Download Behavioral Health Inter Care Plan NNNSG0049

NNNSG0049 03/23/09
Patient Participation In Treatment Planning
 Contributed To Objectives
 Aware of Plan of Care And Objectives
_
Signature of Patient / Guardian
 Unable to Participate
 Refused to Participate
Date
Axis I Admitting Diagnosis:
Patient Strengths:
1.
2.
Patient Weaknesses / Liabilities:
1.
2.
Precipitating event(s) leading to treatment:
Short Term Goals (Admission Phase – First 24 Hours)
□ Nursing Assessment Completed
□ Biopsychosocial Assessment Completed (72 Hours)
□ Medication Compliance
Long Term Goals / Discharge Criteria:
□ Successful completion of program
□ Able to return to baseline level of activities
Of daily living.
□ Verbalizes reduction of crisis symptoms
□ Admission Triggers Addressed
□ Patient Will Be Maintained in Safe Environment
□ Patient will attend Process and Didactic groups seven days
per week.
□ Abstinence and recovery
□ Reduction of future hospitalizations
□ No longer Suicidal or Homicidal
Interdisciplinary Team Members’ Signatures:
___________________
Physician
___________
Date
________________
Registered Nurse
___________________
MSW/Clinical Therapist
___________
Date
________________
___________
Occupational Therapist Date
___________________
Recreation Therapist
___________
Date
________________
Case Manager
___________________
Art Therapist
___________
Date
Behavioral Health
Interdisciplinary
Care Plan
NNNSG0049 09/01/06
Page 1 of 6
Behavioral Health
Interdisciplinary Care Plan
Page 1 of 6
___________
Date
___________
Date
*«PatientNumbe
r»*
*«PatientNumbe
Acct# «PatientNumber» MR# «MedicalRecordNumber»
«Location» «Room» «Bed»
Date
Initial
Problem/Diagnosis
1. Safety Issues:
 High Fall Risk
 Altered Mental Status
 Wandering Behavior/
Elopement Risk
 Self-injurious
behavior
 Sexual Precautions
 Potential for ETOH/
Sedative Withdrawal
 Potential for violence to
others or property
Interventions
Expected Outcome
 Instruct pt and family in Fall
program on admission: side rail
up, bed low in position, bed
alarm on when patient is in
bed.
 Pt will comply with safety
measures
 15 minute safety rounds.
 Pt will report thoughts of selfinjury to staff
 Pharmacological
Interventions as ordered by
MD.
 Monitor pt for thought
disturbances
 Monitor VS per MD orders
and PRN
 Finger foods only
 Monitor with direct
observation
 Pt will exhibit lucid thoughts
Target
Date
Date
Resolved/
Follow up if
discharged
Ongoing
until
discharge
 Pt will remain free of injury
 Pt will demonstrate no
Wandering/
Elopement Behavior
 Pt will verbalize no selfinjury contract
 Pt will give accurate history
of substance abuse
 Pt will report symptoms of
withdrawal to staff
 Pt will exhibit sexually
appropriate Behavior
 No longer exhibit aggressive
or violent behaviors
 Assess on admission, every
shift and PRN
 Pt / family will describe
reason for hospitalization
 Mood swings
 Psychotropic medications as
ordered
 Pt will identify strengths and
weaknesses
 Impulsiveness
 Monitor symptoms:
 Depression
 Mood swings
 Pt will report symptoms to
staff
__________________
 Impulsiveness
 Pt will not injure self / others
__________________
 Depression
2. Psychiatric Symptoms
Interfering with Ability to
Function:
 Anxiety
 Anxiety
 Agitation
 Agitation
 Preoccupation with
thoughts of injury to self
or others
 Preoccupation with
thoughts of injury to self or
others
__________________
 Hallucinations
__________________
 Monitor and encourage
participation in therapeutic
activities:
 Hallucinations
__Auditory
__ Visual
__ Tactile
__ Olfactory
__ Gustatory
 Delusional
 Active substance abuse
Substances of abuse:
 Occupational Therapy
 Recreational Therapy
Day 2
 Pt will participate in
therapeutic activities
Day 5
 Pt will experience reduction in
symptoms precipitating
admission
 Pt will complete detox
Ongoing
Days 7-10
 Pt will demonstrate capacity
to cooperate with outpatient/
home treatment
 Art Therapy
 Process Group
 Education Group
 Case Management / Social
Work Services
__________________
 Redirect inappropriate
behaviors
__________________
 Other: ______________
NNNSG0049 03/23/09
Behavioral Health
Interdisciplinary Care Plan
Page 2 of 6
Within 24
hours of
admission
*«PatientNumbe
r»*
Acct# «PatientNumber» MR# «MedicalRecordNumber»
«Location» «Room» «Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName» «BirthDate» «Age» «Gender»
Date
Initial
Problem/Diagnosis
Interventions
3. Unresolved Trauma
 Having intrusive
thoughts and/or
nightmares about the
event.
 Avoiding thoughts of
traumatic event
 Hyper vigilance
 Feeling numb or
detached
 Assist pt to identify and
process thoughts in group
therapy
 Provide supportive direction
and feedback to pt when
thoughts of event, hyper
vigilance and /or feeling of
numbness and detachment
surface
4. Behavioral Restraint
and Seclusion
 Safety contain patient’s
behaviors
 Initiate 1:1 observation
 RN Certification within
1 hour
 Complete Restraint/
Seclusion flow sheet
q15 minutes
 Debrief situation with
patient as agitation
resolves



Danger to self
Danger to others
Continuous and
significant destruction
of property
5. Psychosocial Needs:
 Homeless
 Alternative placement
 Lack of Support
System
 Probate Court hold
 Complete psychosocial
Assessment within 72 hours
 Assess need for placement
assistance.
 Provide appropriate
community resources information to pt / family
Expected Outcome
Target
Date
 Pt will experience reduction in
intrusive thoughts and/or
nightmares
 Pt will acknowledge decrease
in avoidance of thoughts of past
event
 Pt will demonstrate reduction
or cessation of hyper vigilance
 Pt will experience decrease in
feeling numb or detached
Ongoing
 Pt will not harm self or
others
Within
4hrs
Implementation
 Resolution of acute
agitation
Date
Resolved/
Follow up
if
discharged
ongoing
 Resolution of acute desire
to harm self
 Psychosocial assessment will
be completed within 72
hours
 Pt / family will be familiarized
with community resources
First 24
hours and
ongoing
until
discharge
 Discharge plan with
alternative placement will be in
place
 Arrange appropriate
placement
 Placement in State facility
 Probate liaison involved and
communication with
 Probate petition dropped
 Out-patient commitment
Court, patient, family and
physicians
6. Potential or Actual
Altered Nutrition /
Hydration
 Screen nutritional status;
dietary consult PRN; monitor
dietary intake and record
 Pt will maintain adequate
nutrition requirements
 N/V
 Monitor I and O if
needed/ordered
 weight gain
 Anorexia / Bulimia
 Impaired intake related
to psychiatric or medical
diagnosis
 Water intoxification
 Present small nutritious
snacks if poor intake identified
 patient will not flush
medications from their system
 Present packaged foods if
paranoia is identified
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Behavioral Health
Interdisciplinary Care Plan
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 weight loss
Ongoing
until
discharge
*«PatientNumbe
r»*
Acct# «PatientNumber» MR# «MedicalRecordNumber»
«Location» «Room» «Bed»
«PatientName» «AdmitDate»
«AdmittingDoctorName» «BirthDate» «Age» «Gender»
Date
Initial
Problem/Diagnosis
Interventions
Expected Outcome
7. Potential or Actual
Altered Skin Integrity
 Assess condition of pt skin
(Braden score) daily and PRN
 Pt will have no skin
breakdown
____Braden score
 Incontinent of urine
 Document skin assessment
with each bath
 Pt will have resolving
wound(s)
 Foley catheter
 Initiate skin protocol
 Chronic, non-healing wounds
 Ostomy
 Skin care consult PRN
 Incontinent of stool
 Bowel and bladder
management with perineal care
with every diaper change.
 Wound/break in skin
8. Pain Management /
Comfort
 Acute Pain
 Chronic Pain
 Lack of Mobility
 Assess pain with appropriate
tool with every vital sign check
and / or every 12 hours and
document.
Target
Date
Date
Resolved/
Follow up
if
discharged
Ongoing
until
discharge
will be maintained
 Pt will verbalize relief of pain
 Pt will have decreased pain
according to scale for nonverbal pts
Ongoing
until
discharge
 Administer meds as indicated
and document effectiveness.
Comfort measures
9. Alteration in
Neurological Status
 Recent change
 Unsteady gait /
weakness
 Lethargy / sedation
 Slurred speech
 Baseline assessment;
reassessment every shift with
mental status and PRN;
 Initiate falls program: bed in
low position, side rail up
( call bell within reach,
6 South only )
 Increase frequency of
rounding; ambulate, toilet, and
hydrate every 2 hours and PRN
10. Chronic or New Onset
of Acute Medical
Condition(s) requiring
treatment:
 Initial physical assessment
and reassessment every
24 hours and PRN;

 Medications as ordered;
 Treatments as ordered:
________
___________________
 Medical consults as ordered;
________
________
________
11. Impaired ADLs
 Unable to perform due to
cognition or mental status
 Less than
functional/mobility
issues.
 Assist with ADLs as needed
with as much direction as
needed with cognitively
impaired pts
 OT/PT consult
 Chronic or acute medical
problem(s) which may or
may not contribute to
patient’s psychiatric
condition will be identified on
admission if present or as
symptoms arise.
By
Discharge
Ongoing
On
Admission
and ongoing
until
discharge
 Medical problems will not
prevent participation in or
provision of psychiatric
treatment.
 ADLs completed in a timely
manner
Ongoing
 Pt will maintain present level
or increase level of
performance of ADLs
 Obtain implements as
necessary to help pt regain as
much independence as possible
NNNSG0049 03/23/09
Behavioral Health
Interdisciplinary Care Plan
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 Pt will regain / maintain
usual neurological status
 Pt will remain injury-free
from falls
*«PatientNumbe
r»*
Acct# «PatientNumber» MR# «MedicalRecordNumber»
«Location» «Room» «Bed»
«PatientName» «AdmitDate»
Date
Prioritization of Goals
RN Signature
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8 ( review needed )
Day 9
Day 10
Day 11
Day 12
Day 13
Day 14
Day 15 – Review Needed
NNNSG0049 03/23/09
Behavioral Health
Interdisciplinary Care Plan
Page 5 of 6
*«PatientNumbe
r»*
Acct# «PatientNumber» MR# «MedicalRecordNumber»
«Location» «Room» «Bed»
«PatientName» «AdmitDate»
Review / Update
Review
Date:______________
Date of Tx Team:_________________
Review of Problem List:
_____________________________________________________________________________________________________
___________________________________________________________________________________________
Treatment Team Recommendations (TTR)
_____________________________________________________________________________________________________
___________________________________________________________________________________________
Medication Review
_____________________________________________________________________________________________________
___________________________________________________________________________________________
Discharge Planning
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________________________________
Signatures & Credentials of Team Members Participating in Review (Required)
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
---------------------------------------------------------------------------------------------------------------------------------------------- ------------------------Review Date:______________
Date of Tx Team:_________________
Review of Problem List:
_____________________________________________________________________________________________________
___________________________________________________________________________________________
Treatment Team Recommendations (TTR)
_____________________________________________________________________________________________________
___________________________________________________________________________________________
Medication Review
_____________________________________________________________________________________________________
___________________________________________________________________________________________
Discharge Planning
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________________________________
Signatures & Credentials of Team Members Participating in Review (Required)
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
_________________________________
____________________________________
NNNSG0049 03/23/09
Behavioral Health
Interdisciplinary Care Plan
Page 6 of 6
*«PatientNumbe
r»*
Acct# «PatientNumber» MR# «MedicalRecordNumber»
«Location» «Room» «Bed»
«PatientName» «AdmitDate»