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Concept Map Care Plan E. T/49yr. old female, white Attempted Suicide/Bipolar Disorder Depression/Alcoholism/Herniated Disc Nrsg DX #1 (Psycho social) Supporting Data: (Include subjective, objective, lab, diagnostic, pharmacologic and other data which supports your use of this diagnosis. ) Long Term Goal: Short-term goals: Nursing Interventions: Summary of patient progress: Risk for Suicide related to suicide attempt Patient attempted suicide 4x in the last 3 years. Patient states she wants help, wants to be sober.
Patient identified stressors (death of brother, abusive father, mother enabler, sister an addict) and uses alcohol binging as coping mechanism. Patient currently prescribed Depakote 1500mg/day, Celaxa 40mg PO am. Patient also stated she takes vicodin for pain due to herniated disc. Patient will recover from suicidal episode. Patient will describe available resources Patient will be med compliant. Patient will refrain from harming self. Patient will identify alternate coping strategies. Patient will find AA program and recovery site.
Administer meds, assess suicide ideation, assess moods. Make short-term contract with patient to refrain from harming self. Monitor behavior. Identify alternate coping strategies for patient, identify community resources to help patient. Goal met: Patient states no thoughts of suicide ideation. Patient identifies crisis prevention resources. Patient expresess positive feelings about self. Plan to be continued. Prognosis is good. Patient has identified Star of Hope halfway house where she can ive and attend AA treatment & group milieu therapy.
Risk for Ineffective Coping related to personal vulnerability Patient states that she had a good Job in IT, but lost shortly after bipolar diagnosis. Finances are getting low, causes anxiety. She was also seeing a psychiatrist that prescribed her Klonopin (prn). (Suicide attempt was OD of Klonopin & vicodin, mixed with alcohol). Patient is concerned about herniated discs. Patient stated that she needs to change her circle of friends. Doesn’t need drinking buddies.
Tried an AA rogram in River Oaks, didn’t feel that she fit in there. Patient uses alcohol and pills to deal with anxiety. Patient describes emotions triggered by illness or personal crisis and usual coping behaviors. Patient describes one difficult interpersonal situation that was solved by identifying the problem and choosing alternative way to communicate and take action. Patient will identify effective and ineffective coping techniques. Patient will express understanding of the relationship btn emotional state and behavior.