Question

The nurse completes a physical assessment. When asked what brought her to the hospital, Betheny replies, "things just aren't right" and begins to cry. After further conversation, Betheny describes her mood as "very sad now." She rarely goes out or invites friends to visit. She admits that she feels like strangers are saying bad things about her. Sometimes she hears a man's voice that is a "little bit scary."Betheny's daughter, an only child who is visiting from out of town, offers additional information about Betheny's behaviors. She tells the nurse that her mother's clothes fit looser, and weight loss is evident. Current alcohol use is suspected, and a breathalyzer is positive for alcohol use. Betheny denies current suicidal ideation, but the nurse recognizes that the client has risk factors for suicide based on the SAD PERSONS scaleBetheny is assessed by the nurse, a social worker, and the HCP. Based on their assessments, hospitalization is recommended for psychotic depression.The nurse asks Betheny to sign consent for treatment.Betheny signs the treatment form and is admitted to the mental health unit. During the first days of hospitalization, she begins antidepressant therapy with fluoxetine (Prozac), 10 mg.The nurse is reviewing Betheny's admission lab work on the 3rd day of hospitalization. Admission labs include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine drug screen, and VDRL (RPR).When Betheny awakens in the morning, she sits for periods of time at the edge of her bed. She does not initiate combing her hair, getting dressed, or going to breakfast.One morning, the nurse takes Betheny's vital signs and notes her blood pressure is 141/108 mm/Hg. The progress notes indicate this is the third incidence of a high blood pressure.The nurse reports the elevated blood pressure to the HCP, and Betheny is prescribed hydrochlorothiazide (Hydro-Chlor) 25 mg daily. The nurse collaborates with the dietician about Betheny's meal plan.One morning, the nurse is doing unit rounds and finds Betheny sitting at the edge of her bed with a sheet around her neck.The nurse stays with Betheny until another staff member arrives and safety precautions are initiated. A staff member must keep Betheny within eye sight at all times and document her activity every 15 minutes.Betheny is placed on constant observation for safety precautions, so the nurse must assign a staff member to remain with her at all times.

Make a care plan with 2 nursing diagnosis, 6 interventions, 3 subjective data 3 objective data , goals, and evaluation

Answer 1

The patient is diagnosed with psychotid depression

Major nursing diagnosis

• Risk for self directed violence related to present suicidal ideation as evidenced by SAD person scale result
• Impaired thought process related to auditory hallusination as evidenced by patient verbalisation