Disorder
Analysis Project:
Subject: A case study of a Psychiatric Mental Health
client in an acute care psychiatric hospital with a Major Psychiatric Disorder.
Sources of information: direct interview of client, personal
observation, medical record of client.
Purpose: to inform the reader of a comprehensive case
study pertaining to a particular psychiatric diagnosis and the basis for
nursing care plan.
Document design: cover page, font size 12, APA style format (7th
ed.). The paper must have an
introduction and conclusion. Use a table format for the care plan and
medications but everything else should be written as a formal APA paper.
Length: approximately 12-15 pages
(Points will be subtracted for longer papers)
Guidelines
Body of the paper to
include these areas:
Introduction to the paper
Demographic information: age, sex, religion, cultural
background, marital status, children, and arrangement of residence.
History of psychiatric illness: Date of first diagnosis, number of previous
hospital admissions, treatments offered in past, reason for current hospital
admission and circumstances surrounding admission. Determine if a client’s
medical diagnosis is caused by their psychiatric diagnosis, or vice-versa.
Psychiatric Diagnosis: DSM-5. Include the mental illness diagnosis, medical diagnosis and
stressors. Include the symptoms as they appear in your client. Compare and
contrast these symptoms with the diagnosis from the DSM-5.
Psychotropic
medications: List each psychotropic medication the dosage and frequency
that the patient is receiving in the hospital. Identify the classification of
the medication and explain why it is being given. Include both brand name and
generic name. Describe the action of the medication, effect of the medication,
side effects, drug interaction, therapeutic level and/or usual dosage, and the
nursing care of the client when administering/monitoring the medication. If
your patient is taking a medication that requires monitoring of a serum level,
describe the levels and the implications of those levels. If there is a “black box warning” for the medication that you should be
monitoring, include that in your information. Use references throughout your
paper to support your statements.
Nursing
Management of the Disorder (Care Plan): Do in a table format
Write a
problem list of at least 5 problems that can be managed by nursing. It would not be appropriate to use medical
diagnosis in this section. From the
identified problem list select 2 problems that are mental health related and
write 2 plans of care.
Each
of the two nursing problems should be written as a nursing diagnosis using NANDA
approved diagnosis. Each Nursing Diagnosis will have 2 long-term goals and 2
short term goals that are measurable and reasonable for the problems.
Each
goal will have 2 nursing interventions that are evidenced based with rationale/citations. Always select goals and interventions that
focus on the client as if you were to continue working with them for a week or
more.
Include
what would be the expected outcome for the interventions. If you actually had the chance to discuss the
treatment with your patient add this to your paper i.e. feedback from the
patient, how the plan was changed etc. Do not rely on the care plan in the
patient’s chart for this section. Write
your own care plan.
Conclusion at the end of the paper that summarizes what you
learned from this patient-student nurse interaction. Include information such as: actual discharge
state of patient if possible, how the patient responded to your care plan, what
your take-away from this clinical experience etc.
Reference page and in text citations in APA 7th
edition format.
