,
and anger. Frequency x 1

(In complete sentences!)

(Reference in APA format, including page number)

1.) Providing a safe environment and building trust

will increase the nurse-patient relationship. (Ackly &
Ladwig, p. 285)
2.) Active listening provides the patient with a
nonjudgmental person listening with full attention and
available for provide feedback. (ATI, p. 23)

Evaluation
1.) Patient and nurse relationship established. Patient
displayed trust and comfort to express self.
2.) Patient engaged and displaying comfort with my full
attention. Was able to retrieve good rapport on history and
existing problems.
3.) Patient discussed causes of ineffective coping such as

15

3.) Assess and observe for causes of ineffective

coping such as poor self-concept, grief, lack of
problem-solving skills, lack of support, or
recent change in life situation.
Frequency x1
4.) Observe for strengths such as the ability to
relate the facts and to recognize the source of
stressors. Frequency x1
5.) Provide mental and physical activities within
the client's ability such as reading, television,
radio, crafts, outings, movies, social
gatherings, exercise, sports, and games.
Frequency x1
6.) Encourage use of cognitive behavioral,
relaxation such as deep breathing techniques,
music therapy, guided imagery and mediation.
Frequency x1

3.) Situational factors must be identified to gain an

understanding of the patients current situation and to
assist with coping effectively. (Ackly & Ladwig, p.
285)
4.) Identifying strengths increase confidence and
positive feedback. It encourages the patient to
continue coping with and improve for positive
outcomes. (Ackly & Ladwig, p. 285)
5.) Interventions that enhance body awareness such
as exercise, proper nutrition, and muscular relaxation
may be effective for treating anxiety and depression.
(Ackly, Ladwig, p. 285)
6.) Relaxation techniques, desensitization, music, and
guided imagery can help clients cope to increase their
sense of control, respond to stressful situations and
relieve anxiety. (Ackly & Ladwig, p. 285)

stepfather being abusive and not having stable family

support.
4.) Patient has some college education, cooperative with
others, non aggressive, expressed helping other makes him
feel better.
5.) Patient attended all scheduled activities that were
available. Played air hockey and was very engaged and
excited to play.
6.) Patient enjoyed using breathing and guided meditation.
Currently using as a coping technique to improve anxiety.

Nursing Diagnosis: Knowledge deficit r/t MDD as evidenced by minimal knowledge of illness, medications side effects, not having
coping techniques, no family support, and not having any previous treatment.
P: Knowledge Deficit
E: Patient has long history of depression with suicidal attempt since childhood. Never received medical attention until now. Patient
has no knowledge or able to identify harmful medication side effects, displays not able to use coping techniques with stressors.
S: Patient will have increased knowledge of medications, food or drug interactions and side effects, able to state understanding of
symptoms with his condition of MDD, able to state and obtain how to cope with MDD, patient will be able to report sign and
symptoms of drugs, able to call for crisis management, and identify social support groups he can attend.
ST Goal: Patient will be able to state and understand symptoms of MDD the next day in hospitalization.

16

LT Goal: Patient will be able to understand symptoms of MDD, use coping techniques for stressors, report a crisis and scheduled
social support group by discharge.
Intervention & Frequency
1.) Assess ability to learn or perform desired
health-related care. Frequency x1
2.) Determine clients learning style especially if
client had learned and retained new
information in the past. Styles such as writing,
visual, group activity may be used.
Frequency x1
3.) Assess motivation and willingness of patient.
Remain patient and understanding of patients
capabilities. Frequency x 1
4.) Evaluate learning outcomes using
evaluation strategies such as return
demonstration and verbalizations of new
coping skills, drugs effects and
understanding illness.
Frequency x1

Scientific Rationale
(In complete sentences!)
(Reference in APA format, including page number)

Evaluation

1.) Identifying patients cognitive

1.) Patient was engaged and willing to learn about illness and care
involved for improvement
impairments and behaviors assist the
nurse in applying appropriate focused care 2.) Patient enjoys visual and learning in a group activity setting and
states not wanting to be a lone.
plan. (Ackly & Ladwig, p. 521)
3.) Patient motivation seemed fair. Approached topics about
2.) Finding an effective learning style will
MDD, suicide and coping simply to prevent stress and
increase patients understanding of
overwhelm reaction.
knowledge given. (Ackly & Ladwig, p. 521).
3.) Understanding their readiness to learn 4.) Patient was able to identify triggers and feelings regarding
illness, not yet able to understand medications, was able to
helps the nurse engage how much to
state and obtain one coping skill.
information they can handle. (Ackly & Ladwig
p. 521)
4.) This helps the nurse and patient
evaluate mastery of new learned skills.
(Ackly & Ladwig, p. 522)

Nursing Diagnosis: Social isolation r/t MDD as evidenced by low self-esteem, feelings of isolations, and dysfunctional family
support.
P: Social Isolation
E: Patient sister in Chicago is only family support available. Relationship with brother, mother and stepfather are not involved
with care or supportive. Patient states having no friends that he can count on. Not aware of social support groups available outside of
hospital, feeling worthless and active suicidal ideation.

17

S: Patient will be able to communicate feelings of isolation, increase relationships with staff and social groups, and positively
interact with other patients.
ST Goal: Patient will attempt to build social relationships and attend activities within the next two days of hospitalization.
LT Goal: Patient will be able to establish positive relationships, continue attending social support groups and have scheduled meetings
by discharge.
Scientific Rationale
Intervention & Frequency
1.) Provide safe unit
environment. Establish therapeutic
relationship with patient.
Frequency x1
2.) Encourage patient to express
feelings by using therapeutic active
listening.
Frequency x1
3.) Observe for barriers of social
isolation.
4.) Discuss factors that cause social
isolation.
Frequency x1
5.) Encourage social interactions and
group activities such as crafts,
music, imagery, and games.
6.) Encourage and refer patient to selfhelp support groups.

(In complete sentences!)

(Reference in APA format, including page number)

Evaluation

1.) Patient remained safe and established therapeutic

1.) Providing a safe environment and
relationship.
building trust improve nurse-patient
2.) Patient was able to express feelings of current
relationship. (Ackly & Ladwig, p. 768)
problems such as feeling hopeless, worthless, suicidal
2.) Active listening provide the patient with a
ideation, and dysfunctional family support.
nonjudgmental person listening with full attention and 3.) Noticed patient keeps to self and doesnt take
available for provide feedback. (ATI, p. 23)
initiative. Only will interact and participate if asked in
3.) Observing and understanding illness
activities.
involved will help nurse give appropriate
4.) Patient stated feeling not worthy and unable to
interventions for the patient. (Ackly &
maintain relationships because he feels like a failure.
Ladwig, p. 768)
5.) Encourage patient to attend activates. Patient was
4.) Asking about factors caused by
willing to attend and stated helping others in the
patients illness such as emotions, fear,
activity made him feel better.
concerns, helps understand and manage 6.) Encouraged patient to continue social group
everyday living that influence quality of
activities and informed him of available support
life. (Ackly & Ladwig, p. 768)
groups after discharge. Discussed with RN staff social
5.) Increasing patient social interaction will help
worker will provide information prior to discharge.
patient build behaviors and relationships. (Ackly &
Ladwig, p.769)
6.) To maintain patients adjustment it can be
successful with social support. (Ackly & Ladwig,
p.771)

Frequency x 1

References

18

Ackley, B., & Ladwig, G. (2008). Nursing diagnosis handbook: An evidence-based guide to planning
care (8th ed.). Maryland

Heights, Mo.: Elsevier.

Assessment Technologies Institution (2013) RN mental health nursing, edition 9.0, Overland Park, Kansas: ATI
Orange County Health and Psychology Associates. (2015). Coping with suicidal thoughts. Retrieved from
https://ochpa.com/coping-with-suicidal-thoughts

19

20

21