NURS 360

Capstone Project
PMH Care Plan
Student Nurse Reporting Form
SN: Jonathan Onigama
Pt.: Sex: Male

Age: 17

Date: 10/02/2015
Date of Admission: September 17, 2015

Transferred? ___No _x_Yes:

(Reason/Date) 9/17/2015 MH4 from Hilo Medical Center for depression and SI/SA
Income source: __Parental________________________________________
Legal Status: _________MH5a_______________Expiration Date: __N/A_______
DSM Diagnosis:
I MDD (Major Depressive Disorder) with Substance Abuse
_________________________________________________________________
II Deferred
__________________________________________________________________
III History of Hives when Anxious= Anxiety induced Hives
___________________________________________________________________
IV Pyschosocial & Environmental Problems- Stressors are primary support groups
(social and educational environment)
______________________________________________________________________
V Highest GAF Past year- 55 - GAF at admission- 42
______________________________________________________________________
What brought patient to the hospital?
Patient had a fight with father and girlfriend. Patient went to the police and told them
that he wasnt feeling safe and felt like hurting himself. Brought to Hilo Medical Center
for observation and stabilization. The patient was referred to Kahi Mohala on an MH-4
based on Depression and recent thoughts of suicide.

Patients description of illness/issues:

Per patient, patient had difficulties since 2012. From the age of 3, patient has been
living with uncle and aunt. Aunt passed away suddenly (2012) and had to live with
biological parents. Patient was depressed due to close relationship with his aunt.
Everyone was telling patient to get over the aunts death and move on. Uncle remarried
within the year. Patient felt that it was disrespectful to both him and the aunt. Patient
does not like parents emphasis on religion and how religion can solve everything.
Patient cannot accept familys religion due to Aunts death and parents preoccupation
with religion. Patient does not want to live with biological parents. Due to arguments,
patients father kicked him out, and has been living with girlfriend and her parents for
several months. Prior to admission to Kahi Mohala, the patient had an argument with
his girlfriend and she broke up with him. Patient describes his girlfriend as a person
who can calm him down and make him feel better and due to the break up, patient felt
lost and went to the police feeling unsafe, and had thoughts of hurting himself, and
having no place to live.
Spirituality: None. Per patient, biological family believes that religion is one of the most
important aspects in life. Patients parents are preoccupied with religion and believe that
religion can solve most, if not, all of lifes problems. Patient does not believe that and
feels that there is more to life than religion. Patients parents expect family to primarily
associate with members of the church and avoid unnecessary interactions and/or
activities when possible. Patient believes that this is too much and wants to live life like
a normal person.
Considerations r/t ethnicity or religion: The patient does not believe or accept his
familys religion due to his parents emphasis on it and the disrespect that the family and
church showed towards his Aunts death.

Patients Strengths: Patient enjoys weight lifting, playing football/basketball, and

working on cars. Patient also enjoys other active hobbies that he uses to help cope with
stressors.
Patients Limitations: Patient has maladaptive coping strategies. Patient also been
experiencing difficulty focusing in school and grades hasnt been good. Patient has a
lack of support and has difficulty controlling his anger, depression, and anxiety as
evidence by poor decision-making such as SI/SA via substance abuse and conflict with
biological parents.

Medications:
Order: Melatonin 3 mg PO qhs (before bedtime).
Drug class: sedative/hypnotic
Pts target sx: insomnia/sleep aide
Total 24h dose: 3 mg
Recommended range: 0.3-10 mg at bedtime
: L M H Max
Current Side effects: None noted/assessed
Order: Hydroxyzine Pamoate 25 mg PO, TID, q4h PRN
Drug class:
antianxiety agent, antihistamine w/anticholinergic and sedative effects.
Pts target sx: itching/scratching (pruritis), insomnia, anxiety
Total 24h dose: 75 mg/24 hours
Recommended range: 25-100 mg 4 times/day for anxiety; for antipruritic effects: 25
mg 3-4 times/day
: L M H Max
Current Side effects: None noted/assessed
Order:
Drug class:
Total 24h dose:
L M H Max
Current Side effects:
Order:
Drug class:
Total 24h dose:
L M H Max
Current Side effects:

Pts target sx:

Recommended range:

Pts target sx:

Recommended range:

Order:
Drug class:
Total 24h dose:
L M H Max
Current Side effects:

Pts target sx:

Recommended range:

AXIS III: List all conditions even if they are not listed in multi-axial diagnoses or
on chart. (Particularly note any unstable conditions & all non-medication
interventions.)
1. Stress/Anxiety Induced Pruritis/Hives & Scratching.
Patient is taking Hydroxyzine Pamoate PRN for the itching/scratching. Coping
strategies are also demonstrated for patient to learn to better cope with stress.
2. Insomnia
Patient is taking hydroxyzine pamoate prn for insomnia, and melatonin as a sleep
aid to help patient go to sleep. Insomnia may be associated with depression and/or
stress therefore treatment also include stress management and learning
positive/effective coping strategies.
3.
4.
BMI: 34.5

: Category: Obese

(Height: 57

Weight: 220 lbs )

Food & fluid intake: Good; 100% (breakfast & lunch)

Bladder & bowel status: Regular/normal
Sleep pattern: Some difficulty falling asleep, but sleeps through the night
Total sleep/24 hrs: 7-9 hours of sleep/24 hours
(Circle) Hypersomnia/Difficulty falling asleep/Middle insomnia/Early morning
awakening
Number of hrs of disruption: N/A
Naps: Sometimes, in the afternoon during free-time

Total nap time: 1 hour

Lab & studies

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Date/Panels in which all values were normal:

CBC with Differential: All within normal range
Metabolic Panel: All within normal range
Urinalysis: All within normal range
Date/Any abnormal labs:
Labs you would expect but were not ordered:
Glucose readings x 24h for all diabetic pts.:
Glucose reading: 93; however patient is not diabetic
All drug screen findings:
Urine Opiate: None Detected
Acetaminophen: None detected
Salicylates: None detected
Barbiturates: None detected
Amphetamines: None detected
Benzodiazepines: None detected
Cocaine: None detected
Cannabinoids: None detected
Alcohol: None detected

MENTAL STATUS ASSESSMENT:

Behavior: The patient is well developed and dressed appropriately for the unit/situation.
Hygiene is well maintained. The patient tends to be isolative when left alone, or some
distance is maintained around others within the units milieu. Patient is cooperative
when approached and interviewed. When asked about his feelings regarding family,
girlfriend, or discharge, patient scratches neck, arms, legs (pruritis).

Affect: When alone patient has a flat affect, however when approached or spoken to,
patient portrays a full/wide-range affect. Patient portrays an anxious mood when
sharing feelings regarding certain subjects (see behavior).

Sensorium: Patient is alert and oriented. Attention span, concentration, and abstract
thinking are intact. See cognition for more information.

Imagery: Patient does not have any sensory disturbance such as visual or auditory
hallucination. Patient does portray behaviors indicating stress or anxiety as evidence by
scratching/itchy, fidgeting with hands/legs, etc.

Cognition: Patient is alert and oriented x3 (person, place, and time). The patients
attention span and concentration is intact as evidence by current events (sports).
Patients memory (short-term) is intact as evidence by recalling 3 objects/words after 5
minutes. Patient has fair insight as evidence by identifying the reason for admission
and the cause of it, however the patient has poor judgment as evidence by recent
suicidal thoughts and having a history of suicide attempts/self-harm. Abstract thinking is
intact as evidence by appropriately participating in coping exercise(psycho
Health/Education group) relating animals living in natural/harsh environment to humans
coping with our surroundings, events, and other factors.

Interpersonal relationships: Patient does not like father and does not get along with
biological parents. Patient is unsure of his status with his girlfriend. Patient mentions
having friends, but avoids describing the strength of the bond/friendship between them.
Due to religious beliefs, patient is unable to associate with members of the church or
family members of the same faith, due to not acknowledging and accepting the family
religion.

Developmental level: (Assets & barriers): No developmental delays observed.

Patient lacks primary support group, and due to the situation at home with biological
parents, school attendance and focus has been affected negatively.

Drugs: Substance abuse or dependence: (Include nicotine & any alcohol &
drugs. List by drug: Last date of use/Current acute intoxication or withdrawal
signs and symptoms when SN caring for pt./Used how long/Route/Usual
amount/Negative consequences)
Drug class

Last Use

Acute intox or Length of

withdrawal sx? Time Used

Marijuana

9/14/15

none

(THC)

Route

Usual amt.

Negative

First use @ PO,

N/A;

Consequences
None noted at the time

14 y/o

couple

of interview or

times a

assessment.

Smoking

year

Problems Identified In Hospitals Master Treatment Plan:

1. Identify SI/SA thoughts. Reduce or eliminate thoughts of suicide/self-harm.
2. Mood Disturbance
3. Impulsive Behavior/acting out
4. Family Conflict
5.
Current Discharge Plan: Patient is encouraged to continue outpatient individual
therapy/family therapy. The patients social worker is to work with the school to
provide the patient with school support and intensive in home services. Patient and
family along with the MD are to explore other out patient therapy vs RTS (Religious
Trauma Syndrome).
Nursing interventions you performed this shift (Include safety and teaching!):
Student nurse (me) conducted Psycho Health/Ed group pertaining to coping. Student
nurse encouraged patient to participate in school and group activities. Student nurse
conducted a 1:1 interview/MSE (mental status exam), and educated patient on coping
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strategies. Student nurse also conducted a TM33 and assessed for risk of self-harm or
suicidal thoughts. Patient scored a 3 on the TM33/suicide risk evaluation tool, which is
considered low risk.
Patient-centered Care Analysis
PRIORITIZED PATIENT NEEDS
What are the patients 4 highest needs/problems?
(Use your best nursing judgment! It will be different than the master treatment
plan.) P=Problem, E= Evidence, S= Solution.
1. P: Safety related to risk of Suicide
E: Patient had recent thoughts of self-harm/suicide at the time of admission and has
a history of SI/SA via substance abuse (overdosing on medication from cabinet). Patient
has depression
S: Staff/Student nurse can conduct a TM-33 (suicide risk evaluation). Staff or nurse
in charge of care can ask patient if there was any prior attempts to commit suicide or
harm self. If there is a risk for suicide, nurse can make a contract with patient for
him/her to disclose any/all impulse to harm self or suicide to the staff immediately and
agree to participate in treatment plan to reduce/eliminate suicidal behaviors (Gulanick,
2014). Staff/nurse should assess for any support group, plan or intent to commit
suicide. Encourage/educate patient on community/public resources i.e. hotlines, etc for
ongoing support, and teach patient cognitive-behavioral self-management responses to
suicidal thoughts (Gulanick, 2014).

2. P: Ineffective coping

E: Patient is lacking support system. Patient experiences constant conflict with

biological parents and prior to admission, patient and his girlfriend had an argument and
broke up. Patient has a history of SI/SA and went to police feeling unsafe.
S: Staff/nurse should assess for behavioral/physiological responses to stress, and
triggers. The patients support systems and other resources should be evaluated. To
promote a working relationship with the patient, continuity of care should be assessed
and implemented (Gulanick, 2014). The staff/nurse should allow the patient to express
fears or concerns and encourage the patient to identify his/her own strengths and
weaknesses. Staff should encourage the patient in activities that fosters coping
strategies and other positive behaviors (Gulanick, 2014).

3. P: Readiness for managing stress

E: Patient was able to seek help from the police before any harm was done to self
or others. Patient is cooperative with staff, MD, and nursing student with treatment
plan, group activities, and interviews. Patient verbalized the need to better
manage/cope with stress.
S: Staff/nursing student should determine the patients level of motivation to
participate in stress management program, and assess for specific stressors (Gulanick,
2014). The staff should also explore any stress reduction/coping strategies that the
patient used in the past. Staff should assist patient in setting realistic goals in managing
stress. Staff should assist patient in developing emergency stress stoppers such as
removing self from situation, counting to 10, etc. Education and demonstrate a variety

of coping techniques and passive relaxation techniques, and request patients to

demonstrate. Assist and prepare patient in case of possible relapses (Gulanick, 2014).

4. P: Interrupted Family Processes

E: Evidence of conflict between patient and his biological parents (primarily father).
Problem has persisted for 3 years, since the patient has moved back into the home
since Aunts death. Communication has been non productive between patient and
parents. Patient lacks primary support from parents/family/girlfriend.
S: Staff should assess precipitating events of family problems, evaluate coping skills
and support groups. Staff should assist family in breaking down problems into
manageable parts and refer family to social services/counseling (Gulanick, 2014). Staff
should inform family of community resources that are helpful in the long term of
treatment. Staff should encourage family to empathize with each other (Gulanick,
2014).

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Priority # 1
CARE PLAN
Nursing Diagnosis: Risk of Suicide related to recent thought of SI/SA and history of SA.
P: Safety related to risk of suicide
E: Patient had recent thoughts of self-harm/suicide at the time of admission and has a history

of SI/SA via substance

abuse (overdosing on medication from cabinet). Patient has depression.
S: Staff/Student nurse can conduct a TM-33 (suicide risk evaluation). Staff or nurse in charge of care can ask patient if
there was any prior attempts to commit suicide or harm self. If there is a risk for suicide, nurse can make a contract with
patient for him/her to disclose any/all impulse to harm self or suicide to the staff immediately and agree to participate in
treatment plan to reduce/eliminate suicidal behaviors. Staff/nurse should assess for any support group, plan or intent to
commit suicide. Encourage/educate patient on community/public resources i.e. hotlines, etc for ongoing support, and
teach patient cognitive-behavioral self-management responses to suicidal thoughts.
LT goal: After discharge (~3months), patient is able to utilize community resources and is free from SI/SA.
ST goal: By the end of shift, patient discloses all impulses of self-harm or suicide and is safe.
Scientific Rationale
Intervention & Frequency

(In complete sentences!)

(Reference in APA format, including page number)

Evaluation

By conducting a TM-33 or assessing the

Conduct TM-33/suicide risk evaluation or potential for self-harm daily the staff is
assess for potential self-harm daily.
ensuring the patients safety and
preventing harm to self and others

Provide opportunities for the patient to

express concerns, fears, feelings, and
expectations in a nonjudgmental
environment every shift.

Patient discloses information regarding current

feelings and any impulses regarding suicide, selfharm, or harm to others. Patient is no threat to
him/herself or to others and is free of SI/SA. At the
time of interview, patient was at a low risk for suicide
(Fortinash, 2012).
(3 on tm33 tool), but no current plan or thoughts of
SI/SA.
Patients benefits from talking about
See above. Patient is able to disclose feelings,
suicide with trusted staff. Verbalization of concerns, fears, and expectation to staff during each
feelings may lessen their intensity and
shift/daily or as needed with an improvement in
allows the patient to see that staff
feelings/thought content and reduction in negative
members care and are open to discussion thoughts or suicidal thoughts. Patient is able to

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regarding suicidal thoughts

2014).
Develop a verbal or written contract
stating that the patient will not act on
impulse to do self-harm at time of
admission. Review and update contract
as needed.

Teach the patient cognitive-behavioral

self-management responses to suicidal
thoughts every shift.

(Gulanick,

express concerns and feelings regarding being

discharge and going back home to biological parents.

A written or verbal agreement establishes Patient and staff continuously work on verbal/written
permission to discuss the subject of
contract to promote safety. Patient does not act on
suicide, makes a commitment to not act on impulse and is safe. Over time, with improvement to
impulse and cause self-harm or to others, the patients overall wellbeing, contract can be
and establish a plan for when impulses
revised as needed. A contract was establish at the
time of admission, and has been revised since.
occur (Gulanick, 2014).
Patient appears to have better impulse control
through CBT/DBT activities.
Patients are able to recognize and respond Patient is able to demonstrate a variety of CBT/DBT
better to early thoughts of suicide.
strategies and verbalize positive alternative to the
Patients are able to identify triggers, and negative/suicidal thought. Patient will demonstrate
negative talk/thoughts and develop
and utilize better coping skills. The patient is able to
positive approaches to counter the
inform staff and nursing student about negative
thoughts, and the ability to stop and think of
negative thoughts (Gulanick, 2014).
consequence and attempts to initiate positive self talk
and other coping strategies.

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Scholarly Journal Article review, Source and Implications:

In the article by Layous, Chacellor, Lyubomirsky, Wang, and Doraiswamy (2011), pharmacological treatment is compared
to various forms of psychotherapy such as CBT/DBT, and PAIs or positive activity interventions. The article discusses the
limitation and benefits about both, pharmacological and psychotherapy. Not all patient can afford health care or have the
financial stability to afford medication to maintain therapeutic effects of the medication, but medicine is proven to alter
neurotransmitter regulation, and with some patients treat the symptoms of depression and put them into remission
(Layous et. al, 2011). However, not all patients are susceptible to the medications effects and sometimes will need to
switch medications multiple times or switch treatment altogether i.e. electroconvulsive therapy. That being said,
psychotherapy whether it is CBT, DBT, individual/family counseling, or PAIs are relatively less expensive than other
treatment administrations, carry no side effects, can be done outside of the hospital or facility/office, potential benefits for
depressed patients, and shows promise to yield rapid improvement to mood (Layous et. al, 2014). The article describes
medication as the means to reduce or eliminate symptoms, but it may takes weeks or up to months for therapeutic effects
to show, and if the patient stops the medication, symptoms return. PAI and other form of psychotherapy focuses on
changing the way a patient thinks, assisting them to cope with stress, initiate positive self-talk/thought, effective and
positive coping/stress management skills, and has a more rapid improvement in mood, and can potentially assist the
patient in controlling symptoms or negative thoughts in the long term goal setting (Layous et. al, 2011). Medication
treatment is there if needed, but the article emphasizes the need for further study regarding psychotherapy/PAI as an
adjunct or alternative in the treatment of Major and minor depression.
This article is related to my patient in the sense that according to the charts, the MD does not feel that the patients
symptoms and diagnosis warrants residential care (Patient was initially on the acute unit, but later moved to residential).
MD feels that antidepressants are no warranted and that psychotherapy is the treatment of choice. The MD also feels

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that the patients diagnosis may not be MDD, but rather adjustment disorder based on symptoms shown. The patient
does have a history of self-harm and suicide attempts via overdosing with Tylenol and other medications found in his
homes med cabinet, but on the unit the patient is overall well. Patient does portray a flat/depressed affect, but when
approached or encouraged to participate in activities, the patient will actively do so and show a full/wide range of
emotions, moods, and affect. The patient portrays symptoms of stress and anxiety when talking/thinking about being
discharged back to biological parents, breaking up with girlfriend, getting into conflicts with the father. The in hospital
treatment plan was to reduce and eliminate SI/SA tendencies, while promoting CBT/DBT activities along with learning
coping/stress management strategies, and participating in group activities with patients his age. The social worker also is
involved in setting up living conditions with the parents and has been actively working with the school for more support for
the patient as well as assisting the patient and father to come to terms and agree on lifestyle and living situation changes.
Individual and family counseling has been brought up and patient and family agreed to participate. There are other
precautions being taken, which can be found in its respective care plan. With the summary of the plan of care for the
patient, this article coincides with the treatment plan that the MD and the staff at Kahi Mohala constructed. Aside for
individual and family counseling, the patient has been actively participating in PAIs, DBT/CBT, and coping/stress
management classes. Thats why I felt that this article was relevant to my patients plan of care.
Assessment Tool(s):
TM33/Suicide risk assessment tool was used:
The patient has agreed to tell staff if he/she is feeling unsafe. At the time of interview the patient stated that he has
no plan or thought of committing suicide. Patient has no plan of eloping or running away. The patient admits to having a
history or suicide attempt of low lethality (overdose on Tylenol, medication from medicine cabinet at home). The patient
describes feelings of anger/rage towards father and hopelessness, but has no morbid thoughts at this time. The student

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nurse feels that the patients replies are trustworthy, and this admission was due to feeling unsafe and thoughts of hurting
self due to argument with parents and breaking up with his girlfriend. Based on patients reply and according to the
assessment tool, the patient scored a 3, which is considered low risk or no precaution.
Assessment tools that were not used but could have been utilized:
Coppersmith Self Esteem Tool
Burns Depression Checklist
Burns Anxiety Inventory
The student nurse was not able to utilize these assessment tools, but was aware of the usefulness of these tools to
assess for level of depression, anxiety, and self-esteem which all play a role in positive and maladaptive coping strategies
and ultimately/potentially suicide. The student nurse was not able to utilize these tools due to the patients schedule with
on unit schooling and group activities conducted by the staff. The student nurse was able to conduct a TM33, which is
important to the student nurses priority #1 problem and plan of care.

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References:
References:
Deglin,J.,&Vallerand,A.(2011).Davis'sdrugguidefornurses(12thed.).Philadelphia,PA:F.A.Davis.(formedications)
Fortinash,K.,&HolodayWorret,P.(2012).MoodDisorders:Depression,Bipolar,andAdjustmentDisorders.InPsychiatricmental
healthnursing(5thed.,pp.241242).St.Louis,MO:ElsevierMosby.
Gulanick,M.,&Myers,J.(2014).Riskforsuicide.InNursingcareplans:Diagnoses,interventions,andoutcomes(8thed.,pp.185
188).Philadelphia,PA:Elsevier:Mosby.
Layous,K.,Chancellor,J.,Lyubomirsky,S.,Wang,L.,&Doraiswamy,P.M.(2011).DeliveringHappiness:TranslatingPositive
PsychologyInterventionResearchfortreatingMajorandMinorDepressiveDisorders.JournalofAlternative&
ComplementaryMedicine,17(8),6756839p.doi:10.1089/acm.2011.0139

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