School

of Nursing

Mental Health Nursing Plan of Care

Student Name Harpreet Kaur Date of care 04/28/14 Legal Status 5150 DTS

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Admitting Diagnosis Depressed mood with recurrent attempt

DSM IV: Axis I Major Depression Disorder. Alcohol use in partial remission. Mild cognitive impairment Axis II None Axis III As per
medical history

Axis IV Limited social support, homeless Axis V 50/50

Patients Initials DM Gender F Age 59 Education Level Associates degree of college education

Admitting Date 4/07/14 Vital Signs: T 98.5 R 18 P 94 B/P 116/68 O2 SATS Not taken

Precautions: Suicide Q15 min checks, Suicide risk assessments Homicide N/A

Past Medical/Surgical History (1) status post left temporal injury secondary to gunshot wound. (2) Hypercholesterolemia. (3) Chronic
Back pain due to vertebral deformity.

Past Psychiatric Hospitalizations once for depressed mood through she denied suicidal attempt to current admission.

Use of Alcohol/Drugs (type, frequency, duration) Abuse Alcohol throughout adult life. Abstain for 5 months due to AA. At peak, she was drinking
a bottle of vodka daily. Has hx of withdrawal tremors and multiple failed attempt at abstaining.

Spiritual Assessment Christian Cultural Assessment Caucasian Primary Language English

Pain Assessment scale 0 10 Pt. Denied Location of pain N/A Rx or other for pain N/A
Family History (mental health, ETOH/drug abuse, spouse neglect) Alcoholism in parents and grandparents on both maternal and paternal sides.
Psych Testing Date: N/A Result: N/A
Date

Lab Value

04/05/14 Valproic
Acid Level
04/08/14 BUN
04/08/14 Creatinine
04/08/14 ALT
04/08/14 AST
04/08/14 TSH

Patient Value

Normal Value

30.4

(50 100)

9
0.7
11
17
4.710

(6-20)
(0.7 1.2)
(0-33)
(0 35)
(0.46 4.89)

Nursing Implications

- Tested for Depakote administration.

- Dosage of Depakote may need to be adjusted.
- May increase with Acyclovir
- May increase with Acyclovir
- May increase with Cymbalta
- May increase with Cymbalta
- WNL
- Watch for symptoms of hypothyroidism such as fatigue, weakness,
lethargy, dry skin, intolerance to cold, brittle nails, and yellowish tint to

School

04/08/14 WBC

5.8

of Nursing

(4 -11)

Mental Health Nursing Plan of Care

skin.
- Provide extra clothing or blankets.
- Monitor physical and mental status.
- Gabapentin and Ziprasidone may cause leukopenia.

**ALLERGIES: NKDA
Medication
Name

Route/Ti
me

Effects of Rx on
Symptoms

Side Effects

Nursing Implications

Generic & Trade

Name

Acyclovir
(Zorivax)

400 mg =
2 cap.
Oral BID

Interferes with viral

DNA synthesis.

SEIZURES, dizziness, headache,

diarrhea, nausea, vomiting,
RENAL FAILURE, STEVENSJOHNSON SYNDROME, pain,
phlebitis

- Assess lesions before and daily during therapy.

- Monitor BUN, serum creatinine, and CCr before and during therapy.
BUN and serum creatinine levels or CCr may indicate renal failure.
- Instruct women with genital herpes to have yearly Papanicolaou smears
because they may be more likely to develop cervical cancer.

500 mg =
1 tab
Oral Q
Evening

Increase levels of
GABA, an inhibitory
neurotransmitter in the
CNS.

Suicidal thoughts, agitiation,

dizziness, headache, insomnia,
sadation, visual disturbances,
HEPATOTOXICITY,
PANCREATITIS, abdominal
pain, anorexia, diarrhea,
indigestion, nausea, vomiting,
HYPERAMMONEMIA,
HYPOTHERMIA, tremor

60 mg = 1
tab. Oral
daily.

Inhibits serotonin and

norepinephrine reuptake
in the CNS. Both
antidepressant and pain
inhibition are centrally
mediated.

NEUROLEPTIC MALIGNANT
SYNDROME, SEIZURES,
SUICIDAL THOUGHTS,
fatigue, drowsiness, insomnia,
HEPATOTOXICITY, appetite,
constipation, dry mouth, nausea,
dysuria, ERYTHEMA
MULTIFORME, STEVENSJOHNSON SYNDROME,
SEROTONIN SYNDROME

600 mg =
1 tab. Oral
BID

Mechanism of action is
not known. May affect
transport of amino acids
across and stabilize
neuronal membranes.

SUICIDAL THOUGHTS,
confusion, depression, dizziness,
drowsiness,
RHABDOMYOLYSIS, ataxia,
MULTI-ORGAN

- Assess mood, ideation, and behavior frequently.

- May cause drowsiness or dizziness.
- Advise patient and family to notify health care professional if thoughts about
suicide or dying, attempts to commit suicide; new or worse depression; new or
worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping;
new or worse irritability; acting aggressive; being angry or violent; acting on
dangerous impulses; an extreme increase in activity and talking, other unusual
changes in behavior or mood occur.
- Advise patient to notify health care professional if anorexia, abdominal pain,
severe nausea and vomiting, yellow skin or eyes, fever, sore throat, malaise,
weakness, facial edema, lethargy, unusual bleeding or bruising, pregnancy, or
loss of seizure control occurs.
- Monitor BP before and periodically during therapy. Sustained hypertension
may be dose related; decrease dose or discontinue therapy if this occurs.
- Assess for serotonin syndrome (mental changes [agitation, hallucinations,
coma], autonomic instability [tachycardia, labile BP, hyperthermia],
neuromuscular aberrations [hyperreflexia, incoordination], and/or GI symptoms
[nausea, vomiting, diarrhea]), especially in patients taking other serotonergic
drugs (SSRIs, SNRIs, triptans).
- Assess mental status (orientation, mood, and behavior). Inform health care
professional if patient demonstrates significant increase in anxiety, nervousness,
or insomnia.
- May cause ALT, AST, bilirubin, CPK, and alkaline phosphatase.
- Monitor closely for notable changes in behavior that could indicate the
emergence or worsening of suicidal thoughts or behavior or depression.
- May cause leukopenia.
- Advise patient and family to notify health care professional if thoughts about
suicide or dying, attempts to commit suicide; new or worse depression; new or

Antiviral

Depakote
(Valproic Acid)
Anticonvulsants

Duloxetine
(Cymbalta)
Antidepressants

Gabapentin
(Neurontin)
Anticonvulsants

School

of Nursing

HYPERSENSITIVITY
REACTIONS
Simvastatin
(Zocor)
Lipid lowering
Agents

Ziprasidone
(Geodon)

10 mg = 1
tab. Oral
Q
Bedtime

80 mg = 1
cap Oral
Q
Bedtime

Antipsychotics

Inhibits 3-hydroxy-3methylglutarylcoenzyme A (HMGCoA) reductase, an

enzyme which is
responsible for
catalyzing an early step
in the synthesis of
cholesterol.
Effects probably
mediated by antagonism
of dopamine type 2 (D2)
and serotonin type 2 (5HT2). Also antagonizes
2 adrenergic receptors.

abdominal cramps, constipation,

diarrhea, flatus, heartburn,
rashes, RHABDOMYOLYSIS,

NEUROLEPTIC MALIGNANT
SYNDROME, seizures,
dizziness, drowsiness,
restlessness, PROLONGED QT
INTERVAL, constipation,
diarrhea, nausea,
AGRANULOCYTOSIS

Mental Health Nursing Plan of Care

worse anxiety; feeling very agitated or restless; panic attacks; trouble sleeping;
new or worse irritability; acting aggressive; being angry or violent; acting on
dangerous impulses; an extreme increase in activity and talking, other unusual
changes in behavior or mood occur.
- Monitor liver function tests prior to initiation of therapy and as clinically
indicated. If symptoms of serious liver injury, hyperbilirubinemia, or
jaundice occur, discontinue simvastatin and do not restart. May also cause
alkaline phosphatase and bilirubin levels.
- Instruct patient to notify health care professional if unexplained muscle pain,
tenderness, or weakness occurs, especially if accompanied by fever or malaise.

- Monitor patient's mental status (orientation, mood, behavior) prior to and

periodically during therapy.
- Assess for rash during therapy. May be treated with antihistamines or
corticosteroids. Usually resolves upon discontinuation of ziprasidone.
Medication should be discontinued if no alternative etiology for rash is found
- 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.
- Advise patient to change positions slowly to minimize orthostatic hypotension.

THERAPEUTIC NURSING MANAGEMENT

Problem Identification

Planned Interventions

Evaluations of Interventions

Environment
1) Risk for suicide r/t
history of previous
suicide attempt and
depression

- Pt. Denied any suicidal thoughts.

- Ask client directly: Have you thought about harming yourself in any way? If so, what do you plan to do? Do
- No harmful objects are present in
you have the means to carry out this plan?
the patients room.
- Create a safe environment for the client. Remove all potentially harmful objects from clients access (sharp
- Conducted Q15 min checks.
objects, straps, belts, ties, glass items). Supervise closely during meals and medication administration. Perform
- Pt. is not hoarding or cheeking
room searches as deemed necessary
medications.
- Formulate a short-term verbal or written contract with the client that he or she will not harm self during
specific time period. When that contract expires, make another, and so forth.
- Pt. verbalized desired goals to
accomplish after discharge.
- Maintain close observation of client. Depending on level of suicide precaution, provide one-to-one contact,
constant visual observation, or every-15-minute checks.
- Maintain special care in administration of medications.
- Encourage verbalizations of honest feelings. Through exploration and discussion, help client to identify
symbols of hope in his or her life.
Psychopharmacological treatment (Administer Rx, teach, monitor response)
- Pt. expressed motivation to learn.
1) Knowledge deficit
- Assess motivation and willingness of patient and caregivers to learn.
- Pt. speaks fluent English; thus, she is able to learn
r/t medication
- Assess ability to learn or perform desired health-related care.
about the medications.
administration as
- Identify any existing misconceptions regarding material to be taught.
- Pt. did not show any misconception about the material
evidenced by
- Provide physical comfort for the learner.
to be taught.
incorrect
- Provide instruction for specific topics.
- Pt. did not show any signs of discomfort.
verbalization of
- Refer patient to support groups as needed.
Gabapentins effects.
- Pace the instruction and keep sessions short. Kept the instruction short.

School

of Nursing

Mental Health Nursing Plan of Care

Psychological/Social Treatment (Individual, family, group therapy, etc)

1) Ineffective coping
r/t inadequate
support systems as
evidenced by
alteration in societal
participation

- Assess for presence of defining characteristics

- Provide opportunities to express concerns, fears, feelings, and expectations.
- Explore with client alternative ways of handling frustration that would be most suited to his or her
lifestyle. Provide support and positive feedback to client as new coping strategies are tried. Convey
feeling of acceptance and understanding. Avoid false reassurances.
- Do not debate, argue, rationalize, or bargain with client.
- Point out signs of positive progress or change.

- Pt. verbalized that she will try to socialize more with

people.

Physical Health
1) N/A

Patient Teaching
1) See above