Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications

(^90) 1. Assess client’s level of disorientation to determine specifi 5. Institute necessary safety precautions 2. Obtain a drug history, if possible, to determine the following: 3. Obtain urine sample for laboratory analysis of substance 4. Place client in quiet, private room. Interventions with^ nursing priority.): requirements for safety. c. Pad headboard and side rails of bed with thick towels to tioning is necessary to formulate appropriate plan of care. b. Be sure that side rails are up when client is in bed. a. Type of substance(s) used. b. Time of last ingestion and amount consumed. c. Length and frequency of consumption. d. Amount consumed on a daily basis. content. a. Observe client behaviors frequently; assign staff on one-client agitation.regarding substance ingestion is important for accurate as-sessment of client condition. d. Use mechanical restraints as necessary to protect client if ●^ assist client when ambulating; use wheelchair for trans-protect client in case of seizure.excessive hyperactivity accompanies the disorientation.porting long distances.to-one basis if condition is warranted; accompany and ALTERATIONS IN PSYCHOSOCIAL ADAPTATIONSubjective history is often not accurate. Knowledge Selected RationalesKnowledge of client’s level of func-Excessive stimuli increase (CLIENT safety is a c
2 2506_Ch04_071-104.indd Sec1:90 506 Ch 04 071 - 104 .ind^ 9. Follow medication regimen, as ordered by physician. Com- 7. Frequently orient client to reality and surroundings.^ 6. Ensure that smoking materials and other potentially harmful 8. Monitor client’s vital signs every 15 minutes initially and less d Smon medical intervention for detoxifineed for medication during acute detoxifithe most reliable information about client condition and ingly wanders away fromfrequently as acute symptoms subside. a. ing substances includes:entation may endanger client safety if he or she unknow-self or others in disoriented, confused state.objects are stored away from client’s access. ec 1 :(Valium), and alprazolam (Xanax). In clients with liver group of drugs for substitution therapy in alcohol with-chlordiazepoxide (Librium), oxazepam (Serax), diazepam Alcoholdisease, accumulation of the longer-acting agents, such as chlordiazepoxide (Librium), may be problematic, and the withdrawal is complete. Commonly used agents include drawal. They are administered in decreasing doses until 90. Benzodiazepines are the most widely used^ safe environment. cation from the follow-Vital signs provide cation period.Client may harm Disori- 1 10/1/10 9:34:01 AM 0 / 1 / 10 9 : 34 : 01 AM