Exam (elaborations)
Exam (elaborations) Psychiatric mental nurse practitioner.
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COMPREHENSIVE LEARNING MATERIALS IN THE FIELD OF PSYCHIATRIC MENTAL NURSING
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NURS 406 Nursing Care PlanPsychiatric/Mental Health Concept Map Care Plan
Name: Linetelle Liondo Date: February 24, 2020
Clinical Group/Instructor: Professor Crissey Patient Initials: L.L
I. Nursing Assessment:
Admission Information:
Admission Date: 2/03/20 Age: 38 yrs old Gender: Female
Reason for hospitalization: Surgical procedures:
Patient is a 38-year-old woman with repeated The patient has never had any
history of depression. Patient now being surgical procedures
admitted for evaluation and treatment of
anxiety and psychotic symptoms.
Medical diagnoses: (medical and psychiatric; past and present)
Patient has major depressive disorder, recurrent, severe with psychotic symptoms.
Advance Directives:
Living will: Patient does not Power of Attorney: DNR: Patient does not have a
have a living will Patient does not have DNR
a power of
attorney
Laboratory Data:
Test: Normal values: On Current Interpretation
Admission: values: :
WBC: 4.5-11.0 5.8 6.5 Within normal
level
Differential: 3.7-5.5
Hemoglobin: 11.7-15.0 12.8 12.4 Within normal
, level
Hematocrit: 34.0-47.0 39.0 38.1 Within normal
level
Platelets: 150-450 286 283 Within normal
level
Prothrombin time(PT): N/A
INR: N/A
PPT: N/A
Blood glucose: 70-110 85 93 Within normal
1
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NURS 406/258- 2015
,NURS 406/258 2015
level
Na+: 135-145 136 141 Within normal
level
K+: 3.5-5 3.6 3.9 Within normal
level
Cl- : 98-110 100 102 Within normal
level
Ca+: 9-10.5 9.2 9.6 Within normal
level
BUN: 7-22 18 22 Within normal
level
OTHERS:
DIAGNOSTIC TESTS:
CXR EKG OTHER:
: :
NON NON
E E
MEDICATIONS: List all meds in proper MD order format:
NAME, DOSAGE, ROUTE: RATIONALE: ASSESSMENT/
CONSIDERATIONS:
Magnesium Hydroxide Used for Patient should be assessed for
(Simethicone) 30 mL PO, dyspepsia heartburn and indigestion when
liquid q6hr PRN taking this medication. Make sure
to monitor calcium and potassium
levels while on
this medication. (Townsend, 2015).
Ibuprofen 600 mg PO, q6hr Used for pain Patient must be assessed for pain
PRN and skin rash. Stop taking when
the first sign
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NURS 406 /258
, NURS 406/258 2015
of a skin rash is noted. (Townsend,
2015).
Trazodone 50 mg PO, PRN Used for Patient must be given Trazodone
Insomnia in the evening due to the
drowsiness effect of
this medication. (Kluwer, 2016).
Hydroxyzine 50 mg PO, q8hr Used for anxiety Patient must be watched for
PRN intense sedation. Implications
such as keeping the side rails up
and keeping the bed in a low
position are recommended.
(Townsend, 2015).
Sertraline (Zoloft) 100 mg daily Used for Patient should be assessed for
depression suicidal behaviors. Nutritional
intake should also
be monitored. (Townsend, 2015)
OTC MEDS/HERBALS:
Patient does not take any OTC meds/herbals
ALLERGIES: List all:
Patient is allergic to Penicillin
PAIN ASSESSMENT:
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NURS 406 /258
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