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mental health care plan PLEASE HELP CARE PLAN DUE MONDAY!

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hey! im trying to figure out the priority of my nursing diagnosis for my patient. patient is a 50 year old female admitted with major depressive disorder. she also has anxiety and is bipolar. she came into the ER because of attempting suicide by taking a bottle of xanax. her husband found her in her bedroom and took her to the ER. there's a history of depression in her family. patient was also an LPN in a nursing home and recently became the nurse manager and got overally stressed from her job and broke down. she also said shes not eating well and eats 50% or less of her meals. these are the nursing diagnosis i have come up with in priority order and im not sure if i have them right. i have so many risks that seem to be top priority but im not sure if its ok to put risks before regular diagnosis.

1.) Imbalanced nutrition less than body requirements r/t psychological factors aeb reported food intake less than RDA recommendations.

2.) Risk for constipation r/t depression, changes in usual eating pattern and use of pharmacological agents.

3.) Risk for impaired skin integrity r/t altered nutritional status, poor physical condition and being inactive.

4.) Risk for suicide r/t history of prior suicide attempt, depression, hopelessness and helplessness. ( now i would think this would be one of the top priorities but i put nutrition first because to me thats physiological but am i wrong??)

5.) Risk for injury r/t malnutrition and cognitive factors.

6.) Risk for falls r/t diminished mental status, taking antianxiety and antidepressant agents.

7.) Fatigue r/t disease state aeb verbalization of an overwhelming lack of energy.

8.) Chronic low self esteem r/t repeated unmet expectations aeb expresses shame that she could not handle job as an lpn.

9.) hopelesness r/t deteriorating physiological condition aeb pt states "i feel like i have no reason to get up in the morning" and has a flat effect expression.

10.)chronic sorrow r/t experienced mental illness aeb expresses negative feelings of sadness.

11.) Powerlessness r/t illness or lifestyles of helplessness aeb expression of frustration over inaibility to handle being a nurse manager.

12.) stress overload r/t chronic mental illness aeb expresses difficulty in functioning.

13.)ineffective coping r/t situational crisis aeb attempted suicide.

14.)then there were anxiety and stress ones im still working on

also: my professor wants me to choose 3 top nursing diagnosis and then 5 other back up ones. PLEASE PLEASE HELP! which three are most important! thankyou!-roxy

truern

Specializes in Telemetry & Obs.

If she's dead it doesn't matter what she eats.

The patient already attempted suicide...has a history of depression and axiety and is bipolar. Have you researched bipolar disorder?

im confused by what you are saying. are u saying risk for suicide should come absolutely 1st? and yes i have researched bipolar disorder and i know all about it.

truern

Specializes in Telemetry & Obs.

That's my opinion. If the patient was admitted because of a suicide attempt that is her IMMEDIATE concern. The rest is immaterial if she happens to attempt again and be successful this time :(

She won't die from not eating enough for several days...heck if she's depressed good luck trying to get her to eat. She won't die (not anytime soon anyway) from constipation and skin integrity is the last of her worries. But she can danged well die from being successful at killing herself.

As always, jmho.

Edited to add: look at your #9. This patient is still a danger to herself!

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

i did sequence your diagnoses in the order of priority according to maslow. the exception is risk for suicide. people who have attempted suicide and are hospitalized for this are considered a danger to themselves until their doctors say they are not. that automatically makes them a risk for suicide and suicide precautions are put in effect. a nursing diagnosis reference should be consulted to make sure the correct related factors are matching up whenever a diagnosis is used and that you have correct evidence proving the existence of the problem.

  1. risk for suicide r/t history of prior suicide attempt, depression, hopelessness and helplessness. (need for safety)
    • i would not include depression (which sounds more like a medical diagnosis), hopelessness (which sounds like a judgment call) or helplessness (which also sounds like a judgment call) as risk factors. since its unlikely that hopelessness is going to make it to the list of diagnoses you will hand in, i would list the more severe symptoms of hopelessness as well as of depression or helplessness that might lead to suicide rather than use these terms. look at the risk factors for this diagnosis. they are pretty clear about what a suicidal person acts like.

[*]imbalanced nutrition: less than body requirements r/t psychological factors aeb reported food intake less than rda recommendations. (physiological need for food)

  • i realize this is a psych patient, but this is a physiological-based diagnosis. the related factor has to be why the patient isn't getting an intake of enough nutrients. so, as i read this statement i ask myself, "this patient isn't getting enough to eat because of psychological factors? what does that mean? i know it is listed in the taxonomy for this diagnosis, but can you be more specific with that? if her bipolar disease makes her up and leave her meals when she is manic then there needs to be a way to say that if it is one of her psychological factors. if you know she only eats 50% of her meals, that is not eating enough. it might be clearer (and easier) to say, "not ingesting enough food".
  • when i read reported food intake less than rda recommendations i can't help but think, "well, what was her food intake?" what follows "aeb" is the evidence that proves intake of nutrients insufficient to meet metabolic needs (the definition of this diagnosis). i'm thinking that if your instructor wants 8 diagnoses, she probably knows them pretty well and isn't going to settle for generic evidence. i would give her evidence that is as specific as i could get it. do you have a height and weight for this patient? if she is below her recommended weight for her height she is really imbalanced nutrition: less than body requirements.

[*]fatigue r/t disease state aeb verbalization of an overwhelming lack of energy. (physiological need for rest)

  • fatigue is actually a physiological need the body has for rest. what disease state did you have in mind here as the cause of her energy drain? the anxiety? if so, then nanda says you can say the word "anxiety". you can also say "stress". saying disease state leaves the reader (and your instructor) looking for more information.
  • are there any other symptoms that you observed of this fatigue?

[*]anxiety (safety need)

  • r/t situational crisis and stress in life
  • aeb helplessness and see: anxiety

[*]ineffective coping r/t situational crisis aeb attempted suicide. (coping)

  • suicide is a diagnosis and judgment. say "destructive behavior towards self" or something similar. she also did this because of "inability to deal with job stress" or something like that from what i gathered. that's important information to target because if that isn't addressed she goes back to work without skills to handle that kind of stress and still doesn't know how to cope with it.

[*]chronic sorrow r/t experienced mental illness aeb expresses negative feelings of sadness. (coping)

  • chronic sorrow is something that has been going on for more than 6 months, so the related factor (cause of it) also needs to be there to keep it going. experienced mental illness just doesn't sound right to me. the definition of this diagnosis states that this response exists in response to a loss, throughout a long illness or a disability. saying experienced mental illness doesn't convey that. is it possible that she is in sorrow over the loss of her previous job as a staff nurse. when she was promoted she, in effect, lost the old job. maybe she saw no other way to get it back. you did say that she broke down at work, right?
  • what are negative feelings of sadness? why not just say "expresses feelings of sadness"?

[*]stress overload r/t chronic mental illness aeb expresses difficulty in functioning. (coping)

  • the related factors for this diagnosis needs to be a type of threat or demand that is causing, or is the reason, for the stress to build up. you can't blame it on chronic mental illness.
  • now, never when i sit down and talk to someone do they say to me, "i have difficulty in functioning." what, specifically, are the problems? write them out as the patient told you about them.

[*]hopelessness r/t deteriorating physiological condition aeb pt states "i feel like i have no reason to get up in the morning" and has a flat effect expression. (self-perception)

  • what deteriorating physiological condition does she have? this refers to people who are about to die of a fatal disease (cancer, severe chf, aids). depression, anxiety and bipolar are not deteriorating physiological conditions. i can see where she might feel "abandoned" or "stressed".
  • good evidence.

[*]powerlessness r/t illness or lifestyles of helplessness aeb expression of frustration over inaibility to handle being a nurse manager. (self-perception)

  • powerlessness is a behavior. there is no illness causing her to be powerless. just remove that part from the related factor.

[*]chronic low self esteem r/t repeated unmet expectations aeb expresses shame that she could not handle job as an lpn. (self-esteem)

  • first of all, is this a correct diagnosis? to be a chronic problem, it needs to be present for 6 months or more. you are specifically targeting her "job as an lpn". is that right? not the supervision job?
  • secondly, are these repeated unmet expectations specifically job related? the reason i ask is because your piece of evidence is related to her job. if this is about her job then i would restate the related factor as "unmet job expectations". you don't have to use the word repeated.
  • can you provide examples of what she did and how she express(ed) shame that she could not handle job as an lpn? that would really explain the unmet job expectations and explain some of her shame. basically, it sounds to me like she is giving a self-evaluation of herself as a lpn and it isn't a good one.
  • if this is about her as an lpn then it is chronic low self-esteem; if this is about her in this current job then it is more likely just low self-esteem.

all "risk for" diagnoses are anticipated problems rather than actual problems and go to the bottom of the list.

risk for constipation r/t depression, changes in usual eating pattern and use of pharmacological agents.

risk for impaired skin integrity r/t altered nutritional status, poor physical condition and being inactive.

risk for injury r/t malnutrition and cognitive factors.

what cognitive factors???

risk for falls r/t diminished mental status, taking antianxiety and antidepressant agents.

thankyou so much for helping me! i cant thank you enough! u gave me alot of good information!!! your a lifesaver! : )

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

Good luck with your care plan. For the record, I was primarily a med/surg nurse and all this psychosocial stuff makes me nervous. I had one very memorable patient in the ICU who was admitted because she tried to commit suicide. It was awful. It was easier to focus on her physical problems and because she was in ICU I could do that. Do you know she came up to me a few years later in a store when I was shopping to thank me for saving her?!! I cried for the rest of that day. All I could remember doing for her was telling her that time would change her perspective of the situation (her boyfriend had dumped her, so she downed her mom's bottle of Valium). She was distraught and kept saying she wanted to die the night I took care of her.

RochesterRN-BSN, BSN, RN

Specializes in Psych, ER, Resp/Med, LTC, Education. Has 6 years experience.

PATIENT safety is ALWAYS first, ALWAYS. Think about it. That is the main reason this patient was admitted. All the other stuff is secondary. I work in psych ER where the nurses are the primary evaluators of patients and are a huge part of the decision of if a patient should be admitted or not and honestly a patient can be a hot mess but if not an immediate risk of harm to himself or others we generally will discharge with Partial Hospitalization or outpatient treatment. So the MOST IMPORTANT reason this patient is there is to keep her safe-- Continuious, ATC monitoring for safety, supportive and safe environment--the physical environment as well as the human contacts with all staff. So yes.....always make safety your first priority.

Looks like you got some good stuff from the last poster--

and keep in mind that bipolar patients can be especially at risk if they are rapidlly cycling-- though when depressed they may be suicidal they often don't have the energy to follow through on those thoughts so it kind of sits as a passive suicidality-- however mania can be a catalyst to move the patient from passive to active SI as think about it....they have the energy now, and are generally very impulsive. HUGE risk now for harm to self. Also if you have a patient with a Dx of Bipolar with psychotic features this psychosis part can be a possible catalyst as well-- say if the patient has CAH (Command Auditory Hallucinations) that tell him/her to harm self or others.....

Another catalyst--though not really an issue in the hospital but a big one out in the community---is the use of ETOH or drugs--this can bridge a patient from passive suicidality to active.

I work with a lot of students--med and nursing when they come to see the Psych ER and that is something I always teach...to know the difference between passive and active suicidality and what things can work as a catalyst to move a patient from one to the other. When assessing immediate lethality risk it is very important to understand this concept.

Just some pointers.....Good luck and hope you love psych like the rest of us psych nurses here!! It's a unique area of nursing and takes a certain kind of nurse to really love it and be good at it. But it is very satisfying.

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