Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 NNNSG0049 03/23/09 Behavioral Health Interdisciplinary Care Plan Page 3 of 6 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 Page 4 of 6 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»