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University of Texas at BrownsvilleBachelor Science NursingPlan of Care (Based on Textbook)

Room No:15Students Name:

Pts Initials:SAMFAge:48Date:7/16/15

Patients Medical Diagnosis:Psychosis

State a short term objective for yourself during this nursing care experience:Learn and practice some of the skills that I learned the

last semester. Also practice the correct form of charting and using the nursing care plan.

Define in your words the current diagnosis:It is the condition of the mind involving loss of contact with reality.

Summary of diagnosis (Etiology and pathology) according to textbook: A mental disorder in which there is severe loss of contact with

reality. Evidenced by delusions, hallucinations, disorganized speech patterns, andbizarre or catatonic behavior. Psychotic disorders are

common features ofschizophrenia, bipolar disorders, and some affective disorders. They can alsoresult from substance abuse (such as

hallucinogens), substance withdrawal(such as delirium tremens), or side effects of some prescription drugs. Etiology: alterations in brain

structure and changes in dopamine neurotransmission. The dopamine changes are directly related to hallucination and delusions.

Symptoms according to textbook: In psychotic states patients may express unusual ideas (such as that they can read the minds of

others, send radio messages directly to God or inanimate objects, travel to distant galaxies). These ideas are called delusions. Psychosis

is also marked by patients reports of hearing voices (auditory hallucinations) or seeing objects or persons not visible to others (visual

hallucinations). Auditory hallucinations are hallmarks of schizophrenic and manic states; visual hallucinations are characteristic of drug

intoxication or withdrawal. Disturbances in thought content and form, perception, affect, sense of self, volition, interpersonal relationships,

and psychomotor behavior occur. Thorough physical and psychiatric examinations rule out organic causes of the patient symptoms and

establish the diagnosis.

Textbook Medical Management (Dx studies and treatment):Treatment goals focus on meeting the patients physical and

psychosocial needs, and usually combine drug therapies with behavioral therapies, long-term psychotherapy, psychosocial rehabilitation,

and/or vocational counseling, requiring use of community resources. Patients with psychosis are treated effectively with neuroleptic drugs

(which appear to work by blocking postsynaptic dopamine receptors), such as haloperidol, risperidone, or chlorpromazine. Side effects of

some of these medications include dystonic reactions and tardive dyskinesia. The newer agents produce fewer of these extrapyramidal

symptoms. Treatment drugs also have sedative, anticholinergic, and orthostatic hypotension effects, and about 1% of patients taking these

agents experience neuroleptic malignant syndrome (life-threatening fever, muscle rigidity, and altered level of consciousness).

Textbook Nursing DiagnosisBased on Maslows HierarchyProcedures to be performed by studentsBased on Nursing Diagnosis

1) Constipation1) Assess usual pattern of elimination and compared with present pattern including size, frequency, color and quality

2) Risk for violence2) Assess physiological signs and external signs of anger.

3) Anxiety3) Assess the clients level of anxiety and physical reactions to anxiety. Using the Hamilton Anxiety Scale.

4) Risk for suicide4) Assess for any changes in mood, or behavior every 30 min to 1 hour

5) Disturbed sensory perception r/t biochemical imbalances AEB violent behavior and noncompliances with taking medications5) Assess and identify behavioral response that may indicate mental problems

References (Author & Page No.)Nursing central: Tabers dictionary, disease and disorders.

GENERAL INFORMATIONAdmission Date:7/14/15Number of days in Hospital:2

Admitted Via:Mode Amb:n/aMc:n/aOther:Court Ordered

Statement of Present Complaint:Psychosis, exhibiting self, paranoia, delusions & auditory hallucinations

Last Hospital Admission Date:8/24/06Reason:drug overdose

Immunization Current (y/n):yPPD:yNotes:Influenza

Major Illness, Operations, Blood Transfusions or Pregnancies:

1.Psychosis7.n/a

2.Bipolar disorder8.n/a

3.Hyperlipidemia9.n/a

4.Suicidal ideation10.n/a

5.Depressive disorder11.n/a

6.Schizophrenia12.n/a

Health Maintenance:

Exercise Type:n/aFrequency:n/aQuantity:n/a

Hobbies if any:

Tobacco Type:CigarettesQTY/day x yrs.:4/day 31 yearsIf quit, date:n/a

Alcohol Type:BeerQTY/week:12 cans/ weekIf quit, date:n/a

Other Type:CocaineQTY/week:5 grams/ weekIf quit, date:n/a

MEDICATIONAllergies: Ibuprofen, naproxen

Medication(including IVs)DoseFreq-uencyRouteTime to beClassification / Action / RationaleNursing Intervention

Lithium300mgQDPO0600, 1400, 2200Mood stabilizer

ActionAlters cation transport in nerve and muscle.May also influence reuptake of neurotransmitters.Therapeutic Effect(s):Prevents/decreases incidence of acute manic episodes.

Rationale:Manic episodes of bipolar I disorder (treatment, maintenance, prophylaxis).Assess mental status (orientation, mood, behavior) initially and periodically. Initiate suicide precautions if indicated.Monitor intake and output ratios. Report significant changes in totals. Unless contraindicated, fluid intake of at least 20003000 mL/day should be maintained. Weight should also be monitored at least every 3 mo.Lab Test Considerations:Evaluate renal and thyroid function, WBC with differential, serum electrolytes, and glucose periodically during therapy.Toxicity Overdose: Monitor serum lithium levels twice weekly during initiation of therapy and every 2 mo during chronic therapy. Draw blood samples in the morning immediately before next dose. Therapeutic levels range from 0.5 to 1.5 mEq/L for acute mania and 0.61.2 mEq/L for long term control. Serum concentrations should not exceed 2.0 mEq/L.Assess patient for signs and symptoms of lithium toxicity (vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle weakness, or twitching). If these occur, report before administering next dose.

Quetiapine SEROQUEL

300mgAt bed timePO2200Antipsychotics, mood stabilizersACTIONProbably acts by serving as an antagonist of dopamine and serotonin.Also antagonizes histamine H1 receptors and alpha1-adrenergic receptors.Therapeutic Effect(s):Decreased manifestations of psychoses, depression, or acute mania.

RATIONALESchizophrenia.Depressive episodes with bipolar disorder.Acute manic episodes associated with bipolar I disorder (as monotherapy [for adults or adolescents] or with lithium or divalproex [adults only]).Maintenance treatment of bipolar I disorder (with lithium or divalproex).Adjunctive treatment of depression.

Monitor mental status (mood, orientation, behavior) before and periodically during therapy.Assess for suicidal tendencies, especially during early therapy. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults 24 yr.Assess weight and BMI initially and throughout therapy.Monitor BP (sitting, standing, lying) and pulse before and frequently during initial dose titration. If hypotension occurs during dose titration, return to the previous dose.Observe patient carefully when administering to ensure medication is swallowed and not hoarded or cheeked.Monitor for onset of extrapyramidal side effects (akathisia restlessnessdystonia muscle spasms and twisting motions; or pseudoparkinsonism mask-like faces, rigidity, tremors, drooling, shuffling gait, dysphagia). Report these symptoms; reduction of dose or discontinuation may be necessary. Trihexyphenidyl or benztropine may be used to control these symptoms.Monitor for tardive dyskinesia (involuntary rhythmic movement of mouth, face, and extremities). Report immediately; may be irreversible.Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor,

Lorazepam (Ativan)1mgprnPOAntianxiety agentssedative/hypnotics

ACTIONDepresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter.Therapeutic Effect(s):Sedation.Decreased anxiety.Decreased seizures.

RATIONALEAnxiety disorder (oral).Preoperative sedation (injection).Decreases preoperative anxiety and provides amnesia.Unlabeled Use(s):IV: Antiemetic prior to chemotherapy.Insomnia, panic disorder, as an adjunct with acute mania or acute psychosis.

PallaperidoneINVEGA SUSTENNA6mg QDonce dailyPOQD 0800AntipsychoticACTIONMay act by antagonizing dopamine and serotonin in the CNS. Paliperidone is the active metabolite of risperidone.Therapeutic Effect(s):Decreased manifestations of schizophrenia.Decreased manifestations of schizoaffective disorder.

RATIONALEAcute treatment of schizoaffective disorder (as monotherapy or as adjunct to mood stabilizers and/or antidepressants).

Monitor patient's mental status (orientation, mood, behavior) before and periodically during therapy. Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression, especially during early therapy. Restrict amount of drug available to patient.Assess weight and BMI initially and throughout therapy.Monitor BP (sitting, standing, lying down) and pulse before and periodically during therapy. May cause prolonged QT interval, tachycardia, and orthostatic hypotension.Observe patient when administering medication to ensure that medication is actually swallowed and not hoarded or cheeked.Monitor patient for onset of extrapyramidal side effects (akathisia restlessnessdystonia muscle spasms and twisting motions; or pseudoparkinsonism mask-like face, rigidity, tremors, drooling, shuffling gait, dysphagia). Report these symptoms; reduction of dose or discontinuation of medication may be necessary.Monitor for tardive dyskinesia (involuntary rhythmic movement of mouth, face, and extremities). Report immediately; may be irreversible.Monitor for development of neuroleptic malignant syndrome (fever, respiratory distress, tachycardia, seizures, diaphoresis, hypertension or hypotension, pallor, tiredness). Discontinue paliperidone and notify health care professional immediately if these symptoms occur.Monitor for symptoms related to hyperprolactinemia (menstrual abnormalities, galactorrhea, sexual dysfunction).Lab Test Considerations: Monitor fasting blood glucose and cholesterol levels before and periodically during therapy.Monitor serum prolactin prior to and periodically during therapy. May cause serum prolactin levels.Monitor CBC frequently during initial months of therapy in patients with pre-existing or history of low WBC. May cause leukopenia, neutropenia, or agranulocytosis. Discontinue therapy if this occurs.

DOCUSATE240mgprnPOprn qdLaxative, stool softner

ACTIONPromotes incorporation of water into stool, resulting in softer fecal mass.May also promote electrolyte and water secretion into the colon.Therapeutic Effect(s):Softening and passage of stool.

RATIONALEPrevention of constipation, soften stool

Assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function.Assess color, consistency, and amount of stool produced.

IV SolutionRate (drops/minute)Titration LML/hrAccess PortPump/Type

n/an/an/an/an/a

n/an/an/an/an/a

n/an/an/an/an/a

n/an/an/an/an/a

May use back for more space!!

NEUROSENSORYBest Response to Auditory Hand Grip:Eye Movement:Pupils:

and/or Visual StimulusEqualNormalRight:

Age over 2 years (child/adult)Unequaln/aNystagmusn/aSize:3

Orientation (5)Weaknessn/aStrabismusn/aReaction:1

Confused (4)n/aRightn/aOthern/a

Inappropriate words (3)Leftn/aMood/Affect:Left:

Incomprehensible words (2)n/aMuscle Tone:Happyn/aSize:3

None: (1)n/aNormalContentn/aReaction:1

Age 2 years and under (infant)Archingn/aQuietn/a

Smiles, Listens, Follows (5)n/aSpasticn/aWithdrawnn/aCODE

Cries, consolable (4)n/aFlaccidn/aSadn/a7 mm

6 mm

5 mm

4 mm

3 mm

2 mm

1 mm

Inappropriate persistent cry (3)n/aWeakn/aFlatn/a

Agitated, restless (2)n/aDecorticaten/aHostile

No Response (1)n/aDecebraten/aFontanel/Window:n/a

Eyes OpenOthern/a(pertaining to infant)n/a

Spontaneously (4)LOC:Softn/a

To speech (3)n/aAlert/Orientedn/aFlatn/a

To pain (2)n/aSleepyn/aSunkenn/a

No response (1)n/aIrritableTensen/a

Best Motor ResponseComatosen/aBulgingn/a

Obeys Commands (6)n/aDisorientedn/aClosedn/a

Localizes pain (5)n/aLethargicn/aOthern/a

Flexion Withdrawal (4)n/aAwake

Flection Abnormal (3)n/aSleepingn/a

Extension (2)n/aDrowsyn/a

None (1)n/aAgitatedn/a

COMA SCALE TOTAL:12

Related Dx. Studies (lab work, x-rays, etc):n/a

Collaborative Care Referral: n/a

Related NSG Dx:Anxiety r/t unconscious conflict with reality AEB impaired attention.

CARDIOVASCULARSkin Color:COMMENTSn/aEdema:COMMENTS+2 pitting edema to right arm.

NormalNon/a

Flushesn/aYes

Palen/aChest Pain:

Cyanoticn/aNo

Heart Sounds:Yesn/a

NormalPn/a

Other, Describen/aQn/a

Apical Pulse Rate:n/aRn/a

Regularn/aSn/a

Irregularn/aTn/a

Pacemaker:Family Cardiac

Typen/aHistory:

Raten/aNo

Peripheral Pulses:Yesn/a

PresentTelemetry Monitor

EqualNo

Weakn/aYesn/a

Absentn/aRhythmn/a

Monitor, Lines, & Data:n/a

Related Dx. Studies (lab work, x-rays, etc):HGB: 13.8, HCT: 25.3, Platelets: 214,000

Related NSG Dx: Knowledge deficit r/t lithium adverse effect AEB patient reporting unknown cause of palpitations.

Collaborative Care Referral: RC: hyperlipidemia.

PULMONARYRespirations:Cough:O2 at homeNoAuscultation: (clear, crackles, rhonchi,

Rate18NoneChest expansionn/awheezing)AnteriorPosterior

RegularProductiven/aSymmetrical

Irregularn/aNonproductiven/aAsymmetricaln/aRt. Upper Loben/an/a

SOBn/aDescriben/aExplainn/aLeft Upper Loben/an/a

Dyspnea onn/aRt. Lower Loben/an/a

Exertionn/aLeft Lower Loben/an/a

Devices:n/a

Related Dx. Studies (lab work, x-rays, etc):n/a

Related NSG Dx:Ineffective breathing pattern r/t medication regimen AEB patient taking Seroquel

Collaborative Care Referral: n/a

GASTROINTESTINALAbdomen:STOOL:Diarrhea:n/aWeight Fluctuation

Softn/a# BMs/day1Constipation:Last 6 monthsn/a

Rigidn/aLast BM2/2/15Other: Obesen/apounds (+ -)n/a

Non-tendern/aAmountn/aThinn/aIdeal weight for

Tendern/aFormedEmaciatedn/asex and age:142 or less

DistendedLoosen/aNourishedn/aPresent weight149

Bowel Sounds:Liquidn/a*******Nutrition:Overweight7(lbs)

Present [P] /PMucusn/aRefer to dieticianUnderweightn/a(lbs)

Absent [A]n/aOstomyn/aif available

RUQPType

RLQPIncontinentn/aTube feedingn/a

LUQPStool Color:Chewing Problemn/a

LLQPBrownSwallowingn/a

HypoactiveBlackn/aProblemn/a

Hyperactiven/aRed Tingedn/aNausea/Vomitingn/a

Bloodyn/aPoor Appetiten/a

Devices:n/a

Related Dx. Studies (lab work, x-rays, etc):n/a

Collaborative Care Referral: RC: hyperlipidemia.

Related NSG Dx:Constipation r/t medication regimen AEB verbalize fear of pain while defecating, inadequate fluid intake, and side effects of lorazepam and seroquel

GENITOURINARY / REPRODUCTIVEBladder Habits:n/aLast voidLMP:n/aPregnancies:

Frequency:Color of urineStraw yellowIf any problemn/aPregnantn/a

Dysurian/aAmountSufficientDescriben/aWeeksn/a

Nocturian/aAppearanceClear n/aGravida/Paran/a

Urgencyn/aFluid & Electrolytes5 cups n/aDate of last:

Hematurian/aTotal Shift Intake5 cupsLast Pap Smearn/aProstate Examn/a

Retentionn/aPrevious 24 hrs5 cupsResultsn/aTesticular n/a

Burningn/aTotal Shift Output5 cupsBreast self examn/aself-examn/a

IncontinencePrevious 24 hrs5 cupsUse ofn/a

Daytimen/aCathetercontraceptivesn/a

Nighttimen/aIntermittentn/aType n/a

Stressn/aIndwellingn/aVaginal Dischargen/a

Incontinencen/aCondom-cath.n/aDescribe: n/a

Occasionaln/aDialysis:n/a

Other n/aAccess Site n/aBleeding:n/a

Amount:n/a

Comments:n/a

Devices:n/a

Related Dx. Studies (lab work, x-rays, etc):Urine culture 7/14/15 Negative for UTI. No growth at