NUB 430

Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

NUB 430 Clinical Paperwork and Nursing Care Plan

NURSING ASSESSMENT GUIDE
Student
Name:

Danielle Reed

Admission
Date:
2/23/15
Admission Type (voluntary or
committed)

Clinical
Date:

2/23/15

Ag
e:

36
Patient came to the ER for a cut on his hand.
Voluntary

Gender:

Male

Race:

Caucasian

Marital
Status:

Divorced

Allergie
s:

NKA

Admitting Diagnosis (as designated in

chart):
Axis I: Major Depression
Axis II
Axis III Infected cut on hand
Axis IV
Axis V (current documented
GAF)

Events Leading to Current Admission

The patient came to the ER because he cut his hand while working a
few weeks ago. He noticed that he cut was not healing and was
painful. He suspected the cut was infected.
Patients Psychiatric History:
The patient stated that he had a history of depression while he was in
the military. He was prescribed antidepressants. He no longer takes
the antidepressants because he isnt experiencing any symptoms of
depression.
Familys Psychiatric History:
The patient lives at home with his Father. He claims that his family
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NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

does not have a history of Psychiatric diagnosis.

Substance Use/Abuse (current and past history, including

drug(s) of choice, how much, how often, ect. ):
The patient smokes 1 pack of cigarettes a day. He has been smoking
since 1998. He has not plans to quit smoking. Patient denies use of
any other substances.
Sleeping Patterns:
Patient states he has some trouble sleeping at night, and
occasionally used over the counter sleep aids.

Appetite, Diet, and Eating Patterns:

Patient eats one meal a day. He eats at night. Diet consists of ramen
noodles, lean meat, and fat free foods.

Elimination (bowel and bladder):

Patient voids and eliminates naturally. He stated that he doesnt
suffer from constipation or having the urge to urinate frequently.

Personal Hygiene and ADLs:

Patient is able to perform ADLs independently. The patient appeared
to be clean, and his facial hair was shaved.

Support System:
The patient lives with his father. His mother lives nearby and he visits
with her daily. He doesnt have any siblings.

Cultural/Spiritual Background
The patient is a Christian. He attends a Church of Christ on Sundays.

NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Educational Background:
The patients graduated from high school, and then joined the military
after he graduated. After he served in the military he obtained a
certificate of drafting.

Work and Leisure Activities:

In his spare time the patient enjoys watching TV and doing manual
labor on farms and cars.

Pertinent Physical Assessment:

The patient appeared much older than his actual age. He was 36
years old and looked to be in his late 40s. His skin looked tough from
years of doing manual labor. He teeth were decaying. His skin tone
was normal for his ethnicity. His hair was groomed. He was wearing
his own clothing. His speech was clear, and his tone was loud.

Pertinent Lab Values /Diagnostic procedures (abnormal values,

rationale, and all lab values associated with psychotropic
medications.)
*We did not get the chance to access the patients chart. He was
being treated for a cut on his hand, and I didnt observe the
nurse draw labs on this patient.

Growth and Development (Eriksons current stage with rationale,

ie. Patients chronological age with usual developmental task and
psychosocial crisis; Was the crisis successfully or unsuccessfully
resolved. Why or why not?
(Table on page 23.)
The patient faces the crisis Generativity vs. self-absorption. During
this stage he is concerned with fulfilling life goals that involve family,
career, and society. The patient is divorced, and has no children. I
dont believe he has successfully resolved this crisis because he
doesnt socialize much, and has yet to remarry and build a family.

NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Defense Mechanisms (provide examples) (Table on page 283)

I believe this patient is in denial about being unhappy about his
current living situation, being divorced, and not having children. The
patient stated that he wanted children but his marriage was
unsuccessful. I think that he uses his work to compensate for a lack
of a social life, and friends.

Patient Symptoms/DSM-IV-TR Criteria

1. With Axis I and II, define each diagnosis(es) and give
symptoms of diagnosis(es). Use your text for this
information and give page.

The patient has a history of major depression. He was prescribed

medication when he was experiencing symptom of depression. The
patient states that he would sleep for long periods of time, and
couldnt eat when he was suffering from depression. According to
Halter (2014) major depression, is characterized by a persistently
depressed mood lasting for a minimum of two weeks (p. 250). The
depressed mood is accompanied by a lack of interest in previously
pleasurable activity, also known as anhedonia ; fatigue; sleep
disturbances; changes in appetite; feelings of hopelessness or
worthlessness; persistent thoughts of death or suicide; an inability to
concentrate or make decisions; and a change in physical activity
(Halter, p. 250).
2. In your definition of diagnosis and symptoms of the three
axes, highlight the diagnosis and symptoms that your
patient has demonstrated.

Anhedonia- The patient stated that when he was

depressed he became withdrawn and no longer enjoyed
socializing, reading, and watching TV
Changes in appetite- when he was depressed he was
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Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

unable to eat. He lost about 30 pounds.

Change in physical activity- The patient was no longer
physically active, and was sleeping for long periods of time.

Sample Charting (Brief summary of patients mental status, written

in paragraph form)

The patient is a 36 year old, Caucasian male. He served in the Army for 8 years. He is
divorced and has no children. Patient has a history of depression, but is no longer
experiencing symptoms of depression. When he was experiencing depression he was
prescribed antidepressants. The drugs successfully treated the symptoms the patient
was experiencing. The patient lives at home with his father. He enjoys doing manual
labor on farms and cars. Patient claims to be happy about being divorced, but I was not
convinced he is happy about being alone. Patient has some trouble sleeping and eats
one meal a day. Patient does socialize with friends a lot during his spare time. The
patient was alert and oriented to time, place, and person. He came to the ER because
he had a cut on his hand that had not healed and was painful.

NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

NURSING CARE PLAN

Nursing Diagnosis
(NANDA)
Include R/T (etiology), AEB
(signs/symptoms/ defining
characteristics) for 2 priority
nursing diagnoses

Patient Goals
(include a minimum of
one long term and two
short term measurable
goals
per nursing diagnosis)
Goals should be
measurable, timelimited and realistic

Planned Nursing
Interventions and
Rationale
(minimum of 5
interventions &
rationale
per nursing diagnosis)

Patient Response and

Your Evaluation of
Interventions

Disturbed sleep
pattern related to
lifestyle disruption as
evidenced by difficulty
falling asleep and
awakening after short
periods of sleeping.

The patient will

demonstrate an optimal
balance of rest and
activity A.E.B. 6-8hours of
uninterrupted sleep at
night with in 7 days.

The nurse will:

The patient was

receptive to my
suggestions. He
agreed that he
needs to address
his sleep problem,
and that it affects
his job.

The patient will remain

awake during the day for
the next 7 days.
The patient will exercise
at least 3 times a week
over the next 3 months.

Explore with patient

potential contributing
factors such as caffeine
use, lack of exercise, and
anxiety. This will help
identify the cause of the
sleep problems, and help
the patient identify a
solution.
Help the patient identify
and establish a bedtime
routine per patient
preference such as a
desired bedtime and sleep
environment (darkness,
night light, music). A
routine will help the
patient mentally prepare
for sleep and form a habit
for resting.
Encourage the patient
to ask his PCP for a
sleep aid if the
problem persists. The
patient may need a
sleep aid if the
problem persist longer
than 3 months
Encourage the patient
to void before retiring.
Voiding before bedtime
will help the patient
avoid waking up to go
use the bathroom.
Help the patient
identify ways to be
physically active
(exercise) at least 3
times a week.
Planning to exercise
will help the patient to
establish a workout
routine, and help
relieve stress that may
interfere with sleep.

NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Nursing Diagnosis
(NANDA)
Include R/T (etiology),
AEB
(signs/symptoms/
defining
characteristics) for 2
priority nursing
diagnoses

Patient Goals
(include a
minimum of one
long term and
two short term
measurable goals
per nursing
diagnosis)
Goals should be
measurable,
time-limited and
realistic

Planned Nursing
Interventions and
Rationale
(minimum of 5
interventions & rationale
per nursing diagnosis)

Social isolation
as related to
divorce as
evidenced by
desire to interact
with more
people

The patient will:

The nurse will:

Identify the reasons

for his/her feelings
of isolation during
my shift.
Identify ways of
increasing
meaningful

Patient Response and

Your Evaluation of
Interventions

The patient
admitted that since
Encourage patient to
his divorce he had
verbalize feelings. This will
become socially
help to identify the cause of
withdrawn. He
the social isolation.
expressed a desire
to have more
Assist to identify causative
friends and
and contributing factors. This participate in more
will help the patient to

NUB 430
Mental Health Nursing
relationships during
my shift.
Identify appropriate
diversional activities
over the next 4
weeks

Clinical Paperwork and Nursing Care Plan

determine ways to address
the problems and develop
solutions for the causative
and contributing factors.
Assist to identify diversional
activities such as joining
clubs, going to bars/parties,
being active in church
groups, and try online
dating. Finding activities will
help the patient to socialize
more, and hopefully make
new friends.
Encourage the patient to
perform volunteer activities.
This may help the patient to
gain a sense of fulfillment
and purpose by giving to
others.

Encourage the patient to

keep a daily journal of his
activities. This will help the
patient to keep track of his
progress in becoming more
socially active.

recreational
activities.

NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

MEDICATIONS
Drug Name
(generic &
trade)

Drug Class
& Dose

Reason
Prescribed

Pt.
Understanding
of Drug &
Nurse
Education
( Include
education
important for
patient to
know)

Nursing
Considerations

Most Common
Side Effects &
Most Common
Serious Effects

Hydrocodon
e

325 mg
tab

Pain in
knee and
foot

Patient
understands
that this drug
is to be used
to treat pain
he
experiences
due to a foot
injury

Monitor hepatic,
renal status during
long-term therapy,
bleeding (GI, GU,
skin/mucous
membranes) with
long-term, highdose therapy, signs
of OD, (sweating,
gastric irritation
chills, cyanosis,
oliguria, jaundice,
come, convulsions,
death from
respiratory failure).
Assess hx of
hypersensitivity,

Anemia,
leukopenia,
neutropenia,
pancytopenia,
hemolytic anemia,
methemoglobinema
,

Migraines

Patient
understands
this
medication
relieves pain
caused by
migraines

Assess type, location,

Drowsiness,
hangover,
palpitations,
tachycardia.

Analgesic

ASA
Butalbital

nonopioid
analgesic
s

Caffeine

325mg
50mg
40mg

and intensity of pain

before and 60 min
following
administration.
Prolonged use may
lead to physical and
psychological
dependence and
tolerance. This should
not prevent patient from
receiving adequate
analgesia. Most patients
who receive butalbital
compound for pain do
not develop
psychological
dependence.
Assess frequency of
use. Frequent, chronic
use may lead to daily
headaches in headacheprone individuals
because of physical
dependence on caffeine
and other components.
Chronic headaches
from overmedication
are difficult to treat and
may require
hospitalization for
treatment and
prophylaxis.

NUB 430
Mental Health Nursing

Clinical Paperwork and Nursing Care Plan

Mental Status Exam

A. Appearance- The patient was well groomed and wore his own clothing. He facial hair
was shaved. His posture was upright. His weight was appropriate for his height. He
maintained normal level of eye contact (he wasnt always looking down or staring into
my eyes for long periods of time. His hair was brown and straight. He had a few moles
on his face, I didnt notice any scars or tattoos. He appeared much older than his
chronological age of 36. He appeared to be in his late 40s.
B. Behavior/motor activity- The patient was very friendly toward me. He initiated
conversation, and lead into new topics without being asked. He seemed eager to talk to
me. His gait pattern was steady and fast. He had freedom of movement and wasnt
limited by mobility problems.
C. Attitude toward interviewer- The patient was cooperative and friendly toward me. He
asked me questions about myself. He told a few jokes and overall seemed pleasant.
D. Speech- The patient participated in the content of the conversation when I asked him
about his life, condition, and how he was feeling. He spoke at a moderate pace and loud
tone.
E. Mood- When I asked the patient how he was doing he expressed that he was ok and
that he was visiting the VA for a cut on his hand. He chatted briefly about the weather
and that he was looking forward to summer.
F. Affect The patients facial expression was congruent with his mood. He appeared calm
and cooperative. He was not constricted or blunted. His affect was appropriate for his
mood.
G. Thought Process- The patients thought process was logical and sequential, and his
answered were in response to the correct question. The patient was able to concentrate
on the topic of discussion.
H. Thought Content- The patient was oriented x3. We discussed his family, religious beliefs,
military background, and his divorce. He claimed to be happy about being divorced, but I
wasnt convinced because of his current social isolation.
I.

Suicidal/homicidal ideation (address both)- The patient denies SI and HI.

J. Perceptual Disturbances- The patient was not experiencing any perceptual disturbances.

K. Intellectual Functioning
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Clinical Paperwork and Nursing Care Plan

Sensorium

Orientation- The patient is oriented to time, place, and person

Memory- The patient was able to recall short term and long term
memories such as places traveled, his parents names, and
current city of residence.

Intellectual capacity

Intelligence- The patient seemed to have an average level of

intelligence. His highest level of education was high school and
then he received a certificate in drafting.

Abstract or Concrete Thinking- The patient has abstract thinking.

When I asked what does the phrase cant judge a book by its
cover his response was that You have to get to know a person to
truly understand them.

Comprehension of current events- The patient is aware of current

events. We discussed his activities at work, and the weather.

L. Judgement- The patient is able to use common sense to make reasonable decisions
M. Insight- The patient was aware that he cut his hand a few weeks ago, and that the
wound had not healed. He was also aware that he suffered from depression in the past.
N. Motivation for treatment- The patient is motivated to get his hand healed because it is
interfering with his ability to work.

References:
Varcarolis, E. M. (2013). Foundations of Psychiatric Mental Health Nursing , 10rd. Ed.
Philadelphia: W.B. Saunders.

Vallerand, April Hazard, Cynthia A. Sanoski, Judith Hopfer Deglin, and Holly G.
Mansell. Davis's Drug Guide for Nurses. N.p.: F. A. Davis, 2014. Print

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