OREM PSYCHIATRIC NURSING CARE PLAN

© 2004 Guiomar Goransson-Martin

Patient Initial AP Age 73 Gender M Date of Care March X 2004

PART I: Presenting Diagnosis(es): Major depression

Surgical Procedure(s) (r/t presenting diagnosis: Laparotomy and skin repair r/t self-infllicted stab wounds, laminectomy L3-4-5, hydrocele repair, multiple hernia repairs,

Chronic Disorders: Onychomycosis R foot, chronic lower back pain, osteoarthritis, 2 previous suicide attempts r/t severe depression, hypertension

Definition of Presenting Diagnosis(es)	Clinical Manifestations
Depression is classified as a mood disorder and is marked by a loss of interest in previously pleasurable activities and depressed mood that represents a change from previous behavior or mood. When an individual experiences a discrete episode of persistent and pervasive emotional depression, this term major depression may be applied.	To qualify for this dx, DSM-IV-TR requires the presense of at least one Major Depressive Episode. This episode must last at least 2 weeks, represent a change from previous functioning, and cause some impairment in a person’s social or occupational functioning. During an episode, it is also required that five or more symptoms be present. One of these symptoms must be either depressed mood or loss of interest in preiously enjoyable activities. The pt must also experience at least 4 additional symptoms, which may include: changes in appetite or weight sleep disturbance (usually trouble staying asleep) fatigue or loss of energy feelings of worthlessness or guilt difficulty concentrating, thinking, or making decisions recurrent thoughts of death or suicide.
Brief pathophysiology of Presenting Diagnosis(es)	Usual Collaborative Management
A person experiencing a depressive episode may express feelings of sadness and hopelessness or may express the sense of feeling empty or having no feelings. Some persons express somatic symptoms such as bodily aches and pains rather than sadness. Some will exhibit irritability or crankiness rather than sadness. Family members or close friends will notice a change in the individual most commonly a social withdrawal and neglect of activities that previously brought pleasure.	Psychotherapy Somatic or physical therapies such as electroconvulsive therapy, light therapy Medications such as tricyclics and related antidepressants
Ref: Frisch, Psychiatric Mental Health Nursing

PART II: ASSESSMENT DATA and ANALYSIS

BASIC CONDITIONING FACTORS

Developmental State	Health State
According to Erikson, client’s development state is: Integrity Versus Despair Client is on the Despair end of the continuum. Client exhibits feelings of: Mistrust AEB continual questioning of staff r/t routine procedures he has experience with. e.g client states, “Are you sure you know what you’re doing?” when known nurse changes dressings. Has not found a way to identify with being retired nor has he developed a self-concept with which he is happy. Has not found a way to cope with chronic pain other than attempts at suicide	Believes he’s depressed d/t chronic pain, anxiety and constant night sweats. Initially referred to Flower by Rescue Mental Health Svcs. 2 previous suicide attempts On previous suicide attempts: drug overdose, cut wrists History of aggressive behaviors denied Client states that depression started after back surgery and relates his current mental condition to the loss of his physical health and chronic pain. At discharge of previous hospitalization at Toledo Hospital psychiatric unit, client returned home and immediately overdosed. At discharge of previous hospitalization at St. Luke’s, client returned home and immediately stabbed self. On Jan 29, 2004 this client was admitted to F Hospital as unresponsive. Wife states client was in bathroom earlier that night, called out to him and heard only mumbling. Went in and found client on floor on R side, stuck between sink and toilet. Unable to get up on own. Life squad called and client transported. Other significant event occurred in 1991 when client was seen and treated with anticonvulsants for seizures. Client denies seizures No known allergies
Health Care System	Available Resources
Private hospital tx prior suicide attempt and private practitioner Stated that Toledo Hospital psychiatric unit was “self serve”. Client is under care of psychiatrist, Dr. S. Expects to receive and has asked for electroconvulsive therapy Receiving ECT during this hospitalization 3x per week. Max of 12 treatments ordered. Transfer meds: MS Contin, Ativan, Keflex, Ambien, Dulcolax, Percoset Advance directives on file States he needs more medication for lower back pain	Income: unknown Health insurance: unspecified Medicare: unspecified
Sociocultural-Spiritual Orientation	Environment/Patterns of Living
Episcopal Caucasian Senior citizen	Retired local law enforcement Client states it has been difficult to concentrate d/t the amount of meds he was taking at home. Denies aggressive behavior Leisure activities: reading news, geneology, sports Client states his strengths as, “My positive view of life” and “My logic”.
Family System States family supportive Father of 4 One brother One step brother Lives with wife Developmental stage: Aging family AEB Task -Coping with loss including health, job (retirement), loved ones and/or spouse, home, expectations	Relevant Life Experiences Depression which began after back surgery Airforce veteran 1952-53. Honorable discharge Graduate degree Former municipal judge Retired
Analysis: Highlight BCF Health Care Deficits

PART III: ASSESSMENT DATA and ANALYSIS

PART III: ASSESSMENT DATA and ANALYSIS

UNIVERSAL SELF-CARE REQUISITES

Maintain Adequate Intake of Air: Cardiovascular/Respiratory

Subjective Data

Objective Data

Denies SOB States frequent colds, at least 4 per year Denies chest pain Non-smoker

T 98.4 P 76 R 24 B/P 132/84 Thorax shape 2 x 1, symmetrical Respiratory excursion, slightly diminished on right. Posterior, anterior, lateral lung sounds quiet and unremarkable Capillary refill brisk, 1 seconds Inspiration equal to expiration. No use of accessory muscles while breathing. Skin is warm and dry No known allergies Apical, radial pulse equal, +3 Carotid arteries +3, no bruit Jugular vein, no distension Peripheral pulses, +3 Multiple self-inflicted stab wounds to abdomen, right wrist, left leg and carotid area Argenaid 6 oz. Juice BID for wound healing

UNIVERSAL SELF-CARE REQUISITES

Maintain Adequate Intake of Food and Water: Nutrition/Fluids/Metabolism

Subjective Data	Objective Data
Client states appetite is good however, C/O stomach acid and indigestion Lansoprazole enteric coated cap. (Prevacid) 30 mg PO qd Levofloxacin tab (Levoquin) 500 mg PO qd	Regular diet I&O not being measured. Consumes meals per day while in hospital. Height 6 feet 0 inches Admission Weight n/a Current Weight 208 Metropolitan Chart Weight 160-174 BMI 28 – client overweight Able to feed self.

UNIVERSAL SELF-CARE REQUISITES

Elimination: Bowel/ Bladder/Integument

Subjective Data

Objective Data

Constipation Biscodyl suppository (Ducolax) 10 mg. Rectal prn for constipation Docusate sodium capsule (Colace) 200 mg PO qd prn Magnesium Hydroxide concentrate liquid (Milk of Mag) 30 ml PO qd prn Lactulose solution 20 g/30mL PO BID prn MD order: dressing change to abdomenal wounds, cleanse w/Saf-Clens first. Silvabsorb to L wrist & R leg and neck. Use gel mixed with curity 2x2 and apply to wound base. Cleanse wounds qd with Saf-Clens

UNIVERSAL SELF-CARE REQUISITES

Maintain a Balance Between Activity and Rest

Subjective Data	Objective Data
	Client paces continually in the halls of this ward Temazepan capsule (Restoril) 15 mg PO hs – hold evening before ECT

UNIVERSAL SELF-CARE REQUISITES

Maintain a Balance Between Solitude and Social Interaction

Subjective Data	Objective Data
	Refuses group therapy Client is demanding at times with staff Corrects grammar of staff, comments unfavorably on their speaking abilities No visitors noted during 2 shifts Avoids interactions with other clients

UNIVERSAL SELF-CARE REQUISITES

Promote Normalcy

Subjective Data	Objective Data
Sexuality: client states no issue No substance abuse, however, uses alcohol Client states that depression started after back surgery and relates his current mental condition to the loss of his physical health and chronic pain.	Intellectual functioning within normal limits AEB vocabulary Much circumstantial/tangential speech Eye contact: good Speech tone: normal Speech pace: normal Body movement: normal No delusions noted

UNIVERSAL SELF-CARE REQUISITES

Prevent Hazards

Subjective Data	Objective Data
	No infection at IV site for ECT 0 Risk for falls

ANALYSIS: (Highlight Deficits identified)

Therapeutic Self-Care Demand	Strength	Limitation
1. Client needs to remain safe 2. Client needs relief and coping strategies for pain 3. Client needs therapeutic interaction with other clients	Seeking help and treatment Desires relief Good communication skills when he chooses to use them amicably	Depression Feels only answer is more pain relieving medications Does not seek out others for interation and refuses to attend group therapy

PART IV: PLAN OF CARE and IMPLEMENTATION

MEDICATION ADMINISTRATION

Medication (generic & trade name)	Dosage & method of administration	Action	Purpose Patient Receiving	Adverse Effects	Nursing Implications
Brand Name: Kristalose Generic Name: lactulose Drug Class: CATHARTICS AND LAXATIVES	20g/30nL PO BID prn	causes an increase in stool water content and softens the stool.	constipation	flatulence, intestinal cramps, which are usually transient.	Use with caution in diabetics since this medication contains galactose and lactose
Brand Name: Neurontin Generic Name: Gabapentin Drug Class: MISCELLANEOUS ANTICONVULSANT	100-mg PO TID	analgesic action is unknown	prevents pain-related responses in neuropathic pain	dizziness, somnolence, and peripheral edema	Withdrawal can cause Precipitated Seizure, Status Epilepticus
Brand Name: VISTARIL Generic Name: HYDROXYZINE PAMOATE Drug Class: MISC. ANXIOLYTICS- SEDATIVES AND HYPNOTICS	50 mg/1mL hs IM	action may be due to a suppression of activity in certain key regions of the subcortical area of the central nervous system	symptomatic relief of anxiety and tension associated with psychoneurosis and as an adjunct in organic disease states in which anxiety is manifested	Dry mouth, drowsiness	when central nervous system depressants are administered concomitantly with hydroxyzine, their dosage should be reduced
Brand Name: LASIX Generic Name: FUROSEMIDE Drug Class: DIURETICS	40 mg. Tab qd PO	inhibits primarily the absorption of sodium and chloride not only in the proximal and distal tubules but also in the loop of Henle	edema	Tinnitus and hearing loss Headache Blurred vision Systemic vasculitis Thrombocytopenia	Supplemental potassium chloride and, if required, an aldosterone antagonist are helpful in preventing hypokalemia and metabolic alkalosis
Brand Name: KAOCHLOR SF Generic Name: POTASSIUM CHLORIDE Drug Class: REPLACEMENT SOLUTIONS	20 mEq/15mL PO BID	Potassium is responsible for the conduction of nerve in the heart, brain and skeletal muscle. Also maintains normal kidney function, acid-base balance and carbohydrate metabolism	prevent low amounts of potassium in the blood (hypokalemia)	irregular heartbeat, weak or heavy legs, tingling in hands or feet, or numbness	Check to see if pt is on ace inhibitors such as captopril or lisinopril can increase the amount of potassium in the body
Brand Name: PREVACID Generic Name: LANSOPRAZOLE SR Drug Class: MISCELLANEOUS GI DRUGS	30 mg qd PO	inhibits gastric acid secretion	Short term tx of erosive esophagitis	Abdominal pain, N/V, diarrhea	Take before eating. Should be swallowed whole and not crushed, opened or chewed
Brand Name: LEVOQUIN Generic Name: LEVOFLOXACIN Drug Class: QUINOLONE ANTIBIOTICS	500 mg qd PO Give 2 hrs ac or pc antacid or meds w/zinc or iron	Susceptible pathogen is likely to be inhibited if drug reaches the concentrations usually achievable