Nursing Care Plan
Nursing Care Plan
Student(s) Name: Date:
Medical Diagnosis: depression, suicidal, deliberate self harm, personality disorder, ankylosing spondylitis of lumbar region, anxiety and suicidal behavior.
Nursing Care Plan MUST HAVE 3 DIAGNOSIS 3 related goal, nursing intervention, rationale and evaluation
| Assessment Data | Nursing Diagnosis and Related Goals | Nursing Interventions and Rationale | Evaluation |
| Subjective: patient was hallucinating “stated unable to sleep because im seen thing everytime I close my eyes”
Patient is suspected of taking opiod in his room due to unexplain dillerium and hallucination.
Patient is also suspected of not wanting to leave the mental health unit as it’s a safe space and place hes able to sleep since hes homeless.
Patient suspect of mimicking other disorder or other people diagnosis too seek attention.
Objective: Male, 54 y.o.
Admitted to hospital for post traumatic stress disorder PTSD. Admitted into mental hospital on a Form 1, but currently on a volunteer inpatient psychiatric help.
Diagnosis-depression, suicidal, deliberate self harm, personality disorder, ankylosing spondylitis of lumbar region, anxiety and suicidal behavior.
Vital: B/p- 135/90 on left arm, automatic, in a sitting position. Spo2-98% on room air Temp-36.5 oral Pulse- 68 Automatic Pain- 9/10 aching discomfort in lower back
Rx list: Acamprosate, amlodipine, bupropion, cholecalciferol, cyanocobalamin, duloxetine, Olmesartan, polyethylene glycol, pregabalin, pyridoxine and upadacitinib extended release
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Nursing Interventions
Rationale
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References
Complete Answer:
