Hi! Please follow the following instructions for this care plan:
This is a psychiatric care plan and attached you will find the template in which you have to answer in, there is rubric by which everything has to be followed, and a document with ways to describe the Mental Health Assessment portion. There is also an example of what it should look like
This is the information to be used:
42 yrs old, male, came into the hospital for voluntary admission for suicidal ideation due to auditory hallicinations that were telling him to harm himself. History of substance use, dependency on (Flakka) and marijuana. Diagnosis: Schizophrenia . Allergies: none. Support System: both parents (mom and dad) (live in another state). Has 6 siblings (3 from the dad side and 3 from the mom side). Occupation: none. Single. Highest grade completed: high school. Weight: 180 lbs. Health insurance: N/A. Significant primary caregiver: the mother. Language: english.
For diagnostic results: Put the mini mental exam results which is 30 . Put EKG :normal sinus rhythm detected with possible left atrial enlargement.
Surgical Procedures: N/A
Past Health history: include the following psych and regular past history: say that the client stated that she was receiving psychiatric therapy and has a history of rhabdomyolysis with a history of a seizure at 2 years old”. Write that she has a past of anxiety attacks. Patient has a history of acute rhabdomyolysis .
History of Present Illness: Write about how the client has a history of schizophrenia and had an episode of suicidal ideation. Has a history of substance use, dpendency on (Flakka), depression, anxiety, hallicinations. Explain how the pt was seen at another hospital and was in the ED for auditory hallucinations and suicidal hallucinations 2 days ago.
For the Mental Health Assessment: You can use the attached document for tips on how to write it. Make sure this is detailed please.
Some abnormal things to include for this assessment (include the normal things yourself please) these are key points:
Put somehere that the pt reports agitation, anxiety, insomnia, auditory hallucinations, denies depression.
Appearance: poor eye contact, lethargic.
Speech: slowed rate, low volume.
Mood affect: depressed constricted affect
Thought content: paranoid
Suicidality: eveidence of suicidal intent but no homicidial ideation.
For patho, use the diagnosis and describe it using APA 7th edition with in text citations.
Baseline and Current Vital Signs: BP: 141/87, Pulse: 74, RR:18, SPO2, 98%.
Allergies: none
Diet with rationale: Regular diet because they have no limitations to their diet. explain a little more.
Activity Order: suicide risk, Limitations: N/A
For labs, use the following (APA CITATIONS TOO FOR RATIONALE) put the unit as well for each
Creatinine 1.48 (explain how this is relevant to the medication used which risperdone and explain why its important to check it.)
Calcium 8.0 (explain how this is relevant to the med used which is risperdone and explain why its important to check it)
BUN: 26 (explain how this is relevant to the med used which is ativan and explain why its important to check it)
Hgb: 11 and Hct: 35 (explain how this is relevant to the med used which is risperdone and explain why its important to check it)
For IVs: N/A do not put anything in this section, just delete it
For Medications, Include the following:
Risperidone, ativan, cogentin, haldol, and benadryl. Make sure to follow the instructions as stated on the top of column. Make sure to be specific and detailed. Make sure to use in text citation in APA format for rationale, therapeutic range, and nursing implications. please include the therapeutic range. make sure to include generic and brand names.
For nursing theorists, must find the theory use at least 2, and explain it using APA in- text citations.
For the 3 Nursing Diagnosis, MUST USE NANDA #1.
Make sure the first diagnosis put on the list is the one that exemplifies that safety of the client such as suicidal ideation in this case. When describing the rationale of importance, make sure it is APA citation.
NOW:
When explaining the nursing diagnosis with the goals sections, follow these instructions and the ones on the sample.
– Make sure to write all three nursing diagnosis, but only dive into the most important one and write one short term goal with one long term goals and 3 interventions per goal and a rationale per intervention. YOU MUST TAKE INTO ACCOUNT CULTURAL CONSIDERATIONS.
nursing interventions must have the person completing it, the action, frequency and what’s the role of the nurse. cultural considerations and mention the suicide hotline for the discharge teaching. make sure to use credible sources. make sure to use in text when necessary as well. thank you
– for subjective and objective data, info may be made up.
-Expected outcomes must be realistic and measurable. please make sure that each goal has 3 interventions. Nursing interventions must state action, frequency and person who is going to carry these out. Patient’s cultural, developmental and psychosocial status must be considered in nursing interventions
For the discharge plan, include how you will educate the client and the family among other things.
FOR THE GENOGRAM COMPUTED AT THE END:
MUST CONSIST OF PAST 2 GENERATIONS. MAKEUP THAT THE GRANDMA ON THE MOM’S SIDE HAS A HISTORY OF ANXIETY/DEPRESSION. see if this can be computer generated.
Make sure this has a reference page at the end with all the references!!!Please make sure it sounds complete and realistic
Thank you!!Please make sure its well organized and you adhere to my instructions, thank you. Please make sure its well detailed with no grammatical errors.
MAKE SURE YOU USE CREDIBLE SCHOLARY SOURCES
