capstone tshumway

8/18/2019 Capstone Tshumway

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NURS 360

Capstone Project Template

PMH Care Plan

SN: ___Todd Shumwa____________ !ate: _______________

Pt": Se#: _$ _%&e: ___'( o___ !ate o) %dm*ss*on: _______+,-0'-+.___

Trans)erred/ ___No __1es: 2Reason-!ate_$rom Hawa** State Hosp*tal on an ac4u*tand comm*t o) second de&ree assault__ 5ncome source: The State- $ood State- Unemploed e&al Status: ___(0'7'++ 2+2d____________8#p*rat*on !ate: __0+-+3-+6____

!SM !*a&nos*s:

5 F29 Psychotic Disorder, Not otherwise specified.F15.10 Amphetamine Abuse, in ar!y "emissionF25.9 "u!e #chi$oaffecti%e disorderF&2.& "u!e out 'DD with psychotic featuresF19.959 "u!e (ut Dru) *nduced Depression

_________________________________________________________________ 55 Deferred

__________________________________________________________________ 555 +N, (besity, -hronic De)enerati%e Dis Disease, -hronic /ac Pain

_____________________________________________________________________

59 Psychosocia! and n%ironmenta! Prob!ems, e)a! Prob!ems ______________________________________________________________________ 9 AF admission 3

______________________________________________________________________

hat ;rou&ht pat*ent to the hosp*tal/

#ent from +awaii #tate +ospita!. 4as arrested 'arch 15 for second de)ree assau!t on

husband when attemptin) to cut off his hand. Patient spent 3 months in (---.

1


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Pat*ent


3/25

=rder: oratidine, 10 m) tabs, one dose, 1 tab, %ery Day e one dose ?5!!ru& class: ?ul>7)orm*n& )*;er la#at*@ePt


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!ru& class: #e!eta! 'usc!e "e!a7antPte: Re&ular

?ladder E ;owel status: Re&ular

Sleep pattern: Pat*ent reported sleep*n& earl around ,+00 and wa>*n& up around

0300 *n the morn*n&" Total sleep-,' hrs: 6 hours

2C*rcle Hpersomn*a-!*))*cult )all*n& asleep-M*ddle *nsomn*a-8arl morn*n&

awa>en*n&

4


5/25

Num;er o) hrs o) d*srupt*on: + hour

Naps: 1es

hen: 5n the a)ternoon

Total nap t*me: 307'. m*nutes

a; E stud*es

"an)e :a!ue Ana!ysis

111115

-ho!estero! m)d! 1006200 22& Patient isdia)nosed with(besity whichre!ates to herhi)h !e%e!s ofcho!estero!,

tri)!ycerides, andD.

i)!ycerides m)d! 0619 131

+D m)d! &96150 5&

D m)d! 0699 1&

-/- wDiff andP!ate!ets

4/- 710&u

.0610.5 B.B0

"/- 710&u

.1065.0 .99

+emo)!obin )d! 12.561B.0 1&.2

+ematocrit &.0650.0 0.1

'-: f 30693 30.

'-+ p) 2B.06&.0 2.5

'-+- )d! &2.06&.0 &2.9Neutrophi!s 06B 50.0

m.ranu!ocytes

16 0.&

ymphocytes 16 2.2

'onocytes 61& 9.

osinophi!s 06B 15.

/asophi!s 06& 0.&

P!ate!ets 710&u

10615 23

"D4 11.B615.0 1.&

Abso!uteNeutrophi!s

710&u

1.36B.3 &.3

Abso!ute*mmatureranu!ocytes

710&u

0.B6.5 0.02

-'P

!ucose m)d! 56115 102

/?N m)d! 3625 13

-reatinine m)d! 0.361. 1.0

F" non6af 59

5


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F" Afr Am E0

+emoA1- 5.B

NA m 1&5615 1&9

m &.565.0 .5

-h m 9B6110 101

-o2 m 623 2

-a m)d! 3.5610.5 9.#(


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Thou&ht Content: Patient denied no current auditory%isua! ha!!ucinations but did

report a h7 of auditory command ha!!ucinations when not on medications and

occasiona!!y in the midd!e of the ni)ht.

Co&n*t*@e 8#am: Patient a!ert and oriented G &, attenti%e and concentrated to )roup

acti%ities, therapy sessions, and durin) con%ersations"

5ns*&ht: Patient showed fair insi)ht into her condition aeb now!ed)e of i!!ness, reason

for hospita!i$ation, and treatments. Patient reported difficu!ty in maintainin) medication

comp!iant when not in the hospita!. Patient cou!d identify psychosocia! stressors "

ud&ment: Patients 8ud)ment was )ood aeb bein) ab!e to see he!p if needed and

abi!ity to understand components of treatment"

!ru&s: Su;stance a;use or dependence: 25nclude n*cot*ne E an alcohol Edru&s" *st ; dru&: ast date o) use-Current acute *nto#*cat*on or w*thdrawals*&ns and smptoms when SN car*n& )or pt"-Used how lon&-Route-Usualamount-Ne&at*@e conse4uences

!ru& classastUse

%cute *nto#or

w*thdrawals#/

en&th o) T*me Used

RouteUsualamt"

Ne&at*@eConse4uences

N*cot*ne 0,-+. 5rr*ta;*l*t%n&ercon)us*on

!epressed

S*nce a&e+,

5nhaled Hal)pac> ada

asted a lot o)mone

%lcohol ,0+' HeadacheNausea9om*t*n&

S*nce a&e+.

=ral T*ll?lac>out:Pat*entreportedus*n&IhardF

asted a lot o)mone memorpro;lems dran> topass the da

Meth%mphetam*nes

0,-+. !epressed5nsomn*asweat*n&Nausea9om*t*n&

=@er ,0ears"Cons*stentls*nce +JJ(

5nhaled Pat*entreportedIt*ll 5 )eelh*&hF

asted a lot o)mone )am*lne&lect a@o*ded)eel*n&sdepress*on

Mar*juana 0,-+. Headache S*nce a&e

+,

5nhaled Pat*ent

reportedIt*ll 5 )eelh*&hF

asted a lot o)

mone

7


8/25

Pro;lems 5dent*)*ed 5n Hosp*tal !opement

2. Psychiatric> hou)ht Perceptua! disturbance Psychosis= -o6occurin) substance

abuse dependence

&. 'edica!> +N, (besity, Pain, (steoarthritis and /ac Pain, and "heumatic -horea

. Psycho6socia! stressors

5. Nutritiona!> (besitity

Current !*schar&e Plan:

8st*mated en&th o) Sta: 37' months

Nurs*n& *nter@ent*ons ou per)ormed th*s sh*)t 25nclude sa)et and teach*n&K:

1. #tress 'ana)ement


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depression and schi*oaective symptoms" #atient can demonstratemedication compliance through medication education and day treatmentprograms"

" #$ %neective Health Maintenance

'$ #atient has a history of medication noncompliance that lead tofre)uent hospitali*ations" #atient shows limited knowledge into medicationregimen" #atient shows little insight into current health conditions and littleinterest into managing her conditions" #atient has poor support system inhelping her manage her health conditions"

+$ 'ducate patient about current medication regimen, heathconditions, and techni)ues to improve her health" -er group therapies andexercise programs to help patient express thoughts and feelings and toparticipate in her care

9


10/25

Priority # _1__ CARE PLANNursing Diagnosis: Risk for violence directed at self or at others related to lack of impulse control, auditory commandhallucinations, and excalating anxiety aeb Hx of intentional overdose and attempt to cut o husbands hand d/t auditorycommand hallucinations"Create 3 plans of care one for each of your priorities ienti!e" P: Risk for violence directed at self or at others E: Hx of intentional medication overdose and attempting to cut o husbands hand d/t auditory command hallucinations S: Maintain medication compliance, less stimulating environment (living with sisters and husband at home with nephews!,and attend group therapy"

Behavioral Therapy

• Focus on the consequences of dysfunctional behaviors and ways to change them.

• Teach social skills, activities of daily living, and communication skills.

• Use a token economy to reinforce desired behaviors by rewarding them with special privileges.

Group Therapy

• Focus on daily living skills.

• Teach ways to manage environmental and interpersonal stressors.

• Help the client develop a positive sense of self

• Provide the experience of supportive and directive interactions with others. The client can learn to listen, ask questions, and give appropriate feedback.

• Provide a place to express feelings and to talk about or resolve problems.

• Present opportunities to give and receive support.

Family Therapy

• Focus on promoting an understanding of the structure and functioning of the family system.


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• Assist the family to be supportive and caring of the client without being overprotective.

• Encourage honest expression of feelings.

• Promote effective ways to handle negative feelings and family conflicts, and correct unsuitable communication and distortions of negative events.

• Increase ability to cope with chronic mental illness.

• Clarify boundaries and the roles of family members.

• Discuss the need for involvement in opportunities for social networking.

Outpatient Therapy/Day Treatment Program

• Focus on long-term symptom management.

• Promote medication management.

• Provide for individual therapy, group therapy, and structured activities or vocational training as needed by the client.

• Provide continuing social, occupational, and communication skill development.

• Create and maintain continuity of care, a sense of hope, and a family connection to the mental health system

L goal$ .he client will not harm self or others during hospitali*ation" S goal$ .he client will identify signs of increased violent impulses and learn eective coping skills during my shift

$nter%ention & 're(uencyScienti!c Rationale(%n complete sentences!

(Reference in 0#0 format, including page number!

E%aluation


12/25


13/25

Priority # _)__ CARE PLANNursing Diagnosis: $ne*ecti%e ini%iual coping relate to inae(uate s+ills for hanling stress, poor fa-ilysupport syste- ae. unsta.le physical or e-otional health, nonco-pliance /ith prescri.e rug regi-en,-etha-pheta-ine use, high elope-ent ris+, an intentional o%erose"

P$ %neective &opingE: Patient has o%er )0 years of -etha-pheta-ine use" Patient has e-onstrate poor -eication co-pliance

ae. fre(uent hospitaliations an increase auitory co--an hallucinations leaing to her reason of a-issionof atte-pting to cut o* hus.ans han" Patient has %er.alie auitory hallucinations of running a/ay" Patienthas a history of intentional o%erose ue to se%er epression"

S: Patient can learn %arious coping techni(ues through group therapies an acti%ities to learn a.out .eing

su.stance free an to -anage se%ere epression an schioa*ecti%e sy-pto-s" Patient can e-onstrate-eication co-pliance through -eication eucation an ay treat-ent progra-s"L goal$ .he client will use constructive coping strategies and function without interference from delusional thinking throughouthospital stay" S goal$ .he client will develop adaptive coping strategies during my shift"



E%aluation

.each the client appropriate ways tohandle stress, such as 4ournaling orstructured physical activity like taking awalk"

Acuisition of si!!s, information, and optionsfor dea!in) with stress enhances the c!ientscopin) abi!ity.

#atient reported taking walks, and reading asways for her to calm down" #atient also repor 4ust walk away from stressful activities helps cope with problems"

Help the client identify people andcommunity resources to alleviatedi6culties such as depression andschi*oaective symptoms"

Helping the client develop a personalac)uaintance with community supportpeople alleviates negative feeling, suchas lonliness, anhedonia, or avolition"

#atient reported that taking her medication mher symptoms like auditory hallucinations go #atient has a hard time 2nding help in thecommunity because she is too distracted witnegative in7uences such as illegal substance#atient reports feeling con2dent in talking to she has a problem"


14/25

Help the client formulate plans to contactsupport services such as communitymental health workers or pastoral carepersonnel, to discuss the clients concernsabout self and lifestyle adaptions"

#roviding a plan with speci2c, delineatedsteps enables the client to follow themthrough and achieve success

#atient reports feeling con2dent in talking to shee has a problem" #atient has limited famisupport and community help when she is outhospital" #atient reports that praying and goichurch is helpful in her staying away from nein7uences"

Help the client establish a predictable,daily routine while incorporatingmedication compliance"

8aily routines provide structure and asense of security and reduce the stressthat can provoke delusional thinking"

#atient reports likeing the unit schedule becagives her something to do and be distracted negative thoughts and feelings" #atient reporbene2ts in taking medication in reducing audhallucinations"

Priority # _3__ CARE PLAN


15/25

Nursing Diagnosis: $-paire health -aintenance, relate to o.esity, -etha-pheta-ine a.use, lac+ of e2ercise,lac+ of +no/lege, ine*ecti%e coping, an lac+ of support syste-s ae. -eication nonco-pliance, lac+ ofe2presse interest in i-pro%ing health .eha%iors, failure to recognie or respon to i-portant sy-pto-sreecti%e of changing health state, an ina.ility to follo/ instruction or progra-s for health -aintenanceP: $ne*ecti%e 4ealth 5aintenanceE: Patient has a history of -eication nonco-pliance that lea to fre(uent hospitaliations" Patient sho/s li-ite+no/lege into -eication regi-en" Patient sho/s little insight into current health conitions an little interestinto -anaging her conitions" Patient has poor support syste- in helping her -anage her health conitions"S: Eucate patient a.out current -eication regi-en, heath conitions, an techni(ues to i-pro%e her health"6*er group therapies an e2ercise progra-s to help patient e2press thoughts an feelings an to participate in

her care"L goal$ #atient demonstrates positive health maintenance behaviors aeb keeping scheduled appointments, participating insubstance abuse programs, making diet and exercise changes, improving home environment, and following treatment programsduring hospitali*ation"

S goal$ #atient verbali*es understanding of current health conditions and expresses insight and interest in health improvementduring my shift"



E%aluation

0ssess the patients knowledge of healthmaintenance behaviors, health history,and environmental, social, intrafamilialdisruptions or changes that have

correlated with poor health behaviors"

.he health care provider needs to ensurethat the patient has all the informationneeded to make good lifestyle choices"0ssessment may give some perspective

on poor health habits and on factors ofgeneral condition"

#atient reported being obese due to the medshe was taking" #atient reported not exercisinmuch as she probably should and that she hachronic back pain for years" #atient reported

di6culty in taking her medications due to theamount of medication that she needs to take#atient reported eating a lot of fast food with family because it9s the easiest food to get"

8iscuss noncompliance with instructionsor programs with the patient, andidentify barriers to maintaining healthbehaviors"

.he patient may be experiencingobstacles in compliance that can beresolved"

#atient reported a want to get skinnier but blher medication for being the cause of all her gain" #atient reported switching to dierentantipsychotic medications but still 2nds troubmaintaining her weight" #atient reported the to do more exercise"


16/25

%nvolve family in health planning, andcompliment patient on positiveaccomplishments

:amily members need to understand thatcare is planned to focus on what is mostimportant to the patient and positivereinforcement enhances behaviorchange" #atients with a stronger self1e6cacy are more likely to engage inpositive behaviors"

#atient reported that she has a poor family suwhen it comes to maintaining her health becthe house is so crowded" #atient lives with nephews, and husband and feels she is tootaking care of them" #atient reported getting of her points when it comes to activities anden4oyes getting points so that she can do mothings"

#rovide the patient with a rational for theimportance of proper nutrition, exercise,hygiene, substance abuse cessation,stress management, regular physical andto report changes in health"

;utrition, exercise, hygiene, substanceabuse cessation, stress management,regular physical and reporting unusualchanges in health contribute to positivehealth management and lets the patientbecome involved and in control of self"

#atient reported the want to exercise more, ehealthier, and be substance free" +he reportethe only reason she is substance free is becashe has been locked up for so long and hasn9around it" #atient reported liking the food at thospital and that she has a salad everyday" #has reported the weight gain from her medicand has interest in switching medications"

http:--www"homesteadschools"com-lcsw-courses-Psch*atr*cMental-Chapter06"html

http://www.homesteadschools.com/lcsw/courses/PsychiatricMental/Chapter06.htmlhttp://www.homesteadschools.com/lcsw/courses/PsychiatricMental/Chapter06.html


17/25

Burns Depression Checklist

Place a check ( ) in the box to the right of each category to indicate how much this type of

feeling has bothered you in the past several days.

!ot at "ll

#

$omewhat

%

&oderately

'

" ot

1. $adness Do you feel a! or !o"n in

the !ump#

*

2. Discouragement Doe the future loo$ hopele#

*

3. ow self+esteem Do you feel

"orthle#*

,. -nferiority Do you feel ina!e%uate or

inferior to other# *

. /uilt Do you get elf&'riti'al an! (lame yourelf#

*

0. -ndecisiveness ) it har! to ma$e!e'iion#

*

1. -rritability Do you fre%uently feel

angry or reentful# *

2. oss of interest in life *a+e you lotinteret in your 'areer, ho((ie, family,

or frien!#

*

3. oss of motivation Do you ha+e ot

puh yourelf har! to !o thing# *

#. Poor self+image Do you feel ol! or

unattra'ti+e# *

##. "ppetite changes 4ave you lost

your appetite5 Do you o+ereat or (inge 'ompuli+ely#

*

#%. $leep changes ) it har! to get a goo!night- leep# re you e'ei+ely

tire! an! leeping too mu'h#

*

#'. oss of sex drive *a+e you lot your

interet in e#

*

#,. Concerns about health Do you"orry e'ei+ely a(out your health# *

#. $uicidal impulses Do you ha+ethought that life i not "orth li+ing or

thin$ you-! (e (etter off !ea!#

*

6otal $core on items #+# #1


18/25

Scor*n& e )or ?urns !epress*on Chec>l*st

Total Score!e&ree o)

!epress*on

0 7 '

M*n*mal or No !epress*on

. 7 +0

Normal ;ut Unhapp

++ 7 ,0

?orderl*ne to M*ld

!epress*on

,+ 7 30

Moderate !epress*on

3+ 7 '.

Se@ere !epress*on


19/25


20/25


21/25


22/25

Py'h&0! ea!erhip

Topi' tre

). hat i tre#

a. tre 'an (e !efine! a the (rain repone to any !eman!. any thing 'antrigger thi repone, in'lu!ing 'hange.

)). *o" !oe tre affe't the (o!y#

a. ith 'hroni' tre your immunity i lo"ere! an! your !igeti+e, e'retory, an!repro!u'ti+e ytem top "or$ing normally.

(. Pro(lem o''ur if the tre repone goe on too long, u'h a "hen the our'e of

tre i 'ontant, or if the repone 'ontinue after the !anger ha u(i!e!.

))). *o" !oe tre affe't your o+erall health#a. There are at leat three !ifferent type of tre, all of "hi'h 'arry phyi'al an!

mental health ri$

i. outine tre

ii. tre (rought a(out (y a u!!en negati+e 'hangeiii. Traumati' tre

(. ome people eperien'e mainly !igeti+e ymptom, "hile other may ha+ehea!a'he, leeplene, !epree! moo!, anger an! irrita(ility. People un!er

'hroni' tre are prone to more fre%uent an! e+ere +iral infe'tion, u'h a the

flu or 'ommon 'ol!'. O+er time, 'ontinue! train on your (o!y from routine tre may lea! to eriou

health pro(lem, u'h a heart !ieae, high (loo! preure, !ia(ete, !epreion,

aniety !ior!er, an! other illnee.

). *o" 'an ) 'ope "ith tre#a. The effe't of tre ten! to (uil! up o+er time. Ta$ing pra'ti'al tep to maintain

your health an! outloo$ 'an re!u'e or pre+ent thee effe't. The follo"ing are

ome tip that may help you to 'ope "ith trei. ee$ help from a %ualifie! mental health 'are pro+i!er if you are

o+er"helme!, feel you 'annot 'ope, or ha+e ui'i!al thought

ii. tay in tou'h "ith people "ho 'an pro+i!e emotional an! other upport.iii. e'ognie ign of your (o!y repone to tre, u'h a !iffi'ulty

leeping, (eing eaily angere!, feeling !epree!, an! ha+ing lo" energy.

i+. et prioritie

+. :ote "hat you ha+e a''omplihe! at the en! of the !ay, not "hat you ha+e (een una(le to !o.

+i. +oi! !"elling on pro(lem. )f you 'ant !o thi on your o"n, ee$ help

from a %ualifie! mental health profeional "ho 'an gui!e you.. Other "ay to help yourelf !eal "ith tre

a. 0er'ie regularly&;ut 3< minute per !ay of gentle "al$ing 'an help (oot moo!

an! re!u'e tre.i. =oni!ere! +ital for maintaining mental fitne, an! it 'an re!u'e tre.

tu!ie ho" that it i +ery effe'ti+e at re!u'ing fatigue, impro+ing

alertne an! 'on'entration, an! at enhan'ing o+erall 'ogniti+e fun'tion.

1. e!itate, >reathe !eeply, Tal$ to other


23/25

(. 'he!ule regular time for healthy an! relaing a'ti+itie

'. 0plore tre 'oping program, "hi'h may in'orporate me!itation, yoga, tai 'hi,

or other gentle eer'ie.!. 0ating goo!

i. ater, freh +egeta(le, freh fruit, fih, oup, yogurt

1. ?reh fruit an! +egeta(le pro+i!e an array of +itamin an!mineral that are great for re!u'ing tre. egeta(le alo ha+e a

high fi(er 'ontent, "hi'h i helpful in treating 'ontipation @

another long&term effe't of tre2. ?ih u'h a ma'$erel 'ontain omega fatty a'i!, "hi'h are

etremely goo! for the heart an! 'an prote't you from heart

!ieae. ?ih alo 'ontain 'holine @ a great memory (ooter

3. Aogurt pro+i!e mineral in'lu!ing 'al'ium, eential to maintain"ell fun'tioning ner+e impule.

4. To $eep tre to a minimum, !eign a meal plan for the !ay that

in'orporate a (ig meal in the morning, omething relati+ely light

for lun'h an! another light meal in the e+ening. ala! (efore youre+ening meal "ith fruit an! yogurt after i a ure "ay to atify

your appetite.e. leeping

i. hen you are tire!, you are le patient an! eaily agitate! "hi'h 'an

in'reae tre. ot a!ult nee! 7&8 hour of leep per night. Pra'ti'inggoo! leep hygiene along "ith tre&lo"ering ta'ti' 'an help impro+e

your %uality of lee

0OB=0

http//""".nimh.nih.go+/health/pu(li'ation/tre/in!e.htmlhttp//""".la"o'iety.org.n/la"tal$/la"tal$&ar'hi+e/iue&813/leep&'an&re!u'e&tre&le+el

http//""".a!aa.org/un!ertan!ing&aniety/relate!&illnee/other&relate!&

'on!ition/tre/phyi'al&a'ti+ity&re!u'e&thttp//"""."e(m!.'om/(alan'e/gui!e/(liing&out&1


24/25

• Three Sisters

o Described as fighting a lot and not getting along

• Father was a “rubbish man and mother was a bus driver

o Father: described as her bestie

o Mother: described as her teacher

• Due to limited resources of the family and being sickly with asthma, she was mostlyraised by her grandfather

• Family Mental Health

o Mother has depression

o Uncle has Schizophrenia

o Sister is Bipolar

o She kind of lucked out with all three and then some

• Describes herself as a tomboy and a funny kid, who liked to play volleyball

o Unfortunately at a young age, she described insecurities of self image due to

being made fun of her “huge tits” by children when they were playing Pictionary

o To this day, she still finds trouble in playing this game and speaking in front ofpeople

• History

o Started hearing voices around age 11 or 12

o Started marijuana at age 12

o Heavy alcohol abuse at age 15

o Pregnant in her senior year in High School

• The father of her child is her current husband today. They have known each other for 31

years and have been happily married for 24 years, with bumps in the road.

o Patient describes her husband as her rock

•

The eventually had 2 daughters and 1 sono Poor Family Dynamic: She described her relationship as when she would start to

getting delirious and hallucinations… kids would tell her “Mom go take your

meds.”

• Long history of substance abuse and just got worse as she discovered meth

o Till this day she has well over 20 years of methamphetamine use

o Her Biggest Guilt was starting her husband on meth. The two got so far into it

that they started cooking

• Started hearing voices in the mid 90’s around when she started using meth, which lead to

frequent hospitalizations.

o Lost many jobs (Kmart, Hostess, and Fisher)

o Admitted to Kahi Mohala in 97 d/t Schizoaffective disorder

• Many more medical issues pilled up and her health continued to get worse

• Major Problems

o Poor Family Dynamic with children

Haven’t spoken to them since before her hospitalization and previous jail

time

Only been in contact with her sister


25/25

o Medication noncompliance- doesn’t like the side effects

o Substance abuse

o Frequent Hospitalizations

o Harm to her self (attempted overdose by medication) and harm to husband

o Ineffective coping

• Adjustmento In adjusting to her hospital stay, she attends meetings, participates in group

therapy, and is cooperative and friendly

• Goals

o Be a family again

o Spend more time with her grandchildren (met once) and nieces

o Be substance free

o Continue taking medication (reports benefit from them)

o Eating healthy so she can loose weight

• What must happen

o Maintain medication regimeno 12 step

o Substance free

o Utilize community resources to help her be med compliant

o Learn effective coping techniques

capstone tshumway

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