Yet another care plan question..... psych nurses, help!

[WorkingTowards2011]

Okay, so I hate to be one of those people that asks for help with an answer, but I have spend hours researching and I have to finish this care plan.

My situation is sort of different than most of the care plan posts on this website. I don't have a situation with detailed patient specifics and so forth like everyone else lists. Basically, our instructor split us up into groups of 7, and assigned a leader to each group. (I am not the leader.) Each group had an overall problem. Ours is cystic fibrosis. Basically, the teacher put it this way. She wants us to come up with a patient, who enters the hospital with some sort of problem related to the overall issue. (Cystic Fibrosis) Basically, the leader starts out as his burse, and treats one symptom. She fixes the problem, but another problem arises, and the next person deals with that problem, so on and so forth, until we have all had a shift taking care of the same patient.

We had about an hour to come up with an overall plan of what symptom each of us have. I'm not going to be ugly, but basically our "leader" is scared to death and has done absolutely nothing. The only reason we have gotten anything accomplished is because several of us stepped up and tried to piece this together in our "leader's" aftermath. All the leader did was state that she had ineffective airway clearance, and then attempt to work on her care plan during our meeting time, instead of help the group as a whole make a storyline that makes sense for a cystic fibrosis patient.

Our teacher has not explained care plans to us, except for a very confusing ten minute lecture, in which the whole class was lost. I have read and researched and done my best to try to wrap my head around care plans, and I THINK I put together a pretty good one. I just had one question and wanted an opinion on what sounds better.

Basically, this is the chain of events/nurses that happens to this guy. James Reed, 19 yr. old male, with a hx of cystic fibrosis is our patient.

Nurse 1- Ineffective Airway Clearance

Nurse 2- Deficient Fluid Volume

Nurse 3- Chest Pains

Nurse 4- Noncompliance

Nurse 5- Anxiety/suicide attempt

Nurse 6- This is me, will explain in a minute. Torn between two diagnoses.

Nurse 7- post mortem care

Basically, our instructor said to create an overall story, and make it interesting, but believeable. We went over our basic storyline to her, and she was happy with it. Basically, this 19 yr old kid ends up coming to the hospital because he is developing pneumonia, that is where nurses 1-3 come in. He is sick and tired of being in the hospital for all his life and boycotts his medicines and treatments, which is where noncompliance comes in. Finally, he gets so frustrated with his illness, he becomes basically depressed and tries to kill himself. (nurse 5) Nurse 5 transfers him to the psych ward, and I am the psych nurse assigned to him.

For my subjective data, he is saying that ""I'm so tired of being sick all the time. It's never going to end, so why even try? I've been sick my whole life, so what's the point of living at all?". For objective, I have "Patient shows apathy and resignation towards illness. Shows possible intentions of destructive behavior towards self. Withdrawn appearance."

The two diagnoses I am on the fence about is powerlessness and ineffective coping. Both make sense for his problem, I think. I want it to sound serious, because after my shift, he finds a way to kill himself, and the next nurse finds him dead andis responsible for post mortem care. it's a crazy, mixed up story, I know, but the instructor liked it alot, if we can pull it off.

The only other thing I am wondering about is what medications to list (as "ordered by the doctor, of course, since nurses can't order meds). Our instructor says she wants meds in there. I have looked up what feels like 10,000 meds. Does he need a tranquilizer? Antidepressant? Antipsychotic? I DON'T KNOW, THEY ALL LOOK THE SAME AFTER AN HOUR OF LOOKING!!!!!

I assume that he would be on a 4 point harness to keep from hurting hisself. Does he need a consult with a psych dr or counselor???

I have worked on this thing for days, and still fell completely ignorant and lost. I am one of those people who are annoyed at people that ask for help, because they should work it out for themselves instead of taking the easy way out. But after days and days of research that has me feeling like I am going in circles, asking for help doesn't seem like the easy way out anymore.

Sorry for the long post. Any imput would be appreciated.

[WorkingTowards2011]

I forgot to mention that this is my very first care plan, which is why I'm so confused. It is so intimidating to see people talk in "nursing/medical lingo", and I think, what are they SAYING??? Am I REALLY gonna be able to tak like that and understand what it all means in 5 semesters???????????????? How overwhelming.

[Daytonite, BSN, RN]

he wouldn't be in the psych ward if his respiratory symptoms need attention. that i can tell you from working in an acute hospital that had locked psych wards. the psych wards never took any patients that had medical problems that needed medical attention. the poor nurses on the medical units just had to deal with the psych patient's behavior until they were well enough to get turfed (transferred) to the psych ward. a suicide case would have had sitters placed round the clock on them or the patient was put in the icu for one-on-one care until they could be transferred to the psych ward.

i had a copder who actually did attempt suicide while i was on duty. he watched our routines very carefully. but he needed o2 and without it became hypoxic. he could not ambulate without assistance. the evening before his attempt he gave away some of his possessions, a warning signs of what he was about to do. no one got the hint. at around 5am while it was quiet and most of us were catching up on our charting he took a razor blade from his shaving supplies and slashed both of his wrists and both sides of his neck attempting to slash is carotid arteries. the sad thing is that he was so weak that he failed to do much if any damage. he also removed his oxygen. when i went into his room around 6am to give him his medications i found him in high fowler's position and unresponsive, barely breathing. i couldn't arouse him because he was so hypoxic and cyanotic. he had the razor blade in his hand and i noticed his wounds which were hardly bleeding. it took his doctor over 2 hours to suture all the lacerations. sadly, the man was found face down, dead, over his dinner tray that next evening. natural causes. he never would have been transferred to the psych ward because of his medical condition and his doctor who spent a good deal of time with him that morning felt he was no longer a danger to himself.

a more likely scenario (i've seen this happen, too) is that your patient gets round the clock sitters and on your shift the sitter decides to take a potty break while the patient "seems" to be napping. while she's gone, the patient uses the opportunity to paw through the sitter's purse and finds himself a weapon which he uses later the next shift. a pair of scissors or a knife should do nicely. i had a patient who took a pair of scissors from their makeup kit and stab themselves in the chest with them. a pair of shears would make a great weapon for a teenage male. sitters are not known to be the smartest tacks in the box and this is a highly plausible situation. many sitters are not even certified cnas. all they have to do is literally sit and watch the patient.

the diagnoses for someone who has just attempted suicide are

• risk for suicide r/t prior suicide attempt, chronic illness aeb a suicide plan, talk of suicide and suicide cues
  
• hopelessness r/t deteriorating condition, perceived helplessness, powerlessness, perception of a discouraging future aeb poor affect, lacks motivation and no interest in moving forward in life
  
• ineffective coping r/t situational crisis, inadequate resources, poorly developed social skills aeb inability to problem solve appropriately, destructive behavior, doesn't meet role expectations
  

[WorkingTowards2011]

Thanks for the perspective, daytonite. I knew that there were a few holes in the string, but the instructor seemed happy with the plan, so we stuck to it. She never mentioned that we shouldn't take him to the psych ward (even though what you said makes perfect sense, that they wouldn't send a patient with respiratory problems to the psych ward), so I am hoping she won't hold that against us.

I really wanted to put all three of the diagnoses you listed (I already had them listed to the side), but my instructor was adamant that we only take ONE synptom apiece, and since the girl before me took suicide, I was dangling between which one would sound better to her.

IF a patient were in the psych ward making hopeless statements like the one in my last post, should he have restraints? I assume yes on the restraint since he is suicidal (or would a sitter be more likely and sound better to the instructor?) And what about medications? An antidepressant? Antipsychotic? Stimulant? Tranquillizer? I looked all of them up, but became frustrated after a while. He seems depressed, so an antideressant makes sense, but they increase suicidal thoughts. That doesn't sound smart. A stimulant would elevate his mood and make him more optimistic, I assume? But everything i read on them just talked about ADHD. Antipsychotics focus on schitzophrenia, which he doesn't have. I mentioned the tranquillizer to my instructor, and she didn't object, and she objects to almost EVERYTHING, so that made me wonder....

I know it will get easier from here. It is just so hard in the first semester, because you have such basic knowledge of diagnoses and diseases and symptoms and medications, yet you have to figure out what you would do. It's even more aggravating to hear the people who have previous medical backgrounds talk so easily about this stuff, like they aren't having trouble at all.

[Daytonite, BSN, RN]

the only time i saw them put anyone in leathers and/or the lock down room was if they were violent to other patients or themselves or as a punishment. otherwise, they were allowed to walk around the unit, but the unit itself was locked. only the staff had keys to the door of the unit so they could get in and out. they would have made sure that there were no dangerous objects that the patient could get their hands on. doors to the pantry or utility rooms were closed and locked at all times. i mean the unit was barren of things like lamps (which an angry person could pick up and throw at someone) or a vending machine which someone could put their fist through. when i did my psych rotation on a schizo unit there were a number of people who were suicidal walking around and talking about offing themselves. it was sad. we were told to sit and listen to them. it's when they stop talking about it that the staff starts to worry. that usually means that they have decided to do it and the time for talking about it (indecision) is past.

sure, put him on a mild dose of ativan or valium...something like that.

so, you're getting him after a suicide attempt and you don't know that he's going to try again and be successful. so, when he comes to you he's still despondent. use hopelessness r/t deteriorating condition and perceived helplessness aeb poor affect, despondency, doesn't want to get involved in doing his breathing treatments anymore, lacks motivation to help self. your long-term outcome for him is that he will express the will to live. goal is that he will begin doing his own breathing treatments again and start to attend counseling.

we had 3 locked psych units. there were several deaths on them, i heard. one was a hanging with sheets. the other was someone who took a dive out a window (these units were 8 stories up--don't know what genius made that decision). there had to be people who were not paying attention for these things to happen. then again, like my little copder, patients who are determined to carry out a plan can and will succeed.

[WorkingTowards2011]

Thank you, that helps so much. See, if I had already done some of my clinicals and known how things were done normally in a certain area of the hospital, this wouldn't be so difficult!!! Feels like throwing darts at a bullseye, while blindfolded!

Man, it's really scary thinking about facing those types of situations when I become a nurse. I desire so much to be the hope that pulls someone through!!!