vSIM NRS 3016 Nursing Care Plan Mental Health Case: Li Na Chen Date: 10/1/2021 Student Name: Larissa DiosdadovSim Li Na Chen Part 1 and Part 2 Initials:LCAge:40 (2/5/1981)M/F:F Diagnosis:DepressionAllergies:No knownPrecautions:SuicideSafety ChecksConsults Needed: Psych, Social Worker Critical Labs: Acetaminophen 80 mcg/mL Ibuprofen 150 mcg/mL Why is your patient in the hospital, per patient and per EMR (include history of present mental illness): Pt attempted suicide by overdosing on acetaminophen and ibuprofen and has major depression BioPsychoSocial History:Include Medical Health History/Co-morbities/coping skills/strengths/education (learning difficulties)/work/social history/relationships/Hx of abuse or trauma/Legal history/substance/addiction history: Pt has attempted suicide twice before this event Pt was taking sertraline 100 mg but began tapering 2 weeks ago and beginning a trial of venlafaxine 37.5 mg daily Pt was diagnosed w/ depression 3 years ago, requirement hospitalization both time (last attempt 1 year ago) Pt sees a psychiatric NP twice a week for counseling sessions Pt has a husband and 2 kids Pt’s parents live in China, does not see them often

Pt has lost 10 lbs. in the last month Part 1 Admission Problem #1: Suicide Nursing Diagnosis (two or three part): Risk for Suicide r/t neurochemical imbalance Expected Outcomes: 1. Pt states has no suicidal thoughts 2. Pt has no suicidal actions 3. Pt states she feels hopeful about the future Interventions: 1. Nurse removes hazardous objects/sharps from the room 2. Staff contracts for safety (the pt says they will contact staff if they have thoughts of suicide) 3. Nurse performs cognitive behavioral therapy (change negative thoughts to positive thoughts)

Evaluation of patient response to nursing interventions and recommended changes to Nursing Interventions: No change, continue nursing care plan Problem #2 Depression Nursing Diagnosis (two or three part): hopelessness r/t neurochemical imbalances AEB “I can’t do anything right” “I cant even kill myself right”, Pt appears slouched, avoids eye contact, low voice/monotone, crying/whimpering, hair was unkempt Expected Outcomes: 1. Pt states she feels hopeful 2. Pt states future plans/interests 3. Pt well kept, maintains eye contact, has erect posture, speaks w/ a more emotional inflection Interventions: 1. Nurse will administer medications as prescribed 2. Nurse will encourage pt to attend group and ADLs 3. Nurse performs cognitive behavioral therapy (change negative thoughts to positive thoughts)/ encourages to think of hopeful plans in future Evaluation of patient response to nursing interventions and recommended changes to Nursing Interventions: No change, continue nursing care plan Problem #3 Appetite Nursing Diagnosis (two or three part): imbalanced nutrition: less than body requirements r/t signs and symptoms of depression AEB: Pt states that she lost ten pounds, Pt has no appetite, “I’m not hungry” Expected Outcomes:

1. Pt will gain a pound a week 2. Pt will eat 75% of 3 meals a day 3. Pt states she has increased appetite