psych sig care plans Flashcards
what sx would clue us in that the pt might be depressed
-loss of pleasure (anhedonia)
-depressed mood
-wt & appetite changes
-sleep disturbances
-fatigue
-psychomotor agitation or retardation
-worthlessness or guilt
-loss of ability to concentrate
-recurrent thoughts of death
areas to assess if we believe a pt is depressed
-mood & affect (congruent or incongruent)
-thought process/content
-judgement/insight
-communication
-physical behavior/activity
examples of affect
-full/board range: expresses wide variety of emotions appropriate to the situation
-constricted: less than full range, includes flat & blunted
-blunted: limited expression
-flat: does not demonstrate emotion
-sad: body language implies sadness, downcast eyes, stooped posture
nursing diagnosis/analyze cues: depression
risk for suicide
hopelessness
ineffective coping
social isolation
self care deficit
goal and 2 objectives for a patient w/ depression (pt.1)
Goal: Improve the patient’s mood and emotional well-being
Objective 1:
The patient will verbalize feeling less sad or hopeless within two weeks, as measured by patient self-report or standardized depression scales (e.g., PHQ-9)
Objective 2:
The patient will engage in at least one pleasurable activity or hobby (such as reading, walking, or listening to music) each day within the next two weeks
goal and 2 objectives for a patient w/ depression (pt.2)
Goal: Enhance the patient’s ability to manage depressive symptoms
Objective 1:
The patient will demonstrate understanding of their depression management plan, including medication adherence, coping strategies, and lifestyle changes, by explaining it back to the nurse during each session
Objective 2:
The patient will identify triggers or negative thought patterns that contribute to their depression by the end of the first week, as demonstrated through journaling or discussion
what sx would clue us in that the pt might have schizophrenia
-paranoia/delusions/hallucinations
-altered speech, behavior and thought
how to assess a person who is experiencing a delusion
first build rapport and trust by being open, honest & genuine
-ask pt to describe delusion
-validate if part of the delusion is real and present reality (“yes there is man at the nursing station but I do not hear him talking about you”)
-never doubt or argue the delusions or try to prove delusion isn’t real until reality testing improves
-assess the intensity, frequency and duration of the delusion & ID trigger
example of therapeutic communication with a patient experience a delusion
Patient: “I see the doctor is here. He wants to kill me.”
Nurse: “It is true the doctor wants to see you, as he talks with all patients about their treatment. Would you feel more comfortable if I stayed with you during your meeting?”
how to document a delusion (8)
-type of delusion experienced
-content and theme
-characteristics
-use pt’s own words
-pt’s behavior prior to assessment for delusions
-pt’s behaviors during the delusion
-any actions take to help the pt with the delusion
-if pt posed a threat to self or others, document what actions were taken to ensure safety
Suicidal and/or homicidal themes or commands from a hallucination require
immediate safety measures
how to assess to see if a pt is hallucinating
Moving their eyes back and forth
Muttering or talking to self, including engaging in a conversation with an inanimate object or person who isn’t present
Appearing distracted
Suddenly stopping conversation as if interrupted or Intently watching a vacant area of the room
assessment for hallucinations
-assess for type and contact by asking direct questions
-assess when the hallucinations began and the way the patient experiences them (supportive or distressing? background or intrusive?)
-what do you hear/see/smell/feel
-do you believe it is real
-once over, try to assess for triggers and coping
examples of therapeutic communication when a pt is hallucinating
“I understand that you are feeling worried now. I don’t see or hear anything, but I can understand that it may be difficult, worrying or unpleasant for you.”
“I do not hear the angry voices that you hear, but it must be very frightening for you.”
how to help a person who is experiencing hallucinations
Call the patient by name, speak clearly, keep sentences simple and speak loudly enough to be understood during hallucinations
Convey support, maintain eye contact, and redirect the patient’s focus
Be alert for signs of anxiety which may indicate the hallucinations are intensifying
Engage the patient in reality-based activities, such as card games or listening to music
how to document a hallucination (8)
-type experienced
-content/theme
-characteristics
-pt quotes
-pts behavior prior to hallucinations
-pts behavior during hallucinations
-any actions taken to help the pt during the hallucination
-if the pt posed a threat to self or others, what actions were taken to ensure safety
teaching for a pt with hallucinations
-manage stress
-use other sounds to compete w/ halls.
-ask others what is real or not real
-engage in activities like walking, music, showering to distract self
-tell yourself it is not real, tell the voices to go away, tell yourself you are safe
-make contact w/ others
-develop a coping plan
nonpharm treatments for schizophrenia
CBT: focuses on helping individuals recognize, understand, and change behaviors that they’re not entirely aware of
group therapy
priority problem for pt w/ schizophrenia
o Safety
o Risk of violence towards others
o Risk for suicide or self harm
o Disturbed thought process
o Risk of treatment non-adherence
priority goals for a pt w/ schizophrenia
o the patient will remain free from self-harm during this shift
o the patient will remain free form violent behaviors towards other this shift
o the patient will state 2-3 coping strategies to help cope w/ symptoms burden prior to discharge
o the patient will take medications as prescribed this shift
priority interventions for a pt w/ schizophrenia
o assess the patient using the C-SSRS risk assessment each shift
o assess the patient for thoughts of harm to self or others each shift
o assess patient’s orientation to person, place, time and situation each shift
o collaborate
goal and 3 objectives for a patient w/ schizophrenia (pt.1)
Goal : Enhance medication adherence and management
Objective 1:
The patient will report taking their prescribed medications as directed (either orally or injectable) for the duration of one month, as evidenced by a medication log or nurse observation
Objective 2:
The patient will demonstrate understanding of the side effects of their prescribed medications and how to manage them, as assessed during weekly check-ins
Objective 3:
The patient will identify one strategy to improve adherence to their medication regimen (e.g., setting reminders or having a family member assist) within two weeks
goal and 3 objectives for a patient w/ schizophrenia (pt.2)
Goal : Reduce psychotic symptoms (delusions, hallucinations, etc.) and improve reality orientation
Objective 1:
The patient will report a reduction in the frequency or intensity of auditory or visual hallucinations, as measured by self-report and clinical observations, within four weeks
Objective 2:
The patient will demonstrate improved reality orientation by engaging in appropriate conversation, distinguishing between reality and hallucinations, during each visit within one month
Objective 3:
The patient will participate in at least one therapeutic activity (e.g., group therapy, cognitive-behavioral therapy) to address psychotic symptoms and coping strategies within the next two weeks
nonpharm treatments for depression
-ETC
-CBT
-group therapy
-light therapy
-vagal nerve stim / deep brain stim
-acupuncture or massage therapy
-St.John’s wort
-exercise
-relaxation techniques
what sx would clue us in that the pt might have SI
-expressing hopelessness / worthlessness
-talking about being a burden
-feeling trapped or in unbearable pain
-increase substance use, especially alcohol
-extreme mood swings
-sleeping too much or litter
-giving away prized possessions
what assessment is used to assess SI
Columbia Suicide Severity Rating Scale (C-SSRS)
what is a must do if a patient is at risk for suicide
safety plan
assessment of SI
-verbal and non verbal cues (overt vs covert statements)
-assessment of the lethality of suicide plan
-self assessment
priority problems for a pt at risk for suicide
Risk for suicide
Ineffective Coping
Anxiety
Ineffective Social Supports
Self-care deficit(s)
Sleep pattern disturbance
overt statements
I can’t take it anymore
Life isn’t worth living
I wish I was dead
covert statements
o It is okay now, soon enough everything will be fine
o I won’t be a problem much longer
o Nothing feels good to me anymore and probably never will
outcomes identification for SI
suicide self restraint
coping
hope
treatment and mgt for a patient at risk for suicide
Re-assessment following identified suicide risk (Re-screen for suicide risk if there is a change in patient condition)
safety plan
Identification and mitigation of environmental safety concerns on all patient care units
(May require provider order) observation by a sitter
rounding for safety at regular intervals -Constant (1:1); every 15 minutes; every 30 minutes; hourly
environmental safety for a pt w/ SI
Search patient and assess belongings for harmful objects
Remove any potential lethal objects and mitigate any potential ligature risks
Use plastic utensils and disposable food trays and dispose of tray and implements outside patient room
safety measures to take on the unit for a pt with SI
No private room; always keep door open
Jump-proof and hang-proof bathrooms
Lock doors to non-patient areas or empty patient rooms
Inform sitter that patient is at risk for suicide
Monitor for and remove potentially harmful objects including gifts brought in by visitors
tips to take care of self
Get regular exercise
Healthy eating
Make sleep a priority
Take time to relax
Get outside
Practice mindfulness
Stay connected/talk with a friend
goal and 3 objectives for a patient at risk of suicide (pt.1)
Goal: Ensure the patient’s safety and reduce immediate suicide risk
Objective 1:
The patient will create a safety plan in collaboration with the nurse, including identifying warning signs of suicidal thoughts, coping strategies, and emergency contacts, within the next 24 hours
Objective 2:
The patient will verbalize an understanding of their safety plan and demonstrate awareness of emergency resources (e.g., suicide hotline, support persons), as assessed by the nurse, within one week
Objective 3:
The nurse will assess the patient’s environment for potential hazards (e.g., firearms, medications) and ensure any dangerous items are removed or secured, within the first session.
goal and 3 objectives for a patient at risk of suicide (pt.2)
Goal: Provide emotional support and address suicidal thoughts
Objective 1:
The patient will verbally express feelings and thoughts of hopelessness or distress in a non-judgmental setting at least once during each session with the nurse
Objective 2:
The patient will identify and discuss at least one person (friend, family member, therapist) they can turn to for emotional support within the next two days
Objective 3:
The patient will engage in therapeutic interventions (e.g., cognitive-behavioral therapy, dialectical behavior therapy, or active listening techniques) to address negative thought patterns, and will demonstrate improved emotional regulation within four weeks
goal and 3 objectives for a patient at risk of suicide (pt.3)
Goal: Promote a sense of hope and future planning
Objective 1:
The patient will discuss at least one personal goal (e.g., career, relationship, or self-care goal) they would like to work towards within the next month
Objective 2:
The patient will begin to explore one activity or interest that can provide meaning and fulfillment, such as volunteering or pursuing a hobby, within four weeks
Objective 3:
The patient will verbalize an increased sense of hope and future possibilities, as measured by self-report or behavioral changes (e.g., expressing interest in planning for the future), within six weeks
SBAR: situation
-summary of current condition
-behavior(s)
-presence/absence of sx
-interactions w/ staff & other patients
-participation in treatment
SBAR: background
-medical hx & dx
-psych hx & dx
-reason for admit
-current meds
-living situation
-available support
SBAR: Assessment
-stability
-progress towards treatment goals
-continued needs
-knowledge/insight about illness/meds/discharge
SBAR: recommendation
what should be done to address the patient’s current issues / concerns
