Psychiatric Plan of Care
Patient Initials: R. H Student Name: Marcella Fox Patient age: 37 Admission date: 10/9/15 Allergies: Shellfish
History of Present illness: (reason for admission; include symptoms upon admission, psychiatric, family, employment, educational history).
Patient was brought in to Aurora Behavioral Health on 10/9/15 by his sister who he lives with, and admitted with the diagnosis of suspected schizophrenia possibly related to opiate with draw, post-traumatic stress disorder, and for detoxing. She brought him in at his own wish because he was experiencing both audio and visual hallucinations. Patient stated “someone is out to get me, they told me, I could see them hiding in the bushes everywhere I went”. Patient also reported “I have not slept in days, if I sleep they will get me”. He was recently released from prison within the last month, where he has been on and off the last twelve years. He has a history of substance abuse including heroin, cocaine, MDMA, marijuana, and meth for twenty years and was clean the last two years until relapsing on 10/7/15 “to try to sleep”. Patient reports that hallucinations began at that time, and were a new symptom to him. He also reports that he believe he may have post-traumatic stress disorder from death threats he received in prison. His only family that he has support from he reports is his sister, although he is married he reports they have been separated for 15+ years and he has no contact with his four children from the marriage. His family history includes history of mental illness, and substance abuse. He did report he had a girlfriend for the last 5 years that had died while he was in prison this previous time. ...
... middle of paper ...
...ches to socialization.
At time of discharge depending on if auditory and visual hallucinations subside or not vary on the discharge plan. Assuming they do not subside the plan is for the patient to verbalize hallucinations as just that, identify stressors for anxiety, identify his social support (sister) and include them in the plan, identify and plan to attend outside community referrals to aid in further progression, and both verbalize and identify the importance of adherence to medication regime (Fortinash & Holoday-Worret, 2012).
*Develop a Concept Map for this patient and attach
Fortinash, K. M., & Holoday-Worret, P. A. (2012). Psychiatric mental health nursing (5th ed.). St. Louis, MO: Elsevier Mosby.
Vallerand, A., & Sanoski, C. (2014). Davis 's Drug Guide for Nurses (Fourteenth ed.). Philadelphia, Pennsylvania: F.A. Davis Company.
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