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Discussion

care plan help please

Hi I'm very new to this so I am very sorry if I'm posting under the wrong forum or topic. I had a question regarding a denial care plan. I'm working on my Folstein worksheet for Psych. I need a 3 part statement for my nursing diagnosis. I feel like this should be easy by now but am unsure of how to exactly word things together. So my patient was admitted for alcohol induced mood disorder. On admit she was intoxicated with alcohol and OD on approximately 6 pills of Wellbutrin. So i need a diagnosis based on how the patient was on day of my rotation. So the patient was oriented x4, cooperative, calm. She was willing to talk and overall seemed as she was good and ready to go. The only thing I could think of was denial (which is also what my instructor was hinting me to go with) since she was denying the attempt of suicide (she was on 5150 as danger to self with 2nd attempt of suicide). She denied she had overdosed and said shes only there because shes getting help for her drinking. (By the way this is in a psychiatric unit and pretty much all we are allowed to do is talk to the patients while their in the activities room). So I'm going with possibly ineffective denial but not sure of where to go from there. Any help would be really appreciated. Thank You.

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You would have to have your R/T and AEB in your statement. What is the denial related to? What is the evidence that she is in denial? Those should help you write your 3 part statement.

Ineffective coping? Do you have a NANDA-I?

You need your assessment to make a nursing diagnosis not the other way around. If your assessment days meets the diagnostic features (as evidenced by) and related factors (related to).

So what is your assessment of this patient? There are quite a few nursing diagnoses that apply to a patient with a mood disorder and suicide attempt.

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