Apologies in advance for the long novel but I wanted to give a brief & concise description of my patient.
I just had my Mental Health Clinical and am practicing on writing a problems list with diagnosis and then I have to pick one diagnosis for a care-plan. I think I am making it more difficult than it should but, that's because I push myself to learn more!
First half of this semester I was in Maternal Newborn Clinical Rotation and my instructor loved the diagnosis and care-plan that I typed up...Thanks with the help on Allnurses!!! Unfortunately it took me about 3 days to type it all up but fortunately my teacher loved it! With that being said, it should be a breeze for me to type up Mental Health...but it is/was not! I am not sure if I am satisfied with my diagnosis because I am still learning. Also, I don't know which 1 to focus on creating a care plan for.
Majority of the assignment is made-up (for practice) but the patient that I was dealing with for a brief moment is a...
39/F admitted for Benzo OD, daughter found her. Pt. has 4 kids (1 is sort of adopted), 23 F with 3 kids, 19 F in college, two 23 M (working and in school, one is adopted). Pt. takes care of the 23 year old and grand children in own home. Pt's home was foreclosed, resulting in the family having to move out and then (unknown reasons) was able to move back into the foreclosed home. Pt. c/o of having to reorganize and unpacking the items at home and is not ready to return to that and the responsibilities.
What led to the SA was after having an argument with her husband (not the father of the 3 kids), she pushed him, he pushed her back, she OD'd.
Diagnosed with anemia, MDD, and GAD.
Past history: first husband (father of children) was shot in the head 30+ times in front of their home in Puerto Rico (Pt. from there), she did not witness it, but the police showed her a picture for identification without any warnings...all she remembered was his teeth and his blood distorted face, but it was his teeth that she recognized. I'd say she was around her late teens or early twenties when it happened.
Also, her mother continues to ask her to visit her in Puerto Rico, but Pt. states "There is nothing for me to do there, everybody that I use to know is either dead or in jail. I have no one to visit. My mom was just in WI. visiting me, so i don't have to go see her."
In order by Priority (I will abbreviate some words just for here)
**1. Risk for injury R/T depression and anxiety AEB previous history of attempted suicide.
2. Imablanced nutrition less than body requirements R/T lack of interest in food AEB lost five-pounds in four days
3. Disturbed sleep pattern R/T stress AEB patient reported difficulty concentrating and functioning the following day because of interrupted sleep.
4. Grieving R/T recent home foreclosure AEB patient's statement "I just can't handle losing my home and having my children being unstable."
5. Low self-esteem R/T depression AEB patient feels like a failure
1. Knowledge deficit R/T constipation AEB patient statement (ps) "is it normal for me to not have to poop in four days?"
2. KD R/T medication compliance AEB ps "I take my medications whenever I can remember to take them. I don't even notice anything changing"
3. KD R/T stress management AEB ps "when I feel stressed, I just isolate myself, but it seems to make things worse for me."
4. KD R/T MDD AEB ps "I don't know what depression is. It's annoying because my doctor just tells me to take medications for it."
5. KD R/T GAD AEB Patient Statement (PS) "I don't know how to control my anxiety!"
I am leaning towards Risk for Injury as a care plan.
Thanks in advance in taking your time in reading this and giving your input. I want to make sure I am well prepared at comprehending and creating care plans