Nursing concept map for mental health
Care Plan 2
Psychiatric/Mental Health
PATIENT CARE PLAN
Client Initials: H.C. Admission Date: 01/14/13 Unit: 4 South
Age: 28 Sex: Female Race/Culture: Caucasian
ASSESSMENT
Presenting Problem: This is a 28 year-old Caucasian female who was admitted to Doctors Hospital Psychiatric Unit 4 South due to an overdose on multiple medications. The patient was found by the police on January 13th picking through garbage near the hospital. Patient overdosed on approximately 30 Alprazolam, Venlafaxine, Trazadone, Benadryl, and Nyquil. She stated she remembered taking the all of the drugs, but does not remember anything after that. Patient believes that the stressors in her life are what caused to overdose on medication. Patient also states that the main reason she overdosed was because she was raped three days prior.
Patients Perception of Stressors/Illness:
Patient states that she is aware of her diagnosis. Patient believes that the stressors in her life are what caused to her overdose on medication. These stressors included financial issues, overwhelmed by school, and her job at a plastic factory where she has conflict with her boss.
MENTAL STATUS EXAM
Behavior: Patient was dress appropriately for the weather. The patient appears her stated age of 28. Patient’s weight was appropriate to height. She was not well groomed and did not practice proper hygiene. Patient sat stiff in the chair, often drifted during the conversation, and did not give consistent eye contact throughout the interview or at group therapy. Facial expressions were flat and she showed no emotion. Patient did not participate in group activities unless she was called upon by the social worker, and she would vaguely share her insight.
Speech: Patient’s speech was organized and clear. She spoke at an extremely slow rate with a very soft volume.
Attitude: Patient’s
Psychiatric/Mental Health
PATIENT CARE PLAN
Client Initials: H.C. Admission Date: 01/14/13 Unit: 4 South
Age: 28 Sex: Female Race/Culture: Caucasian
ASSESSMENT
Presenting Problem: This is a 28 year-old Caucasian female who was admitted to Doctors Hospital Psychiatric Unit 4 South due to an overdose on multiple medications. The patient was found by the police on January 13th picking through garbage near the hospital. Patient overdosed on approximately 30 Alprazolam, Venlafaxine, Trazadone, Benadryl, and Nyquil. She stated she remembered taking the all of the drugs, but does not remember anything after that. Patient believes that the stressors in her life are what caused to overdose on medication. Patient also states that the main reason she overdosed was because she was raped three days prior.
Patients Perception of Stressors/Illness:
Patient states that she is aware of her diagnosis. Patient believes that the stressors in her life are what caused to her overdose on medication. These stressors included financial issues, overwhelmed by school, and her job at a plastic factory where she has conflict with her boss.
MENTAL STATUS EXAM
Behavior: Patient was dress appropriately for the weather. The patient appears her stated age of 28. Patient’s weight was appropriate to height. She was not well groomed and did not practice proper hygiene. Patient sat stiff in the chair, often drifted during the conversation, and did not give consistent eye contact throughout the interview or at group therapy. Facial expressions were flat and she showed no emotion. Patient did not participate in group activities unless she was called upon by the social worker, and she would vaguely share her insight.
Speech: Patient’s speech was organized and clear. She spoke at an extremely slow rate with a very soft volume.
Attitude: Patient’s
References: Varcarolis, E.M. (2011). Manual of psychiatric nursing care planning: assessment guides, diagnoses, psychopharmacology (fourth edition). St. Louis, MO: Saunders. Varcarolis, E.M., Halter, M.J. (2011). Foundations of psychiatric mental health nursing, a clinical approach. (sixth edition). St. Louis, MO: Saunders.