Can you check my psych care plan please?

Little_Bear2013 · Nov 28, 2014

Also, would risk for injury r/t methamphetamine withdrawal apply as well? I think if I recall he's been free from meth use for at least 6 months now.

Esme12, ASN, BSN, RN · Nov 28, 2014

I am no good in psych....no my speciality. It looks good to me. I wouldn't think meth withdrawal applies as he has been off meth. I'm going to move this to psych where you will get better responses

Whispera, MSN, RN · Nov 29, 2014

I'll put my thoughts in bold after yours. I'm a psych nursing professor, and assume things are done in the same way, where I teach as where you learn. I could be incorrect, so don't take my thoughts as gospel:

Diagnosis: For each of these, do you have evidence within your assessment? if not, don't use them.

- Axis I: Psychosis NOS; r/o substance induced psychosis, schizophrenia, schizoaffective, or nicotine abuse

- Axis II: None

- Axis III: History of seizure disorder and head trauma

- Axis IV: Legal and social stressors What are the stressors specifically? Some schools require more details than you've given.

- Axis V: 40

NANDA's: Again, you must have evidence for each of these in your assessment, or don't use them.

1.) Risk for self-directed violence r/t:

- auditory hallucinations

- daily meth use

- Poor insight judgement call...what indicates he has poor insight?

2.) Ineffective How do you know it's ineffective? Maybe it's working just fine for him. denial r/t threat of unpleasant reality what unpleasant reality? AMB: AMB? What's M? I'm used to AEB (as evidenced by).

- Client made dismissive judgemental--what indicates he was dismissive? comment about how family personally thanked him for letting their mother die when he worked as a graduate nurse

- Client doesn't seem to understand the severity of his situation he's in evidence?

- Client has failed to register as a sex offender 3 times

- Client stated, "I believe my charges will be dropped due to a lack of evidence"

3.) Disturbed sensory perception r/t biochemical imbalance AMB:

- Client states he has auditory hallucinations of a woman trying to tell him something

- Client has a long history of meth abuse

- On Zyprexa for auditory hallucinations

4.) Anxiety r/t overwhelming life stressors AMB:

- Client stated he's worried about his new debit card not coming in before he's discharged

- Client very preoccupied with debit card

- Client projects blame more details?

- Client appears jittery

- Meth abuse

- Financial concerns of girlfriend and mother stealing his money

5.) Dysfunctional family processes r/t inadequate coping skills AMB: ??????? Does this one apply to the data??????? To what data? I'm unsure where you're going with this one.

- Family history of using, selling, and making meth

- Blamed mother for stealing money

- Client stated he's married but doesn't know who she is He doesn't know who his wife is? This is more than dysfunctional family process.

- Client was neglected and sexually abused as a child

6.) Defensive coping r/t uncertainty about what? AMB:

- Client projects blame that others installed Mediaographic images onto computer

- Client gets defensive when asked about charges

- Client denies how Mediaographic images got onto his computer This and the first seem to be pretty similar.

7.) Ineffective coping r/t use of substances to cope with life events AMB:

- Client stated he's used meth on a daily basis since 1997

- Client stated he used meth on occasion as an adolescence to help with school stress

I agree that he's past the risk for injury diagnosis.

TriciaJ, RN · Nov 29, 2014

I agree with Whispera. Many of the nursing diagnoses are not backed by sufficient evidence. One part that jumped out was that he was in denial about how Mediaographic images got into his computer. He may be in denial, he may be lying through his teeth, or he may genuinely not know how the images got there. This one needs a jury to sort out, not a nurse.

Are you sure he doesn't meet any criteria for an Axis II diagnosis? Some of the behaviours you describe could match some Axis II traits. Good luck.

Little_Bear2013 · Dec 15, 2014

Sorry everyone that I didn't get back to this thread and didn't initial provide enough information for you all to help me further, unfortunately I was on a time crunch when I posted these. But long story short, I passed the class and clinical but thank you for all the help everyone, I did definitely take all the tips and advice to heart and looked over this set of clinical paperwork like a hawk before turning it in :).