Fill out a mental health treatment plan template

Chamberlain University

Mental Health Treatment Care Plan

STUDENT’S NAME: _____ __________DATE:___ ______

Admission Data (20 pts)

Date of admission: (02/09/23) How long has the client been here? 15 Days.

Last Vital Signs: T: 47.7 F HR: 58bpm RR: 18/min BP: 98/64 mmHg PAIN: 2/10

In this section describe what you SHOULD assess for- and then what you were able to see with your client. You will not get an opportunity to assess every body system in this clinical- but based on what you know about the client- what would you want to look for.

General Survey - Observed: The patient had an Athletic body build, good hygiene, his appearance was appropriate for age, his mood was happy, and he was active.

HEENT - Observed: The patient’s hair was well distributed, no signs of dysphasia, no deafness, no blurred vision, or discharge from the eye. His skin color is appropriate for ethnicity. I would assess for legions on the head, and neck. Also, for a deviated septum and patency of each nostril.

Neurological - Observed: The patient showed no muscle weakness. I would have assessed for the effectiveness of the remaining cranial and facial nerves.

Cardiovascular (including peripheral vascular) - Observed: The patient showed no signs of chest pain, and exercise tolerated. I would have assessed

Respiratory - Observed: The patient had no cough and did not show signs of shortness of breath. Steady rate and rhythm of expiration. I would have assessed for chest symmetry during respiration and listen to lungs sounds.

Gastrointestinal - Observed: The patient had no signs of nausea, and no apparent abdominal pain. I would have assessed for abdomen symmetry, masses, and muscle separation on the abdomens.

Genitourinary – Observed: The patient showed no signs of urgency or frequency.

Musculoskeletal – Observed: The patient had mild left knee pain, he showed no signs of stiffness or spasms. I would have assessed for C.V.A. tenderness. Pain, tenderness, and ROM at any other joints besides the left knee.

Integumentary – The patient had no rashes or hives. I would have assessed head to toe any lesions, cuts, or bruises.

Pertinent laboratory values- GFR, BUN, albumin, Creatinine for kidney function due to the potential of damage from substance and alcohol abuse, Full liver function (bilirubin, ALT, AST, APS, and protein) to asses for liver damage due to alcohol and substance abuse. Urinalysis

DSM V DIAGNOSIS: F10.20 Alcohol use disorder. F12.20 Cannabis dependence. F15.20 Other stimulant dependence. F13.20 Sedative, hypnotic, or anxiolytic. F17.200 Nicotine dependence. F11.10 Opioid use disorder. F32.1 Major depressive disorder. F90.0 Attention deficit disorder hyperactivity. M25.562 Pain in left knee. F43.12 Post-traumatic stress disorder.

Client’s understanding of Dx Do they know what their DSM V diagnosis is? The client is understanding of his current situation and acknowledges most of his DSM V diagnosis.

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Client’s perceived reason for admission: Drug and Alcohol abuse

Chief Complaint: “My dad brought me here”

Reason for admission: Substance Abuse

Cultural Assessment: N/A

Spiritual Assessment: N/A

Home Assessment: Patients mother kicked him out and his father brought him here.

Discharge Plan: If none on the chart ask pt & document their response.

Who is involved in discharge planning? Counselor, case worker, and family.

What is the role of Case Management in this setting? Plan the patients care plan.

Are there any Complementary Medicine Practices that would benefit? The patient was educated in group therapy about deep breathing techniques and was interested. I think giving the patient resources regarding breathing techniques would be an acceptable compliment to current treatment.

What would be the optimal plan for this client if the client had unlimited resources and time? After talking with the patient, I think he would benefit from correct medication, goal-oriented therapy, family involved therapy, and resources for education with idea about future careers.

REFLECTION (20 pts)

Using the “What” “So What” “Now What” Critical Reflective Model- Describe your learning today.

Describe your reaction to this clinical experience. Include thoughts & feelings; demonstrate self awareness.

What?​ (What happened, objectively). Without judgment or interpretation,
describe in detail the facts and event(s) of this experience. Today, I observed and assisted the nurses within the adolescent unit. The schedule for the day entailed group meetings, exercise, game room activities, and art. The group meeting contained a group leader and all the adolescents within the unit. They pulled individuals for one-on-one counseling throughout the meeting. Exercise and activity was done in groups.

So What?​ ​ (What did you learn? What difference did the event make?) Discuss feelings, ideas, and analysis of this experience. The adolescent unit experience was tough emotionally. During group meetings you would here the stories of neglect or abuse that these adolescents have experienced. It answers a lot of the questions on why they have an adolescent unit. I learned that a lot of the diagnosis stem from traumatic events within the lives of the adolescents. This experience made a difference on being more sympathetic to situation regarding alcohol/drug abuse. It is more of a cry for help rather than a self-control issue.

Now What?​ ​(How will you think or act in the future as a result of this experience?) As a result of this experience, I would try to get the root cause of why the abuse if occurring. There are layers to the reason behind the abuse. Also, adolescents are not quick to open up about the truth 100% right away. I would act with more patience with a client in this situation in the future.

Describe the Milieu of the unit and did you feel it helped or hindered the clients.

The milieu of this group is accepting, open, and nonjudgmental. They all encourage each other during group and are respectable to one another. There are certain clicks that like to share past stories and curse at each other in a jokingly way. I think this environment built among the adolescents made it encouraging for others to share with each other and at group. No one adolescent was shy during any of the activities we participated in.

Describe any groups you attended? Do you feel they helped or hindered the clients? What did you find effective and what would you do differently? The group meetings took place within the adolescent unit and was hosted by the group leader that typically leads. They went over a power point that encourage sharing. A couple of the slide required the participation of the entire group, but one was shy, so everyone shared. The group meeting seemed to have the adolescents open up and becoming more comfortable with one another. This comfortability brought out the tough topics from the adolescents. I don’t think any changes are necessary because they have the kids talking and opening up.

__________________________________________________________________________Describe the role of each Provider on the unit and what did you learn from them or about their role?

RN: Medication administration, chart daily, and carry out orders directed by the practitioner/physician.

Tech: Takes vitals and assist the nurse with any daily tasks that can be delegated.

Doctor or NP: Assess clients upon entering the center, diagnose, order medication, and refer clients.

Social worker or Case Manager: Provides resources and works with the patient and family.

Group Leaders: Lead group therapy and provide daily counsel.

CARE PLAN (20pts)

Chart professionally EXACTLY as you would in the client’s record:

Priority Problem: Substance Abuse

Situation: The patient is a 17-year-old male that originally got kicked out of his mother’s home for repeated drug use. He then moved in with his dad and got brought here after lying to his father about having drugs in the house.

Background (history): The patient has a history of alcohol, marijuana, nicotine, and opioid abuse. The patient got influenced by others to consume drugs and alcohol originally, which led to the mother removing the patient from the home. The drug and alcohol use continued at the fathers how which led to his admission to the recovery center.

Assessment (what do you see): The patient is well groomed, with appropriate weight and height for age and gender. His behavior is pleasant and cooperative. The patient’s mood is euthymic with no suicidal ideation. There is no loosening of associations or flight of ideas.

Nursing Diagnosis (from Ackley): Ineffective coping related to inadequate opportunity to prepare for stressor as evidence by alteration in sleep pattern, inability to deal with situation, and risk-taking behavior.

Short Term Goal (by end of shift) Must be SMART: The short-term goal would be to use behavior to decrease stress by verbalizing his stress level out of 10 by 1500 on 2/24/23. Three interventions would be (1) use verbal and nonverbal therapeutic communication. (2) Educate the patient on effective coping strategies. (3) Observe contributing factors of ineffective coping by the patient.

Long Term Goal (3 months) Must be SMART: The long-term goal for my patient would be remain free of destructive behavior toward self by having 0 incidents of consuming alcohol or drugs. The three interventions would be (1) Encourage the use of social services, (2) Provide mental and physical activities within the clients ability, (3) Collaborate with the client to identify the source of the stressors.

Mental Status Assessment (20 pts)

(Use you MSE handout to address each area- Use medical terminology as you would in the medical record- This should paint a picture of what the client looks like)

* Appearance: The patient is of athletic build, with appropriate weight and height for age. He is appropriately groomed, dressed, and with good hygiene. The client has good posture.

* Behavior: Pleasant and cooperative

* Speech: Normal rate and volume

* Mood: Euthymic

Potential for suicide thought: No suicide Ideation

Plan: N/A

Means to carry out the plan: N/A

Intent to carry out the plan: N/A

* Affect: Appropriate

* Thought process: Logical and goal directed. No loosening of associations or flight of ideas. Concrete thinking.

* Thought content: No homicidal ideations. No suicidal ideations. No delusions.

Attention and concentration: Intact

* Orientation: Alert to person, place, and time. AOx4

Memory: Intact (recent and remote)

Judgment: Good, ability to solve problems and make decisions.

* Insight: Good, Knowledge about self. Adaptive use of coping strategies.

Comparison with admission mental status exam (Is the client the same, better, worse than admission- find the admission MSE on your chart or description in MD and Nursing notes):

The patient MSE performed today (2/24/23) is unremarkable in comparison to the initial screening MSE (2/09/23) except for two focal findings; The patient demonstrated improved mood from irritable to euthymic. The patient demonstrated mild distractibility consisted with diagnosis of ADHD. This is a change from the initial finding of an intact attention and concentration.

Client's Current Medications (20 Pts)

Name 3 medications that would require an AIMS assessment:

1. Perphenazine (Trilafon)

2. Risperidone (Risperdal)

3. Haloperidol (Haldol)

Define:

1. Extrapyramidal effects: Symptoms of antipsychotic medications that are described as uncontrolled movement.

2. Tardive Dyskinesia: The symptoms of extrapyramidal effects such as uncontrolled muscle contraction and tremors.

What is Benadryl used for in this population? Why is it important? OTC Benadryl is used as a fast-acting anti-anxiety medication. It is important because of the rapid onset effect it has for psych patients with anxiety.

How and why are Vitamins and Minerals used in the mental health client? Vitamins and minerals are taken by patients with substance abuse disorders because of the improper intake due to diet, hepatic, renal function, and reduced psychological function.

Make as many of these cards as your client has meds.

AIMS Assessment

Either before or after completing the examination procedure, observe the patient at rest

The chair to be used in this examination should be a hard, firm one without arms.

1. Ask the patient whether there is anything in his or her mouth (such as gum or candy) and, if so, to remove it.

2. Ask about the *current* condition of the patient's teeth. Ask if he or she wears dentures. Ask whether teeth or dentures bother the patient *now*.

3. Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If yes, ask the patient to describe them and to indicate to what extent they *currently* bother the patient or interfere with activities.

4. Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at the entire body for movements while the patient is in this position.)

5. Ask the patient to sit with hands hanging unsupported -- if male, between his legs, if female and wearing a dress, hanging over her knees. (Observe hands and other body areas).

6. Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.) Do this twice.

7. Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement.) Do this twice.

8. Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first with right hand, then with left hand. (Observe facial and leg movements.) (Is this movement activated?)

9. Flex and extend the patient's left and right arms, one at a time.

10. Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips included.)

11. Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth.) (Is this movement activated?)

12. Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.) Do this twice (Is this movement activated?)

For the movement ratings (the first three categories below), rate the highest severity observed. 0 = none, 1 = minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. One point is subtracted if movements are seen only on activation,

Facial and Oral Movements

Muscles of facial expression,
e.g., movements of forehead, eyebrows, periorbital area, cheeks. Include frowning, blinking, grimacing.

0

Lips and periorbital area,
e.g., puckering, pouting, smacking.

0

Jaw,
e.g., biting, clenching, chewing, mouth opening, lateral movement.

0

Tongue,
Rate only increase in movement both in and out of mouth, not inability to sustain movement.

0

Upper (arms, wrists, hands, fingers).
Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements).

0

Lower (legs, knees, ankles, toes),
e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot.

0

Neck, shoulders, hips,
e.g., rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements.

0

Severity of abnormal movements.

0

based on the highest single score on the above items.

Incapacitation due to abnormal movements.

0 = none, normal

Patient's awareness of abnormal movements.

0 = no awareness

Current problems with teeth and/or dentures.

0 = no

Does patient usually wear dentures?

0 = no

Total score: 0

Patient's condition: N/A

Implications for nursing: To assess the patient on an antipsychotic for extrapyramidal effects

Have you communicated significant information to the nurse in charge in a timely manner? N/A

To your clinical instructor? N/A

Mental Health Clinical Portfolio

Grading Criteria: Mental Health CARE PLAN

Student: __________________________________________________ Date: _____________

Each PSYCHIATRIC CARE PLAN is worth 9% of your course grade.

Comments:

Students______________________________________________________________________

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Faculty: Your care card shows a good understanding of all the components that answers to a wholistic patient care.