PSYCHIATRIC NURSING CARE PLAN-

 CASE STUDY

Ms. Janet Steel is a 26-year-old female with a History of HTN, Anxiety, Asthma, Hypochondria and PCOS. She was admitted to Millwood Hospital due to a Panic Attack she experienced 1 month ago. She was initially admitted to JPS psych unit, was discharged home but she is still unstable at this time. The patient has been complaining of having a wound and pain (level 6) under her left foot, but there is no wound under her left foot. The patient’s mother is her support system and Responsible Party. When the charge nurse entered the room to ask the reason for admission, the patient stated “I have severe anxiety and I had a panic attack last month. I am having pain under my left foot because I have a wound”. The charge nurse did a head to toe assessment, but there is no wound under her left foot. The family indicated that the patient will often complain of having something wrong with her all the time. She has been going to the hospital every week for the last 6 months and the physicians diagnosed her with Hypochondria. The patient has been very restless and anxious. She has been very uncooperative with care because she thinks everyone is going to hurt the wound on her left foot, that does not exist. She has a flat affect and is very anxious. She has very soft speech and a medium tone. She denies having any homicidal, suicidal, visual or auditory hallucinations. She is having delusions about the wound on her left foot, that does not exist. Her perception is that she is in lots of pain due to a wound that does not exist per the charge nurse assessment. Her thought processes are illogical. She is alert and oriented x 2, has moderate insight and judgement, is independently ambulatory and is able to toilet herself. She is continent of bowel and bladder. She is non-denominational and does not attend church regularly. She is on a Regular diet with thin liquids. She has good dentition. She has good health and sleeps for 6 hours every night. She does not attend group activities; she has abused marijuana in the past 3 months. She finished Highschool. She plans to go home with her mother upon discharge. 

Medication List:

Seroquel 25mg 1 tab PO BID

Xanax 1 mg 1 tab PO q12 hours PRN

Lisinopril 10mg 1 tab PO QD

Acetaminophen 325mg 1 tab PO q4 hours PRN 

Metformin 500mg 1 tab PO QD

Vital signs:

VS: 98.6°, 110/74, 72, 18, 99% ra

Objective Data

Alert and Oriented X 2

Normal Dentition

Height 5ft 10in; Weight 135lb.

Cardiovascular:  S1, S2, S3 present; all peripheral pulses palpable

Respiratory: Normal lung sounds in all lobes

Gastrointestinal: BS present in all 4 quadrants.

Labs:

Test Results Ref.  Range Units

Sodium 139  137-145 mmol/L

Potassium 3.7   3.5-5.3 mmol/L

Chloride 101  98-107 mmol/L

Carbon dioxide 24  22-30 mmol/L

Anion gap 13.0  7.0-16.0 mmol/L

Creatinine 1.20  0.66-1.25 mg/dL

Estimated GFR Non AFR American 100  >60 ml/min/1.73m2

Anion gap 12  7.0- 16.0 mmol/L

Blood Urea Nitrogen (BUN) 28  9-20 mg/dL

WBC: 8.0  3.4 -10.8 x10E3/ul