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LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
Azusa Pacific University-LVN-BSN Program UNRS 404P NURSING CARE PLAN I – Patient’s Information (total 10 points) Student: Jennifer Garcia Date : Instructor : Bryan Mayrona Course : UNRS 404 Patient Initial: SW Room No: _ 3101 __ DOB: _ Code Status: Height/Weight: 130 lbs Allergies: NKDA Admitting Diagnosis: Suicidal 51/50- 72 hour hold Chief Complaints in Patient’s/Parent’s Own Words:
- used the UBS section of the phone charger to cut her wrist but she only made superficial cuts.
- After a visit from her biological family that's when her suicidal ideation (SI) started.
Current Vital Signs:
RR: 16 /min. HR: 85 Temp: 97.4 source: axilla/Oral/Rectal/Temporal/Tympanic BP: _99/64 mmHg O2 Sat: _99% Room Air/with O2 @ liter/minute Pain: no pain
Patient’s Developmental Stage per Erik Erickson: in APA format and with
Rationales. Use a separate sheet of paper if needed. Industry vs. Inferiority (Ages 6 - 12) In this stage, children are interested in developing a sense of pride and competence in their accomplishments. When the children are successful it makes them feel competent and when they are failing it makes them feel inferior. At this stage, the children are learning to write, read, and perform different activities on their own and they are establishing a self-concept in accord with their interactions and achievements in school and their social life. (Erikson, E.H., 1963)
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
Rationale: Development Tasks: Children at this age are learning how to master their knowledge and intellectual skills, which means that they are easily influenced by their school peers and school experiences. They are constantly trying to gain their approval and competence. (McLeod, S.A.,
Psychosocial Conflict: These children are in a battle between industry and inferiority. These children need a lot of positive reinforcement to help them develop a sense of pride in their achievements. (McLeod, S.A., 2018) Impact of Adversity: When a child experiences negativity such as lack of care or mental stress this can hinder a child’s development. They will start to acquire feelings of inferiority and this can impact their confidence and self-esteem.
History of Present Problem:
According to her chief complaints, this shows an indication that my patient’s
current health crisis could be associated with her recent visit with her biological
family. Regarding the superficial cuts on her arm, this could be a cry for help. My
patient needs to seek psychological support and some interventions to help with
her mental state.
Past Medical History:
- MDD (Major Depressive Disorder)
- PTSD (Post-Traumatic Stress Disorder)
- Anxiety
- ADHD (Attention-Deficit/Hyperactivity Disorder)
- Repeated SI (Suicidal Ideation - 5 th^ attempt)
- Depression
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
Diagnostic tests, procedures, and radiology reports: What diagnostic results are RELEVANT and must be recognized as clinically significant to the nurse? NONE RELRRelevant Results/LaCblisn:i II. Patient Care Begins: Vital Signs Time Temp F/C (^) Pulse (apical/radial) Resp/min (^) BP in mmHg Right or Left Pulse Ox % Room air/oxygen & delivery 1500 97.4 85 16 99/64 99% ROOM AIR 1200 98.0 90 17 99/69 99% ROOM AIR Pain Assessment Time Pain Tool Used Pain Rating (OLDCART) Functional Pain Goal Pain Medication (or other care) Response To Intervention 1500 0 1200 0
What VS data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance: NO VS DATA IS ALL VITAL SIGNS - WNL Clinical Significance: None
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
RELEVANT THAT MUST
BE RECOGNIZED.
What body system(s) will you most thoroughly assess based on the primary problem or nursing care priority? Current Assessment: These are examples; write in your actual & complete assessment findings! Be sure to use appropriate terminology by using your Health Assessment textbook and other provided resources GENERAL APPEARANCE: Appears well-nourished, dressed appropriately for age and location NEURO: Alert^ and^ oriented^ to^ person,^ place^ and^ time.^ Speech^ clear,^ Pupils^ equal^ and reactive, muscle strength 5/5 in all ectremities, reflexes normal. MUSCULOSKELETAL : No deformities, swelling, or tenderness noted, full range of motion in all joints, and gait normal. RESPIRATORY: Respiratory^ rate^16 - 17/min,^ regular^ rhythm,^ no^ use^ of^ accessory^ muscles, lung sounds clear bilaterally, no wheezes or crackles CARDIAC: Heart^ rate^ 85/min,^ regular^ rhythm,^ no^ murmurs^ or^ extra^ heart^ sounds. peripheral pulses strong and equal bilaterally, capillary refill <2 secs. GI: Abdomen^ soft,^ non-tender,^ bowel^ sounds^ present^ in^ all^ quadrants.^ No masses or distention, no nausea or vomiting reported GU: No^ abnormalities^ or^ discharge^ noted,^ urinary^ output^ normal,^ no^ dysuria reported. SKIN: Skin^ warm,^ dry^ and^ intact,^ no^ lesions,^ rashes^ or^ bruising,^ normal^ skin turgor. PSYCH/SPIRITUAL Mood^ appears^ anxious,^ affect^ appropriate^ but^ occasionally^ flat,^ engages minimally with staff, feels overwhelmed, no specific spiritual needs expressed.
What above assessment data is RELEVANT that must be recognized as clinically
significant?
Please elaborate here.
RELEVANT Assessment Data: Clinical Significance:
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
3. What nursing priorities capture the “essence” of your patient’s current status and will guide your plan of care? (List each in the form of a NANDA three-part nursing diagnosis, MUST have a minimum of three) Provide one long-term and one short-term goal for each diagnosis: A. Nursing Diagnosis #1: Risk for Self-Harm R/T emotional distress AEB recent self- harm attempt. a. Long-term goal: Within 24 hrs the patient will verbalize at least 3 coping strategies to manage emotional distress without resorting to self-harm b. Short-term goal: The patient will demonstrate an understanding of healthy coping mechanisms and will have developed a safety plan to manage SI thoughts and impulses effectively. B. Nursing Diagnosis #2 Ineffective coping R/T familial stressors and exacerbation of AEB suicidal ideation. a. Long-term goal: within 48 hrs the patient will participate in a least one therapeutic activity to explore and express emotions related to family interactions. b. Short-term goal: by the end of 2 weeks the patient will demonstrate improved coping skills and will actively engage in family therapy sessions to address underlying interpersonal conflicts and improve communication within the family unit. C. Nursing Diagnosis #3 Risk for impaired social interaction R/T isolation and withdrawal AEB secondary to SI a. Long-term goal: Within 72 hrs the patient will engage in a least one social activity to reduce feelings of loneliness and isolation. b. Short-term goal: by the end of 1 month the patient will actively participate in social support networks and will demonstrate improved interpersonal relationships and communication skills.
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
4. What interventions will you initiate based on these priorities? List ALL here Nursing Interventions: Rationale: Expected Outcome:
- Risk of Self- Harm - Establishing a therapeutic relationship helps to create a supportive environment, where the patient feels comfortable expressing her feelings and thoughts. - The patient will demonstrate increased awareness of personal triggers and use coping strategies from the safety plan.
- Ineffective Coping
- assessing coping mechanisms and stressors will help her identify areas of concern and build interventions to the patient’s needs.
- The patient will demonstrate improved coping skills and will engage in more compatible ways of managing stress. And engage in family therapy sessions.
- Risk for Impaired Social Interaction
- Group therapy and recreational activities provide opportunities for socializing and great peer support and reduce feelings of isolation.
- The patient will actively participate in group activities show improved social skills and have confidence in social interactions. 5. What is the worst possible/most likely complication to anticipate based on the primary problem? The most and worst possible complication that I can anticipate based on the primary problem of self-harm and suicidal ideation is complete suicide. 6. What nursing assessments will identify this complication EARLY if it develops? We need to monitor the patient’s behavior, mood, and risk factors associated with SI. We can do regular assessments of SI and intent. Assess frequent behavioral observation of the patient’s behavior.
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
Dose? Yes Min. Dose: 10mg/kg/d Max Dose: 15mg/kg/d neurotransmitter s gamma- aminobutyric acid in the brain indigestion, life-threatening pancreatitis Risperdal (Risperidone) 2mg Is this a Safe Dose? Yes Min. Dose:0. mg/day Max Dose:2.5mg/day Classification: Antipsychotics MOA: high affinity to dopamine type 2 receptors, binds to dopamine D receptors with 20x lower affinity than that for 5-HT receptors The patient is taking this medication to treat her mood disorder (MDD) Agitation, arrhythmias, anxiety, aggression, bone marrow depression, cognitive/moto r impairment, constipation If restarting tx, follow initial dose guidelines, using extreme care due to increased risk of severe adverse effects w/re- exposure. VI. Education Priorities/Discharge Planning: What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? My most important discharge priority is to have the patient transferred to a Child & Adolescent inpatient psychiatry services so she can have continuous monitoring and get some therapy. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? I can have the patient repeat to me in her own words the information I explained to her about what her next step is going to be. I can have her explain to me what type of facility she will be transferred to and what she will do there. I can engage with my patient and ask her open-ended questions about how she feels going to a new facility and if she has any concerns or questions. Spiritual & Emotional Caring: The “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? How do you know?
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
I know that the patient is feeling overwhelmed and distressed because when Tim and I passed her room she looked like she was hyperventilating. She seemed uneasy and frustrated. I stopped at her door and asked if she was ok and she lifted her head with hair in front of her face and looked at me with a deep stare. She did not say a word and I just smiled at her and told her we would be back. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? (Note: This is your opportunity to address spiritual care, therapeutic interventions & communication strategies I don’t have much experience with my patient’s admitting diagnosis so I wouldn’t have much to say other than listen to her express herself. And reassure her that we are all here to help and want the best for her. I would give her an example of a time when I was going through a rough time in my life and all I could think to do was say a prayer. I can teach her how to pray if she doesn’t know how or has never prayed before. I can explain to her how it made me feel every time I prayed and assure her that God listens to everyone's prayers no matter if we are good or bad, and that God knows what we need before we even ask. We need to trust in God that things will get better. V. Ending Your Shift It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job on this point, now finish strong and provide an SBAR report to the nurse who will be caring for this patient after you ☺ S ituation: Patient is in room 01, her name is S.W. 12/F, she was admitted for SI on a 72 hr (51/50) on she is currently stable, she taking her daily meds, but at high risk for self harm and SI, she does have a sitter in her room. B ackground: Her medical history; MDD, PTSD, Anxiety, ADHD, Depression and mulitple attempts of SI, this would be her 5th attempt. Patient try to cut herself with a USB section of a charger cord but her only superficial cuts on her wrist. Her SI started after a visit from her biological family. A ssessment: Vitals are stable; RR: 16, HR: 85, Temp 97.4, BP: 99/64, O2: 99% in room air, no pain reported. She seems anxious and her communication is flat, no emotions, very minimal engagement with staff.
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
McLeod, S. A. (2018). Erik Erikson's stages of psychosocial development. Simply Psychology. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html Karch, A. M. (2019). 2020 Lippincott Pocket Drug Guide for Nurses. Lippincott Williams & Wilkins. Cherry, K. C. (2023). Identity vs. Role Confusion in Psychosocial Development. Retrieved June 12, 2024, from https://www.verywellmind.com/identity-versus-confusion- 2795735
LVN-BSN PROGRAM
UNRS 404P Care of Children and Young Adults
