This is a psychiatric care plan and attached you will find the template in which you have to answer in, there is rubric by which everything has to be followed, and a document with ways to describe the Mental Health Assessment portion.
This is the information to be used:
35 yrs old, female, came into the hospital for voluntary admission for suicidal ideation. Not a smoker, nor alcohol, or drugs. Diagnosis: Bipolar 1, severely depressed without psychotic features. Allergies: none. Support System: both parents (mom and dad). Has 2 sisters (one older and one younger). Occupation: was a babysitter 10 years ago. Single. Highest grade completed: some college. Weight: 190 lbs. Health insurance: N/A. Significant primary caregiver: the mother. Language: english.
For diagnostic results: Put the mini mental exam results which is 30 .
Surgical Procedures: N/A
Past Health history: include the following psych and regular past history: say that the client stated that she was receiving psychiatric therapy and has a history of rhabdomyolysis with a history of a seizure at 2 years old”. Write that she has a past of anxiety attacks.
History of Present Illness: Make up a story about how the client has had a history of bipolar disorder and anxiety. State how they were having frequent and consistent attacks of anxiety that lead them to thoughts of self harm and how their psychiatrist recommended the client to volunteer themselves for help.
For the Mental Health Assessment: You can use the attached document for tips on how to write it. Make sure this is detailed.
For patho, use the diagnosis and describe it using APA 7th edition with in text citations.
Baseline and Current Vital Signs: BP: 126/76, Pulse: 67, RR:17, SPO2, 100.
Allergies: none
Diet with rationale: Regular diet because they have no limitations to their diet. explain a little more.
Activity Order: N/A, Limitations: N/A
For labs, use the following (APA CITATIONS TOO FOR RATIONALE)
Lithium Serum Level of 0.9 mEq/L (explain how this is relevant to the medication being used which is lithium)
White blood cell count (WBC): 8,000 per microliter (explain how its relevant to the medication of abilify)
ALT/AST: ALT: 50 U/L and AST: 15 U/L (explain how this is relevant to taking Ativan when explaining the rationale of the result)
Platelet Count: 250,000 per microliter (explain how this is relevant to taking Zyprexa when explaining the rationale of the result)
For IVs: N/A
For Medications, Include the following:
Lithium, Abilify, Benadryl, Ativan and Zyprexa. Make sure to follow the instructions as stated on the top of column. Make sure to be specific and detailed. Make sure to use in text citation in APA format for rationale, therapeutic range, and nursing implications.
For nursing theorists, must find the theory use at least 2, and explain it using APA in- text citations.
For the 3 Nursing Diagnosis, MUST USE NANDA 1.
Make sure the first diagnosis put on the list is the one that exemplifies that safety of the client such as suicidical ideation in this case. When describing the rationale of importance, make sure it is APA citation.
NOW:
When explaining the nursing diagnosis with the goals sections, follow these instructions and the ones on the sample.
– Make sure to write all three nursing diagnosis, but only dive into the most important one and write one short term goal with one long term goals and 3 interventions. YOU MUST TAKE INTO ACCOUNT CULTURAL CONSIDERATIONS.
– for subjective and objective data, info may be made up.
-Expected outcomes must be realistic and measurable. please make sure that each goal has 3 interventions. Nursing interventions must state action, frequency and person who is going to carry these out. Patient’s cultural, developmental and psychosocial status must be considered in nursing interventions
For the discharge plan, include how you will educate the client and the family among other things.
FOR THE GENOGRAM COMPUTED AT THE END:
MUST CONSIST OF PAST 2 GENERATIONS. MAKEUP THAT THE GRANDMA ON THE DAD’S SIDE HAS A HISTORY OF ANXIETY/DEPRESSION. SAY THE GRANDMA ON THE MOM’S SIDE HAD HYPERTENSION. see if this can be computer generated.
Make sure this has a reference page at the end with all the references!!!Please make sure it sounds complete and realistic
Thank you!!Please make sure its well organized and you adhere to my instructions, thank you.Please also erase the sample stuff from it. Please make sure its well detailed with no grammatical errors.