Fundamentals of Psychiatric Treatment Planning, Second Edition

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FUNDAMENTALS OF PSYCHIATRIC TREATMENT PLANNING Second Edition

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FUNDAMENTALS OF PSYCHIATRIC TREATMENT PLANNING Second Edition

James A. Kennedy, MD Associate Professor of Psychiatry University of Massachusetts Medical School Worcester, Massachusetts Director Demonstration Unit Westborough State Hospital Westborough, Massachusetts President KennedyMD Consulting Shrewsbury, Massachusetts

Washington, DC London, England

Copyright Copyright © 2003 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED. Users of the manual are free to make unlimited photocopies of the following: Blank forms for the Master Treatment Plan and Treatment Plan Review, Step-by-Step Instructions for using the blank forms, Sample Master Treatment Plan, Quick Reference to Problem Categorization by the Kennedy Axis V, and the AIMS Plus EPS (Abnormal Involuntary Movement Scale Plus EPS). Permission must be obtained from American Psychiatric Publishing, Inc., to copy other parts of this manual. Use of the Kennedy Axis V and the Kennedy NOSIE (Kennedy Nurses’ Observation Scale for Inpatient Evaluation) questionnaires requires a licensing agreement. Royalties may be waived when these questionnaires are used for piloting or research purposes. Visit www.kennedymd.com for details on licensing agreements. Cautionary Note Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association. The author has worked to ensure that all information in this manual is accurate at the time of publication and consistent with general psychiatric and medical standards and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this manual. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a family member. This manual is not presented as a standard of care. The clinical examples are just that: examples. They are not intended to prescribe care for patients. This manual is intended to help treatment teams take a more systematic approach to treatment planning. Each treatment team must use its own clinical judgment to decide how to use this manual and its clinical examples. Even within this manual, the examples vary in the standard of care that they set (i.e., some of the examples represent clearly higher standards than other examples). The varying nature of the examples in this manual represents to some degree the wide range of treatments available, as well as varying clinical standards for many clinical problems. Also, there are often different interpretations of the standards set forth by various accrediting bodies. Finally, treatment teams have a limited amount of time to complete treatment plans. Many examples are intended to represent plans taken from actual team meetings; those examples certainly reflect to some degree that limited time. Users should slowly replace the examples in this manual with examples developed by their own treatment team members. These examples should better reflect the standards and treatment style expected from their own treatment teams. Computerized Treatment Planning The current standard for computerized treatment planning is to generate the plan using a word processor; however, this standard is rapidly changing. Visit www.kennedymd.com for updates on computerized treatment planning and to download electronic copies of blank treatment planning forms. Also available by Dr. Kennedy: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (Washington, DC, American Psychiatric Publishing, 2003) Manufactured in the United States of America on acid-free paper. 07 06 05 04 03 5 4 3 2 1 Second Edition American Psychiatric Publishing, Inc. 1000 Wilson Boulevard Arlington, VA 22209 www.appi.org Library of Congress Cataloging-in-Publication Data Kennedy, James A., 1946– Fundamentals of psychiatric treatment planning / James A. Kennedy.—2nd ed. p. ; cm. Includes bibliographical references. ISBN 1-58562-061-0 (alk. paper) 1. Mental illness—Treatment. 2. Psychiatric records. 3. Diagnostic and statistical manual of mental disorders. I. Title. [DNLM: 1. Mental Disorders—therapy. 2. Patient Care Planning. WM 400 K35f 2003] RC480.5 K445 2003 616.89′1—dc21 2002027688 British Library Cataloguing in Publication Data A CIP record is available from the British Library.

CONTENTS Preface .......................................................................................................................................... vii Acknowledgments ....................................................................................................................... viii Identifying Patient Data.............................................................................................................. viii Introduction.......................................................................................................................... Intro–1 Master Treatment Plan (Sample)..........................................................................................MTP–1 Psychological Impairment ......................................................................................................... 1–1 Social Skills ................................................................................................................................. 2–1 Violence ...................................................................................................................................... 3–1 ADL–Occupational Skills ............................................................................................................. 4–1 Substance Abuse......................................................................................................................... 5–1 Medical Impairment .................................................................................................................. 6–1 Ancillary Impairment .................................................................................................................. 7–1 Blank Forms ............................................................................................................................. BF–1 Questionnaires............................................................................................................................Q–1 Appendix..................................................................................................................................... A–1


Fundamentals of Psychiatric Treatment Planning

vii

Preface This manual forms the cornerstone for the Kennedy Approach to Psychiatric Treatment Planning. This approach is based on the Kennedy Axis V questionnaire, which organizes psychiatric problems into seven categories or problem areas: • • • • • • •

Psychological Impairment Social Skills Violence Activities of Daily Living (ADL)–Occupational Skills Substance Abuse Medical Impairment Ancillary Impairment

This approach allows use of the Kennedy Axis V to capture baseline problems and baseline level of functioning for each of these problem areas. These baseline findings can then flow directly into the Master Treatment Plan and Nursing Care Plan via the Problem List and the problem descriptions. This approach can then continue through Treatment Plan Reviews and Nursing Care Plan Reviews, progress notes, and measurements of outcome. This manual includes blank Master Treatment Plan forms, blank Treatment Plan Review forms, sample Master Treatment Plans, and numerous sample Individual Problem Plans. In addition to this manual and the Kennedy Axis V questionnaire, support for the Kennedy approach is available in Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric Publishing 2003) and online.

Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning is both a training manual and a reference for the Kennedy Axis V questionnaire. It maximizes your ability to use the Kennedy Axis V to capture, track, and profile your clinical impressions. Numerous clinical vignettes demonstrate the use of the Kennedy Axis V. Mastering the Kennedy Axis V also shows how the Kennedy Axis V can condense your psychiatric outcome measures into a single clinical instrument, including using the Global Assessment of Functioning (GAF) Equivalent to replace the GAF Scale and using the Kennedy Axis V’s subscales to replace or act as a screening tool for other instruments that focus on specific problem area(s).

Online Support Visit www.kennedymd.com for support and updates to the Kennedy approach to psychiatric treatment planning and outcome measurement, including additional sample plans, training and credentialing opportunities, updates of blank forms, and other information.

viii


Acknowledgments I express my gratitude to the contributors to the first edition of this manual. Their help was essential to its success. Many aspects of the first edition continue to be vital to treatment planning, therefore, they have been included in this edition. Since the first edition, many clinicians have helped with numerous suggestions and clinical examples related to treatment planning, many of which have been integrated into this second edition. Especially useful have been recommendations relating to the integration of the Nursing Care Plan into the Master Treatment Plan. Clinicians from a wide range of facilities, as well as visitors to www.kennedymd.com, have provided suggestions and help. At Worcester State Hospital, Worcester, Massachusetts, I owe thanks to many current and past nursing and psychiatric staff who were helpful with the integration of the Nursing Care Plan into the Master Treatment Plan. Also, staff in the Mental and Behavioral Health Services at Our Lady of the Lake Hospital, Baton Rouge, Louisiana, were very supportive, including Frank Silva, MD, medical director, and Cami Ledford, BSN, RNC, clinical instructor. I express my appreciation to Rose Mary Carroll-Johnson, MN, RN, editor, Nursing Diagnosis: The International Journal of Nursing Language and Classification. She provided vital help with the integration of nursing diagnoses into the Master Treatment Plan. My thanks to Gretchen H. Horner, RNC, former administrative director, Memorial Hospital, Johnstown, Pennsylvania, and Kathy Andolina, RN, MSN, CS, at The Center for Case Management, Inc., South Natick, Massachusetts, for their support of the concept of using an outcome measure to help structure and track clinical care. Special thanks to Chris Beaudoin, CNS, for her support during my visits to work with staff on treatment planning at Greater Bridgeport Community Mental Health Center, Bridgeport, Connecticut; Steve Sorkin, PhD, for his support during my work with staff on treatment planning at the Northern Virginia Mental Health Institute, Falls Church, Virginia; and Dorothy Erney, RRA, Quality Coordinator, Binghamton Psychiatric Center, Binghamton, New York. I also express my thanks to staff from the Hudson River Psychiatric Center, Poughkeepsie, New York, and the New Hampshire Hospital, Concord, New Hampshire. I appreciate Joseph Black, MD, Chief Psychiatrist, Competency Program, North Texas State Hospital–Vernon, Vernon, Texas, for his years of support for my systematic approach to psychiatric treatment planning, including the use of the Kennedy Axis V questionnaire. The appendix includes a sample Master Treatment Plan provided by Dr. Black, which is organized around the Kennedy Axis V subscales. Finally, without the structure provided by the Kennedy Axis V questionnaire, this manual would not be possible; therefore, I refer you to the “Acknowledgments” section in the companion manual, Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric Publishing 2003).

Identifying Patient Data The patient and client names and associated responsible staff and treatment facilities used in this book are fictitious. They are intended to aid in identifying individual Master Treatment Plans, Treatment Plan Reviews, and Individual Problem Plans being discussed among staff using this manual. Even though patient names are fictitious, the plans are based on many years of clinical experience writing psychiatric treatment plans and gathering case material from colleagues and conferences. Even though the plans and reviews are not based on actual cases, they are usually composites of actual cases; therefore, the plans should resemble plans that would be generated during actual team meetings. Identifying data has been changed or eliminated. Any resemblance to or association with real individuals is purely coincidental.

INTRODUCTION

Intro–1


Introduction

Intro–3

INTRODUCTION CONTENTS History and Development of the Manual .......................................................................................... Intro–5 Overview ................................................................................................................................................... Intro–5 Moving From Diagnosis to Level of Functioning ...................................................................................... Intro–5 Kennedy Axis V ......................................................................................................................................... Intro–5 Abbreviations ............................................................................................................................................ Intro–6 Online Support.......................................................................................................................................... Intro–7

Rationale for Categorization of Problems by the Kennedy Axis V .................................................... Intro–8 Overview ................................................................................................................................................... Intro–8 No Perfect Fit............................................................................................................................................. Intro–9 Quick Reference to Problem Categorization by the Kennedy Axis V ........................................................ Intro–9

Quick Reference to Problem Categorization by the Kennedy Axis V .............................................. Intro–10 General Instructions for Treatment Planning.................................................................................. Intro–11 Overview ................................................................................................................................................. Intro–11 Is It Necessary to Use This System and the Forms in This Manual? ........................................................ Intro–11 Standards for Treatment Planning and Use of the Manual by Accreditors.............................................. Intro–12 Treatment Planning Depends on the Total Clinical Picture.................................................................... Intro–13 Treatment Plan Reviews .......................................................................................................................... Intro–13 Integration of the Nursing Care Plan Into the Master Treatment Plan ................................................... Intro–14 Significant Problems Should Not Be Omitted From the Problem List ..................................................... Intro–14 Tracking the Flow of Treatment .............................................................................................................. Intro–15 Date Problem Established Versus Date of Onset...................................................................................... Intro–15 Long-Term Goals and Short-Term Goals Versus Goals and Objectives ................................................... Intro–15 Treatment Goals Versus Treatment Modalities ....................................................................................... Intro–16 Treatment Modalities That Have Effects Across Problem Areas............................................................... Intro–17 Steps for Building Goals and Treatment Modalities ................................................................................ Intro–18 Individual Problem Plan for Each Active Problem .................................................................................. Intro–19 Avoiding Excessive Documentation ........................................................................................................ Intro–20 Inclusion of Milieu Staff in Treatment Planning..................................................................................... Intro–23

Master Treatment Plan Forms (Step-by-Step Instructions)............................................................. Intro–24 Problem List/Cover Sheet ........................................................................................................................ Intro–24 Strengths/Discharge Plan/Diagnosis Page ............................................................................................... Intro–30 Individual Problem Plan.......................................................................................................................... Intro–31 Signature Page ......................................................................................................................................... Intro–34 Treatment Plan Review Form .................................................................................................................. Intro–34

Notes

Introduction

Intro–5

History and Development of the Manual Overview First, I would like to say that I am a clinician and much of my clinical experience comes from my work over many years primarily at Worcester State Hospital in Worcester, Massachusetts. My expertise in treatment planning comes from developing treatment plans as a member, and often as the leader, of a treatment team. I also act as a consultant to help other clinicians improve their treatment plans. Since the first edition of this manual was published in 1992, it has been the standard for treatment planning throughout the country. Before its publication, I saw numerous treatment planning systems fail because of their inability to manage the complexity of treatment planning. This was especially true when it came time to review and modify the plan. The first edition has helped guide clinicians and administrators toward a much more rational and systematic approach to treatment planning. This second edition will further efforts toward improving the quality of treatment plans and will improve the efficiency of writing treatment plans. As with the first edition, the second edition is built around the structure of the Kennedy Axis V (formerly the Axis V Subscales). Outcome measurement is a vital part of the treatment planning process. Therefore, Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (Kennedy 2003), which introduces the latest version of the Kennedy Axis V, is released in conjunction with this second edition of Fundamentals of Psychiatric Treatment Planning.

Moving From Diagnosis to Level of Functioning Because of the increasing importance of treatment planning and continuing difficulties with this process, I began attempting to develop a system that would allow our treatment teams to more effectively plan, document, evaluate, and revise treatment. The first step in that process involved moving from diagnosis to psychiatric symptoms and level of functioning as the basic system of categorization used for treatment planning. Most psychiatric treatment and nursing care planning manuals address treatment planning from the perspective of the diagnosis. However, for many years, treatment planning has been mostly based on a problem-oriented record. A major difficulty in organizing treatment planning around the diagnosis is the fact that symptoms and behaviors are by no means unique to a diagnosis or even a group of diagnoses. Also, level of functioning, not diagnosis, often determines treatment needs, including the need for hospitalization. Therefore, this manual is based on categories of the symptoms and behaviors that make up Problem Lists.

Kennedy Axis V To develop this systematic approach to treatment planning, I selected Axis V from the Diagnostic and Statistical Manual of Mental Disorders. Axis V, which measures psychiatric symptoms and level of functioning, seemed ideal because of its focus on adaptive, problematic behaviors and outcome. In the next step, drawing from Axis V and similar scales, I developed the Kennedy Axis V (see the “Questionnaires” section of this manual for a copy of the Kennedy Axis V). The Kennedy Axis V divides the symptoms and behaviors from Axis V into four problem areas: Psychological Impairment, Social Skills, Violence, and ADL–Occupational Skills. To complete the problem categorization, I added Substance Abuse, Medical Impairment, and Ancillary Impairment. This categorization forms the basic structure of the manual. The categories are elaborated in the next section, “Rationale for Categorization of Problems by the Kennedy Axis V.” In addition, the Kennedy Axis V can be used to measure outcome of treatment in each of the subscale areas.

Intro–6


Abbreviations The following abbreviations are often associated with the treatment planning system presented in this book:

AA

Alcoholics Anonymous

ADL

Activities of Daily Living–Occupational Skills

AEB

As evidenced by

AIMS Plus EPS

AIMS Plus Extrapyramidal Side Effects

AIMS

Abnormal Involuntary Movement Scale

ANC

Ancillary Impairment

ASA

Aspirin (acetylsalicylic acid)

AWA

Away without authorization

bid

Twice a day

BP

Blood pressure

BPRS

Brief Psychiatric Rating Scale

BUN

Blood urea nitrogen

COPD

Chronic obstructive pulmonary disease

COTE

Comprehensive Occupational Therapy Evaluation

CT scan

Computer-aided tomography scan

DBT

Dialectical behavioral therapy

DL

Dangerousness Level

ECG

Electrocardiogram

ECT

Electroconvulsive therapy

EEG

Electroencephalogram

EPS

Extrapyramidal side effects

FBS

Fasting blood sugar

GAF Eq

GAF Equivalent

GAF Scale

Global Assessment of Functioning Scale

HS

Hour of sleep

Hx

History

Hz

Hertz (cycles per second)

IPP

Individual Problem Plan

K Axis

Kennedy Axis V

LTG

Long-Term Goal

MED

Medical Impairment

meds

Medications

MHA

Mental health assistant

MHW

Mental health worker

Introduction

MRI

Magnetic resonance imaging

MTP

Master Treatment Plan

NCP

Nursing Care Plan

Nsg.

Nursing

po

By mouth, orally

prn

As needed

PSY

Psychological Impairment

pt.; pts.; pt.’s

Patient, patients, patient’s

q

Every

R/O

Rule out

SAb

Substance Abuse

SNF

Skilled nursing facility

SOC

Social Skills

SSDI

Social Security Disability Income

SSRI

Selective serotonin reuptake inhibitor

STD

Sexually transmitted disease

STG

Short-Term Goal

Sx

Symptoms

TLE

Temporal lobe epilepsy

TPR

Treatment Plan Review

Tx

Treatment

VIO

Violence

WBC

White blood cell count

WNL

Within normal limits

Intro–7

Online Support Visit www.kennedymd.com for support and updates of the Kennedy Approach to Psychiatric Treatment Planning and outcome measurement using the Kennedy Axis V questionnaire. Additional sample plans, training opportunities, updates of blank forms, and other materials are also available at the website. You can contact the author at the website and you are encouraged to make comments or ask questions about psychiatric treatment planning.

Intro–8


Rationale for Categorization of Problems by the Kennedy Axis V Overview The purpose of this categorization system is to simplify problem identification and planning by grouping problems using the Kennedy Axis V. The wide range of psychiatric symptoms and behaviors are divided into the four broad categories of the Kennedy Axis V: 1. 2. 3. 4.

Psychological Impairment Social Skills Violence ADL–Occupational Skills

To complete the system, the following three categories were added: 5. Substance Abuse 6. Medical Impairment 7. Ancillary Impairment The use of the Kennedy Axis V Categorization System for problem identification and treatment planning has several advantages: •

•

•

• •

These categories are not new theoretical areas. The areas are well known to clinicians and they make a lot of clinical, intuitive sense. The areas are consistent with much of the training received by clinicians. Because of the universal nature of the categories, they can be easily used across disciplines. Minimal training is required to understand the categories. By going step by step through these seven categories, practitioners can take a systematic approach to identifying the problems. When one has proceeded through these seven categories, one is very unlikely to have overlooked significant clinical areas. Many symptoms and behaviors cluster together in syndromes that can be found within each of the seven areas. Therefore, treatment can be directed at the syndrome within a problem area, rather than at several individual problems. For example, use “depressive symptoms” rather than “sadness,” “loss of appetite,” “insomnia,” and “lethargy.” Training can be directed toward the individual categories as well as toward the categories as an interactive system. Finally, the Kennedy Axis V can be used to measure baseline functioning and the outcome of treatment.

The Kennedy Axis V Categorization System allows the clinician to set a reasonable balance between being too broad when defining problems and being too specific. Problem Lists that are broken up into a lot of individual, discrete problems often lead to treatment plans and progress notes that are choppy and disconnected. Defining a problem somewhat broadly allows clinicians to more easily integrate what is happening in a clinically meaningful way. Progress notes tracking treatment and its outcome are often more coherent and useful when directed at syndromes consisting of discrete problems. However, the use of very discrete problems can tighten up one’s thinking and planning. There are certainly advantages to directing treatment toward individual, discrete problems as opposed to very broad groups of problems. Again, the Kennedy Axis V Categorization System allows clinicians to set a reasonable balance between discrete versus broad problem names based on one’s clinical judgment. The system discourages collapsing problems from separate subscale areas into a single problem, even though there may be a clear relationship between the problems. For example, “depressive symptoms” and “suicidal ideation” should not be collapsed into a single problem, nor should “cocaine

Introduction

Intro–9

abuse” and “assaultiveness” be collapsed into a single problem, even if there is a clear relationship between the problems. If a problem area consists of a single, specific symptom or behavior, a broad problem name should not be used. For example, “psychotic symptoms” should not be used if the patient’s only symptom of psychosis is paranoia.

No Perfect Fit Any classification system that attempts to divide human behaviors into their component parts will quickly run into areas in which the components do not fit cleanly into one problem area or “box.” In such systems, ambiguity and disagreement about where particular symptoms and behaviors should be placed is unavoidable. Despite the drawbacks and difficulties of classifying human behavior, use of the Kennedy Axis V Categorization System serves to organize the complexity of clinical features that patients present. As indicated earlier, if a syndrome does not fit into one problem area, the syndrome should be broken down so its components can fit into the appropriate problem areas. For example, “suicidal ideation“ should be removed from “depressive symptoms” and placed under the subscale area of Violence. “Lack of motivation” should be removed from the problem of “poor job skills” and placed under the subscale of Psychological Impairment. Further, “lack of motivation” may be placed under the problem name of “depressive symptoms” or “psychotic symptoms.”

Quick Reference to Problem Categorization by the Kennedy Axis V The next page in this manual, “Quick Reference to Problem Categorization by the Kennedy Axis V,” can be copied and used as a reference guide to problem names. Additional listings of problem names and descriptions classified by the Kennedy Axis V can be found at the beginning of each chapter on the individual subscale areas of the Kennedy Axis V.

Intro–10


Quick Reference to Problem Categorization * by the Kennedy Axis V This classification system serves to simplify problem identification and treatment planning by categorizing problems using the Kennedy Axis V subscales. The wide range of psychiatric and medical symptoms, syndromes, and issues are divided into the following seven problem areas. Listed below are some examples of problems from each of the seven areas.

1.

Psychological Impairment Psychotic symptoms Poor motivation Mood disturbance Personality disturbance Poor focal attention Eating disturbance

2.

Social Skills Limited interpersonal skills Poor communication skills Lack of awareness of social norms Sexually inappropriate behavior

3.

Violence Threatening and assaultive Suicidal Homicidal Sexually violent Arsonist

4.

ADL–Occupational Skills Poor job skills Lack of skills to care for self Poor workmanship Lack of basic survival skills Poor personal hygiene skills

5.

Substance Abuse Alcohol abuse Cocaine abuse Polysubstance abuse Nicotine addiction

6.

Medical Impairment Hypertension Allergy to penicillin Diabetes Family planning concerns Tardive dyskinesia Dental problems

7.

Ancillary Impairment Homelessness Financial problems Abusive spouse (domestic violence) Legal problems Incarceration Need for guardianship

Permission granted by American Psychiatric Publishing, Inc., and James A. Kennedy, MD, to copy this page.

Introduction

Intro–11

General Instructions for Treatment Planning Overview These instructions are intended to address a few of the key issues often raised when doing treatment planning, including nursing care planning. This manual is based to a great degree on treatment planning for long-term-care patients. However, the principles and methods can be generalized to any psychiatric treatment setting or population. This manual is based on the assumption that the Master Treatment Plan (MTP) can form the working center of the patient’s record (see Figures 1 and 2). It can guide staff through complicated, interdisciplinary treatment processes. Certainly it is hoped that the manual will be used as a reference and teaching guide outside the treatment team; however, its main function is to assist team members during the actual planning process. To this end, I attempted to make the manual thorough, but brief. Further, the organization of the manual is intended to allow rapid access to needed material during the actual treatment team meeting. Quick access to information is critical during the limited time for a team meeting. Therefore, tabbed divider pages and separate numbering for each section facilitate access to information. Comprehensive lists of problems, goals, and treatment modalities characterize the manual. To a great degree, the complexity of human symptoms and behaviors, as well as the limitless range of goals and the numerous treatment approaches, drove the length of these lists. A close look at the lists reveals many entries that should apply to patients whose MTPs you are currently writing. Finally, it is suggested that you explore using the Kennedy Approach to Psychiatric Treatment Planning across inpatient and outpatient care providers. A standard MTP approach across treatment providers can be very helpful to ensure continuity of care.

Database Assessments

Psychological Tests

Master Treatment Plan

Consults

& Laboratory Tests

Nursing Care Plan

Progress Notes

& Legal

Treatment Plan Reviews

Physician’s Orders

Figure 1. Treatment plans do not stand alone. The treatment plan, including the Nursing Care Plan, is the engine that drives the treatment process; however, it must work in conjunction with the rest of the patient’s record. Only when the treatment plan is working effectively with the other sections of the patient’s record will it be acceptable to the accreditors as well as to the clinicians who use the plan.

Is It Necessary to Use This System and the Forms in This Manual? What if you do not want to change to this system or use the forms included in this manual? Because almost all accreditors require treatment plans with behaviorally oriented problem definitions, measurable treatment goals, and treatment modalities, this manual will be useful even when the

Intro–12


clinicians are not using the systematic approach and forms in this manual. The audience to which this manual is addressed includes staff at psychiatric hospitals, halfway houses, and community mental health centers and students in academic programs—that is, anyone working where treatment planning or nursing care planning is practiced or taught. Problem List Problem Description

Goals and Target Dates

Master Treatment Plan Strengths

&

Treatment Modalities

Nursing Care Plan Diagnosis

&

Discharge Planning

Treatment Plan Reviews Signatures Status and Status Changes Figure 2. The parts of the treatment plan, including the Nursing Care Plan, must work together as a unit. The goals and treatment modalities should reflect the problem description. The treatment modalities should consist of treatments that will help attain the goals. The signatures should reflect real contributions to the interdisciplinary plan. The plan should be able to easily and accurately reflect any changes or additions in the goals, treatment modalities, target dates, and so forth. Without these capabilities, it will not be an effective tool for clinicians.

Standards for Treatment Planning and Use of the Manual by Accreditors The treatment planning system presented in this manual is increasingly becoming the standard for psychiatric treatment planning. This is evidenced as accreditors and consultants use this manual as a standard for comparison when checking psychiatric treatment plans. Also, the manual is well known to many reviewers and consultants who use it when making decisions and recommendations concerning psychiatric treatment planning. For example, an accreditor could compare a patient’s plan on “suicidal ideation” with an Individual Problem Plan (IPP) on suicidal ideation in the Violence subscale section of this manual. In the same section, the accreditor could compare the plan against lists of goals and treatment modalities that address the suicidal patient, as well as suggestions on what would be expected in the problem description of a patient with suicidal ideation. Use of this manual makes it much easier for an accreditor to discuss how treatment planning deviates from what he or she sees as acceptable. In addition, by using this manual, the mental health facility can more intelligently respond to any criticism by the accreditor and more easily implement corrective actions within the facility. The accreditors may also modify this manual so that it approximates the standard of care expected in a specific type of facility. Increasingly, there are accepted standards of treatment for various psychiatric symptoms and behaviors. This manual will continue to be a part of the process of developing such standards in treatment planning. As a part of those standards, it is hoped that increasingly there will be support for the integration of formal outcome measures into the treatment planning process. The Kennedy Axis V questionnaire is presented as ideal for meeting such a standard.

Introduction

Intro–13

Treatment Planning Depends on the Total Clinical Picture Treatment planning cannot be conducted in a vacuum (see Figure 1). It touches on and interacts with all aspects of the clinical process. Of special importance is the interaction between the treatment plan and the discipline assessments and progress notes. The need for thorough assessments and good progress notes cannot be overstated. Without accurate, complete clinical evaluations by the various disciplines, rational treatment planning and reviewing are impossible. Once the assessments are completed, a consistency must be established between the assessments and the MTP. This consistency must then continue between the plan and progress notes. Accreditors often cite inconsistencies between the treatment plan and the assessments or progress notes as deficiencies.

Treatment Plan Reviews Once the MTP has been completed, subsequent changes in the plan must be documented. This is done through formal Treatment Plan Reviews during a treatment team meeting and through less formal documentation, such as using progress notes to document changes. The day-to-day changes in the patient’s status and progress toward goals are generally captured in the progress notes. These changes are then summarized in subsequent Treatment Plan Reviews. Accreditors, such as the Joint Commission on Accreditation of Healthcare Organizations and CMS (Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration [HCFA]), generally require formal treatment plan reviews in the following situations: • • • •

When the patient is admitted, transferred, or discharged When a major change occurs in the patient’s clinical condition When the patient has successfully completed any treatment goals When the patient fails to reach treatment goals despite reasonable clinical care

These formal Treatment Plan Reviews are generally used to review, summarize, and update changes. These formal reviews are also used to ensure that changes in treatment are added or have been added to the MTP itself. Scheduling team meetings to immediately review changes is often impossible. The inability to hold a treatment team meeting each time a review is needed or a change is made in the treatment plan is often dealt with in one of two ways: 1. A team member who wants a change in the treatment plan discusses the change with available, relevant team members. The patient should also be included in this process to the degree that is clinically appropriate. If it is decided that the plan should be changed, the team member enters the change on the MTP and dates and initials the change. The team member enters details of the change and the rationale for the change in the progress notes. At the next treatment team review, the change is discussed with the entire treatment team. 2. The same as #1, except no entry is made on the treatment plan until the next Treatment Plan Review meeting. As in #1, a team member enters details of the change and the rationale for the change in the progress notes. When a change in the plan occurs, it is unacceptable not to make an entry in one of the following: the Master Treatment Plan, the Treatment Plan Review, or the Progress Notes. Finally, the clinical team may be so conservative in its definition of “major changes” or “reasonable clinical care” that few, if any, formal Treatment Plan Reviews occur. Therefore, to ensure that treatment reviews occur at least with some minimal frequency, it is recommended to use a combination of reviews according to the four clinical requirements mentioned earlier, as well as scheduled periodic reviews. For example, for a very stable patient, Treatment Plan Reviews might be scheduled for every 3 months. If a review were done before 3 months, then the next review would be rescheduled for 3 months following the last completed review. This schedule would ensure that a review is done at least every 3 months, as well as when clinically indicated by the clinical criteria.

Intro–14


The minimal frequency for formal Treatment Plan Reviews should be based on the usual rate of change in the patients’ clinical treatment/status within a particular facility or unit within the facility. For many facilities, it seems reasonable to have a scheduled review every month for the first 6 months to 1 year and every 2 to 4 months thereafter. One may also want to make allowances for patients readmitted after only a short time out of the hospital.

Integration of the Nursing Care Plan Into the Master Treatment Plan There is tremendous overlap between the MTP and the Nursing Care Plan (NCP). The description of the problems (nursing diagnoses), including response to previous treatments, should be identical. The nursing interventions on the NCP and the MTP should be essentially identical; therefore, simply consolidating them into the MTP can eliminate the redundancy. All members of the team should be working toward the same long-term goals and short-term goals (objectives), even though specific team members may be more focused on particular goals. Therefore, it is recommended that nursing staff integrate the NCP into the MTP rather than have separate plans. Because the nursing interventions (nursing treatment modalities) often form the main component that differentiates the MTP from the NCP, it is suggested that the nursing interventions (treatment modalities) in the MTP be labeled as the “Nursing Care Plan.” Another equally important reason for integrating the NCP into the MTP is to encourage nursing staff to be more actively involved with the development and implementation of the MTP. It is not unusual for nursing staff members to complete their NCP and feel they have met their obligations to the treatment planning process. They may then move forward with implementing their plan with minimal investment in the MTP—that is, they feel little ownership of the MTP because they already have their own plan. Nursing staff may even see the NCP as a means of separating themselves from the problems, difficulties, and even at times the chaos that can be associated with poorly developed MTPs. With their own plan, nursing staff members may not have to worry about the difficulties of becoming an integrated member of the team process. They have their separate, defined role as outlined in their NCP. If there are problems with the MTP, those problems can be seen as problems for other team members. Because they have their own plan, nursing staff members may have little vested interest in the MTP. Finally, it is suggested that the inclusion of the NCP in the MTP be the “standard of care.” Throughout this manual, it is assumed that the NCP has been integrated into the MTP. Often in this manual, you will see that the NCP has been clearly indicated as part of the MTP; however, even when not clearly indicated, it should be understood that the NCP has been integrated into the MTP.

Significant Problems Should Not Be Omitted From the Problem List If the Problem List is complete, clinicians will not be surprised by significant clinical issues or problems lost or buried in the patient’s chart. Generally the Problem List is the only place in the chart where there is a comprehensive, condensed, and updated outline of all significant clinical issues. This list is a key part of any clinical chart. The Problem List is one of the first places clinicians should go when attempting to get a quick overview of the patient’s clinical situation. To help ensure that significant problems are not overlooked, when determining the Problem List you should work your way systematically through each problem area, starting with Problem Area 1 Psychological Impairment and ending with Problem Area 7 Ancillary Impairment. The Problem List should contain all significant clinical problems. In addition to the obvious problems, the Problem List should contain items such as history of assaultive behavior, history of suicidal attempt, allergy to penicillin, single kidney, and so on. These problems should not be listed if they are felt to be of no clinical significance (e.g., if the suicidal attempt was an isolated incident that occurred years ago and is of no future clinical relevance to the case). Problems should not be listed if they are already incorporated into an active problem. Allergies do not need to be included on the Problem List if there is already a system in place to prominently display allergies in the patient’s record. Also, in addition to problems, the list should contain other clinical factors that require treatment or clinical resources, such as pregnancy, criminal charges, Tarasoff warning, placement, health

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maintenance, and so on. This is the treatment plan, not the problem plan; therefore, important areas involving treatment should not be omitted from the treatment plan simply because they are not seen as a “problem.”

Tracking the Flow of Treatment A very important feature of the treatment planning system in this manual is the innovative ability of the IPP forms to illustrate the flow of treatment. The clinical process is a fluid process; therefore, the treatment planning system and forms must be able to reflect the progressive changes that occur in the clinical process. This system is able to capture the changes in treatment when the patient progresses to the point that new treatments are clinically useful. It can also capture any changes in treatment when the desired results are not obtained. The details on the use of the IPP forms to track the flow of treatment are presented in the “Master Treatment Plan Forms (Step-by-Step Instructions)” section presented later in this chapter.

Date Problem Established Versus Date of Onset There is often confusion over the difference between the “date established” for the problem and the “date of onset” of the problem. The date established serves the purpose of marking how far back into the chart one should search to review the documentation on a problem. Without a date established, the entire chart might have to be searched to find all the information on a problem. In a long-term-care facility, this could mean unnecessary searching through years of records. The date of onset of the problem means exactly what it says. The date of onset is often at or near the date the problem was established. However, these two dates can often be very different. There are often major problems in psychiatry determining the date of onset of a problem. The onset of many psychiatric problems is insidious. It is not unusual for the onset to span a period of years. Attempting to establish an exact date for onset of a problem often leads to long, nonproductive arguments within the treatment team. The date of onset of the problem is certainly important and, if known, can be included in the description of the problem. Figure 3 shows a few examples.

1.1 Depressive Symptoms Problem Description: Over the last several months, there has been a progressive return of patient’s depression. About 2 weeks ago, there was a marked worsening in association with several arguments with his wife … 3.1 Suicidal Attempt Problem Description: Patient’s first suicidal attempt was at age 13; however, about 8 years passed before his next attempt just before his current hospitalization … 6.1 Laceration of Left Forearm Problem Description: The laceration on the patient’s left forearm occurred on 01/01/03 as a result of his suicidal attempt with a razor …

Figure 3.

Examples of the date of onset.

In these examples, except for “laceration of left forearm,” various arguments could be put forth as to which date to include as the date of onset. These arguments can be very time consuming. Including this information in the problem description allows the clinicians the opportunity to explain the progression of the development of a problem and often eliminates the arguments and confusion.

Long-Term Goals and Short-Term Goals Versus Goals and Objectives In this system, long-term goals and short-term goals are used to track outcome of treatment. In other treatment planning systems, especially NCPs, the terms “goals” and “objectives” are substituted for “long-term goals” and “short-term goals.”

Intro–16


Use of either pair of outcome measures is acceptable; however, the use of long-term goals and short-term goals has several advantages. • The phrases “long-term goals” and “short-term goals” are unambiguous. Little or no training is needed to have at least some working understanding as to the meaning of these phrases. However, the term “objective” has a wide range of commonly used meanings. Due to its wide range of definitions, the introduction of “objective” can be confusing to the writer and anyone who reads the plan. This confusion leads to the need for additional training, which can be timeconsuming and expensive. • The concepts of long-term goals and short-term goals fit very well along a continuum. However, goals and objectives do not intuitively fall along a continuum. The terms imply much more of a qualitative difference than should exist between them. • Separate categories of possible long- and short-term goals are not necessary. Depending on the clinical situation, a long-term goal can be a short-term goal and vice versa. For example, “patient will be free of assaultive behavior for a 1-week period” can be a long-term goal in an acute setting if freedom from assaultive behavior for 1 week is determined to indicate that the problem is no longer active or is adequately treated so that the patient can be discharged from the acute setting. The same goal may be a short-term goal in a chronically assaultive patient if it is determined that being assault-free for 1 week simply indicates improvement; however, a much longer assault-free period is felt necessary to indicate that the problem is no longer active or that adequate improvement has occurred for discharge. As a rule of thumb, long-term goals are essentially the same as goals, and short-term goals are essentially the same as objectives. Of course, all outcome measures, regardless of how they are named, need to comply with rules that ensure they are observable and measurable. See “Master Treatment Plan Forms (Step-by-Step Instructions)” later in this chapter for further information on long- and short-term goals and target dates.

Treatment Goals Versus Treatment Modalities Several issues are frequently raised concerning treatment goals and treatment modalities (interventions): Differentiating Goals and Treatment Modalities The difference between goals and treatment modalities seems very simple: goals equal “ends” and modalities equal the “means” by which the goals are attained. However, the picture clouds when goals are further defined as “targeted, measurable” changes that occur in the patient. Completing a test or procedure can be seen as a goal or an end point; however, such tests or procedures cannot be seen as “targeted, measurable” changes in the patient. When deciding whether to define an item as a goal rather than a treatment modality, one may also want to consider that goals have target dates. If the item is defined as a goal, target dates can be easily assigned and a mechanism is in place to track whether the test or procedure has been completed. For certain items, especially tests and evaluations, these target dates can be very useful. A rule of thumb that many clinicians find helpful to distinguish goals from modalities is the fact that most goals can be stated as “Patient will …,” whereas most treatment modalities can be stated as “Staff will …” However, this manual does not make an inflexible distinction between goals and modalities. One is, therefore, encouraged to use his or her clinical judgment as to whether particular items should be defined as goals or modalities. Establishing the Importance of Treatment Modalities Treatment modalities are generally real, actual occurrences. Even well thought out goals can often turn out to be the clinician’s “wish list.” This is especially true for the long-term-care patient. For this reason, it is often argued that more emphasis should be placed on treatment modalities. Another reason for the emphasis on modalities is that staff members frequently go to treatment plans to get an update on

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treatments for various problems. Though certainly important, goals have never seemed to gain the clinical usefulness to the staff that treatment modalities have. Further, if the goals are reached, but the treatment modalities are unclear, it may appear as if one accidentally stumbled into attaining the goals. Finally, it is much easier to defend inaccurate goals and inaccurate target dates than to defend inaccuracies in the treatment modalities. Predicting the future is difficult; however, failing to accurately represent what is happening in the present, such as treatment modalities, can leave one open to criticism. Working Backward From Treatment Modalities to Goals In filling out treatment planning forms, one major argument concerning the sequence is often raised. That argument relates to whether one should enter the treatment modalities before the goals. Logically, it seems to make a lot of sense to start with the goals; however, clinically, it is sometimes much more useful to start with the treatment modalities. It is not unusual for the availability of resources to drive treatment to a greater degree than the goals do. This is especially true for the long-term patient who has exhausted many of his or her resources, including family supports. The availability of specific treatments, including the expertise needed for those treatments, can markedly affect the development of realistic goals and realistic target dates. Therefore, once treatment modalities have been determined, the modalities can be surprisingly helpful when attempting to write realistic treatment goals.

Treatment Modalities That Have Effects Across Problem Areas Psychotropic medications often have effects in several problems areas; however, in some areas, the effects are brought about primarily by improvements made by the medications in other areas. Therefore, it is recommended that medications be listed only within the one or two problem areas in which they are expected to have their primary effects. For example, even though antipsychotics and antidepressants can have significant direct and indirect effects in Problem Area 2 (Social Skills), Problem Area 4 (ADL–Occupational Skills), Problem Area 5 (Substance Abuse), and Problem Area 7 (Ancillary Impairment), the improvements are often due to the secondary effects of improvements in energy, motivation, focal attention, paranoia, and hostility. These medications are often given primarily as a treatment for Problem Area 1 (Psychological Impairment) and Problem Area 3 (Violence), even though they have clear, important roles in other problem areas. Therefore, it is recommended that antipsychotics and antidepressants be listed under Problem Area 1 and Problem Area 3, if Problem Areas 1 and 3 are the primary problem areas being targeted by these medications. This pervasive effect is also true for many nonmedication treatments. Treatment should be listed only in the one or two primary problem areas to which it is being targeted. For example, a substance abuse group may have significant effects on the patient’s depressive symptoms and social skills; however, its primary target is substance abuse. Therefore, generally the substance abuse group would only be listed on an IPP under Problem Area 5 (Substance Abuse). Other groups and treatments would probably be used to treat the patient’s depressive symptoms and problems with social skills. These other groups and treatments would then be listed as the treatments for the depressive symptoms and social skills problems, rather than the substance abuse group.

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Steps for Building Goals and Treatment Modalities In this section, simple steps are presented as a “rule-of-thumb” for writing goals and treatment modalities. These steps will guide you through writing basic goals and treatment modalities and help ensure that important components of goals and treatment modalities are not overlooked. When you have decided on the components, you do not have to follow the same sequence when actually entering them; however, the sequence often flows easily into the goal or treatment modality. Use four steps to write goals (Figure 4): 1. “Pt. will ______ [plus active verb]”: Document that the patient is the one expected to accomplish the goal. This goal includes an active verb, which indicates the patient’s action to accomplish the goal. 2. Behavior expected [observable and measurable]: Present and write the target behavior in observable and measurable terms. The more effective one is in writing the goal in observable and measurable terms, the more likely it will be that it is clear when the goal has been attained. 3. Target frequency: Enter the expected frequency for the expected behavior when the goal has been attained. 4. Time period: Enter the expected length of time it should take the patient to attain the goal.

Four Steps for Building Goals 1. Patient will ... [plus active verb]

2. Behavior expected [observable/measurable]

Pt. will make …

3. Target frequency

4. Time period

at least one nondelusional, relevant comment in community meeting …

twice a week …

for 1 month.

Pt. will discuss …

the importance of taking his meds as prescribed …

for 15 minutes twice weekly …

for 1 month.

Pt. will cooperate …

with at least one treatment team member in the treatment planning process …

once daily …

for 1 week.

Pt. will maintain …

relevance and focus on topics beyond the first two sentences of a conversation …

three times a week …

for 1 month.

Pt.’s motivation will improve such that she will have …

her personal dorm area in acceptable order …

at least 3 out of 5 weekdays …

for 1 month.

Pt. will cooperate with discharge plans so that he is accepted …

into a halfway house program.

[not needed]

[not needed]

[not needed]

[not needed]

Pt.’s score on the from the current score of 40 to 60. Kennedy Axis V subscale Social Skills will improve …

Figure 4.

Examples of goals generated using the four steps.

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Also use four steps to write treatment modalities (interventions): 1. “Staff will ________ [plus active verb]”: Document that the staff will be providing the treatment. This step includes an active verb that indicates the action that the staff will take to provide the treatment. 2. Time period: Enter the length of time that the staff will use to provide the treatment. 3. Frequency: Enter the frequency with which the staff will provide the treatment. 4. Modality: Enter the treatment. At this point, you may also want to enter a reason for recommending this particular treatment modality. Figure 5 illustrates examples of treatment modalities generated using these four steps.

Four Steps for Building Treatment Modalities 1. Staff will ... [plus active verb]

2. Time period

3. Frequency

4. Modality

Nurse will meet with pt. for at least 15 minutes … once weekly … …

to educate pt. about her illness and the importance of taking her meds.

Psychologist will lead pt. …

1 hour …

once weekly …

in anger management group to help him understand how his violent behavior acts as a barrier to his discharge.

Nursing staff will assess pt. …

[time necessary]

when she returns from passes …

for any evidence of intoxication and will report significant findings to the psychiatrist.

Rehab staff will schedule pt. …

for 1 hour …

twice weekly …

for AA meetings to learn more about alcohol abuse risk factors and how to avoid them.

Psychiatrist will rate pt. …

[time necessary]

once every 6 months …

on the Kennedy Axis V to help track pt.’s level of assaultiveness.

Nurse will begin …

[as soon as clinically reasonable]

[as often as clinically to assess pt.’s level of understanding of reasonable] antidepressant medication and his readiness to learn before educating him.

Psychiatrist will meet with pt. ...

for at least 35 minutes … once weekly …

to assess pt.’s level of psychosis and to prescribe medications such as Zyprexa (olanzapine).

Nursing staff will encourage pt. …

[as needed]

to attend program activities and provide escort, if needed.

Figure 5.

[on an ongoing basis]

Examples of treatment modalities generated using the four steps.

Individual Problem Plan for Each Active Problem It is recommended that one have a separate IPP sheet for each active problem on the Problem List. There are several reasons why this is important to a good, comprehensive treatment planning system: Ease of Documentation of Treatment Progress and Rapid Access to Current Status of Treatment An individual sheet for each active problem allows changes for each problem to be entered easily. The clinical process is a fluid process; the treatment planning system needs to be able to reflect the flow of

Intro–20


that clinical process. A benefit of including the IPP forms in this manual is their ability to reflect these shifts in the clinical process. As a result, IPPs can allow a clinician to quickly determine the current status of treatment for particular problems. The clinician can also quickly review the progress of the treatment that has led to the current IPPs. It is not necessary to move back and forth between the original MTP, Treatment Plan Reviews, and progress notes to determine the general progress and current standing of the treatment. Sharing of IPPs IPPs are critical to the sharing and exchange of ideas on treatments for individual problems. If a good plan is developed for a particular problem, then the IPP for that problem can be removed from the MTP and copied and distributed as a guide for members of other treatment teams. Also, as indicated earlier, IPPs could be written by experts in various areas and made available to users of the manual. These new IPPs and shared plans can be added to the manual for quick reference. Training Training can be done for problem areas using IPPs. For example, IPPs on suicide and suicidal ideation could form the basis for training related to treatment planning for the suicidal patient. IPPs on symptoms and behaviors of the psychotic patient could be used for training related to treatment planning for the psychotic patient. No Increase in Documentation Finally, there should be no significant increase in the amount of documentation. The information required by the accreditors is the same regardless of whether the documentation is collapsed into one central document or organized in a different manner. There may be more pages in a plan that requires a page for each active problem; however, because both systems contain the same required information, there should be no difference in the amount of documentation needed. This can create a problem because there is a tendency by clinicians to want to completely fill any blank areas based on the size of the blank area rather than the amount of information needed. Staff members need to be trained to write briefly and concisely, regardless of the size of the blank areas.

Avoiding Excessive Documentation Staff members want to provide clinically good treatment planning while avoiding excessive documentation and use of valuable team time. Determining the necessary level of documentation is often a difficult clinical decision. The following guidelines suggest where cuts can and cannot be made as well as the costs and benefits of these decisions. Situations in Which Cuts Are Not Recommended An IPP is requested for each active problem. Also, taking a thorough, systematic approach to listing the problems can lead to an increase in the number of problems identified. However, when a thorough treatment planning process leads to a dozen separate sheets of paper, the patient obviously has multiple impairments. In such cases, a good, comprehensive treatment plan can be very helpful and can save time. These plans act as effective, clinical blueprints for integrating and working with a complex group of goals and treatments. It is not unusual for clinicians to exclude even active problems from the treatment plan. This is unacceptable. A practitioner should not discover after reading the treatment plan that important symptoms and behaviors (or even medical problems) have been excluded. These “surprises” can have dangerous consequences. Treatment planning without cutting corners or making major compromises can be timeconsuming and expensive. These high costs are up front and obvious. The savings gained by making major compromises in treatment planning are often clearly evident, and the hidden costs may be almost totally obscured. This illusion has led to an almost knee-jerk reaction to opt for major cuts and compromises when developing the MTP; however, without the solid foundation of a good MTP, subsequent treatment planning and reviews can be disorganized and confusing.

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A major contributor to this knee-jerk reaction is the fact that many clinicians falsely believe that treatment planning has no clinical value. These are often responsible clinicians who think treatment planning is necessary for satisfying accreditors but for little else. This attitude is fueled by years of frustration with the poor results of even genuine attempts to generate good, useful treatment plans. One of the primary purposes of this manual is to assist clinicians in their attempts to quickly generate clinically effective treatment plans. If successful, it will help to reduce some of the frustration, anger, and cost of treatment planning, while helping to improve the quality of care. Situations in Which Cuts Are Recommended There are certainly many ways to achieve direct compromises and cost-cutting measures. There are situations in which such cuts and compromises can lead to better staff acceptance and more appropriate treatment plans. • Anticipated length of hospitalization. Certainly there may be less need for a comprehensive treatment plan in an acute setting in which the average stay of the patient is only 8 to 10 days. Many treatment decisions may be fresh in the minds of the clinicians; therefore, there may be less of a need to refer to a comprehensive treatment plan. This is especially true if the treatment team relies almost exclusively on other parts of the record for clinical information and documentation of the clinical progress, for example, the progress notes. The opposite is often true of the long-term-care patient. In the long-term-care patient, treatment may be no more complicated than treatment for the acute-care patient; however, the treatment is often much more unconventional and individualized. These patients have generally failed to respond to the initial, somewhat standardized treatment strategies. As plans get increasingly individualized, comprehensive treatment plans become increasingly important to keep the team informed and working together. Also, as the length of hospitalization increases, treatment planning decisions will no longer be fresh in the minds of the clinicians; therefore, a comprehensive treatment plan can be helpful to remind staff of their roles with a particular patient. Problems in the long-term-care setting that are often deferred in the acute-care setting also have to be addressed. For example, deficits in work skills may not be addressed at all in an acute-care setting. However, these same deficits in work skills may be the primary focus of treatment in a long-term-care facility. • Degree to which the rest of the record effectively reflects treatment and its progress. If the treatment planning information is well organized and easily accessed in the rest of the record, the team may be less dependent on having a very comprehensive treatment plan. However, if information about the team’s treatment plan and its outcome is buried in the record and difficult to locate, then a comprehensive treatment plan can be extremely helpful with keeping the team focused on their common goals and the methods to achieve those goals. • Clinical style of the treatment team. Clinical styles vary greatly in the development and use of MTPs. Some clinical styles may work better with an abbreviated, short plan. This manual and its forms do not limit the use of the system to clinicians with a particular style. Therefore, if the clinician wants to do a short, quick MTP, the system will allow for it. If the clinician wishes to write a comprehensive plan, the system will continue to satisfy the needs of the clinician. The system also allows clinicians and the quality assurance department a lot of flexibility to impose their clinical judgments and standards onto what should be included in the treatment plan. • Time constraints for a hurried treatment team. Obviously, if the team is not provided with adequate time to prepare a reasonable treatment plan, the plan may lack many critical elements or the plans may be extremely “canned” as clinicians take desperate steps to meet various deadlines. It has been my experience that it is not unusual for clinicians to be expected to write comprehensive treatment plans without the minimal time and staff needed to write reasonable plans. I have seen this lead to anger and frustration among the staff.

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Clinically Appropriate Cuts Finally, the following discussion covers several clinically appropriate ways to limit the size of a treatment plan and to decrease the amount of team time needed to complete a plan. • Limit the number of active problems that will require an IPP. This limit can result in a clinically effective plan as short as three or four pages. Two methods can be used to achieve this goal: 1. Collapse related problems under one name (e.g., delusions, hallucinations, and bizarre behavior can be treated under the problem “psychotic symptoms”). The problem description would contain an explanation of the symptoms and behaviors being addressed by the problem “psychotic symptoms.” In this way, individual symptoms and behaviors are retained in the plan without the plan being overwhelmed by the number of problems. The system allows for collapsing of problems within the same subscale area; however, one should not collapse problems from different subscale areas. For example, one should not collapse the problem of suicidal attempts from the subscale area of Violence into depressive symptoms because depressive symptoms should be under the subscale Psychological Impairment. 2. Defer the treatment of active problems, if they do not require acute attention (“Deferred” should be written in the problem status column of the Problem List). This can be especially useful in acute-care settings. • Delegate parts of the treatment plan to individual team members. Once these individuals have completed drafts of their sections, the team should meet to finalize the plan. The full team should meet to quickly put together a Problem List and Strength List by systematically going through the seven problem areas and then assign the active IPPs to specific team members. Generally speaking, IPPs from Problem Area 1 (Psychological Impairment) and Problem Area 3 (Violence) might go to the psychiatrist or psychologist. IPPs from Problem Area 2 (Social Skills) and Problem Area 4 (ADL–Occupational Skills) might go to the team member from rehabilitation or to nursing. IPPs for Problem Area 5 (Substance Abuse) might go to the individual or discipline that is most involved in substance abuse treatment. IPPs for Problem Area 6 (Medical Impairment) may go to the psychiatrist, nurse, or the primary care physician. IPPs for Problem Area 7 (Ancillary Impairment) often address placement or financial issues and often go to the social worker. Legal problems under Problem Area 7 may go to the psychiatrist, psychologist, or social worker. The assigned clinicians then enter the problem description and goals. They enter only the treatment modalities for treatment that they will provide. They do not write any treatment modalities for other disciplines. When the team meets to finalize the plan, the clinicians responsible for implementing the remaining treatment modalities can then enter those modalities. At that time, the nurse(s) could also complete the NCP section of the treatment modalities. • Be brief and to the point with the problem description, treatment goals, and treatment modalities. As mentioned earlier, there is a tendency by clinicians to fill blank areas based on the size of the area rather than the amount of information needed. Staff members need to be trained to write briefly and concisely, regardless of the space available. • Don’t reinvent the wheel. When you write IPPs on active problems in your patient’s MTP, refer to this manual or go online at www.kennedymd.com for sample IPPs. This resource is especially helpful if there is a sample IPP similar to the IPP that you are about to enter into your patient’s MTP. If an earlier MTP is available on your patient, it is likely to be similar to the new MTP that the team is going to write. I recommend that the earlier plan be photocopied. The team can often quickly update the copy and then type the edited copy onto the MTP forms to create the new plan. If an electronic version of an earlier plan is available, the editing could be

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done directly on the electronic version and then stored, printed, or both. I also recommend that IPPs created within your facility be categorized by the Kennedy Axis V and placed in a binder for later reference. As more IPPs are added, this binder can be an invaluable resource for writing future plans.

Inclusion of Milieu Staff in Treatment Planning Even though the milieu staff members often form the backbone of treatment, they are frequently excluded from the treatment planning process. This exclusion will certainly alienate them from this process. If the milieu staff members disagree with a plan, the plan is often doomed from the beginning. Therefore, a critical part of an effective plan is the working relationship between the treatment team and the milieu staff. In developing this working relationship, it is vital to include the milieu staff as much as possible in relevant parts of the treatment planning process.

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Master Treatment Plan Forms (Step-by-Step Instructions) These instructions are intended to walk the reader through the process of completing the MTP and the Treatment Plan Review forms. The instructions follow the sequence of the forms. In the next section is a sample of a completed MTP with five Treatment Plan Reviews. It may be helpful to follow that sample plan and its reviews when going through these instructions.

I.

Problem List/Cover Sheet A.

Date of Admission Enter the date of the current admission.

B.

Patient Identification Data In the upper right corner, place the patient’s name, hospital ID number, ward (area), and the current date.

C.

Problem Number Enter the number of the problem. A suggested numbering system is a categorization in which all problems are placed into one of seven categories (based on the Kennedy Axis V subscales). This is the numbering system used in this manual: 1. 2. 3. 4. 5. 6. 7.

Psychological Impairment Social Skills Violence ADL–Occupational skills Substance Abuse Medical Impairment Ancillary Impairment

The following sample Problem List is based on this system: 1.1 3.1 3.2 6.0 6.1 6.2 6.3 7.0

Depressive Symptoms Suicidal Ideation Homicidal Ideation Health Maintenance Diabetes Hypertension Kidney Failure Placement

In the above numbering system the period (.) separates the problem area from the designation of a specific, individual problem within that problem area. The problem numbers should be entered in numerical order when developing the Problem List. As additional problems are added, they would be added in the next available row at the bottom of the list and assigned the next available number within that problem area. In the Problem List example, if all the problems were active, seven IPPs would have to be completed. However, in two subscale areas, there is more than a single problem number: 3.1 3.2 6.0 6.1

Suicidal Ideation Homicidal Ideation Health Maintenance Diabetes

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6.2 Hypertension 6.3 Kidney Failure Whenever clinically reasonable, problems within a subscale area should be covered under a single problem number. This can reduce the complexity of the MTP by decreasing the number of IPPs that have to be tracked separately. Therefore, if it is clinically reasonable to collapse the above problems into a single number within their respective subscale areas, the list may appear as follows: 1.1 3.1 6.0 6.0a 6.0b 6.0c

Depressive Symptoms Suicidal and Homicidal Ideation Health Maintenance Diabetes Hypertension Kidney Failure

Even if all the problems listed were active, only three IPPs would need to be completed for this list. Because the hypertension and kidney failure may be secondary to diabetes, the list could also be collapsed as follows: 1.1 3.1 6.0 6.1 6.1a 6.1b

Depressive Symptoms Suicidal and Homicidal Ideation Health Maintenance Diabetes Hypertension Kidney Failure

In this example, four IPPs would be needed. Problems 6.1a and 6.1b would be collapsed into problem 6.1 Diabetes. The “.0” position, as illustrated in the example, is reserved for a special problem within a problem area. No other problem would be assigned the “.0” position, even if it were not used on a particular plan. Currently two such problem names are often associated with the “.0” position: 6.0 Health Maintenance 7.0 Placement It is common for a 6.0 to be entered into the Problem List of every patient being treated at a particular facility and given an active status, even when a patient has no significant medical problems. This listing allows for tracking of routine health issues, as well as relatively minor health problems. Serious health problems should generally be given a separate problem number, for example, a serious case of diabetes could be assigned 6.1 Diabetes, rather than being collapsed under 6.0. A case of diabetes that is stable and well controlled by diet and an oral hypoglycemic medication may be easily tracked under 6.0 Health Maintenance. The problem number should follow revisions of the problem name, if it continues to be essentially the same problem. For example, in the original MTP “psychotic symptoms” may have been identified; however, later the patient was determined to have bipolar symptoms. This would lead to the following changes in the Problem List: Problem Number

1.1 1.1

Problem Name

Psychotic Symptoms Bipolar Symptoms

Discharge Barrier

Date Estab. & Status

Yes

01/15/03

02/15/03

Active

Revised to 1.1

Yes

01/15/03 Active

Date Changed & New Status

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In a similar example, “hostile and threatening” may be revised to “assaultive:” Problem Number

Problem Name

Discharge Barrier



02/15/03 Revised to 3.1

3.1

Hostile and Threatening

Yes

01/15/03 Active

3.1

Assaultive

Yes

01/15/03 Active

Discharge Barrier



02/15/03 Revised to 6.1

Another example: Problem Number

Problem Name

6.1

Hypothyroidism

No

01/15/03 Active

6.1

Hypothyroidism Secondary to Lithium

No

01/15/03 Active

At the time of a rewrite of the MTP (often annually), it may be reasonable to redo the problem numbers to allow the most prominent problem in a problem area to be moved to the numerical top of the problem area. For example, at the time of the rewrite on 01/15/04, the old Problem List for the Violence area would appear as follows: Problem Number

Problem Name

Discharge Barrier



3.1

Hx of Suicidal Attempt

No

01/15/03 Noted

01/15/04 Revised to 3.2

3.2

Assaultive Behavior

Yes

02/15/03 Active

01/15/04 Revised to 3.1

In the new MTP on 01/15/04, “assaultive behavior” can be moved to the numerical top: Problem Number

Problem Name

Discharge Barrier


3.1

Assaultive Behavior

Yes

02/15/03 Active

3.2


No

01/15/03 Noted


Similarly, if information was gathered concerning the patient’s suicide attempt and on 04/15/03 it was determined to have been fabricated by family to get needed treatment for their mentally ill family member, then on 04/15/03, “Hx of suicidal attempt” could be canceled:

Introduction

Problem Number

Problem Name

Intro–27

Discharge Barrier



04/15/03 Canceled

3.1


No

01/15/03 Noted

3.2

Assaultive Behavior

Yes

02/15/03 Active

In the annual rewrite of the MTP on 01/15/04, “assaultive behavior” can be moved to the numerical top and “Hx of suicidal attempt,” which was canceled, would not appear on the Problem List: Problem Number

3.1

D.

Problem Name

Assaultive Behavior

Discharge Barrier


Yes

02/15/03 Active


Problem Name Write the name of the problem in this column. The name should be brief, generally no longer than three words. The name is intended to be a quick, concise way of identifying the problem. For example, use “suicidal ideation” rather than “suicidal ideation because of recent job loss.” Document descriptive and interpretive statements related to the problem, such as “because of recent job loss,” in the problem description section on the IPP sheets. As indicated earlier, to help ensure that significant problems are not overlooked, when determining the Problem List work your way systematically through each problem area, starting with Problem Area 1 (Psychological Impairment) and ending with Problem Area 7 (Ancillary Impairment). The Problem List should contain all significant clinical problems. In addition to the obvious problems, the Problem List should contain items such as history of assaultive behavior, history of suicidal attempt, allergy to penicillin, single kidney, and so on. These problems should not be listed if they are thought to be of no clinical significance (e.g., if the suicidal attempt was an isolated incident that occurred years ago and is of no future clinical relevance to the case). Problems should not be listed if they are already incorporated into an active problem. Allergies do not need to be included on the Problem List if there is already a system in place to prominently display allergies in the patient’s record. Also, in addition to problems, the Problem List should contain other clinical factors that require treatment or clinical resources, such as pregnancy, criminal charges, Tarasoff warning, placement, health maintenance, and so on. This is the treatment plan, not the problem plan; therefore, important areas involving treatment should not be omitted from the MTP simply because they are not seen as a “problem.” If the Problem List is complete, clinicians will not be surprised by significant clinical issues or problems lost or buried in the patient’s chart. Generally, the Problem List is the only place in the chart where there is a comprehensive, condensed, and updated outline of all significant clinical issues. This is a key part of any clinical chart and is one of the first places clinicians should go when attempting to get an overview of the patient’s clinical situation.

Intro–28

E.


Discharge Barrier Enter “Yes” or “No” as appropriate: Yes—This problem is a significant barrier to discharge. No—This problem is not a significant barrier to discharge. There is no column to indicate a status change in the discharge barrier. When the problem is no longer active, it is assumed to no longer be a discharge barrier. If needed, one can revise the problem on the Problem List to the same problem number and enter the revised problem on the next available row on the Problem List. You can then indicate that the problem is no longer a discharge barrier or indicate that it is now a discharge barrier. Finally, it is important to note that if a problem is not a barrier to discharge, funding sources may mandate that any treatment of that problem be deferred.

F.

Date Established and Status The date established should be the date that the problem was entered into the treatment plan. This date will frequently not correspond to the date that the problem started. The date the problem actually started may be documented on the IPP sheet under problem description. The status of the problem can be any of the following: Active, Inactive, Inactive With Tx, Deferred, or Noted. Section H contains a brief explanation of each status.

G.

Date Changed and New Status This column is intended to allow anyone reviewing the Problem List to quickly determine the current status of all problems. The treatment team should indicate the date that the status changed and the new status. The date that the team changed the status should be entered here. The actual date that the change in the problem occurred should be documented in the progress notes, the Treatment Plan Review, or both. The status changes include all of the statuses listed for the previous column (Active, Inactive, Inactive With Tx, Deferred, and Noted) plus Resolved, Revised, and Canceled. The next section briefly explains each status.

H.

Brief Explanation of Each Status 1. Active Problem: A problem that would require active assessment, treatment, or both. An IPP

sheet is required, and progress notes should be written on active problems. 2. Inactive Problem: A problem that is inactive and requires no treatment; however, it should

be noted because it is likely that it may become active or it could have some significant impact on treatment. Some examples include history of homicidal attempt, history of suicidal attempts, allergy to penicillin, only one functioning kidney, abnormal ECG. No IPP is required. 3. Inactive With Tx: A problem that is inactive; however, continued treatment is required to

prevent the recurrence of the problem. An example includes assaultiveness under control with lithium and present when lithium is withdrawn. Therefore, continued treatment would be indicated for this inactive problem. An active problem should not be changed to “Inactive With Tx” until you are fairly certain that the change in status is real and not just a fairly temporary state. The IPP for the active problem would continue to be used; however, all goals, including long-term goals, would have been Attained or Canceled. Any changes in treatment would be documented in the same way that changes were documented for the active state for the problem, including writing progress notes to document the continued treatment and with hope, continued control of symptoms.

Introduction

Intro–29

4. Noted Problem: Similar to an inactive problem; however, it is even less likely to become

active or to require treatment. Noted problems fit along the following continuum: Active or Inactive With Tx

Å

Inactive

Å

Noted

Å

Resolved

For example, a fractured arm will be an “Active” problem while it is in the cast healing and being followed up. After a few weeks, when the arm is taken out of the cast and appears to have healed and no follow-up is recommended, the problem may be changed to “Inactive.” After a few months, if there is a rewrite of the MTP, the problem may be “Noted” on a treatment plan. After about 6 months or longer, if the arm continues to appear to have healed well and the patient does not appear to be at risk for another fracture, the problem may be listed as “Resolved.” If “Resolved,” it would be taken off the Problem List at the next rewrite of the MTP. Of course, no IPP is needed for a “Noted” problem. 5. Resolved Problem: This status is used when a problem has reached a state whereby it is felt

to be of little or no clinical significance. For example, as indicated in the last example, a well-healed fracture of an arm that in no way predisposes the patient to future fractures would be considered “Resolved.” No IPP is required once a problem has resolved and as indicated above, it would be removed from the Problem List at the next rewrite of the MTP. 6. Revised Problem: This status is used when a change is made in the problem name, number,

or in rare cases the discharge barrier. This revision is intended to clear up any confusion or misunderstanding in the present problem name or number. Revisions in the problem name include better wording for clarity, changes in the name to reflect changes in the nature of the problem itself, and so on. For example, “allergy to Risperdal” could be revised to “severe EPS on Risperdal,” if it were determined that rather than an allergy, the patient had severe EPS when on Risperdal. If the problem is revised for inclusion with one or more other problems, the resultant problem could be assigned a number already held by one of the problems or it could be assigned a new number. Problems losing their numbers would be “Revised” to the chosen number. If there were a change in the status of the revised problem, the need for an IPP would depend on the final status assigned to the problem. For example, if the Revised status was an Active status, an IPP would be required. If the problem were revised to an Inactive status, no IPP would be needed. 7. Deferred Problem: An active problem whose assessment, treatment, or both have been

postponed until a later time or another place. For example, treatment of a learning disability may be deferred in an acutely psychotic or acutely suicidal individual. A deferred problem could also be an active problem that for various reasons would probably never be treated or require further assessment. In addition, a deferred problem could be a problem that is being actively treated; however, a decision to stop treatment is made for various reasons and any further treatment is deferred until a later time or another place. As indicated earlier, it is important to note that if a problem is not a barrier to discharge, funding sources may mandate that any treatment of the problem be deferred. No IPP is required on deferred problems; however, a partial IPP can be completed at the discretion of the treatment team. On such a partial IPP, one would enter the description of the problem. “Deferred problem” and the reason for deferral could then be written in the area for the long-term goal. Later, if the problem changes to an Active status, a line could be drawn through “Deferred problem” and the rest of the form could then be updated and completed.

Intro–30


8. Canceled Problem: This status should be used to cancel out a problem that may have been

incorrectly identified as a problem for the patient. For example, “suicidal ideation” would be canceled if it were determined that the patient is not and has never been suicidal or self-abusive. Of course, no IPP would be needed for a canceled problem.

II.

Strengths/Discharge Plan/Diagnosis Page A.

Patient’s Strengths Enter either a list of the patient’s strengths or a narrative statement listing and integrating the patient’s strengths. These strengths should be related to treatment and discharge. As with the Problem List, to help ensure that significant strengths are not overlooked, it is suggested that you work systematically through each strength area as defined by the Kennedy Axis V subscale problem areas as shown in Table 1.

Table 1.

Kennedy Axis V Categorization System for problems and strengths

PROBLEMS

STRENGTHS

1. Psychological Impairment

1. Psychological Strengths

2. Social Skills (Deficits)

2. Social Skills (Assets)

3. Violence

3. Nonviolence

4. ADL–Occupational Skills (Deficits)

4. ADL–Occupational Skills (Assets)

5. Substance Abuse

5. Sobriety

6. Medical Impairment

6. Medical Strengths

7. Ancillary Impairment

7. Ancillary Strengths

As with the problems, once you have gone through the strengths areas it is unlikely that significant strengths will be overlooked. B.

Discharge Criteria/Planning Discharge criteria are often equated with the long-term goals of the problems that are discharge barriers; therefore, you may want to work backward from the long-term goals to the discharge criteria. Prediction of placement should be realistic (i.e., based on the patient’s strengths and weaknesses and the availability of resources in the community). Enter here the realistic placement plans, rather than the idealistic ones. Also enter concerns about the lack of availability of appropriate community resources. If needed, complete an IPP on placement. Such a problem plan helps the social workers to document in the progress notes their efforts to place the patient. This also makes it easier to locate information in the progress notes concerning placement that has been written by social work staff, as well as non–social work staff. Enter the target discharge date here. It is rare for the target discharge date to be beyond 1 year; however, if realistic, it is acceptable to indicate a discharge date of 2 or 3 years or even “indefinite.” Be sure to document one’s clinical reasons for such an extensive length of stay.

Introduction

C.

Intro–31

Psychiatric Diagnosis Enter the patient’s DSM-IV-TR diagnosis at the time of the MTP. The Kennedy Axis V should be used for both Axis IV and Axis V (Kennedy 2003). Figure 6 shows an example of a psychiatric diagnosis. Psychiatric Diagnosis (DSM-IV-TR): AXIS I:

Major Depression, Recurrent, Severe Without Psychotic Features

AXIS II:

Obsessive-Compulsive Personality Disorder

AXIS III:

Insulin-Dependent Diabetes Mellitus

AXIS IV:

Ancillary Impairment = 45 (Divorce)

AXIS V:

PSY = 40 + SOC = 65 + VIO = 40 + ADL = 75 = 220/4 = 55

Figure 6.

Psychiatric diagnosis.

III. Individual Problem Plan A.

Problem Number and Name Enter the number and name of the problem directly from the Problem List.

B.

Nursing Diagnosis As a part of the integration of the NCP into the MTP, enter the nursing diagnosis below the † problem name. To assist with this task, nursing diagnoses have been categorized by the Kennedy Axis V (see Appendix).

C.

Patient Identification Data In the upper right corner, place the patient’s name, hospital ID number, ward (area), and current date. Enter the date the IPP was completed. For most problems, this date will be the same as the date for the MTP. However, following the completion of the MTP, new problems may be entered. The date entered on each new IPP should reflect the date that IPP was completed and placed in the chart.

D.

Problem Description Enter a brief description of the problem. The following six components are often seen in problem descriptions: 1. 2.

3. 4.

†

Onset of symptoms and chronicity Precipitants (e.g., noncompliance with treatment, command hallucinations, substance abuse, losses, stress, poor frustration tolerance, poor coping mechanisms, peer pressure, lifestyle) Characteristics, frequency, intensity, and variance of symptoms Response to previous and current treatments and expected response to any proposed treatments

Nursing Diagnoses: Definitions and Classifications 2001–2002. Philadelphia, PA, North American Nursing Diagnosis Association, 2001.

Intro–32


5. 6.

Presence of need for psychotropic medication guardianship, guardianship of person and/or estate, or any other related legal issues Current level of symptoms, activity level, including frequency of attendance at therapeutic activities

These components should relate to goals, treatment modalities, and target dates. E.

Long-Term Goal(s) (Discharge Criteria) Indicate reasonable expectations of what the patient is thought to be capable of achieving 1) at discharge or 2) within 1 year for patients expected to remain in treatment for 1 year or longer. Goals must be obtainable, measurable outcomes. The measures of outcome should address 1) frequency, 2) duration, or 3) change in condition or status. The outcome measures should allow the clinician to ascertain, at any time, whether the goal has been obtained. Standardized questionnaires should be considered as an ongoing part of the measurement of outcome. Often there is only one long-term goal for each problem. The Kennedy Axis V score is suggested for consideration as a second long-term goal. For example, long-term goals for psychotic symptoms could be as follows: 1. 2.

Pt.’s psychotic symptoms will decrease such that she can participate in full-time program activities for 1 month without serious disruption by psychotic process. Pt.’s Kennedy Axis V for Psychological Impairment will improve from a score of 30 to 50.

At a minimum, the long-term goal(s) should reflect the intention of preventing further deterioration in the patient’s mental or physical condition. One exception would be a problem that is part of a progressive disease process. In such a disease, there may be no treatment that will fully stop the progressive nature of the illness (e.g., the cognitive deterioration associated with Alzheimer’s disease). The goals for these progressive problems should reflect realistic attempts to minimize the deterioration. No active problem should be without a long-term goal. F.

Target Date Indicate the anticipated date when the long-term goal(s) or the short-term goal(s) will be achieved. Attempt to make these dates realistic. The treatment team should take into account the various expected delays and difficulties. The date should not reflect an “ideal” date or a “best-case scenario.” Generally the treatment team should set up long-term goals that are thought to be achievable before discharge or within 1 year for patients who are expected to remain in the hospital for 1 year or longer. The target date for the short-term goals may vary widely depending on many clinical factors. Generally, the date should not be longer than 6 months for short-term goals. If a target date has to be extended, draw a line through the target date and place the new target date below the old target date. Initial the change and document the reason for the change in the progress notes, the Treatment Plan Review, or both. “Ongoing” as a target date for an attained goal can be useful. Ongoing reflects that the goal has been attained; however, the team does not want to eliminate the goal from the plan because it helps to convey that the patient has achieved a specific level of functioning. An additional goal would not have to be added to the plan to replace this attained goal if the team is satisfied that the level of functioning achieved is adequate for discharge. The team would work on at least maintaining the patient at the level of the “ongoing” goal. For example, if an assaultive patient has attained a goal of being assault free for 6 months and this is adequate for discharge, the team may want to simply indicate “ongoing” as the target date. At the time of the MTP rewrite, the “ongoing” goal could be moved forward or

Introduction

Intro–33

incorporated into the problem description to document the current level of functioning for the problem. Ongoing can also be useful for problems that are “Inactive With Tx” because use of the term allows the level of functioning necessary for the patient to have achieved the “Inactive With Tx” status to be clearly documented, as well as the level of functioning needed to maintain the status of “Inactive With Tx.” G.

Date/Status Indicate status change and date of that change in this column. The status changes include Attained, Canceled, and Revised (see Section J). Draw a line through the long-term goal when its status has changed. If this is the only long-term goal and the problem is not Inactive, Inactive With Tx, Deferred, or Resolved, then another long-term goal or a revised long-term goal should be added.

H.

Short-Term Goal(s) (Objective[s]) A short-term goal is an expected or desired change in a current patient behavior, condition, or situation. As with the long-term goal, it should be stated in observable, measurable terms. The following system can be helpful in identifying short-term goals: First, establish where the patient is currently with respect to the problem and where the patient is expected to ultimately be as defined by the long-term goal. Then describe the next step that would have to occur if the patient were to make progress toward the long-term goal. This next step can often be used as a short-term goal. This next step must be converted into observable, measurable behaviors or symptoms that could signify to the team that the improvement has occurred. Additionally, it may be useful to focus first on the treatment modalities before determining the short-term goals. Once some of the treatment modalities have been laid out, the short-term goals may become obvious. Two or three short-term goals should be used for a problem. If it is not used as one of the long-term goals and if it is appropriate, a Kennedy Axis V score might be used as a shortterm goal. Each short-term goal should have its own target date.

I.

Treatment Modalities (Interventions) Treatment modalities, also known as “interventions,” are specific services, treatments, therapies, or other active interventions that the patient will receive or participate in or a staff action taken on the patient’s behalf. Treatment modalities may be Completed, Canceled, or Revised (see Section J). Draw a line through any treatment modality that has been Completed, Canceled, or Revised. Include the name and discipline of staff members who will either directly provide or supervise a treatment, therapy, or staff action. If someone is responsible for supervising or overseeing others in implementing the treatment modality, use an arrow to indicate the person(s) being supervised. For example, Linda Larkin, RN Å Ward Staff This arrow indicates that Linda Larkin, RN, will be responsible for supervising the ward staff with the particular treatment modality. This documentation indicates the responsible person(s) and the person(s) actually providing the treatment. Both are certainly important. If helpful, place the identifying number of associated short-term goals after each treatment modality to indicate which short-term goals are being addressed by each treatment modality. However, because it is often obvious which goals are associated with which treatment modality and because of the limited time to complete treatment plans, this numbering is discouraged.

Intro–34

J.


Status The goals may be Attained, Canceled, or Revised, depending on the patient’s response to treatment and additional information obtained. A treatment modality can be Completed, Canceled, or Revised. Draw a line through a goal or treatment that has been Attained, Completed, Canceled, or Revised: 1.

2.

3.

K.

Attained goal or completed treatment: This status indicates that the goal or treatment has been reached or completed. Enter a date and status change and draw a line through the goal or treatment. If appropriate, enter another goal or treatment, along with a target date for each new goal. Revised goal or treatment: This status indicates that a change has been made in the goal or treatment. Enter a date and status change and draw a line through the goal or treatment to be revised. In the appropriate column, enter the revised goal or treatment. If a goal is being revised, enter a target date in the column next to the new goal. Canceled goal or treatment: This status indicates that a goal or treatment has been canceled. At this time, enter the appropriate date and status change and draw a line through the goal or treatment that is being canceled.

Date Treatment for the Problem Ended and Final Status Indicate the date that the treatment ended for the overall problem (not the end of treatment for a specific goal) by drawing a line across the front of the IPP. Around the middle of the line, enter the date and change in problem status that led to the discontinuation of treatment for the problem. Possible changes in status include Resolved, Revised, Inactive, Canceled, or Deferred. This change in status would also be indicated on the MTP’s Problem List.

IV. Signature Page

V.

A.

Patient Participation in Treatment Planning Indicate the level of participation by the patient in the development of the MTP. Areas are available for patient and staff comments. If the patient refuses to sign the plan, the team should indicate the reason for the patient’s refusal, if known, in “Staff Members’ Comments.”

B.

Treatment Team Members The signatures entered here should document the treatment team members who were involved in developing and completing the MTP. Everyone involved in the planning should sign; however, the accreditors require only the signatures of the physician, nurse, and social worker.

Treatment Plan Review Form A.

Patient Identification Data In the upper right corner, place the patient’s name, hospital ID number, ward (area), and current date.

B.

Psychiatric Diagnosis (DSM-IV-TR) Enter the patient’s DSM-IV-TR diagnosis as of the time of the Treatment Plan Review. If the diagnosis has changed, enter any changes here. On the Strengths/Discharge Plan/Diagnosis page of the MTP, enter the date of the Treatment Plan Review, which documents the changes and the reason for the change. It is also recommended that you enter the changes directly onto the diagnosis section of the Strengths/Discharge Plan/Diagnosis page and date and initial the changes. This documentation will allow you to go directly to the MTP for the current diagnosis without having to go to the Treatment Plan Reviews. If more information is needed about the change in diagnosis, you could then go to the appropriate Treatment Plan Review. If there are no changes in the Problem List, simply indicate “no change” in this area.

Introduction

Intro–35

C.

Changes in the Problem List Enter any changes in the Problem List in this section. These changes should also be entered onto the MTP’s Problem List. If there are no changes, simply indicate “No Change” in this area.

D.

Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems Enter the summary of the progress for each active problem made by the patient since the last MTP or the last Treatment Plan Review. If there are no changes, indicate the reasons for the lack of progress, rather than simply indicating “no change” in this area.

E.

Changes in Treatment Plan Goals or Modalities Enter changes in the MTP directly onto the MTP, then date and initial the entry. Enter the summary of those changes, including goals that have been attained or added or modalities that have been completed or added. If there are no changes, simply indicate “no change” in this area.

F.

Reasons for Continued Hospitalization Enter the summary of the reasons for continued hospitalization, especially issues related to violence and other forms of dangerousness. The Kennedy Axis V’s “Dangerousness Level” may be helpful with documenting the reasons for continued hospitalization. Also use this section to address any obstacles to securing an appropriate community placement when the patient is clinically ready for discharge.

G.

Discharge Planning Update Enter the update to discharge planning, including progress toward overcoming various obstacles to discharge. If there are no changes, indicate the current status of discharge planning.

H.

Continuation/Comments Section This area provides additional space if adequate space is not available in the previous sections. Patient or staff comments can also be entered here.

I.

Level of Care This section can be useful for Medicare and Medicaid billing purposes by indicating the following: Active Treatment [ ]

Extended [ ]

Awaiting SNF [ ]

Refer to the Centers for Medicare and Medicaid Services (formerly HCFA) for details and help with Medicare and Medicaid billing (SNF, skilled nursing facility). J.

Treatment Team Members The signatures entered here should document the treatment members who were involved in developing and completing the Treatment Plan Review. For clinical purposes, all participants involved in the Treatment Plan Review must sign it; however, the accreditors require as a minimum the signatures of the physician, nurse, and social worker. The patient should also be asked to read and sign the Treatment Plan Review to indicate that he or she participated in the review and is aware of its content. The patient’s signature on the review does not indicate that he or she agrees with the review. If the patient does not agree with the review, the patient should be encouraged to enter his or her concerns in the “Continuation/Comments” section.

Notes

MASTER TREATMENT PLAN (Sample)

MTP–1


Master Treatment Plan (Sample)

MTP–3

MASTER TREATMENT PLAN (Sample) CONTENTS Kennedy Axis V: Scoring Sheet ...........................................................................................................MTP–4 The sample Master Treatment Plan is based on a Kennedy Axis V rating of a fictitious patient, Derek Rossi. The Kennedy Axis V organizes information that can then flow into Master Treatment Plans.

Master Treatment Plan (Sample) ........................................................................................................MTP–5 This sample Master Treatment Plan will help demonstrate the treatment planning system used in this book, including how the Kennedy Axis V can help organize information that is often critical to good treatment planning.

Treatment Plan Reviews (Samples) ...................................................................................................MTP–17 These sample Treatment Plan Reviews demonstrate how the Treatment Plan Reviews act with the Master Treatment Plan to capture the flow of treatment. The sample Treatment Plan Reviews will take one through about half of the patient’s hospitalization.

MTP–4


Kennedy Axis V: Scoring Sheet Name: Derek Rossi

© 1986–2003

#: 12345

Age:

26

Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.

ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Primarily (check one): Not Impaired___ Antisocially Impaired___ Other Impairment X Both___ Derek’s current depression is characterized by feelings of hopelessness and worthlessness. He is anxious, lethargic, socially isolated, and frequently up most of the night. His depression is also associated with self-deprecating and command hallucinations.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Derek’s attempts to be pleasant and engaging are usually awkward. He has a couple of friends; however, he does see them often. He often gets into conflicts due to inappropriate social behavior.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 X 40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one): Nonviolent___ Violent to Self X Violent to Others___ Violent to Self and Others___ Derek has a long history of suicidal attempts, gestures, and manipulations. He has made serious attempts to hurt himself in response to command hallucinations, including taking overdoses of meds and attempting to hang himself. Since he stopped drinking 2 years ago, he has not acted on any suicidal impulses. Currently he continues to have command hallucinations and suicidal ideation; however, he reports that he would not actually attempt to harm himself.

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Derek is a high school graduate with average intelligence. He has some mild difficulty following instructions on his job as an office assistant. He has a driver’s license and has no more than mild difficulty maintaining his own apartment. Overall he has fairly good independent living skills.

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Primarily (check one): Nonabuser___ Alcohol Abuser X Drug Abuser___ Both___ Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and self-medicating his depression. He had some very serious problems with alcohol that led to serious attempts to hurt himself when intoxicated, including taking overdoses of meds and attempting to hang himself. Generally, since he stopped drinking 2 years ago, he has had much better control of these impulses. He goes to AA on a weekly basis and is committed to continued sobriety. Derek smokes one pack of cigarettes a day.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 X 60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Derek is in fairly good physical health, even though he has mild reflux esophagitis secondary to a hiatal hernia. This disorder is fairly well controlled with a prescription med to reduce stomach secretions; however, currently he drinks 8 to 12 carbonated beverages every day and eats other foods that exacerbate his heartburn.

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Derek has his own apartment that his family maintains if he is unable to pay the rent. He has some mild difficulties paying his credit card bills. He is not in trouble with the law.

GAF Equivalent:

#1

40

+ #2

60

+ #3

45

+ #4

70

Dangerousness Level (indicate only the most dangerous rating): Signature:

Victor Dyson, MD

=

215

/

4

=

55

45 Date:

01/05/03


MTP–5

Name: Rossi, Derek

MASTER TREATMENT PLAN & NURSING CARE PLAN

Problem List

ID #: 12345

Lakeview Hospital Name of Facility

Area: West Unit

Date of Admission: 01/15/03 Problem Number

Problem Name

Date: 01/15/03 Discharge Barrier*

Date Estab. & Status**

1.1

Depressive and Psychotic Symptoms

Yes

01/15/03 Active

2.1

Impaired Social Skills

No

01/15/03 Deferred

3.1

Suicidal Ideation

Yes

01/15/03 Active

5.1

Alcohol Abuse

No

01/15/03 Inactive With Tx

6.0

Health Maintenance

No

01/15/03 Active

6.0a

Reflux Esophagitis

No

01/15/03 Active

Date Changed & New Status***

02/12/03 Inactive With Tx

*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge **ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted ***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted Check if list is continued [ ]

MTP–6

Fundamentals of Psychiatric Treatment Planning Name: Rossi, Derek


ID #: 12345

Strengths/Discharge Plan/Diagnosis Area: West Unit

Date: 01/15/03 Patient’s Strengths (related to treatment and discharge):

• • • • • • • • • • •

Interests: watching TV, especially sports Motivated for treatment Good verbal skills No history of assaultive behavior Fairly good independent living skills High school graduate with average intelligence; holds job as an office assistant Alcohol-free for 2 years and is motivated to continue sobriety Fairly good physical health Supportive family Apartment in the community Good working relationship with community case manager

Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on Placement.):

Derek Rossi will be free of any suicidal ideation or any command hallucinations to harm himself for 4 weeks. Derek will be able to participate in a full schedule of program activities for 2 weeks. Plans will be in effect for Derek to return to his job in the community immediately following discharge. Derek will complete three overnight passes back to his apartment without any return of suicidal ideation. Derek will continue to participate in community AA meetings after discharge. Discharge Coordinated By: Brenda St. Martin, MSW

Anticipated Discharge Date: 04/15/03

Psychiatric Diagnosis (DSM-IV-TR): AXIS I:

Depressive disorder with psychotic features; history of alcohol abuse

AXIS II:

No diagnosis

AXIS III:

Reflux esophagitis and hiatal hernia

AXIS IV:

Ancillary Impairment =

AXIS V:

PSY =

40

SOC =

GAF Equivalent =

70 60

55

VIO =

45

ADL =

70

SAb =

70

Dangerousness Level =

MED =

65

45

Significant changes have been made in the diagnosis and those changes have been documented on the Treatment Plan Review dated: / / / / / / / /__


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.1 Depressive and Psychotic Symptoms

MTP–7

Name: Rossi, Derek ID #: 12345 Area: West Unit

Nursing Diagnosis: Disturbed Thought Processes

Date: 01/15/03

Problem Description: Derek has a long history of depressive symptoms that began during his senior year of high school following a breakup with a girlfriend. His current depression appears to be associated with his stopping his meds and his perception that he was not doing a good job at work. However, his employer reports being satisfied with Derek’s performance. Pt. reports being a loner with lots of feelings of hopelessness and worthlessness. He is anxious, lethargic, and frequently up most of the night. His depression is also associated with self-deprecating and command hallucinations. The hallucinations generally occur only during periods of decompensation and disappear when he is doing fairly well. Derek’s compliance with aftercare is poor, despite his having a reasonable understanding of his meds. Last week, he started taking his meds as prescribed. Social isolation is felt to be a significant contributor to his depressive symptoms and associated noncompliance with his meds. In the past, Derek has responded well to a combination of Risperdal and Effexor. His hospitalizations usually last about 2 to 3 months before he has recompensated to the point that he is ready for discharge.

Long-Term Goal(s) (Discharge Criteria) (Please number all goals.)

Target Date

1.

Derek will complete at least three overnight passes into the community, including returning part-time to his job in the community.

04/15/03

2.

Pt. will comply with a full schedule of program activities, including social activities, for 2 weeks.

04/15/03

Short-Term Goal(s) (Objectives) (Please number all goals.)

1.

Derek will accept prescribed meds and lab work for 2 weeks.

Date/Status*

Target Date

Date/Status*

01/29/03

01/29/03 Attained

2.

Derek will be free of auditory hallucinations for 2 weeks.

02/29/03

3.

Derek will engage in 5-minute conversations twice daily with staff in which he makes at least two positive self-statements for 2 weeks.

02/29/03

4.

Derek will be free of feelings of hopelessness and worthlessness for 2 weeks.

02/29/03

5.

Derek’s anxiety, lethargy, and social isolation will improve such that he will complete one scheduled program activity at least 4 of 5 weekdays for 2 weeks.

02/29/03

6.

Derek will be able to consistently and realistically report the fact that he is an asset at his job in the community for 2 weeks.

03/15/03

7.

Derek’s score on the Kennedy NOSIE score will improve from his current score of –11 to at least +4.

03/15/03

02/12/03 Attained

02/05/03 Attained

*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)

MTP–8


INDIVIDUAL PROBLEM PLAN

Continued on Problem #: 1.1

Date: 01/15/03

TREATMENT MODALITIES (Include the modality, time period, and frequency. Also include the individual responsible and discipline. Please number all modalities.)

Date/Status*

Psychiatry: 1.

Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any changes in Derek’s psychotic and depressive symptoms in order to monitor Derek’s response to being restarted on a combinations of antipsychotic meds such as Risperdal and an antidepressant such as Effexor. Labs will be ordered as needed.

Victor Dyson, MD

Social Work: 1.

Social worker will meet with Derek twice weekly for 30 minutes to discuss his depression and psychotic symptoms and the effect on his discharge. She will evaluate Derek’s readiness for discharge and discuss discharge options with Derek. She will also help Derek work on a list of activities to help structure his life.

Brenda St. Martin, MSW

Psychology: 1.

Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive therapy sessions to direct Derek back to reality and to help improve Derek’s ability to identify stressors, including dispelling stressors that are not real, and helping improve his ability to better cope with those stressors that are real.

Joseph LeBlanc, PhD

Rehab: 1.

Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to review his daily treatment schedule and refer him to appropriate groups to improve his contact with reality and self-esteem, increase his social interactions, and develop structure in his daily routine. His groups will include stress management group and socialization group (see weekly Rehab Schedule for details).

Albert Sanchez, Rehab

Nursing Care Plan: 1.

Nsg. staff will redirect and refocus Derek to reality issues. When derogatory hallucinations are present, nsg. staff will express an understanding of Derek’s distress, give reassurance, suggest interventions, and if indicated, offer prn meds to help relieve his distress. Nsg. staff will provide support and praise for reality-based statements.

2.

Nsg. staff will encourage Derek to attend morning meeting, other on-ward activities, and rehab groups; staff will provide escort, if needed.

3.

Building on Derek’s understanding of the need to take his meds, nsg. staff will explore with Derek his difficulty continuing his meds in the community and help pt. develop a plan for him to work with his community case manager to correct this problem.

4.

Nsg. staff will rate the Kennedy NOSIE once per week to help track Derek’s response to treatment.

5.

Nsg. staff will encourage appropriate interactions with his peers.

Marilyn Davis, RN Å Nsg. Staff

*Status:

Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.1 Suicidal Ideation

MTP–9


Nursing Diagnosis: Risk for Self-Directed Violence

Date: 01/15/03

Problem Description: Derek has a long history of suicidal attempts, gestures, and manipulations beginning at age 17 when he was a senior in high school. When decompensated, he has command hallucinations to hurt himself. In the past, when intoxicated, he has made serious attempts to hurt himself in response to command hallucinations, including taking overdoses of meds and attempting to hang himself. Since he stopped drinking 2 years ago, Derek has not attempted to hurt himself and overall has had much better control of these impulses. Immediately before this hospitalization, Derek was having command hallucinations to harm himself, including commands to jump from the fourth floor at work. He was concerned that he was losing control of these impulses. Currently he continues to have command hallucinations and suicidal ideation; however, he reports that he would not actually attempt to harm himself.


Target Date

1.

Derek will be free of any suicidal ideation or command hallucinations to harm himself for 4 weeks.

04/15/03

2.

Derek’s K Axis score on Violence will improve from his current score of 45 to a score of 60.

04/15/03


1.

2.

3. 4.

Derek will be able to consistently identify at least three coping mechanisms to help direct him away from self-destructive impulses for 1 week. Derek will be able to identify feelings of worthlessness, hopelessness, and frustration as they occur, AEB his coming to staff for support rather than attempting to hurt himself for 2 weeks. Derek will be free of any command hallucination to harm himself for 2 weeks. Derek will be free of any suicidal ideation for 2 weeks.

02/19/03 5. Derek will be able to go safely on three independent day passes into the community during 1 week. VD

Date/Status*

Target Date

Date/Status*

02/29/03

02/05/03 Attained

02/29/03

02/29/03

02/19/03 Attained

02/29/03

03/15/03


MTP–10




Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any changes in Derek’s suicidal impulses, including command hallucinations to hurt himself. This will allow the psychiatrist to assess the need for special precautions. This meeting will also allow the psychiatrist to prescribe treatment with antipsychotic meds such as Risperdal and an antidepressant such as Effexor (as outlined under Problem 1.1).

Victor Dyson, MD

Social Work: 1.

Social worker will meet with Derek twice weekly for 30 minutes to discuss his suicidal impulses and the effect on his discharge. Social worker will evaluate Derek’s readiness for discharge, discuss discharge options with Derek, and help him to locate community supports that will help him to remain free of suicidal ideation following his discharge.


Psychology: 1.

Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive therapy sessions to help Derek develop strategies to more effectively cope with stressors rather than becoming suicidal.

2.

Psychologist will lead the suicide prevention group once weekly for 45 minutes to help pt. reduce feelings of hopelessness and worthlessness and more effectively deal with stress.

Joseph LeBlanc, PhD

Rehab: 1.

Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to review his daily treatment schedule and refer him to appropriate groups to decrease his self-destructive impulses and frustration tolerance, including stress management group and anger management group (see weekly Rehab Schedule for details).



Nsg. staff will immediately redirect and refocus Derek away from self-destructive impulses and discuss appropriate alternative means of coping.

2.

Nsg. staff will question Derek at least once each shift to determine whether he is having impulses to hurt himself.

3.

When command hallucinations are directing him to harm himself, nsg. staff will give reassurance, suggest interventions, and if indicated, offer prn meds to help relieve his impulses to harm himself.

4.

If there are any concerns about Derek attempting to hurt himself, at a minimum, nsg. staff will have him verbally contract for safety each time he goes off the ward. For safety reasons, pt. may be restricted to the ward and placed on special precautions until the psychiatrist can evaluate him.

5.

Nsg. staff will provide support and praise when Derek is demonstrating appropriate coping skills to maintain safe behaviors.


*Status:



INDIVIDUAL PROBLEM PLAN Problem # and Name: 5.1 Alcohol Abuse

MTP–11


Nursing Diagnosis: Ineffective Coping

Date: 01/15/03

Problem Description: Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and selfmedicating his depression. He had some very serious problems with alcohol that led to serious attempts to hurt himself when intoxicated, including taking overdoses of meds and attempting to hang himself. Generally, since he stopped drinking 2 years ago he has had much better control of these impulses. He goes to AA on a weekly basis and is committed to continued sobriety. Derek smokes one pack of cigarettes a day; however, he has no interest in quitting smoking.


1.

Derek will continue to be free of alcohol for at least 3 months.


1.

Derek will continue to demonstrate his commitment to maintain sobriety by going to AA meetings once a week for at least 1 month.

Target Date

Date/Status*

Ongoing

Target Date

Date/Status*

Ongoing


MTP–12




Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with Derek weekly and as needed to monitor for any evidence of intoxication and any changes in intensity of impulses to abuse alcohol. If needed, psychiatrist will order Breathalyzer to ensure that pt. has not been abusing alcohol.

Victor Dyson, MD

Rehab: 1.

Derek will attend AA meetings once weekly to help support his continued sobriety. Derek will start the AA meetings in the hospital; however, when it is safe for him to go into the community, rehab staff will take him to AA meetings in the community.



Nsg. staff will monitor Derek for any evidence of intoxication and report any significant findings to the psychiatrist.

2.

Nsg. staff will do a Breathalyzer test if substance abuse is suspected.

3.

Nsg. staff will be alert to a return of any impulses to abuse alcohol and, if present, will assist him to deal with these in an appropriate, sober manner.

4.

Nsg. staff will give encouragement and verbal praise for Derek’s involvement in non-drug-related social activities.


*Status:



INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.0 Health Maintenance

MTP–13


Nursing Diagnosis: Health Maintenance

Date: 01/15/03

Problem Description: Derek’s physical exam revealed no significant abnormality. Derek’s medical history reveals that he has mild heartburn due to reflux esophagitis, which is fairly well controlled with Zantac (ranitidine) 150 mg po bid. However, currently he drinks 8 to 12 carbonated beverages every day and eats other foods that exacerbate his heartburn.


1.

Derek will maintain an optimal level of health while hospitalized, AEB his compliance with all prescribed meds, lab work, and treatments for his medical problems.


1.

Derek will eat a diet that will help promote control of his reflux esophagitis, AEB no heartburn for 2 weeks.

Target Date

Date/Status*

02/29/03 Ongoing

Target Date

Date/Status*

02/29/03

Attained 02/12/03


MTP–14




Date: 01/15/03


Date/Status*

Medical: 1.

MD will treat Derek’s reflux esophagitis with Zantac (ranitidine) and monitor him as needed for any burning in his stomach. MD will request a dietary consult to assess Derek’s diet and make needed recommendations.

Virginia Coleman, MD


Nsg. staff will monitor Derek daily and follow up on any signs and symptoms of illness.

2.

Nsg. staff will work with Derek and the dietician on developing a dietary plan to help control Derek’s heartburn.

3.

Nsg. staff will administer all prescribed meds and treatments as ordered, including dietary recommendations, and will document Derek’s compliance.

4.

Nsg. staff will assess and document pt.’s level of understanding of prescribed treatments, including diet, and will provide necessary teaching at Derek’s level of understanding.

5.

Nsg. staff will prompt Derek to comply with treatments, diet, lab work, and any other medical procedures. If needed, nsg. staff will support and accompany Derek to procedures. Staff will offer praise for compliance and document compliance.


*Status:



MTP–15

Name: Rossi, Derek


ID #: 12345

Signature Page Lakeview Hospital Name of Facility

Area: West Unit

Date: 01/15/03 Patient Participation in Treatment Planning (check as appropriate): Contributed to goals and plan Aware of plan content Present at team meeting Refused to participate Unable to participate Refused to sign plan

X X X

Derek Rossi

01/15/03

(Patient’s or guardian’s signature and date)

(If guardian, relation to patient)

Patient’s Comments (optional):

Staff Members’ Comments (optional): Derek appears to have a reasonably good understanding of his Master Treatment Plan. He is motivated to work with the team on his problems, especially on getting rid of the voices. At discharge, Derek hopes to return to his own apartment; however, he does not believe that his employer wants him back because pt. feels that his performance at work was inadequate.

Treatment Team Members (all participants in the treatment planning must sign below): Psychiatrist:

Victor Dyson, MD

Date:

01/15/03

Print Name:

Victor Dyson, MD

Nurse:

Marilyn Davis, RN

Date:

01/15/03

Print Name:

Marilyn Davis, RN

Social worker:

%UHQGD6W0DUWLQ06:

Date:

01/15/03

Print Name:


Psychologist:

Joseph LeBlanc, PhD

Date:

01/15/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:


Date:

01/15/03

Print Name:


Other:

Date:

Print Name:

Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.” ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress note(s) and/or Treatment Plan Review(s).

Notes


MTP–17

Treatment Plan Reviews (Samples) The following sample Treatment Plan Reviews (TPRs) demonstrate how the TPRs act with the Master Treatment Plan (MTP) to capture the flow of treatment. The sample TPRs take the reader through about half of the patient’s (Derek Rossi’s) hospitalization.

MTP–18



Name: Rossi, Derek

Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN

ID #: 12345 Area: West Unit


Date: 01/22/03

1. Changes in Psychiatric Diagnosis (DSM-IV-TR): AXIS I: No change in diagnosis AXIS II: AXIS III: 2. Changes in Problem List: No change in Problem List.

3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems: Problem 1.1. Derek is continuing to take his meds. Yesterday he started going to some program activities. However, he continues to have lots of feelings of hopelessness and low self-esteem. Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself; however, they may be decreasing somewhat. Derek continues to feel that he has control of the impulses to hurt himself. Problem 6.0. Nsg. staff and the dietitian are working with Derek on getting him to cooperate with moving toward a bland diet to help control his heartburn.

4. Changes in Treatment Plan Goals and/or Modalities: Continue to titrate pt.’s Risperdal and Effexor upward.

5. Reasons for Continued Hospitalization: Due to continued suicidal ideation, pt. is unsafe to be discharged.

6. Discharge Planning Update: When ready, Derek is to be discharged back to his apartment with support from Case Management.

7. Level of Care: Active Treatment [ X ] Extended [ ]

Awaiting SNF [ ]

8. Treatment Team Members (all participants in the treatment planning must sign below): Psychiatrist:

Victor Dyson, MD

Date:

01/22/03

Print Name:

Victor Dyson, MD

Nurse:

Marilyn Davis, RN

Date:

01/22/03

Print Name:

Marilyn Davis, RN

Social worker:

%UHQGD6W0DUWLQ06:

Date:

01/22/03

Print Name:


Psychologist:

Joseph LeBlanc, PhD

Date:

01/22/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:


Date:

01/22/03

Print Name:


Other:

Patient: I participated in the review:

Date:

Derek Rossi

Print Name: Date:

01/22/03

Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed. Check if review is continued on reverse [ ]


MTP–19


Name: Rossi, Derek




Date: 01/29/03


3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems: Problem 1.1. Derek is continuing to cooperate with treatment, including taking his meds and going to at least one program every day. However, he continues to have lots of feelings of hopelessness and low self-esteem. Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself. Recently Derek has been having problems with feeling that he is losing control of the impulses to hurt himself; however, he has not made any plans to hurt himself. Problem 6.0. Derek’s heartburn appears to be responding to a bland diet, including cutting back on carbonated beverages.

4. Changes in Treatment Plan Goals and/or Modalities: Problem 1.1 Short-Term Goal attained. Continue to titrate patient’s Risperdal and Effexor upward. Special one-onone close observation may be needed, if Derek’s suicidal impulses worsen.

5. Reasons for Continued Hospitalization: Due to worsening suicidal impulses, patient is unsafe to be discharged.

6. Discharge Planning Update: When ready, Derek will be discharged back to his apartment with support from Case Management.


Awaiting SNF [ ]

8. Treatment Team Members (All participants in the treatment planning must sign below): Psychiatrist:

Victor Dyson, MD

Date:

01/29/03

Print Name:

Victor Dyson, MD

Nurse:

Marilyn Davis, RN

Date:

01/29/03

Print Name:

Marilyn Davis, RN

Social worker:

%UHQGD6W0DUWLQ06:

Date:

01/29/03

Print Name:


Psychologist:

Joseph LeBlanc, PhD

Date:

01/29/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:


Date:

01/29/03

Print Name:


Other:


Date:

Derek Rossi

Print Name: Date:

01/29/03


MTP–20



Name: Rossi, Derek




Date: 02/05/03


3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems: Problem 1.1. Derek is continuing to cooperate with treatment and has completed 1 week of at least 4 days/week of program activities. He is having much fewer feelings of hopelessness and low self-esteem. The hallucinations are decreasing. Problem 3.1. Derek has done better for the last few days; however, he continues to have some suicidal ideation. For the last couple of days, the command hallucinations have stopped, and for the last week, pt. has been able to identify ways to help direct himself from self-destructive impulses. Problem 6.0. Derek’s heartburn appears to be responding to a bland diet, including cutting back on carbonated beverages. He denies having any heartburn for about 1 week.

4. Changes in Treatment Plan Goals and/or Modalities: Problem 3.1 Short-Term Goal 1 was attained. Increase Risperdal to 8 mg/day and continue current dose of Effexor 150 mg/day.

5. Reasons for Continued Hospitalization: Pt. continues to be a risk for a suicidal attempt; therefore, patient is unsafe to be discharged.

6. Discharge Planning Update: When ready, Derek will be discharged back to his apartment with support from case management.


Awaiting SNF [ ]


Victor Dyson, MD

Date:

02/05/03

Print Name:

Victor Dyson, MD

Nurse:

Marilyn Davis, RN

Date:

02/05/03

Print Name:

Marilyn Davis, RN

Social worker:

%UHQGD6W0DUWLQ06:

Date:

02/05/03

Print Name:


Psychologist:

Joseph LeBlanc, PhD

Date:

02/05/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:


Date:

02/05/03

Print Name:


Other:


Date:

Derek Rossi

Print Name: Date:

02/05/03



MTP–21


Name: Rossi, Derek




Date: 02/12/03

1. Changes in Psychiatric Diagnosis (DSM-IV-TR): AXIS I: No change in diagnosis AXIS II: AXIS III: 2. Changes in Problem List: Problem 6.0a was changed from Active to Inactive With Treatment.

3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems: Problem 1.1. Derek’s spirits are improving and he is no longer having feelings of hopelessness and low self-esteem. Next week, he is expected to participate in a full schedule of program activities. For the last couple of days, all hallucinations stopped completely. Problem 3.1. Derek reports that he in now free of both suicidal ideation and command hallucinations. Problem 6.0. Derek’s heartburn appears to have responded very well to a bland diet, including cutting back on carbonated beverages. He denies having any heartburn for about 2 weeks.

4. Changes in Treatment Plan Goals and/or Modalities: Problem 1.1 Short-Term Goals 3 and 5 were attained. Problem 6.0a Short-Term Goal 1 was attained. Problem 6.0 Long-Term Goal 1 was changed to ongoing. Continue current meds, including Risperdal 8 mg/day and Effexor 150 mg/day.

5. Reasons for Continued Hospitalization: Suicidal impulses appear to be just getting under control; however, without further progress, Derek is very likely to quickly relapse. Staff is continuing to work with him on ways to help prevent a return of suicidal impulses.

6. Discharge Planning Update: When ready, Derek will be discharged back to his apartment with support from case management.

7. Level of Care: Active Treatment [ X ] Extended [ ] Awaiting SNF [ ] 8. Treatment Team Members (all participants in the treatment planning must sign below): Psychiatrist:

Victor Dyson, MD

Date:

02/12/03

Print Name:

Victor Dyson, MD

Nurse:

Marilyn Davis, RN

Date:

02/12/03

Print Name:

Marilyn Davis, RN

Social worker:

%UHQGD6W0DUWLQ06:

Date:

02/12/03

Print Name:


Psychologist:

Joseph LeBlanc, PhD

Date:

02/12/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:


Date:

02/12/03

Print Name:


Other:


Date:

Derek Rossi

Print Name: Date:

02/12/03


MTP–22



Name: Rossi, Derek




Date: 02/19/03

1. Changes in Psychiatric Diagnosis (DSM-IV): AXIS I: No change in diagnosis AXIS II: AXIS III: 2. Changes in Problem List: No change in Problem List.

3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems: Problem 1.1. Derek’s spirits continue to be good and he continues to be free of feelings of hopelessness and low self-esteem. For the last few days, he has participated in a full schedule of program activities. No hallucinations since 02/10/03. Problem 3.1. Derek reports that for the last week he has been free of suicidal ideation and impulses to hurt himself. The command hallucinations to hurt himself stopped more than 2 weeks ago. Problem 6.0. Derek continues to be free of any heartburn or any other medical complaints.

4. Changes in Treatment Plan Goals and/or Modalities: Problem 3.1 Short-Term Goal 3 was attained and Short-Term Goal 5 was added.

5. Reasons for Continued Hospitalization: Suicidal impulses continue to be under control; however, without further progress, Derek continues to be at risk to relapse shortly after discharge. Staff is continuing to work with him on ways to help prevent a return of depression, psychosis, and suicidal impulses.

6. Discharge Planning Update: Pt.’s case manager will be contacted to discuss Derek’s returning part-time to his job in the community and to begin plans for him to go for an overnight to his apartment.

7. Level of Care: Active Treatment [ ] Extended [ X ] Awaiting SNF [ ] 8. Treatment Team Members (all participants in the treatment planning must sign below): Psychiatrist:

Victor Dyson, MD

Date:

02/19/03

Print Name:

Victor Dyson, MD

Nurse:

Marilyn Davis, RN

Date:

02/19/03

Print Name:

Marilyn Davis, RN

Social worker:

%UHQGD6W0DUWLQ06:

Date:

02/19/03

Print Name:


Psychologist:

Joseph LeBlanc, PhD

Date:

02/19/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:


Date:

02/19/03

Print Name:


Other:


Date:

Derek Rossi

Print Name: Date:

02/19/03


PSYCHOLOGICAL IMPAIRMENT (Problem Area 1)

1–1


Psychological Impairment (Problem Area 1)

1–3

PSYCHOLOGICAL IMPAIRMENT (Problem Area 1) CONTENTS Kennedy Axis V for Psychological Impairment......................................................................................... 1–4 This rating scale can be used to measure the outcome of treatment. It also helps to define the problems that fit into the category of Psychological Impairment and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 1–5 Examples of problem names and descriptions that may relate to Psychological Impairment are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 1–7 Examples of strengths that may be related to treatment and discharge in the area of Psychological Strengths are listed here.

Goals ......................................................................................................................................................... 1–7 Examples of treatment goals that may relate to problems in the area of Psychological Impairment are listed here.

Treatment Modalities ............................................................................................................................. 1–10 Examples of treatment modalities that may relate to problems in the area of Psychological Impairment are listed here.

Individual Problem Plans (Frequent Entries).......................................................................................... 1–16 Two Individual Problem Plans that contain examples of information frequently entered into Individual Problem Plans for Psychological Impairment are included here.

Sample Individual Problem Plans ........................................................................................................... 1–21 A wide range of Individual Problem Plans relating to Psychological Impairment are included here.

1–4


Kennedy Axis V—Psychological Impairment 100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems never seem to lead to any significant anxiety or depression. No symptoms. 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday problems or concerns. 80 If symptoms are present, they are transient and expected reaction to psychosocial stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The stress is too much”); not considered to have mental problems by those who know him/her.

70 Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally functioning fairly well; however, those who know him/her well might express some concerns about his/her mental state.

60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others; to those who know him/her well it is clear that he/she has mental problems. 50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety attacks, moderately guarded, mild but definite manic syndrome). 40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however, probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have mental problems. 30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications; inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job, home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children. 20 Thinking and communication are generally grossly impaired; manic excitement or catatonia; largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe food off shirt; smears feces for bizarre, delusional reasons). 10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a few seconds; chronic, self-induced vomiting has led to a very life-threatening situation. NR Not rated


Problem Names and Descriptions I.

II.

Mood Disturbance Problems (depressive symptoms, manic symptoms, anxious symptoms) A.

Sadness 1. Low self-esteem 2. Extremely fragile and brittle self-esteem 3. Depression with persecutory delusions 4. Difficulty accepting significant loss 5. Preoccupation with perceived rejection

B.

Anxiety and tension 1. Hyperactivity 2. Agitation and restlessness 3. Chronic tension 4. Apprehensiveness about changes in routine or environment 5. Work-related anxiety

C.

Lethargy and lack of motivation 1. Loss of interest in surroundings 2. Loss of interest in hobbies or usual activities 3. Slow moving and sluggish 4. Marked lethargy 5. Fatigue 6. Lack of motivation for ADLs 7. Lack of motivation for care of personal hygiene 8. Indifference to personal appearance

D.

Other 1. Insomnia 2. Disturbance in eating habits 3. Poor attention span 4. Rumination or racing thoughts 5. Mood swings 6. Manic episodes, elation, grandiosity

Thought Disorder Problems (psychotic symptoms) A.

Primary psychotic symptoms 1. Delusions 2. Fixed paranoid delusions 3. Auditory or visual hallucinations or both 4. Marked distraction by hallucinations and delusions 5. Disorganized, confused cognition caused by psychotic process 6. Psychotically impaired judgment and insight 7. Inappropriate affect 8. Periods of psychotic decompensation 9. Work or social adjustment difficulty secondary to paranoia

B.

Withdrawal and apathy 1. Is withdrawn, reclusive 2. Has minimal interpersonal interactions 3. Is noncommunicative 4. Will not initiate social interactions 5. Has no hobbies or normal interests

1–5

1–6


6. 7.

Wants to be left alone Has limited motivation to improve and leave the hospital

C.

Bizarre behaviors 1. Bizarre behavior such as lying on the floor or exhibiting constant rocking, head banging, and stereotypical movements 2. Bizarre, inappropriate dress 3. Bizarre compulsive eating or drinking habits (e.g., occasionally drinking from the toilet, eating feces) 4. Bizarre episodes of screaming and yelling

D.

Other 1. Poor attention span 2. Agitation and restlessness

III. Miscellaneous Psychological Impairment Problems A.

Personality disturbances 1. Obsessive-compulsive behaviors 2. Ritualistic, compulsive mannerisms 3. Overemphasis on cleanliness and neatness 4. Psychosomatic symptoms and conversion reactions 5. Stealing and other antisocial behaviors toward property 6. Dependent personality style 7. Overly dependent on others for decision making and support 8. Resistant to independent functioning 9. Passive-aggressive manipulation

B.

Eating disturbances 1. Anorexia (inadequate food or fluid intake or both) 2. Obesity 3. Bulimia (gorging and vomiting) 4. Polydipsia (drinking fluids to dangerous excess) 5. Pica (persistent and compulsive craving to eat nonfood items such as dirt, clay, coffee grounds, or cigarettes)

C.

Other 1. Noncompliance with treatment 2. Escape risk 3. Nocturnal enuresis secondary to psychological factors 4. Gender identity confusion 5. Manipulative behavior 6. Nonviolent attention seeking


1–7

Strengths (Brief List) I.

Psychological Strengths A. B. C. D. E. F. G. H. I. J. K. L.

Has no thought disorder Has insight into problems Copes well with stress Has good self-esteem Has satisfactory sense of social and family belonging Is motivated to work on realistic treatment goals and returning to the community Is interested in relating to others in a therapeutic relationship Has had good response to past treatments Is treatment and medication compliant Is able to appropriately advocate for self Is motivated for leisure or recreational activities Participates in leisure interests 1. Sports 2. Exercise 3. Reading 4. Socializing, developing friendships, developing relationships 5. Watching TV, movies 6. Listening to radio, music, concerts 7. Shopping trips 8. Computers, Internet, computer games

M.

Other

Goals I.

Expected Improvements in Symptoms A.

Thought disorder 1. Pt. will make at least one nondelusional, relevant comment in community meeting twice a week for 1 month. 2. Pt. will be able to engage in one 2-minute conversation during the 7-to-3 shift with no evidence of delusional content three times weekly for 1 month. 3. Pt. will complete a two-step task successfully without performance being impeded by ritualistic behavior or delusional speech twice weekly for 1 month. 4. Pt. will gain insight into delusions and hallucinations so that he or she will suspect that they are a part of the illness for 1 month.

B.

Mood disturbance 1. Pt. will consistently verbalize a sense of self-worth and express realistic hopes for his or her future for 1 week. 2. Pt. will be able to participate in a program activity without extreme mood swings at least four times a week for 1 month. 3. Pt. will be free of depressive or manic symptoms for 1 week.

C.

Focal attention 1. Pt. will maintain relevance and focus on topics beyond the first two sentences of a conversation consistently for 1 week. 2. Pt.’s focal attention will improve to the point that pt. will be able to maintain involvement in one day-program activity each weekday for 1 month. 3. Pt.’s focus will improve such that he or she will consistently carry out three-step tasks with only a single prompt for 1 week.

1–8

II.


D.

Apathy and motivation 1. Pt.’s motivation will increase to the point that he or she will get out of bed at least 3 days a week with a single prompt for 1 month. 2. Pt.’s motivation will increase to the point that the pt. will have his or her personal ward dorm area in acceptable order at least 3 out of 5 weekdays for 1 month. 3. Pt. will shave and dress self 4 out of 7 days a week for 1 month. 4. Pt.’s apathy will diminish such that he or she will use independent privileges once daily for 1 week. 5. Pt.’s motivation will improve such that he or she will attend two art therapy classes a week for 1 month.

E.

Social withdrawal 1. Pt. will initiate at least a one one-word greeting daily for 1 month. 2. Pt. will initiate and sustain a 5-minute conversation once each shift for 1 week. 3. Pt. will spontaneously initiate a request to go on “buddy” privileges with one of the other pts.

F.

Other 1. Psychosomatic complaints will be reduced such that these complaints will interfere with assigned program no more than once per week for 1 month. 2. Pt. will attempt to escape no more than once per month during a 3-month period. 3. Pt. will be able to go on supervised privileges with staff once a day for 1 week without attempting to escape. 4. Pt. will decrease his or her excessive fluid intake, such that his or her blood Na level remains WNL for 3 months. 5. Pt.’s anorexia will improve, AEB gaining 2 pounds per month for 2 months. 6. Pt. will cooperate with staff requests to toilet self for 1 week. 7. Pt.’s incidences of nocturnal enuresis will decrease to fewer than three times per week for 1 month.

Reporting of Symptoms A. B.

C. D. E.

Pt. will verbalize any return of hallucinations for 1 week. Pt. will verbalize any return of hallucinations for 1 week AEB pt. not being noted to be responding to hallucinations without having notified staff of the return of hallucinations. When tormented by hallucinations, pt. will learn to approach staff and try interventions for reducing the hallucinations. In psychotherapy, pt. will express feelings of sadness and loss, if present, once weekly for 1 month. Pt. will not feign or exaggerate symptoms for 1 week.

III. Participation in Groups, Program Activities, and the Like A. B. C. D. E. F. G.

Pt. will consistently remain in the group activity area with minimal redirection for at least ½ hour per weekday for 1 month. Pt. will attend two program activities per week for 1 month. Pt. will attend art therapy twice a week for 1 month to help improve self-esteem. Pt. will participate in a full-time load of day-program activities for 1 month. Pt. will start a supportive job in the hospital gift shop. Pt. will start a job in the community. Pt. will attend assigned programs (with medical clearance), despite psychosomatic complaints, at least once per weekday for 1 month.


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IV. Understanding of and Compliance With Treatment Plans

V.

A.

Medication and laboratory work 1. Pt. will discuss the importance of taking meds as prescribed once a week for 1 month. 2. Pt. will spontaneously state the benefits of taking antipsychotic meds twice during 1 month. 3. Pt. will take antipsychotic meds as prescribed for 1 month. 4. Pt. will comply with blood and other laboratory work for 3 months. 5. Pt. will understand the possible benefits of Clozaril AEB cooperating with the necessary workup for a trial on Clozaril.

B.

Program activities 1. Pt. will state the benefits of attending program twice weekly for 2 weeks. 2. Pt.’s level of compliance will improve such that he or she will attend art therapy class twice a week for 1 month.

C.

Treatment planning 1. Pt. will cooperate with at least one treatment team member in the treatment planning process for 1 week. 2. Pt. will be willing to participate in the evaluation process AEB meeting with the psychologist weekly for 1 hour. 3. Pt. will demonstrate cooperation with all aspects of the treatment plan, including meds and blood work, for 1 month. 4. Pt. will be free of unrealistic, grandiose discharge plans for 1 month.

D.

Consequences of actions 1. Pt. will demonstrate a realistic orientation toward his or her progress such that the pt. understands and explains the connections between the following: a. Rational, trusting behavior; program attendance; medication compliance; and the ability to be discharged from the hospital b. Bizarre, paranoid thinking; inconsistent program attendance; medication noncompliance; and recurring setbacks, including the need for continued care at the hospital

Diagnostic Tests and Evaluations A.

Assessments 1. Pt. will cooperate so that psychological tests can be completed. 2. Pt. will cooperate so that rehabilitation assessment for an appropriate day-program referral can be completed.

B.

Evaluations to R/O various diagnoses 1. Pt. will cooperate so that he or she can complete evaluation to R/O psychotic process. 2. Pt. will complete evaluation to R/O borderline personality disorder. 3. Pt. will cooperate with psychological testing to R/O organic etiology for psychosis. 4. Pt. will overcome fears to complete evaluation to R/O cardiac disease.

C.

Laboratory tests 1. Pt.’s medication compliance will improve so that the medication blood level is in the therapeutic range for 3 months. 2. Pt. will control his or her drinking of excessive fluids AEB maintaining a proper electrolyte balance for 3 months.

1–10


VI. Standardized Outcome Measures A.

Kennedy Axis V (K Axis) 1. Pt.’s K Axis score on Psychological Impairment will improve from a current score of 30 to 40.

B.

Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE) 1. Pt.’s K NOSIE score on Manifest Psychosis will improve from a current score of –20 to –12. 2. Pt.’s K NOSIE score on Social Interest will improve from a current score of +12 to +20. 3. Pt.’s K NOSIE score on Motor Retardation will improve from a current score of –16 to –10.

C.

Mini-Mental State Exam 1. Pt.’s score on the Mini-Mental State Exam will improve from a current score of 12 to 18.

D.

Brief Psychiatric Rating Scale (BPRS) 1. Pt.’s score on the BPRS will improve from a score of 62 to 40.

E.

Beck Depression Inventory 1. Pt.’s score on the Beck Depression Inventory will improve from a score of 35 to 18.

Treatment Modalities I.

Verbal Treatment Modalities (emphasis on verbal interactions) A.

Support and reassurance 1. Staff will provide one-to-one supportive problem-solving therapy for 1 hour once weekly. 2. Staff will provide one-to-one relationship to increase trust in staff, to build a trusting relationship, and to reduce paranoia. 3. Staff will provide one-to-one contact to provide pt. with needed support and reassurance that people care for him or her for 1 hour once weekly. 4. Staff will reassure and reality test with pt. about his or her delusions that the pt.’s thoughts can kill. 5. Staff will express understanding of pt.’s distress and suggest interventions when tormenting hallucinations are present.

B.

Cognitive refocusing (redirecting focus toward reality and realistic self-appraisal) 1. Staff will treat drops in pt.’s self-esteem by helping pt. focus on his or her assets and accomplishments (e.g., program attendance, hobbies, relatives who care for the pt., memories of happy experiences). 2. Staff will help pt. recognize and express self-worth (e.g., compliment pt. when appearance improves to bolster self-esteem; engage pt. in activities in which he or she can succeed). 3. Staff will intervene to refocus, redirect, and orient to reality whenever pt. is confused and disorganized. 4. Staff will redirect pt. away from behavior based on delusional thinking toward adaptive requirements of the moment. 5. Staff will maximize structured activities to minimize regressive episodes by helping the pt. to stay focused away from psychotic processes, including delusions and hallucinations. This can be done by maximizing the pt.’s involvement in structured day program, including open workshop, patient wage program, leisure interest group, and community meeting. 6. Staff will engage the pt. in two sessions weekly of 30 to 45 minutes in woodworking, using one-toone with pt. to maintain maximum focus. 7. Staff will focus pt. away from plans based on pt.’s psychotic thinking to plans based on realistic, achievable goals (e.g., passes with family, shopping trips, and discharge to a halfway house). 8. Staff will use a substitute stimulation (e.g., listening to radio headset) to help pt. focus away from tormenting hallucinations.


C.

II.

1–11

Psychotherapy 1. Staff will meet with pt. for one-to-one, insight-oriented psychotherapy once a week to help work through psychological conflicts that result in high levels of anxiety. 2. Psychologist will provide supportive, problem-solving psychotherapy to help the pt. more effectively cope with day-to-day problems. 3. Social worker will provide weekly one-to-one dialectic behavior therapy (DBT) counseling for pt. and lead weekly DBT skills practice group to help reduce pt.’s depressive symptoms.

Behavioral Treatment Modalities A.

Positive reinforcement 1. Staff will give pt. positive feedback and encouragement for coherent, reality-based communications. 2. Staff will praise pt. for reality-based speech. 3. Staff will provide positive verbal reinforcement for independent action when around the ward or when in program (to reduce apathy and lack of motivation). 4. Staff will provide constant encouragement to help relieve pt.’s lack of motivation to wash face, comb hair, wipe nose, and so on. 5. Staff will give positive reinforcement for any spontaneous activity other than going to bed. 6. Staff will give positive verbal reinforcement for each step toward greater involvement in ward activities. 7. Staff will encourage pt. to be involved in the treatment-planning process. 8. Staff will give pt. reinforcement for accumulating points for specific compliant acts (e.g., making bed, dressing appropriately, going to program). When pt. receives 10 points, he or she will be given an identified reinforcer. (See attached behavioral plan for details.) 9. Staff will give pt. money, clothes, and gym activities to richly reinforce independent, self-initiated behaviors such as getting dressed, making bed, and going to program.

B.

Negative reinforcement (including discouragement, restriction, and withholding of reinforcement) 1. Staff will restrict pt. to supervised privileges for 24 hours if he or she fails to go to morning program activities. 2. Pt.’s independent privileges will be held for 1 week following his or her return from escape. During the 1-week period, pt. will be assessed for the safety of restarting independent privileges. 3. Pt. will lose smoking privileges for 24 hours when he or she steals from other pts.

C.

Extinction 1. All staff will ignore bizarre and delusional speech, thus helping to extinguish this psychotic behavior. 2. Staff will acknowledge psychosomatic complaints but will encourage pt. to attend assigned program. 3. Staff will disregard delusional speech.

D.

Shaping and modeling 1. Staff will provide primary and secondary positive reinforcers for incremental increases in focal attention. 2. To improve focal attention, pt.’s contact will involve pt. at least twice daily in 15-minute sessions, such as tossing and catching a ball, playing pool, and so on. 3. Nsg. staff will assign pt. on-ward activities with gradually increasing focal requirements as pt.’s focal attention improves. 4. Rehab staff will refer pt. to day programming for involvement in tasks that require gradually increasing amounts of time attending to the task. 5. Staff will promote pt.’s independence by gradually increasing his or her decision-making responsibilities.

1–12


E.

Channeling of energies 1. Staff will channel pt.’s high level of anxiety into structured day-program activities, including exercise group.

F.

Task simplification (reducing confusion and frustration by simplifying tasks and providing consistency and assistance) 1. Nsg. staff will use the same person as consistently as possible for redirection. 2. All staff will be as consistent as possible in redirecting pt. away from inappropriate, bizarre behavior. 3. To reduce level of dependency, contact will help pt. write down all basic answers and procedures to questions and routines that confuse him or her. When appropriate, contact will direct pt. to these written lists.

III. Miscellaneous Verbal and Behavioral Treatment Modalities A.

Family/couple treatment modalities 1. Family will engage in therapy to help improve the pt.’s feelings of inadequacy. 2. Social worker will provide pt. with family therapy once a month for 1 hour to help pt. and his or her family to cope better with pt.’s delusions. 3. Psychologist will work with pt. and his or her significant other for 1 hour each week on recognizing and coping with pt.’s manic episodes.

B.

Religious treatment modalities 1. Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling for support and hope in relation to depression once weekly for 1 hour. 2. Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling to help pt. get a religious perspective on his or her delusions of demonic possession. 3. Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling to help pt. objectively examine his or her guilt and to give appropriate assurance of forgiveness, as needed. 4. Religious services will be provided to enhance pt.’s self-esteem and feelings of meaning and community twice weekly for 1 hour.

C.

Other modalities 1. DBT a. Social worker trained in DBT will meet with pt. for therapy and training on means of managing his or her impulsive behaviors for 1 hour twice a week. b. Because of failure to respond to treatment, the team will refer pt. to the DBT ward for treatment of his or her problems with borderline personality disorder. 2.

Group therapy a. Group therapy to facilitate discussion of problems and to learn means of more appropriately coping with those problems will be undertaken once weekly for 1 hour.

3.

Psychodrama a. Role playing will be used to help reduce pt.’s anxiety about talking about his or her illness once weekly for 1 hour.

4.

Behavioral plan a. Psychologist will oversee behavioral plan to change specific behaviors (see attached behavioral plan).

5.

Desensitization a. Psychologist will develop a plan to help desensitize the pt. to his or her fear of driving. b. Rehab staff will provide activities that pt. can successfully complete to help relieve pt.’s fear of failure. c. Recreational therapist will work with pt. in bowling group to reduce anxiety associated with participating in groups.


1–13

IV. Milieu Treatment Modalities

V.

A.

Stimulus reduction 1. Staff will redirect pt. from triggering events or overstimulating areas to reduce level of hallucinations. 2. Sound-absorbing material will be added to pt.’s dorm area to help reduce noise.

B.

Protective procedures (including special observations) 1. Staff will keep pt. away from street drugs and alcohol to prevent further neuropsychological damage and associated bizarre behavior. At the same time, pt. will be treated for substance abuse (as outlined under Problem 5.1 Polysubstance Abuse) in the hopes that pt. will abstain from substance abuse once pt. has the opportunity to use drugs again. 2. Nsg. staff will use escape precautions when pt. is on the ward. 3. Staff will closely monitor pt. whenever pt. is off the ward to minimize escapes. 4. Staff will install a locating device in pt.’s car to locate pt. when he or she takes off in the car during a manic episode.

C.

Other milieu treatment modalities 1. Staff will use increased lighting and brighter colors in the pt.’s day area. 2. Staff will move pt. to a semiprivate room, and pt. will be allowed to bring in items to give the room a “home” look and feel.

Medical Treatment Modalities A.

Medication 1. Psychiatrist will prescribe antipsychotic meds to reduce intensity of persecutory beliefs. 2. Nsg. staff will give pt. prn meds to relieve pt. from acute episodes of tormenting hallucinations.

B.

Other medical treatment modalities 1. Electroconvulsive therapy (ECT) a. Intractable depressive symptoms will be treated at St. John’s Hospital with a series of ECT followed by maintenance ECT. 2.

Light therapy a. Pt.’s seasonal depressive symptoms will be treated using light therapy for 1 hour daily.

3.

Psychosurgery a. Pt.’s severe unremitting depression will be treated using psychosurgery. b. Severe, incapacitating obsessive-compulsive symptoms will be treated at a general hospital by psychosurgery.

4.

Miscellaneous a. Restrict fluids to 350 cc following dinner to prevent nocturnal enuresis. b. Nsg. staff will toilet pt. every 2 A.M. to help reduce nocturnal enuresis. c. Staff will provide wheelchair to increase pt.’s independence around the ward.

VI. Patient and Family Education A.

Mental illness 1. Staff will discuss ways to cope with mental illness with pt. for 1 hour once weekly. 2. Staff will teach pt. and the family ways to recognize the signs of manic decompensation. 3. Staff will discuss the nature of pt.’s mental illness and its prognosis with the pt. and family.

B.

Medication 1. Psychiatrist will discuss the risks and benefits of meds with pt. once weekly for ½ hour. 2. Nsg. staff will point out concrete benefits of taking meds (e.g., “There is a decrease in the hallucinations,” “You are more focused on tasks,” “You are less paranoid”). 3. Pt.’s psychiatrist will discuss with pt.’s family the reasons pt. needs to take meds.

1–14


C.

Benefits and consequences of behaviors 1. Staff will discuss connections between daily appropriate behavior (such as being out of bed, attending program) and realistic progress toward pt.’s goals, including passes, shopping trips, and discharge planning. 2. Psychiatrist will discuss with pt. alternative means of gaining freedom (demonstrating ability to appropriately use pt.’s independent privileges within the hospital and off the grounds) rather than escaping. 3. Staff will discuss for ½ hour once a week the benefits of neatness and good personal hygiene to improve pt.’s motivation to attend to daily personal hygiene. 4. The social worker will discuss with pt.’s family members the benefits of their visits, their support, and their money for pt.’s shopping trips.

D.

Miscellaneous 1. Staff will involve pt.’s family in a psychoeducational program to improve their ability to cope with pt.’s psychotic symptoms. 2. Psychologist will meet to educate pt.’s parents about the effect that lack of monitoring and lack of discipline has on the pt. for 1 hour once a month.

VII. Evaluations and Assessments A.

Psychological tests (and other formal verbal tests) 1. Psychological testing for personality assessments 2. Psychological testing to assist in the diagnostic evaluation 3. An inventory of reinforcements, including activities, money, relationships with significant others, and so forth 4. Psychological testing to determine pt.’s ability to engage in treatment 5. Neuropsychological testing

B.

Psychiatric evaluations 1. Psychiatric diagnostic evaluation 2. Psychiatric medication evaluation 3. Neuropsychiatric evaluation 4. AIMS or AIMS Plus EPS exam, as needed

C.

Medical/laboratory tests and evaluations 1. Urology consult to determine if there is an organic basis for pt.’s bed-wetting 2. Blood levels to help determine medication compliance 3. Blood levels to determine whether the psychotropic medication is in the therapeutic range 4. EEG to R/O temporal lobe epilepsy 5. CT scan/MRI to R/O organic etiology 6. Incontinence chart to follow enuresis

D.

Other evaluations and assessments 1. Rehab staff will assess pt.’s areas of interests and motivation to assign structured activities congruent with pt.’s interests. 2. Social worker will interview family members to assess their ability to communicate with each other and to identify areas of significant conflict. 3. Social worker will complete the Residential Care Scale for level of care needed at discharge. 4. Conduct weekly one-to-one meetings with pt. and monthly meetings with family to determine pt.’s ability to tolerate increased involvement with family. 5. Conduct vocational assessment to develop a step-by-step plan to reengage pt. in vocational activities. 6. Psychologist will meet with pt. once a week for ½ hour to attempt to understand pt.’s stealing behavior. 7. Nsg. staff will monitor pt. for evidence that pt. is planning an escape. 8. Conduct religious assessment to determine consistency of potentially delusional thinking with pt.’s religious community.


9.

1–15

Conduct religious assessment to evaluate validity of pt.’s guilt feelings from a religious perspective.

VIII. Legal Treatment Modalities A.

Court commitment 1. Psychiatrist will seek court commitment under Sections 7 and 8 for a period of up to 6 months because pt. is unable to safely function in the community due to her poor insight and judgment. 2. Psychiatrist will initiate petition for mandatory outpatient commitment and treatment under Section 23c.

B.

Court approval for forcing meds 1. Team will seek court approval for the use of antipsychotic meds for treatment of pt.’s disabling psychosis.

IX. Miscellaneous Treatment Modalities A.

Treatment of related problems (optional and can be included with the treatment modalities or in the problem description) 1. Treat pt.’s problem with suicidal ideation as indicated under Problem 3.1 (Suicidal Ideation). 2. Treat pt.’s problem with assaultiveness as indicated under Problem 3.1 (Violence Secondary to Paranoia). 3. Treat pt.’s problem with substance abuse as indicated under Problem 5.1 (Polysubstance Abuse).

1–16


Individual Problem Plans (Frequent Entries) INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.1 Psychotic Symptoms

Name: Smith, John ID #: Area:

Nursing Diagnosis: Disturbed Thought Process

Date: 01/15/03

Problem Description: 1.

The problem description should include the following:

• • • • • • • 2. 3.

4.

Onset of symptoms and chronicity Precipitants (e.g., noncompliance with treatment, substance abuse, stress) Characteristics, frequency, intensity, and variance of symptoms Response to previous and current treatments and expected response to any proposed treatments Barriers to treatment, such as poor insight into the need for treatment, including meds Presence or need for psychotropic medication guardianship, guardianship of person and/or estate Current level of symptoms and activity level, including frequency of attendance at therapeutic activities

Make sure that the above relate to goals and treatment modalities. If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment. Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem Area 3, Violence.

Goal(s) (Discharge Criteria and Objectives) (Please number all goals.)

1.

Pt. will participate in _______________________ group(s) at least ___ out of ___ days a week for ___ month(s).

2.

Pt. will be involved in at least ___ hours per day of either treatment programs or vocational programs for a ___-week/month period without significant interference from psychotic symptoms.

3.

Pt. will be free of overt psychosis AEB not acting on delusions or hallucinations for ___ week(s)/month(s).

4.

Pt. will accept prescribed meds and lab work for a ___-week/month period.

5.

Pt. will engage in reality-based, ___-minute conversations with staff without evidencing delusional ideas at least ___ time(s) per week for ___ month(s).

6.

Pt. will cooperate with a least one treatment team member in the treatment planning process.

7.

Pt. will be able to explain the nature of his or her illness and its treatment in a fairly rational, fairly accurate manner.

8.

Pt. will tolerate ___ overnight visits to a community residence without significant interference from psychotic symptoms.

9.

Pt.’s score on the Kennedy Axis V Psychological Impairment will improve from the current score of ___ to ___.

Target Date

Date/Status*

10. Pt.’s score on the Kennedy NOSIE’s Manifest Psychosis and Social Interest will improve from the current score of ___ to ___.





1–17

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for ____ minutes at least ______ time(s) weekly/monthly to monitor any changes in psychosis to prescribe treatment with antipsychotic meds, ______________, and _____________ for EPS. Lab (blood levels, WBCs). AIMS q 6 months.

Victor Dyson, MD

Social Work: 1.

Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to discuss the effect of pt.’s psychosis on discharge, to evaluate pt.’s readiness for discharge, and to discuss discharge options with pt.


Psychology (or Social Work): 1.

Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___ times weekly/monthly in supportive, problem-solving, cognitive therapy to direct pt. back to reality or help pt. function, even if psychotic symptoms persist.

2.

Psychologist (social worker) will rate the Kennedy Axis V quarterly/annually.

Susan Green, Psychologist Brenda St. Martin, MSW

Rehab: 1.

Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s) weekly/monthly to review and revise the daily treatment schedule. Staff will refer pt. to appropriate groups working to improve contact with reality, self-image, motivation, and focal attention and to develop structure in pt.’s daily routine.

2.

Staff will work with pt. in _____________________ group program for ___ hour(s) a day/week to help improve pt.’s (contact with reality, self-image, motivation, focal attention, ____________________).

Jane Hoover, Rehab


Nsg. staff will provide decreased stimulation, verbal redirection, and refocusing to reality issues. If tormenting hallucinations or paranoid thoughts are present, nsg. staff will express understanding of pt.’s distress, give reassurance, suggest interventions and, if indicated, offer prn meds to help relieve pt.’s distress.

2.

Nsg. staff will encourage attendance at morning meeting (staff will encourage role modeling of appropriate behavior), other on-ward activities, and rehab groups. Staff will provide escort if needed. Nsg. staff will document frequency of attendance.

3.

Nsg. staff will offer support and praise for appropriate, reality-based interactions.

4.

Nsg. staff will begin to assess pt.’s level of understanding of antipsychotic meds and his or her readiness to learn before educating pt.

5.

Nsg. staff will meet with pt. for ___ minutes at least ___ time(s) a week/month to educate pt. about his or her illness and the importance of taking his or her meds. This process will be simple, clear, concrete, and according to pt.’s ability to understand. Nsg. staff will request feedback from pt. to validate pt.’s level of comprehension.

6.

Nsg. staff will rate the Kennedy NOSIE once weekly/monthly/quarterly.

7.

Nsg. staff will prompt pt. to perform ADLs and will document compliance.

Marilyn Davis, RN

*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)

1–18


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.2 Depressive Symptoms

Name: Smith, Jane ID #: Area:

Nursing Diagnosis: Chronic Low Self-Esteem; Hopelessness; Powerlessness

Date: 01/15/03



• • • • • • • 2. 3. 4.

Onset of symptoms and chronicity Precipitants (e.g., noncompliance with treatment, substance abuse, stress) Characteristics, frequency, intensity, and variance of symptoms Response to previous and current treatments and expected response to any proposed treatments, Barriers to treatment, such as poor insight into the need for treatment, including meds Presence or need for psychotropic medication guardianship, guardianship of person and/or estate Current level of symptoms and activity level, including frequency of attendance at therapeutic activities

Make sure that the above relate to goals and treatment modalities. If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment. Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem Area 3, Violence.


1.

Pt. will be able to engage in a _____-minute conversation without any evidence of helplessness or hopelessness.

2.

Pt. will be able to discuss options for the future beyond feelings of helplessness and hopelessness for a _____-day/week period.

3.

Pt. will be able to report improvement in his or her depressive symptoms consistently for a ___-day/week period.

4.

Pt.’s motivation will improve to the point that pt. will get out of bed and have his or her dorm area in acceptable order at least ___ weekdays per week for a ___-week/month/period.

5.

Pt.’s energy and motivation will improve so that he or she will be involved in a least ___ hours per day ___ days per week of either treatment programs or vocational programs for a ___-week/month period.

6.

Pt.’s depressive symptoms will improve to the extent that he or she will be able to successfully function during ___ overnight visit(s) to community residence or home.

7.

Pt.’s score on the Beck Depression Inventory will improve from the current score of ___ to ___.

8.

Pt.’s score on the Kennedy Axis V Psychological Impairment will improve from the current score of ___ to ___.

9.

Pt.’s score on the Kennedy NOSIE’s Social Interest and/or Motor Retardation will improve from the current score of ___ to ___.

Target Date

Date/Status*





1–19

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to monitor any changes in depression to prescribe treatment with antidepressant meds, such as _______________________ . Labs as ordered, including antidepressant levels.

Victor Dyson, MD

Social Work: 1.

Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to discuss pt.’s depression’s affect on discharge, to evaluate pt.’s readiness for discharge, and to discuss discharge options with pt.



Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___ time(s) weekly/monthly in supportive, problem-solving cognitive therapy to improve pt.’s mood and/or help pt. function, even if depressive symptoms persist.

2.

During these meetings, drops in pt.’s self-esteem will be treated by helping pt. focus on his or her assets and accomplishments (e.g., career accomplishments, relatives who care for pt., hobbies, memories of happy experiences).

Susan Green, Psychologist Brenda St. Martin, MSW

Rehab: 1.

Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s) weekly/monthly to review and revise pt.s’ daily treatment schedule. Staff will refer pt. to appropriate groups working to improve his or her contact with reality, self-image, motivation, and sense of helplessness or hopelessness (see weekly schedule).

2.

Staff will work with pt. in _____________________ group program for ___ hour(s) a day/week to help improve pt.’s ______________ (self-esteem, self-image, motivation, and sense of helplessness or hopelessness).

Jane Hoover, Rehab


Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive aspects of his or her life. Nsg. staff will help pt. learn ways to resolve or cope with negative aspects of his or her life.

2.

Nsg. staff will begin to assess pt.’s level of understanding of antidepressant meds and his or her readiness to learn before educating pt.

3.

Nsg. staff will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to educate pt. about his or her illness and the fact that pt.’s meds can help to reduce his or her sadness and sense of hopelessness or helplessness. Nsg. staff will request feedback from pt. to validate pt.’s level of comprehension.

4.

Nsg. staff will begin to assess pt.’s level of understanding of antipsychotic meds and his or her readiness to learn prior to educating pt.

5.

Nsg. staff will offer support and praise for realistic, positive interactions or statements about self or about pt.’s future.

Marilyn Davis, RN


Notes


1–21

Sample Individual Problem Plans CONTENTS Depressive Symptoms............................................................................................................................. 1–22 Manic-Depressive Symptoms ................................................................................................................. 1–24 Depressive and Psychotic Symptoms ..................................................................................................... 1–26 Psychotic Symptoms............................................................................................................................... 1–28 Residual Psychosis................................................................................................................................... 1–30 Apathy and Lack of Motivation .............................................................................................................. 1–32 Poor Focal Attention............................................................................................................................... 1–34 Noncompliance With Treatment............................................................................................................ 1–36 Resists Independent Functioning ........................................................................................................... 1–38 Escape Risk.............................................................................................................................................. 1–40 Stealing ................................................................................................................................................... 1–42 Psychosomatic Complaints ..................................................................................................................... 1–44 Work-Related Anxiety............................................................................................................................. 1–46 AIDS-Related Distress ............................................................................................................................. 1–48

1–22


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.1 Depressive Symptoms

Name: Williams, Alice ID #: Area:

Nursing Diagnosis: Hopelessness

Date: 01/15/03

Problem Description: Pt. presents with consistent attitude of hopelessness and helplessness about situation. She has no plans for future and views her immediate situation as totally beyond her control. Behavior has adolescent quality in that negative behaviors are used as retaliatory measures against others and to keep others at a distance. Pt. will be able to discuss options for future.


1.

Patient will be able to discuss options for future beyond feelings of helplessness and hopelessness.


Target Date

Date/Status*

07/15/03

Target Date

1.

Pt. will be able to engage in a 5-minute conversation without any evidence of helplessness or hopelessness.

04/15/03

2.

Pt. will cooperate with at least one treatment member in the treatment planning process.

04/15/03

3.

Pt. score on the Beck Depression Inventory will improve from the current 30 to 18.

04/15/03

Date/Status*





1–23

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for at least ½ hour once weekly to monitor any changes in depression to prescribe treatment with antidepressants, such as Zoloft (sertraline). Order labs, including antidepressant levels.

Victor Dyson, MD

Psychology: 1.

Psychologist will perform psychological testing to assess depressive cognition.

2.

Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive, problem-solving therapy to improve pt.’s mood and help her function even if depressive symptoms persist.

Joseph LeBlanc, Psychologist

Social Work: 1.

Social worker will meet with pt. for ½ hour once weekly to evaluate pt.’s readiness for discharge.

2.

Social worker will consistently offer pt. the opportunity for treatment planning involvement.


Rehab: 1.

Rehab staff will meet with pt. as needed to review and revise her daily treatment schedule and will refer her to appropriate groups working to improve her self-image, motivation, and sense of helplessness and hopelessness (see weekly schedule).

Jane Hoover, Rehab


Staff will verbally reward pt. for cooperative acts on ward and toward other pts.

2.

Staff will discuss with pt. the fact that the meds reduce her sense of hopelessness and helplessness.

3.

Nsg. staff will offer support and praise for positive interactions, positive statements about herself, or positive statements about her future.

Ronald Donahue, RN


1–24


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.2 Manic-Depressive Symptoms

Name: Chabot, Joe ID #: Area:


Date: 01/15/03

Problem Description: For the last several years, pt. has been having increasing problems with mood swings, which occur every few months. During the depressive phase, pt. experiences motor retardation and low self-esteem and becomes withdrawn. During the manic episodes, pt. experiences euphoric mood, marked insomnia, hyperactivity, intrusiveness, marked irritability, and assaultiveness. Pt. often feels that the moods are related to external events, and he is reluctant to take his lithium on a regular basis. When pt. takes his lithium as prescribed, there is a marked reduction in the severity of his mood swings. Tremors appear to be the only significant side effect of the lithium. Treatment of irritability as outlined under Problem 3.1 Assaultive, Irritable Behavior.


1.

Pt.’s manic-depressive symptoms will be controlled to the point that he can be discharged back to an independent living situation in the community.


Target Date

Date/Status*

07/15/03

Target Date

1.

Pt.’s mood will stabilize such that he gets at least 6 hours of sleep each night for 1 month.

03/15/03

2.

Pt. will be able to express an understanding of his illness, including his own “first signs” of manic and depressive trends and the need to take his meds.

03/15/03

3.

Pt.’s mood will stabilize such that he maintains a normal level of activity (i.e., reasonably socially outgoing and involved in recreational activities for 1 month).

04/15/03

4.

Pt. will be free of any significant side effects from the lithium for 1 month.

03/15/03

Date/Status*





1–25

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for at least 1 hour and 35 minutes monthly to monitor any changes in manic-depressive symptoms and to prescribe treatment with mood stabilizer (such as lithium or Depakote) and beta-blockers (such as Inderal) to help relieve tremors secondary to the lithium therapy.

2.

Psychiatrist will conduct periodic lab tests to monitor lithium levels and to detect possible adverse effects of lithium on the thyroid gland, kidney, and the like.

Victor Dyson, MD


Nsg. staff will lead medication group once weekly to help pt. understand the nature of his cyclic mood disturbance, to help him monitor signs of changing mood, and to help him recognize the benefits of medication for relieving his symptoms.

2.

Nsg. staff will encourage attendance at morning meeting and program activities. Nsg. staff will document frequency of attendance.

Ronald Donahue, RN

Rehab: 1.

Staff will engage pt. in meaningful activities to redirect excessive energy when pt. is manic and to minimize withdrawal and drifting when pt. is depressed.


Social Work: 1.

Social worker will hold a family meeting once weekly to address pt.’s brothers’ concerns about pt. illness, to educate them regarding his cyclic mood disturbance, and to support them in coping with his behavior.



1–26


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.3 Depressive and Psychotic Symptoms

Name: Murphy, John ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a long history of depressive and psychotic symptoms, including persecutory delusions, constant auditory hallucinations, disorganized thinking, marked sadness, and marked apathy. Exacerbation of depressive and psychotic symptoms often occurs in association with stress, noncompliance with his meds, or both. Currently pt. is actively psychotic and very unmotivated. He rejects most interpersonal contact, including that of family members. Pt. often appears depressed and at times self-reports feelings of depression. The depression is reflected in his lack of motivation to attend to personal hygiene and his appearance, as well as a generalized appearance of sadness.


Target Date

1.

Pt. will improve to the extent that he can participate in two offward groups per day for 1 month.

01/15/04

2.

Pt.’s Kennedy Axis V score on Psychological Impairment will improve from current 30 to 40.

01/15/04


Target Date

1.

Pt. apathy and poor motivation will diminish such that he is out of bed for at least 2 hours per shift for 2 weeks.

04/15/03

2.

Pt. will use unsupervised privileges at least ½ hour per shift for 2 weeks without significant interference from his psychotic symptoms.

04/15/03

3.

Pt. will participate in rehabilitation groups three times a week for 2 weeks.

04/15/03

Date/Status*

Date/Status*





1–27

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for ½ hour once a week to monitor pt. for any changes in his depressive and psychotic symptoms. Antipsychotic and antidepressant meds as prescribed. Labs as needed and AIMS Plus EPS exam q 6 months.


Social Work: 1.

Social worker will hold weekly meetings with pt. for 45 minutes (family to be included monthly) to assess and address individual and family issues.

2.

Social worker will hold weekly meetings with pt. to assess readiness for discharge and to determine obstacles to his discharge.


Psychology: 1.

Psychologist will hold weekly reality testing for ½ hour to determine obstacles to improved level of functioning.



Nsg. staff will provide positive feedback to pt. for spontaneous attendance to his appearance.

2.

Nsg. staff will engage pt. in one-to-one contact two to three times per day to encourage interpersonal contact in on- and off-ward supervised activities.

3.

Nsg. staff will provide support and praise for appropriate, reality-based interactions.



1–28


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.4 Psychotic Symptoms

Name: Kaplan, Carolyn ID #: Area:


Date: 01/15/03

Problem Description: For more than 10 years, pt. has been almost constantly experiencing auditory hallucinations, persecutory delusions, and bizarre behavior. Because of interference from her thought disorder, she currently is unable to engage in meaningful conversation for more than 30 seconds. Pt. is becoming increasingly apathetic and does not participate in any structured activities. Numerous treatment interventions have failed to bring about significant improvement in her psychosis. These treatments have included trials of several different antipsychotics. Pt. has recently been approved for a trial on clozapine. Pt. has a borderline abnormal ECG and tardive dyskinesia.


Target Date

1.

Pt. will improve to the extent that she can function on an unlocked ward successfully for 3 months.

01/15/04

2.

Pt.’s Kennedy Axis V subscale score on Psychological Impairment will improve from current 20 to 40.

01/15/04


Target Date

1.

Pt.’s thought disorder will improve to the extent that she is able to participate in supervised groups for 1 hour, twice weekly for 1 month.

04/15/03

2.

Pt.’s hallucinations and disorganized thinking will diminish to the extent that she is able to engage in a focused conversation for 5 minutes twice a week for 1 month.

04/15/03

3.

Pt. will participate in rehabilitation groups three times a week for 1 month.

04/15/03

4.

Pt.’s score on the BPRS will improve from current 61 to less than 40.

07/15/03

Date/Status*

Date/Status*





1–29

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. to monitor any changes in pt.’s psychotic symptoms to prescribe antipsychotic meds, such as clozapine.

2.

BPRS will be completed q 3 months. Kennedy Axis V to be completed q 6 months.

3.

Psychiatrist will order weekly WBC for first 6 months of treatment with clozapine, then WBC twice a month.

4.

AIMS Plus EPS evaluation will be repeated as needed.



Nsg. staff will monitor pt.’s pulse, BP, and temp weekly for the first month of clozapine treatment, then monitor her as needed.

2.

Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a conversation.

3.

Nsg. staff will provide one-to-one contact to encourage pt. to participate in program activities two to three times per day.

4.

Nsg. staff will provide positive feedback to pt. for spontaneous participation in any structured activity.

5.

Nsg. staff will monitor pt.’s weight monthly for possible excessive weight gain secondary to clozapine.


Rehab: 1.

Rehab staff will meet one-to-one with pt. to refer pt. to appropriate groups to increase her motivation and develop structure in her daily routine.

2.

Rehab staff will work with pt. to develop and update her weekly program schedule (see attached weekly schedule).

Thomas Parker, Rehab


1–30


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.5 Residual Psychosis

Name: Newman, Anne ID #: Area:


Date: 01/15/03

Problem Description: Pt. thinking is often disorganized and she is easily overwhelmed by external stimuli. Pt. demonstrates moderate to marked lethargy and frequently spends much of the day in bed. Pt. has a history of active psychosis; however, currently she isn’t delusional and she does not appear to be hallucinating. Pt.’s insight and judgment are moderately impaired. Care has to be taken when planning activities for pt. because she often, at a superficial level, appears able to function higher than her actual skills will allow. Recently pt. has been able to function well several days a week in a community day program.


Target Date

1.

Pt. will participate in full-time community day program 5 days a week for 3 months.

01/15/04

2.

Pt.’s Kennedy Axis V score on Psychological Impairment will be maintained at level 50 or better.

Ongoing


Target Date

1.

Pt. will participate in full-time community day program 3 days per week for 1 month.

04/15/03

2.

On days when not in community program, pt. will attend 2 hours of a ward- or hospital-based program per day for 1 month.

04/15/03

Date/Status*

Date/Status*





1–31

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for ½ hour once a month to monitor pt. for any return of delusions or hallucinations and adjust pt.’s antipsychotic meds accordingly. Lab work as needed and AIMS Plus EPS q 6 months.

Victor Dyson, MD

Social Work: 1.

Social worker will conduct weekly one-to-one meeting with pt. for 1 hour to discuss methods of coping with and tolerating group interactions in daily ward and program routine.

2.

Social worker will conduct weekly one-to-one meeting with pt. to evaluate pt.’s readiness for discharge.


Rehab: 1.

Rehab staff will encourage pt. to participate in hospital and community programs.

2.

Rehab staff will make ongoing assessments of pt.’s actual abilities through observation of her ability to perform specific ward and program tasks.



Nsg. staff will encourage pt. to attend morning meeting and rehab groups.

2.

Nsg. staff will provide positive feedback to pt. for staying out of bed during the day for periods of 2 hours or more.



1–32


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.6 Apathy and Lack of Motivation

Name: King, Robert ID #: Area:

Nursing Diagnosis: Activity Intolerance

Date: 01/15/03

Problem Description: Pt. has a lifelong history of noninvolvement in productive activities. He spends the bulk of the day lying in bed, preoccupied with internal thoughts. Hospital staff has consistently been unsuccessful during previous hospitalizations in getting pt. involved in on- or off-ward activities. Recently pt. has expressed some interest in earning money for extra cigarettes. Pt. has been tried on a number of antipsychotic meds, including typical and atypical meds. Pt. has not had a trial on Clozaril.


1.

Pt. will participate in 3 of 10 regularly scheduled program activities.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will participate in 1 of 10 regularly scheduled program activities.

03/15/03

2.

Pt. will participate in one structured work activity of 15 minutes per day, such as washing windows on the ward.

03/15/03

3.

Kennedy NOSIE score in area of Motor Retardation will improve from current score of –16 to –10.

07/15/03

Date/Status*





1–33

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will meet with pt. for ½ hour once a week to prescribe antipsychotics, such as Clozaril, to help relieve the negative symptoms of pt.’s psychotic process. Lab as needed, such as weekly WBC and periodic Clozaril blood levels.


Rehab: 1.

Rehab staff will arrange for pt. to participate in the Patient Wage Program.

2.

Rehab staff will schedule pt. for activities that he can complete successfully and that lead to increased self-esteem and motivation to continue with the activities (see pt.’s weekly schedule).



Nsg. staff will provide encouragement for pt. to participate in structured work activities, such as washing windows or cleaning the dayroom.

2.

Nsg. staff will provide support and praise for pt.’s involvement in any program activity.

Linda Larkin, RN Å Nsg. Staff

Social Work: 1.

When pt. is able to consistently participate in program activities, social worker will begin meeting with pt. for ½ hour once weekly to evaluate his readiness for discharge and to discuss discharge options.



1–34


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.7 Poor Focal Attention

Name: Brown, William ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a very short attention span; however, with frequent staff redirection, he is able to complete assigned program tasks. This has been a long-standing problem for pt.; however, he does appear to respond to staff member’s attention and verbal praise. Implementation of treatment of Problem 1.1 Psychotic Symptoms to help relieve the contribution of pt.’s psychotic symptoms to pt.’s poor focal attention.


Target Date

1.

Pt.’s focal attention will improve as measured by his ability to maintain involvement in program 5 days a week with minimal prompts.

01/15/04

2.

Score on the Kennedy Axis V Psychological Impairment will improve from a current 40 to 60.

01/15/04


Target Date

1.

Pt.’s focal ability will improve such that he will be able to maintain involvement in program 3 days per week.

07/15/03

2.

Pt. will be able to consistently maintain focus on topic beyond the first two sentences of a conversation for 2 weeks.

07/15/03

Date/Status*

Date/Status*





1–35

Date: 01/15/03


Date/Status*

Rehab: 1.

Staff will increase focal attention through the use of graded activities designed to meet his needs and interests.

2.

Staff will give verbal reinforcement for incremental increases in focal attention during tasks.

Jane Hoover, Rehab


Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a conversation.

2.

When nsg. staff members observe pt. wandering off task or off verbal focus, they will immediately redirect pt. back to task, with immediate reinforcement for returning to task, even though it requires guided redirection.



1–36


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.8 Noncompliance With Treatment

Name: Krause, Cheryl ID #: Area:

Nursing Diagnosis: Noncompliance

Date: 01/15/03

Problem Description: Pt. has a long history of noncompliance with her meds, despite being under a court order to take her psychotropic meds. When she stops her meds, she gradually decompensates over a few weeks to a few months. Once decompensated, she is very slow to recompensate after being restarted on her meds. There are concerns that after a period of decompensation she never fully recovers back to her baseline. Currently she continues to be very resistant to taking her meds. Pt. also refuses blood work and often refuses to go to program.


1.

Pt. will demonstrate cooperation with all aspects of the treatment plan, including meds and blood work for 6 months.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will comply with blood work for 3 months.

04/15/03

2.

Pt. will attend assigned programs at least three times weekly for 3 months.

07/15/03

3.

Pt. will accept meds as prescribed for 3 months.

07/15/03

Date/Status*





1–37

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will maintain permission for forced treatments, including antipsychotic meds, as outlined under Problem 7.1 Court Guardianship Plan.


Psychology: 1.

Psychologist will inventory reinforcing events, activities, and objects specific to this pt.

2.

Pt. will receive second-level reinforcement by accumulating one point for each compliant action (e.g., allowing blood to be drawn or attending assigned group). When pt. accumulates five points, she will receive a previously identified reinforcer (see attached behavioral plan).



Staff will discuss with pt. the importance of blood work and meds.

2.

Staff will give verbal reinforcement for all aspects of treatment compliance, such as taking meds, complying with blood work, and going to program.



1–38


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.9 Resists Independent Functioning

Name: Smith, Mary ID #: Area:

Nursing Diagnosis: Ineffective Role Performance

Date: 01/15/03

Problem Description: Since adolescence, pt. has had difficulty functioning independently of her family or institutions. She is terrified of growing up and separating from caregivers. However, she denies these fears and expresses a desire to leave the hospital to live on her own. To avoid independence, she gets herself restricted by breaking the rules, assaulting others, dressing inappropriately, making somatic complaints that have no physical basis, going AWA (away without authorization), and refusing to go to programs or social activities that she has identified as interesting. Pt.’s family often does things that increase pt.’s dependence, such as interrupting treatment despite their agreement to schedule visits when she is not involved in program activities.


1.

Pt. will demonstrate progress toward independent functioning AEB at least ½ day involvement in off-ward program activities of her choice 5 days per week for 3 months.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will be up, dressed appropriately, and have completed all personal hygiene with no more than two verbal cues in time for cafeteria at least 3 days per week for 1 month.

04/15/03

2.

Pt. will complete two ½-day sessions of off-ward programs per week for 1 month.

07/15/03

3.

Pt.’s family will support pt. treatment plan.

07/15/03

Date/Status*





1–39

Date: 01/15/03


Date/Status*


Nsg. staff will give pt. immediate verbal reinforcement for any significant independent functioning, such as getting out of bed without cues, going to program with no more than one cue, and independently preparing to go to program without any cues (see attached behavioral plan).

2.

Nsg. staff will remind pt. to get ready for program activities with minimal verbal cues (e.g., she will be reminded to get ready for her DBT group only once, 15 minutes before the group).


Psychology: 1.

Psychologist will use DBT techniques to work with pt. one-to-one and in the DBT group for 1 hour twice a week.

2.

Psychologist will inventory reinforcing events, activities, and objects specific to the pt. and make modifications in the DBT plan as indicated by the results of the inventory.


Social Work: 1.

Family education meetings will be held once weekly for ½ hour to engage parents in pt. treatment, to help them identify and modify behaviors they contribute that slow pt.’s improvement, and to teach them to identify and reward small improvements in pt.’s independent functioning.

2.

Social worker will meet with pt. ½ hour once weekly to help pt. see the advantages of living in the community and how her acting-out behaviors sabotage her transition into the community.

Roger Sing, MSW


1–40


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.10 Escape Risk

Name: Jeneski, Raymond ID #: Area:


Date: 01/15/03

Problem Description: Pt. has an extensive history of escaping from the hospital while on independent privileges. While on such unauthorized passes, pt. has abused alcohol and attempted to break into houses. His escaping appears to be related to his impulsivity and disorganized thinking. Pt. may put himself and others in dangerous situations while on escape because of his poor judgment, especially when intoxicated. Implementation of treatment of Problems 1.1 Psychotic Symptoms and 5.1 Alcohol Abuse to help lower pt.’s escape risk.


1.

Pt. will not attempt to escape for 6 months or more from independent privileges and day passes.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will attend off-ward programs and supervised privileges without attempting to escape for at least 1 month.

04/15/03

2.

Pt. will be able to go on independent privileges for ½ hour three times daily for at least 1 month without attempting to escape.

04/15/03

3.

Pt. will be able to verbalize an understanding of the relationship between his continued escaping and the increasing difficulty of placing him in the community consistently for 1 month.

07/15/03

Date/Status*





1–41

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Pt.’s supervised privileges will be held for at least 1 week following his return from escape. During this week, he will be assessed as to whether he is safe to restart supervised privileges.


Social Work: 1.

Social worker will meet with pt. for 45 minutes once weekly to help pt. understand how escaping from his treatment leads to increased loss of freedom and increased difficulty with placing him in the community.


Rehab: 1.

Rehab staff will closely monitor pt.’s whereabouts while he is off-ward in scheduled groups.

Thomas Parker, Rehab Å Rehab Staff

Psychology: 1.

Staff will provide one-to-one to assistance pt. to develop appropriate alternative means of gaining freedom and independence.



Nsg. staff will monitor pt. for evidence that he is planning an escape (e.g., hoarding money, wearing a coat while going to in-hospital activities).

2.

If suspicious behavior is noted, nsg. staff will discuss it with pt. to assess his rationale for the behavior. If suspicions continue, staff will be very conscientious about monitoring pt. and will notify psychiatrist of concerns.

3.

Prior to pt.’s going on privileges, nsg. staff will caution him against attempting to escape. Upon his return from successful privileges, nsg. staff will praise pt. for his not having attempted to escape.

4.

Nsg. staff will provide verbal praise and reinforcement for comments and behaviors that suggest that he is working on alternatives to gain freedom, rather than escaping.

Ronald Donahue, RN Å Nsg. Staff


1–42


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.11 Stealing

Name: Miller, Nancy ID #: Area:


Date: 01/15/03

Problem Description: Pt. steals a wide variety of items, most frequently cosmetics. While on pass in the community, she has been arrested twice during the last year. No charges were filed. Pt. could easily buy the items that she steals. Because of her psychotic process, it is very difficult to understand why she steals; however, there does appear to be a compulsive quality to her stealing. Her stealing makes it very difficult to give her unsupervised passes. Her family is very interested in having pt. return home to live with them; however, her stealing makes it very difficult to allow her to go unsupervised in the community. Rewarding her for not stealing with weekly trips to visit her family has decreased the frequency of the stealing. Generally pt. does not steal when at home. Prozac has been helpful with reducing pt.’s compulsion to steal.


1.

Pt. will refrain from stealing and thus demonstrate behavioral control such that she earns a pass home 3 weeks per month for 6 months.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will refrain from stealing and thus demonstrate behavioral control such that she earns a day pass for 2 weeks per month for 3 months.

04/15/03

2.

Pt. will be able to verbalize an understanding of why she steals.

07/15/03

Date/Status*





1–43

Date: 01/15/03


Date/Status*


On each day there is an absence of conclusive evidence that she has stolen, staff will take pt. to the canteen for a snack.

2.

In association with taking pt. on an earned trip to the canteen, staff will verbally reinforce her appropriate (nonstealing) behavior. For example, saying, with smiling approval, “You did such a good job controlling your impulse to steal that I want to take you to the canteen.”

3.

Pt. will be rewarded with a day pass to home once weekly, if she is able to control her urge to steal on the ward or in the community during the preceding week. This control will be measured by the absence of conclusive evidence that she has stolen during the last week.


Social Work: 1.

Social worker will arrange the schedule for passes with pt. family.

2.

Social worker will meet with pt.’s family for 1 hour once a month for supporting, problem-solving family therapy.


Psychology: 1.

Psychologist will meet with pt. once a week for ½ hour to attempt to understand her stealing and to develop strategies that will help decrease her stealing.


Psychiatry: 1.

Psychiatrist will meet with pt. in treatment team for 1 hour once a month to monitor any changes in pt.’s stealing and to prescribe treatments with SSRIs, such as Prozac (fluoxetine).



1–44


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.12 Psychosomatic Complaints

Name: Stone, David ID #: Area:

Nursing Diagnosis: Impaired Health-Seeking Behaviors

Date: 01/15/03

Problem Description: Pt. has a long history of somatic complaints that are related to attention seeking and avoidance of involvement in activities. Complaints include problems with stomach, bowel, broken bones, and headaches. Only rarely is there a physical basis for the complaint.


1.

Somatic complaints will be reduced such that these complaints interfere with assigned program no more than 1 day per week.


1.

Somatic complaints will reduce such that they interfere with program attendance a maximum of 3 days per week.

Target Date

Date/Status*

01/15/04

Target Date

Date/Status*

07/15/03





1–45

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will assess medical aspects of all somatic complaints and treat or arrange for treatment of actual physical problems. Psychiatrist will give staff feedback concerning the medical safety of pt.’s participation in various activities.

Victor Dyson, MD


Following medical assessment of complaints and reasonable assurance that pt. is not at risk, nsg. staff will provide strong support and encouragement to patient for functioning in program despite complaints.

2.

Nsg. staff will discuss health issues with pt. and teach healthy lifestyle changes for ½ hour once weekly.

3.

Nsg. staff will provide support and praise for any reductions in pt.’s seeking medical attention for his psychosomatic complaints; for example, staff will praise pt. for being able to go for a day without any significant attention obtained through the use of psychosomatic complaints.


Psychology: 1.

Psychologist will discuss stress reduction training with pt. and initiate if appropriate.

Susan Green, Psychologist


1–46


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.13 Work-Related Anxiety

Name: Pierce, Kenneth ID #: Area:

Nursing Diagnosis: Anxiety

Date: 01/15/03

Problem Description: Two years ago, pt. developed temporal lobe epilepsy (TLE) syndrome. With treatment, he still has an episode about once a month that is characterized by confused, disorganized thinking. The episodes are preceded by a “weird” feeling and last only a few minutes. Since the development of TLE, pt. has not been involved in any productive activity. Pt. states that his confidence is low and he is afraid of having an episode of TLE in front of customers in a work setting. Pt. had been a very successful computer programmer before the onset of TLE, and the TLE should not have significantly impaired his work performance. Implementation of the medical treatment of Problem 6.1 Temporal Lobe Epilepsy.


1.

Pt. will work 10 to 20 hours per week as a computer programmer for a 3 months.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will be able to participate in scheduled exercise groups for 1 month.

03/15/03

2.

Pt. will able to participate in the sports and fitness club three times weekly for 1 month.

04/15/03

3.

Pt. will be able to work in the hospital computer work program 5 hours per week for 1 month.

07/15/03

4.

Pt. will begin taking small programming jobs in the community for 5 to 10 hours a week for 1 month.

10/15/03

Date/Status*





1–47

Date: 01/15/03


Date/Status*

Rehab: 1.

Pt. will participate in exercise group three times weekly for 20 minutes to engage pt. in a structured social activity to reduce anxiety in group activities.

2.

Pt. will participate in sports and fitness club three times weekly for 2 hours to engage pt. in a structured social activity that will help reduce anxiety in group activities.

Albert Sanchez, RT 3.

Pt. will participate in vocational counseling for 1 hour once weekly to develop stepwise plan of engagement in vocational activities.

Thomas Parker, OT 4.

Pt. will participate in hospital industries program 5 hours weekly to assess and renew his confidence in his work skills and to develop means of coping with the episodes of TLE.

5.

Pt. will participate in vocational group for 1 hour once weekly to explore and encourage vocational adjustment activities and to develop a means to cope with occasional episodes of TLE while on the job.

Jane Hoover, OT

Psychology/Rehab: 1.

Pt. will participate in behavioral treatment to reduce anxiety correlated with the initiation of structured activities (see Behavioral Plan).

Thomas Parker, OT, and Susan Green, Psychologist

Psychiatry: 1.

Pt. will take anxiolytics as prescribed for job-related anxiety and panic.

Victor Dyson, MD


1–48


INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.14 AIDS-Related Distress

Name: Diamond, Dennis ID #: Area:

Nursing Diagnosis: Disturbed Personal Identity

Date: 01/15/03

Problem Description: Pt. is a 23-year-old gay male. He is HIV+ by history and appears to have a good understanding of being HIV+. He presents with an adjustment disorder, which is apparently secondary to the stress of being labeled as an AIDS patient. Despite no physical evidence of illness or any evidence of danger of transmitting the disease to others, he has lost his job and his health insurance. He feels shunned by many of the people in his community. He is having increasing financial difficulties and often wonders whether life is worth living; however, pt. is not believed to be suicidal. Implement treatment of medical aspects of being HIV+ and AIDS precautions as outlined under Problem 6.1 HIV+ (including an appointment with an infectious disease specialist).


1.

The painful psychological and psychosocial impact of HIV diagnosis will be minimized AEB pt. regaining a sense that his life has meaning and that he is able to again enjoy living consistently for a 2-month period.


1.

Pt. will have fewer and milder psychological symptoms (depression, anxiety, panic, and isolation) of AIDS-related distress consistently for a 1-month period.

Target Date

Date/Status*

07/15/03

Target Date

Date/Status*

04/15/03

2.

Pt. will use legal and social supports consistently for a 1-month period.

04/15/03

3.

Pt. will regain access to ongoing, optimal medical care consistently for 1 month.

04/15/03





1–49

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will begin individual psychotherapy (being sure to include a discussion of the limits of confidentiality) and pt. education with a plan to address the distress pt. is feeling. This would include exploring pt.’s individual understanding of the meaning of the infection, ostracism, and discrimination. Psychiatrist will reassure pt. that he is not “losing his mind” and that this is a psychological reaction at present, not AIDS dementia complex. Psychiatrist will explore possible solutions and sources of relief of the pt.’s distress. Psychiatrist will caution pt. to be selective about informing others of his infection, given the current social climate. However, psychiatrist will encourage pt. to give appropriate warning at the appropriate time to anyone he could infect, such as a potential sexual partner. Also, psychiatrist will address and monitor pt.’s feelings of hopelessness and thoughts that life is not worth living. Consider antidepressant meds and family therapy (including lover).

Victor Dyson, MD

Social Work: 1.

Social worker will discuss and introduce the pt. to the notion of group psychotherapy and community support groups. These can lessen sense of being the “only one.” The theme of the group is that some choices have been taken away by the nature of the illness but that other choices remain and should be used and appreciated.

2.

Social worker will help pt. see how other gay men cope and ideally will stick with pt. when healthy and when hospitalized.

Roger Sing, MSW, and Robert Weaver, Community Case Manager 3.

Social worker will explain to pt. that job and insurance discrimination is illegal and refer pt. to community advocacy groups (both gay and HIV). Advise pt. that asserting his rights can be psychologically therapeutic.

Roger Sing, MSW


Nsg. staff will conduct ongoing assessment of pt.’s sexual practices with regard to encouraging safe ways to have physical intimacy. Staff will provide extensive teaching of safer sex practices, as well as reassurance that the need for intimacy increases when people are faced with the HIV diagnosis.

2.

Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive aspects of his life. Staff will support him in learning ways to cope with being HIV+.

Marilyn Davis, RN

Psychology: 1.

Psychologist will perform baseline neuropsychological testing.


Rehab: 1.

Psychologist will perform detailed functional history.

Jane Hoover, Rehab


Notes

SOCIAL SKILLS (Problem Area 2)

2–1


Social Skills (Problem Area 2)

2–3

SOCIAL SKILLS (Problem Area 2) CONTENTS Kennedy Axis V for Social Skills ................................................................................................................ 2–4 This rating scale can be used to measure the outcome of treatment. It also helps to define the problems that fit into the category of Social Skills and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 2–5 Examples of problem names and descriptions that may relate to Social Skills are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 2–5 Examples of strengths that may be related to treatment and discharge in the area of Social Skills are listed here.

Goals ......................................................................................................................................................... 2–6 Examples of treatment goals that may relate to problems in the area of Social Skills are listed here.

Treatment Modalities ............................................................................................................................... 2–8 Examples of treatment modalities that may relate to problems in the area of Social Skills are listed here.

Sample Individual Problem Plans ........................................................................................................... 2–13 A wide range of Individual Problem Plans relating to Social Skills are included here.

2–4


Kennedy Axis V—Social Skills 100

Superior social skills, sought out by others because of his/her outstanding social/communication skills, has many friends and no difficulty making new friends. No symptoms.

90 Good social skills, no difficulty being pleasant and engaging, good communication skills, socially effective.

80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships. 70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally functioning fairly well, has some meaningful interpersonal relationships. 60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of problems with social skills; communications are understandable but vague. 50 Serious impairment in social skills; has no friends because of clearly impaired social skills; however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear difficulty; frequently intrusive; inappropriate, nonsexual touching. 40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others; great difficulty recognizing that his/her sexual advances are not welcome. 30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how to share with others, and/or how to show sympathy toward others; conversations with others are grossly inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual touching, and the like. 20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing of feces or making sexual advances toward young children; however, may have some understanding that such behavior is inappropriate.

10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others); extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social situations). NR Not rated


2–5


II.

Poor Social Skills Problems A.

Nonsexual 1. Limited interpersonal skills 2. Extremely impoverished social skills secondary to social isolation 3. Socially inappropriate behavior due to lack of awareness of social norms 4. Lack of consideration for others due to poor interpersonal skills 5. Demanding, intrusive behavior 6. Teasing, pestering, or agitation of peers due to poor social skills 7. Poor communication skills

B.

Sexual 1. Overly affectionate 2. Inappropriate seductive dress and sexual actions with little or no understanding that these actions are inappropriate 3. Frequent, inappropriate masturbation without an understanding of the social and legal consequences of such behavior 4. Inappropriate sexual advances without awareness that the behavior is inappropriate 5. Inappropriate hugging or inappropriate touching of other without an understanding of the inappropriate nature of these acts

Other A.

No examples given


Social Skills Strengths A. B. C. D. E. F.

Has fairly good social skills Is able to be polite and pleasant Is able to make and maintain friendships Is able to communicate fairly well Has good sense of humor Other

2–6


Goals I.

II.

Expected Improvements in Skills and Symptoms A.

Demonstration of socially appropriate behavior 1. Pt. will initiate at least one socially appropriate interaction during each social activities group for 1 month. 2. Pt. will make one clear, socially appropriate statement to a peer once a day for 1 week. 3. Pt. will display appropriate social behavior for at least 30 minutes of each social skills group for 3 months. 4. Pt. will make at least one comment that acknowledges the feelings or needs of the other person once each waking shift in interactions with staff for 1 month. 5. Pt. will develop an inventory of alternative, socially appropriate behaviors. 6. Pt. will be able to consistently express an understanding of what is needed to assess prospective relationships for 2 weeks. 7. Pt. will consistently express an understanding of the effect on others of not attending to personal hygiene for 1 month.

B.

Extinction of socially inappropriate behavior 1. Pt. will not grab drinks or cigarettes from others for 2 out of 5 weekdays for 1 month. 2. Pt.’s inappropriate attention-seeking behavior will decrease such that pt. requires no more than two staff interactions for limit-setting during each social activities group for 1 month. 3. Pt. will decrease inappropriate touching of others to less than one time per each 7-to-3 shift for 1 month. 4. Pt. will not expose genitals to others for 6 months. 5. Pt. will not make sexually provocative statements for 1 week. 6. Pt. will be free of screaming episodes for at least 1 day per week for 1 month. 7. Pt. will be able to consistently recognize inappropriate sexual impulses for 1 month. 8. Pt.’s inappropriate teasing of others will decrease to one incident or less per week for 1 month.

Reporting of Symptoms A.

Pt. will consistently discuss any problems that he or she is having in social interactions for 1 month.

III. Participation in Groups, Program Activities, and the Like A. B. C. D.

Pt. will participate in on-ward group activities for 5 minutes a day for 1 month. Pt. will attend morning ward meeting twice per week for 1 month. Pt. will attend one off-ward group activity per week for 1 month. Pt. will engage in one independent off-ward social activity with a peer at least once a week for 3 months.

IV. Understanding of and Compliance With Treatment Plans A.

Medication and laboratory work 1. Pt. will consistently acknowledge the importance of taking his or her meds for 1 month. 2. Pt. will spontaneously express an understanding of the need to take psychotropic meds at least once a week for 1 month.

B.

Program activities 1. Pt. will consistently express the benefits of attending program activities focused on improving social skills for 3 months. 2. Pt.’s level of compliance will improve such that he or she will attend the group social activities twice a week for 4 weeks.


V.

2–7

C.

Treatment planning 1. Pt. will consistently cooperate with at least one treatment team member in the treatment planning process for 1 month. 2. Pt. will be willing to participate in the evaluation process. 3. Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and blood work, for 2 weeks.

D.

Consequences of pt.’s actions 1. Pt. will demonstrate a realistic orientation toward his or her progress such that pt. understands and explains the connections between— a. Appropriate social interactions with others and positive responses and acceptance from others, and b. Inappropriate social interactions and negative responses and avoidance by others.


Assessments 1. Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it can be completed. 2. Pt. will cooperate so that an assessment can be made as to whether cultural factors significantly interfere with the demonstration of pt.’s social skills.

B.

Evaluations to R/O various diagnoses 1. Pt. will cooperate with testing to R/O mental retardation.

C.

Laboratory tests 1. No examples given.


Kennedy Axis V 1. Pt.’s Kennedy Axis V subscale score on Social Skills will improve from a current score of 30 to 40.

B.

Comprehensive Occupational Therapy Evaluation (COTE) 1. Pt.’s COTE Rehabilitation score in the area of Interpersonal Behavior will improve from a current score of ___ to ___.

VII. Miscellaneous A.

No examples given

2–8



II.


Support and reassurance 1. Staff will provide pt. with regular one-to-one support and reassurance, even when pt. is doing well in the development of new social skills.

B.

Cognitive refocusing (redirection of focus toward reality and realistic self-appraisal) 1. Staff will conduct one-to-one weekly meeting with pt. to discuss and assess pt.’s interpersonal relationships with the opposite sex and to discuss appropriate alternatives to inappropriate behavior. 2. Staff will focus pt. away from plans based on psychotic thinking to realistic, achievable relationship goals.

C.

Psychotherapy 1. Staff will conduct weekly one-to-one interview to encourage and help increase social involvement as a means of improving pt.’s social skills. 2. Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand how his or her behavior impacts others and how to modify behavior to more effectively meet pt.’s needs. 3. Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand and cope with conflicts in pt.’s relationships.


Positive reinforcement 1. Staff will praise pt. for improvements in social skills. 2. Staff will give positive verbal feedback to pt. for appropriate social interactions, such as asking for things wanted, rather than grabbing them. 3. Staff will reinforce alternative, appropriate attention-seeking behaviors, such as pt. playing guitar. 4. Nsg. staff will praise pt. when pt. makes appropriate statements and requests to peers. 5. Nsg. staff will give pt. one extra cigarette, token, or quarter as a reward for appropriate social interactions during community meeting. 6. Staff will positively reinforce pt. with trips to the canteen for attending social skills group. 7. Nsg. staff will give encouragement and praise when patient knows the daily schedule.

B.

Negative reinforcement (including discouragement, restriction, and withholding of reinforcement) 1. Staff will discourage inappropriate touching. 2. Nsg. staff will confront pt. when he or she neglects personal hygiene to the point that pt. drives others away with body odor, bad breath, or both. 3. Staff will give pt. frequent reminders as to the offensiveness to others of unattended drooling and nasal drainage. 4. Staff will withhold privileges unless pt. is relatively free of sexually inappropriate behavior. 5. Staff will limit pt. to supervised privileges for 24 hours when pt. fails to attend social skills group.

C.

Extinction 1. All staff will ignore inappropriate social behavior, thus helping to extinguish it. 2. Nsg. staff will interact with pt. as little as possible during screaming incidences in the hope of extinguishing this behavior. 3. Staff will ignore incoherent communications in an attempt to get pt. to try to communicate more clearly.


2–9

D.

Shaping and modeling 1. Staff will use daily modeling of appropriate social behavior, such as addressing others by their first name, maintaining eye contact, asking for things, and the like. 2. Staff will consistently request pt. to articulate his or her speech more distinctly and more slowly. 3. Nsg. staff will encourage pt. to restate incoherent communications in understandable terms. 4. Staff will consistently reinforce incremental improvements in pt.’s ability to communicate. 5. Rehab staff will assign social activities with gradually increasing levels of skill requirement as pt.’s social skills improve. 6. Staff will use group therapy to help pt. learn to model the behavior of others by observing appropriate behaviors in relationships, such as dating or leisure activities group. 7. Staff will assign a higher functioning pt. as a “buddy” for pt. to model during off-grounds outings. 8. Pt.’s case manager will take pt. off the grounds once a week to model appropriate social behavior in various off-grounds activities, such as eating in a restaurant or shopping in a store.

E.

Channeling of energies 1. Staff will help pt. sublimate his or her sexual energies into more appropriate social activities.

F.

Task simplification (reduce confusion and frustration by simplifying tasks and providing consistency and assistance) 1. All staff will be as consistent as possible in redirecting pt. away from the inappropriate social behavior. 2. Nsg. staff will redirect pt. to go to his or her ward contact for all questions concerning appropriate sexual behavior. 3. Rehab staff will reduce the level of frustration and disorganization by breaking simple social interactions into small, concrete, realistic steps. 4. Staff will redirect pt. away from social interactions and relationships that are grossly unrealistic or overly complicated for the pt. 5. Nsg. staff will engage pt. during ward activities in relevant, appropriate conversations that will help the pt. to understand how to communicate in a socially appropriate manner during various activities.


Family treatment modalities 1. Staff will encourage family involvement in helping pt. to develop more effective social skills. 2. Social worker will engage family members in psychoeducational counseling to help them model appropriate social behaviors.

B.

Religious treatment modalities 1. Staff will arrange small-group, supportive, religious outings to improve pt.’s ability to interact with others and broaden his or her interests. 2. Spiritual counselor will encourage members from pt.’s congregation to take pt. to services so that pt. can interact with other members in a social environment.

C.

Other modalities 1. Group therapy a. Staff will hold group therapy once weekly to facilitate discussions of problems with forming relationships. b. Group leader will regularly attempt to engage pt. in topics being discussed. 2.

Psychodrama a. Psychologist will provide role playing to assist pt. in understanding and dealing with complicated social interactions.

3.

Rehabilitation a. Rehab counselor will lead social skills building group for 1 hour once a week to help pt. learn more appropriate social interactions.

2–10


4.

Practicing social skills a. Staff will encourage pt. to practice social skills in various social settings, including community meetings, dances, and leisure group activities. b. Staff will encourage pt. to participate in task-oriented groups that will allow pt. to socially interact with peers.


V.

A.

Stimulus reduction 1. Staff will redirect pt. to a quiet environment to allow pt. to practice appropriate social interaction with fewer distractions. 2. Staff will remove pt. from overwhelming social situations and place pt. in supportive, nonthreatening social situations until his or her skills improve to allow pt. to interact in these more demanding situations.

B.

Protective procedures (including special observations) 1. Staff will provide a safe, secure environment so that the pt. is not victimized. 2. Nsg. staff will observe pt. for signs that he or she is engaging in social activities that place him or her at risk.

C.

Other milieu treatment modalities 1. No examples given.


Medication 1. Meds will be taken as prescribed.

B.

Other medical treatment modalities 1. Staff will provide a wheelchair to improve pt.’s social skills by allowing better access to social outings.


Social skills deficits 1. Social worker will discuss with pt. and the family the effect of pt.’s inappropriate social interactions on others and how pt.’s family can assist pt. to be more socially appropriate when visiting at home.

B.

Medication 1. Staff will discuss with the pt. the risks and benefits of meds. 2. Staff will conduct one-to-one discussion for ½ hour once weekly about the need to take meds as prescribed. 3. Staff will show the concrete benefits of taking meds (e.g., “You seem more relaxed in social situations,” “You act more appropriately toward others,” “You have more friends”).

C.

Benefits and consequences of behaviors 1. Staff will discuss connections between improvements in pt.’s social skills and getting positive responses from others, having friends, and going out on dates. 2. Nsg. staff will provide recognition of pt.’s comment(s) and will praise to help the pt. understand the consequences of his or her actions when pt. makes at least one socially appropriate comment in the community meeting. 3. Staff will demonstrate to pt. the benefits of being able to appropriately request something from someone. 4. Staff will work with pt. to help pt. to have a clearer understanding of the negative effects alcohol has on pt.’s social skills. 5. At least once weekly, staff will discuss the benefits of neatness and generally good personal hygiene when trying to develop a relationship with someone.


D.

2–11

Miscellaneous patient and family education 1. Nsg. staff will provide one-to-one education to help pt. recognize inappropriate social behaviors and to develop alternative behaviors.


Psychological tests (and other formal verbal tests) 1. Pt. will complete psychological testing for personality assessments. 2. Pt. will complete psychological testing to determine pt.’s ability to engage in social interactions.

B.

Psychiatric evaluations 1. Pt. will receive psychotropic medication evaluation to help determine whether psychotropic meds will enhance his or her ability to participate in social skills training.

C.

Medical tests and evaluations 1. See section on Psychological Impairment for examples of medical tests and evaluations for psychological impairment that may apply to social skills.

D.

Other evaluations and assessments 1. Pt. will complete speech evaluation at the Communication and Language Disorders Clinic at the local university. 2. Staff will refer pt. to rehab for standardized testing of social skills. 3. Nsg. staff will make on-ward observations of pt.’s social interactions to assess pt.’s level of social skills. 4. Rehab staff will assess pt.’s areas of greatest interests and motivation to begin social activities congruent with pt.’s interests.


No examples given


Treatment of related problems (This is optional and can be included with the treatment modalities or in the problem description.) 1. Staff will treat pt.’s bizarre behavior as indicated under Problem 1.1 Psychotic Symptoms. 2. Staff will treat pt.’s social withdrawal as indicated under Problem 1.1 Psychotic Symptoms. 3. Staff will treat pt.’s sexually assaultive behavior as indicated under Problem 3.1 Sexually Assaultive Behavior.

Notes


2–13

Sample Individual Problem Plans CONTENTS Impoverished Social Skills....................................................................................................................... 2–14 Impaired Social Skills (Deferred) ............................................................................................................ 2–16 Sexually Inappropriate Behavior ............................................................................................................ 2–18

2–14


INDIVIDUAL PROBLEM PLAN Problem # and Name: 2.1 Impoverished Social Skills

Name: Snow, Karen ID #: Area:

Nursing Diagnosis: Impaired Social Interaction

Date: 01/15/03

Problem Description: Pt. has a 15-year history of mental illness. Skills acquired before the onset of her illness have decreased dramatically. Most of her interactions are with family members, and her skills demonstrated with her family are often very awkward and ineffective. Her verbal responses are passive and monosyllabic. She generally avoids others and has no close friends because of her impaired social skills. Pt. has only a minimal awareness of social norms; however, she doesn’t act grossly inappropriately toward others, such as by initiating inappropriate sexual touching.


Target Date

1.

Pt. will be able to follow the rules of a task group environment (e.g., ask for things she needs about four out of five times instead of taking things from others) for 3 months.

01/15/04

2.

Pt.’s Kennedy Axis V subscale score on Social Skills will improve from a current score of 40 to 50.

01/15/04


1. 2. 3.

Pt. will ask for materials that she needs about 50% of the time for 1 month. Pt. will ask for things that she needs about four out of five times for 1 month. Pt. will be able to consistently interact with her peers in social skills group without the interactions leading to very awkward situations for 1 month.

Target Date

Date/Status*

Date/Status*

07/15/03 10/15/03 10/15/03





2–15

Date: 01/15/03


Date/Status*

Social Work: 1.

Staff will provide psychoeducational counseling of family with focus on helping the family to model effective social interaction skills.


Rehab: 1.

Staff will focus on feedback of basic social skills, cooperative behavior, approximation to the group, discrimination, and demand for minimal interaction with group leader (e.g., asking for materials and instructions).

2.

Rehab programs will allow pt. to observe and practice social skills, including leisure awareness, leisure exploration, recreational groups, and the like (see Program Schedule).

3.

Staff will redirect her through modeling for more functional alternatives when pt.’s social behaviors are ineffective.



Staff will interact with pt. one-to-one for at least 5 minutes for a minimum of three times per shift to model effective social behaviors (e.g., addressing pt. by her first name, maintaining eye contact, asking for things needed).

2.

Staff will provide pt. with daily encouragement and praise for keeping track of her daily schedule of activities.

3.

Staff will provide support and praise for appropriate social interactions on the ward.



2–16


INDIVIDUAL PROBLEM PLAN Problem # and Name: 2.2 Impoverished Social Skills (Deferred)

Name: Cosby, Laura ID #: Area:


Date: 01/15/03

Problem Description: Pt. has markedly impaired social skills that prevent her from having any friends or peer relationships. Her skills are not so impaired that she displays grossly inappropriate social acts. As indicated under Problem 1.1 Psychotic Symptoms, pt. is withdrawn and has great difficulty trusting others.


Target Date

Date/Status*

Target Date

Date/Status*

Deferred: Due to the high level of psychotic symptoms, pt. is currently not using the social skills she already possesses.






2–17

Date: 01/15/03


Date/Status*

Psychiatry:

Social Work:

Psychology:

Rehab:

Nursing Care Plan:


2–18


INDIVIDUAL PROBLEM PLAN Problem # and Name: 2.3 Sexually Inappropriate Behavior

Name: Royal, Rebecca ID #: Area:


Date: 01/15/03

Problem Description: Pt. is generally pleasant and engaging; however, she will often attempt to inappropriately kiss others. About once a month, she will attempt to touch others in private areas. She does not appear to be aware of the inappropriateness of her behaviors. She appears to be looking for love, affection, and acceptance. Her inappropriate advances generally turn people off instead of meeting her needs for a caring, affectionate relationship. However, because of her desperateness for affection, strangers could easily take advantage of her.


Target Date

1.

Pt. will be able to develop a caring, appropriate relationship with at least one person and maintain that relationship for at least 3 months.

01/15/04

2.

Pt. will not inappropriately touch others on their private areas for 6 months.

01/15/04


Target Date

1.

Pt. will be free of inappropriate kissing and hugging for 1 week.

04/15/03

2.

Pt. will touch others on their private areas no more that once during 3 months.

07/15/03

3.

Pt. will be able to appropriately participate in a social activity for 1 hour three times a week for 1 month.

04/15/03

4.

Pt. will be able to recognize inappropriate sexual impulses and avoid acting on them for 1 month.

05/15/03

5.

Pt. will develop an inventory of at least three alternative behaviors to use when inappropriate impulses are recognized.

06/15/03

6.

Pt. will be able to identify criteria for evaluating prospective relationships.

07/15/03

7.

Pt. will consistently demonstrate appropriate behavior related to initiating prospective relationships for 2 months.

07/15/03

Date/Status*

Date/Status*





2–19

Date: 01/15/03


Date/Status*

Rehab: 1.

Pt. will participate in relationships group for 1 hour once weekly to review and learn appropriate social interactions, especially with someone with whom she may develop a relationship.

2.

Pt. will have one-to-one daily modeling of appropriate interactions with others, including appropriate expressions of affection.

3.

Pt. will participate in leisure activity group for 1 hour three times weekly to help her develop interests and skills in activities that would allow her to appropriately interact with others at a social, affectionate, friendship level, such as going for a walk, meal, or movie with a friend or playing board games or a physical sport with a friend.

Albert Sanchez, Rehab Å Program Staff


Pt. will participate in women’s group for 1 hour once weekly to explore the issues of relationships and the skills related to these issues.

2.

Staff will provide stern one-to-one redirection when pt. inappropriately touches others on private areas.

3.

Staff will redirect pt. with a minimum of attention to avoid reinforcing inappropriate sexual behaviors that do not involve sexual touching.

4.

Staff will encourage and praise pt. for appropriate expression of affection.

5.

Staff will provide one-to-one skill teaching regarding the recognition of inappropriate sexual impulses and development of alternative behaviors for 1 hour once weekly.

Linda Larkin, RN & Marilyn Davis, RN Å Nsg. Staff


Notes

VIOLENCE (Problem Area 3)

3–1


Violence (Problem Area 3)

3–3

VIOLENCE (Problem Area 3) CONTENTS Kennedy Axis V for Violence..................................................................................................................... 3–4 This rating scale can be used to measure the outcome of treatment. It also helps to define the problems that fit into the category of Violence and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 3–5 Examples of problem names and descriptions that may relate to Violence are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 3–6 Examples of strengths that may be related to treatment and discharge in the area of Nonviolence are listed here.

Goals ......................................................................................................................................................... 3–6 Examples of treatment goals that may relate to problems in the area of Violence are listed here.

Treatment Modalities ............................................................................................................................... 3–9 Examples of treatment modalities that may relate to problems in the area of Violence are listed here.

Individual Problem Plans (Frequent Entries).......................................................................................... 3–14 Two examples of information that is frequently entered into Individual Problem Plans relating to Violence are listed here.

Sample Individual Problem Plans ........................................................................................................... 3–19 A wide range of Individual Problem Plans relating to Violence are included here.

3–4


Kennedy Axis V—Violence 100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to any inappropriate anger, frustration, or conflicts. No symptoms. 90 No significant evidence of violence to self or others; generally satisfied with life, no more than everyday problems or conflicts (e.g., an occasional argument with family members). 80 No more than slight problems with anger and irritability; if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild anger after family argument); no suicidal ideation. 70 Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior; thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning; severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant problems with violence or self-harm. 60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with violence. 50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or others; however, some precautions including close observation may be indicated. 40 Major problems with anger and irritability; some real danger of hurting self or others; violent outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual; occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others; set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or two minor fires. 30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met; suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or restraints may be necessary to prevent serious harm to self or others. 20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone; attempted to very violently harm or violently rape someone within the last month; constant suicidal preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal attempts without clear expectation of death within the last month; close observation to prevent harm to self or others may be required 1 or 2 days a week. 10 Persistent danger of severely hurting self or others; attempted to kill someone within the last month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of death; little or no control of impulses to hurt self or others; expressing loss of control of command hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within the last 2 years. NR Not rated


3–5

Problem Names and Descriptions Note: This problem area relates to acts where one appears to be intentionally putting self or others at risk. Not all dangerousness and risk factors are included here. Additional examples of dangerousness can be found in all of the other problem areas.

I.

Assaultive and Threatening Behavior A.

II.

Assaultive behavior (general) 1. Assaultive, hostile, or combative behavior 2. Assaultiveness associated with alcohol 3. Periodic assaults against a particular person 4. Retaliatory assaultiveness 5. Agitated and explosive behavior 6. Hostile, assaultive mood swings 7. Episodes of bizarre behavior associated with violence 8. Violent attention-seeking behavior 9. Assaultiveness due to command hallucinations 10. Teasing, pestering, or agitation of peers 11. Disruptive behavior 12. Unpredictable displays of hostility 13. Overt hostility to any delay in immediate gratification 14. Attempted murder or murder

B.

Threatening, irritable, and oppositional behavior 1. Argumentative and threatening behavior 2. Low frustration tolerance 3. Oppositional attitude 4. Anger and yelling in response to hallucinations 5. Hostility in response to excessive stimulation (noise) 6. Aggressive acts to get coffee or cigarettes 7. Explosive outbursts (motivated by obvious secondary gains) 8. Explosive outbursts (not motivated by obvious secondary gains)

C.

Sexually assaultive behavior 1. Rape 2. Sexual assault 3. Overly or dangerously sexually aggressive 4. Sexually disordered (e.g., sexual predator)

D.

Other violent acts or threats 1. Stalking 2. Kidnapping 3. Potentially violent antisocial acts such as arson or armed robbery

Suicidal Ideation or Attempts A.

Suicide (general) 1. Suicidal ideation or attempts 2. Self-abuse in response to hallucinations 3. Self-abuse (due to obvious secondary gain) 4. Noncontingent self-abuse 5. Self-mutilation

III. Other 1.

No examples given

3–6



Nonviolent Strengths A. B. C. D. E. F. G.

No significant problems with being assaultive No significant problems with being suicidal or self-abusive Strong ethical and moral values against violent behavior Strong ethical and moral values against suicidal and self-abusive behavior Motivation to work on problems with violent behavior Good response to past treatments for self-abusive behavior Other

Goals I.


Assaultiveness 1. General a. Pt. will be able to converse with staff for 1 minute once per shift without threatening or attempting to assault staff. b. Pt.’s threatening behavior will decrease to no more than once per week for 1 month. c. Pt.’s frequency of explosive episodes (e.g., throwing chairs, ripping curtains) will be reduced to no more than one time per week for 1 month. d. Pt. will be able to control his or her behavior such that other pts.’ complaints of his or her aggression toward them will diminish to a maximum of one per week. e. Pt.’s assaultive behavior will decrease such that no incidences of assault occur for 2 months. f. Pt. will be able to demonstrate control of hostility by being able to apologize to anyone he or she threatens. g. Pt. will maintain current status of no evidence of threatening or assaultive behavior. h. Pt. will be able to consistently express an understanding of the connection between his or her paranoia and hostility and his or her assaultive behaviors for 1 month. 2.

Anger and frustration associated with having to perform a. Pt. will be able to tolerate the frustration of cooperating with the ward routine with a maximum of one disruptive episode per waking shift for 1 week. b. Pt. will able to consistently complete two-step tasks without his or her performance being impeded by angry, hostile behavior for 1 week. c. Pt.’s hostility will decrease to the point that pt. will be able to participate in one dayprogram activity each day for 2 weeks. d. Pt.’s irritability will decrease to the point that he or she can participate in community meetings on a daily basis for 1 week.

3.

Tolerance of delays in gratification a. Pt.’s frequency of verbal outbursts when needs are not met will decrease to once per week or less for 1 month. b. Pt. will be able to consistently tolerate delay of promised gratification for 2 hours without irritable, demanding, intrusive behavior for 1 month. c. Pt. will be able to tolerate corrective feedback without becoming threatening once daily for 3 of 5 weekdays during the 7-to-3 shifts for 1 month.

4.

Alternative coping behaviors a. For 2 weeks, pt. will verbalize feelings of anger and frustration at least once per shift rather than acting out on them. b. For 1 week, when feeling out of control pt. will demonstrate at least one alternative coping skill per shift rather than losing control.


B.

5.

Sexually assaultive behavior a. Pt. will be free of any inappropriate sexual touching for 6 months. b. Pt. will not show any inappropriate hostility toward the opposite sex for 6 months. c. Pt. will not have any interactions with children for 1 year. d. Pt. will cooperate with taking meds to reduce his or her hostile, sexual impulses AEB a reduction in pt.’s urge to masturbate from pt.’s current frequency of twice a day to no more than twice a week for 3 months.

6.

Miscellaneous a. Pt. will be prevented from acting on aggressive, homicidal impulses directed at his or her parent for 6 months.

Suicidal and self-abusive behavior 1. General a. Pt.’s head slapping will decrease to once per week. b. Pt. will display no more than one incident of self-abuse or suicidal gesture per month for 3 months. c. Episodes of self-abuse or suicidal gesture will decrease to less than one every 3 months for 6 months. d. Pt. will be free of suicidal ideation for 3 months. e. Pt. will maintain his or her current status of showing no evidence of suicidal ideation or acts of self-abuse. f. Pt. will be able to express an understanding of the connection between his or her feelings of hopelessness and helplessness and pt.’s suicidal impulses. 2.

II.

3–7

Attention seeking and manipulative acts a. Pt. will not use threats of suicide to receive extra cigarettes or to avoid program attendance for 1 week. b. Pt. will learn more appropriate methods of getting needed attention (such as verbalizing feelings or asking for attention) other than cutting herself.


Suicidal and homicidal ideation and impulses 1. Upon inquiry, pt. will accurately express either the presence or absence of homicidal threats toward pt.’s parent. 2. Upon inquiry, pt. will attempt to accurately express the degree of suicidal impulse. 3. Pt. will make a verbal or written contract not to hurt self when he or she is suicidal. 4. Pt. will spontaneously verbalize any thoughts of hurting self or others for 1 month. 5. Pt. will consistently reveal to staff commands by voices to hurt self or others for 1 month. 6. Pt. will consistently reveal to staff suicidal plans before attempting to act on them for 1 month.

III. Participation in Groups, Program Activities, and the Like A. B. C. D. E. F. G.

Pt. will remain in the group activity area with minimal redirection for 15 minutes per day for 1 week. Pt. will attend two program activities per week for 1 month. Pt. will attend full-day programs 3 days a week for 1 month. Pt. will start a Corps Services job. Pt. will start a job in the community. Pt. will participate in the anger management group once a week for 1 month. Pt. will attend the self-abuse prevention group once weekly for 4 weeks.


Medication and laboratory work 1. Pt. will discuss the benefits of taking his or her meds as prescribed twice weekly for 1 month. 2. Pt. will be able to explain the reasons for taking his or her meds as prescribed. 3. Pt. will take his or her antipsychotic or antidepressant meds as prescribed for 1 month. 4. Pt. will comply with blood work for 3 months.

3–8


B.

Treatment planning 1. Pt. will consistently cooperate with at least one treatment team member in the treatment planning process for 1 month. 2. Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and blood work, for 4 weeks. 3. Pt. will express a willingness to participate in the evaluation process.

C.

Program activities 1. Pt. will verbalize the reasons for attending program. 2. Pt.’s level of compliance will improve such that pt. will attend art therapy class twice a week for 1 month.

D.

Consequences of pt.’s actions 1. Pt. will demonstrate an understanding of his or her progress by being able to explain that— a. Having control of suicidal and homicidal ideation leads to privileges, passes, and ultimately discharge; and b. Losing control of suicidal and homicidal ideation leads to restrictions and continued care at the hospital. 2. 3. 4. 5. 6.

V.

Pt.’s statements will reflect a clear understanding of how others feel threatened and intimidated by pt.’s aggressive, erotic attachments. Pt. will express an understanding as to the association between pt.’s use of drugs and alcohol and violent behavior. Pt. will express an understanding as to the connection between pt.’s paranoia and his or her violent behavior. Pt. will express an understanding of the connection between possessing a gun and the pt. not being allowed to live in the community. Pt. will agree not to purchase a gun, despite his or her failure to understand that owning a gun would pose a serious danger to pt. and others.


Assessments 1. Pt. will allow needed psychological tests to be completed. 2. Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it can be completed. 3. Pt. will cooperate with psychological assessment to determine whether low self-esteem leads to an expectation of failure to which pt. reacts with hostility and suicidal ideation. 4. Pt. will cooperate with the assessment to determine whether pt.’s irritability reflects his or her attempts to avoid communicating with anyone.

B.

Evaluations to R/O various diagnoses 1. Pt. will allow the completion of an evaluation to R/O temporal lobe epilepsy. 2. Pt. will allow the completion of an evaluation to R/O borderline personality disorder.


Kennedy Axis V 1. Pt.’s Kennedy Axis V subscale score on Violence will improve from a current score of 40 to 60.

B.

Kennedy Nurses’ Observation Scale for Inpatient Evaluation 1. Pt.’s K NOSIE score on Irritability will improve from a current score of –24 to –10. 2. Pt.’s K NOSIE score on Social Competency will improve from a current score of +10 to +26.


No examples given


3–9

Treatment Modalities I. Verbal Treatment Modalities (emphasis on verbal interactions)

II.

A.

Support and reassurance 1. To help pt. cope with delayed gratification (e.g., delay in privileges, coffee) and to reduce frustration, staff will reassure pt. that gratification will occur. 2. When pt. is agitated, nsg. staff will give pt. support and reassurance by expressing acceptance of his or her emotional distress. Nsg. staff will avoid arguments with pt. over the justification of his or her distress. 3. Even when pt. is doing well, staff will provide pt. with regular one-to-one support and reassurance at least once each shift (this should help reduce pt.’s inappropriate attention-seeking behaviors, such as suicidal gestures).

B.

Cognitive refocusing (redirecting focus toward nonassaultive, nonsuicidal areas) 1. Staff will reduce level of frustration by redirecting pt. toward alternative responses rather than feelings of anger and frustration. 2. Staff will ask pt. to apologize to anyone pt. threatens.

C.

Psychotherapy 1. Staff will provide pt. with one-to-one insight-oriented psychotherapy once a week to help reduce psychological conflicts that result in periods of uncontrollable anger and hostility. 2. Psychologist will provide supportive, problem-solving psychotherapy to help pt. better cope with life’s day-to-day frustrations and thus lessen pt.’s anger. 3. Social worker will provide one-to-one DBT counseling for pt. and lead DBT skills practice group to help reduce pt.’s level of self-abusive behavior.


Positive reinforcement 1. Nsg. staff members will verbally reinforce pt. for informing them of his or her suicidal feelings and then suggest interventions 2. Ward staff will provide positive feedback to pt. for appropriate control of pt.’s hostile impulses. 3. Staff will praise pt. for completion of 1 hour of program without any evidence of anger or hostility. 4. Staff will positively reinforce pt. with canteen and cafeteria privileges for nonassaultive behaviors.

B.

Negative reinforcement (including discouragement, restriction, and withholding of reinforcement) 1. Staff will restrict pt. to supervised privileges for 1 week if pt. is self-abusive, such as by breaking a window with his or her fist. 2. To closer evaluate pt., staff will restrict pt. to the ward for 1 week following assaultive behaviors. 3. Staff will restrict pt. to the ward for at least 1 week for reassessment if pt. is found bringing weapons to the ward. 4. Staff will restrict pt. from independent use of the phone for 1 week if pt. continues to call 911 for frivolous reasons. 5. After full review, staff will use aversive therapy to stop head banging (see court-approved plan).

C.

Extinction 1. Following a suicidal gesture, staff will carry out all necessary medical procedures with minimal dialogue and conversation with pt.

D.

Shaping and modeling 1. Staff will provide primary and secondary positive reinforcers for incremental decreases in level of hostility.

3–10


E.

Channeling energies 1. Pt. will participate in weekly group therapy to facilitate expression of anger in a more appropriate manner. 2. Pt. will talk with staff or go for a short walk with staff to reduce the level of frustration. 3. Staff will increase structured periods to appropriately channel potentially aggressive behavior into various activities; for example, maximize pt.’s involvement in structured day program, including open workshop, patient wage program, leisure interest group, and community meeting. 4. Staff will encourage pt. to verbalize his or her agitation rather than become oppositional or unreasonable. 5. Staff will divert pt. into acceptable channels to reduce chronic hypersexual arousal and associated sexual assaults.

F.

Task simplification (reduce confusion and frustration by simplifying tasks and providing consistency and assistance) 1. Staff will break tasks down into small, concrete, realistic steps to reduce the level of frustration and disorganization. 2. Staff will break down the steps of dressing into small, understandable, reachable goals to reduce pt.’s anger over failure.


Family treatment modalities 1. Staff will provide family therapy to explore conflicts within pt.’s family. 2. Staff will provide family counseling to help pt.’s family learn means to cope with pt.’s hostile, threatening episodes. 3. Priest/rabbi/reverend will provide religious counseling to help pt. survive the loss of a child.

B.

Religious treatment modalities 1. Spiritual advisor will counsel pt. concerning his or her reported voices from God demanding pt. to kill others. 2. Spiritual/religious advisor will counsel pt. concerning suicidal ideation.

C.

Other modalities 1. Group therapy a. Pt. will participate in group therapy for 1 hour once weekly to facilitate discussions of suicidal impulses. b. Pt. will participate in relapse prevention group to help pt. understand the importance of his or her meds and of continuing DBT treatments. 2.

Psychodrama a. Pt. will participate in role playing to allow pt. to see alternative ways of responding to frustrations and disappointments in life.

3.

Confrontations and pressures a. Staff will avoid pressuring pt. when pt. indicates that he or she wishes to be left alone because pressuring pt. often simply leads to increased agitation and assaultiveness. b. Staff will avoid giving pt. ultimatums because ultimatums often lead to pt. striking out in anger at a perceived authority figure.

4.

Empowerment a. Staff will empower pt. with the opportunity to make choices as to which activities to pursue to reduce his or her anger and frustration of feeling unimportant and helpless.

IV. Milieu Treatment Modalities A.

Stimulus reduction 1. Staff will redirect pt. to a quiet environment if the pt. is agitated or expresses threats. 2. Staff will redirect pt. to a quiet room when necessary to decrease stimulation and agitation.


3. 4. 5. B.

C.

V.

3–11

When pt. makes threats, staff will redirect him or her to the quiet room for 15 minutes or until pt. is no longer threatening. Staff will redirect pt. from triggering events or overstimulating areas. Staff will remove pt. from overwhelming situations to reduce his or her level of frustration.

Protective procedures (including special observations) 1. Staff will provide a safe, secure environment with special monitoring as necessary. 2. Staff will continue to monitor the pt. for evidence of suicidal impulses. Pt. will be placed on special precautions as necessary (strict suicidal precautions, suicidal precautions, or close observation). 3. If there appears to be a return of suicidal impulses, staff will ask pt. whether these are active impulses or just isolated ideas, whether pt. has a plan, is future oriented on other matters, and the like. 4. If there appears to be a return of suicidal impulses, staff will ask pt. to provide a written or verbal contract not to harm self. 5. Nsg. staff will observe pt. for signs that pt. is becoming assaultive, such as agitation and internal torment. 6. Staff will consider transfer to the observation room for closer monitoring of sexual assaultiveness and/or self-destructive behavior. 7. Staff will refer pt. for screening for the Intensive Treatment Unit if pt.’s assaultive behavior significantly worsens. 8. When pt. becomes agitated, staff will place mitts on his or her hands to prevent self-abuse. 9. Staff will employ escape precautions. 10. If pt. brings weapons to the ward, staff will search pt. upon return to the ward for at least 1 month, in conjunction with continued counseling on the dangers of bringing weapons into the hospital. Other milieu treatment modalities 1. No examples given.


Medication 1. Staff will prescribe antipsychotic meds to reduce the intensity of pt.’s anger and irritability. 2. Psychiatrist will prescribe mood stabilizers, such Depakote, to help control pt.’s explosive episodes. 3. Prn meds, such as a combination of Haldol and Ativan, will be used to relieve acute explosive episodes. 4. Psychiatrist will prescribe an SSRI, such as Zoloft, or hormonal therapy, such as Depo-Provera, to reduce pt.’s libido and associated hostile, sexual impulses.

B.

Other medical treatment modalities 1. ECT a. Staff will give the pt. a course of ECT to help relieve intractable suicidal ideation.


Mental illness 1. Psychologist will discuss the association between the pt.’s paranoia and his or her assaultiveness. 2. Social worker will discuss with the pt. and family the association between pt.’s feelings of hopelessness and suicidal impulses.

B.

Medication 1. Psychiatrist will discuss with pt. the risks and benefits of meds. 2. Nsg. staff will meet one-to-one to educate pt. about the fact that the meds decrease pt.’s level of anger and irritability.

3–12


3.

Staff will show concrete benefits of taking meds (such as, “You are less angry and irritable,” “Your suicidal impulses are decreased,” “You spend less time in restraints,” “People are less fearful of you”).

C.

Benefits and consequences of behaviors 1. Staff will discuss with pt. the fact that pt.’s paranoid, threatening behavior is running off all his or her friends. 2. Staff will discuss with pt. the fact that the effect of his or her threats is simply to cause others to avoid pt. and that the threats do not result in getting what the pt. wants from other people. 3. Psychologist will discuss with pt. the association between paranoia, drugs, alcohol, and violence. 4. Social worker will discuss with the pt. and family the effect on pt.’s family of his or her dependent, attention-seeking behaviors, including suicidal gestures. 5. Staff will discuss connections between control of hostile, threatening behavior and realistic progress toward pt.’s goals, including passes, shopping trips, and discharge planning. 6. Nsg. staff will verbally outline for pt., three times per shift, the steps necessary to obtain gratification (e.g., act civilly in community meeting and be in reasonable control of his or her hostility before receiving coffee, privileges, and such) to help pt. understand the consequences of his or her actions. 7. Staff will work with pt. to help him or her have a clearer understanding of the effects alcohol has on hostile, threatening behavior.

D.

Miscellaneous patient and family education 1. No examples given.


Psychological tests (and other formal verbal tests) 1. Staff will conduct psychological tests to assess the potential lethality of pt.’s hostile impulses. 2. Staff will conduct psychological tests to evaluate impulse control. 3. Staff will conduct neuropsychological tests for evidence of organicity as the cause of pt.’s explosive episodes. 4. Staff will conduct neuropsychiatric tests for evidence of organicity as the cause of pt.’s assaultive behavior.

B.

Psychiatric evaluations 1. Psychopharmacology staff will consult for recommendations of meds that may reduce pt.’s explosive behavior. 2. Staff will conduct a psychiatric assessment of pt.’s violent behavior.

C.

Medical/laboratory tests and evaluations 1. Staff will conduct an EEG to R/O TLE as the etiology of pt.’s explosive episodes. 2. Staff will conduct a urine toxicology screen to R/O substance abuse as the etiology of pt.’s explosive episodes. 3. Staff will test pt.’s blood levels to help determine medication compliance. 4. Staff will test pt.’s blood levels to determine whether the psychotropic meds are in the therapeutic range.

D.

Monitoring for suicidal and homicidal ideation 1. Staff will have one-to-one contact with pt. to assess suicidality. 2. Nsg. staff will make on-ward observations to assess pt.’s level of irritability and potential for assaultiveness. 3. Staff will observe pt. for evidence of agitation and hostility and, if present, monitor pt. from a distance to ensure reasonable safety to others. 4. Psychologist will attempt to determine the nature of pt.’s frustration that leads to acts of selfabuse. 5. Staff will conduct extended one-to-one evaluations to develop a working hypothesis as to the source of the interactional hostility.


E.

3–13

Other evaluations and assessments 1. Rehab staff will assess pt.’s areas of greatest interests and motivation to begin structured activities congruent with pt.’s interests.


Court commitment 1. Staff will seek court commitment for 6 months because of the dangers to self and others due to mental illness.

B.

Guardianship 1. Staff will seek court approval of the forced use of antipsychotics to control pt.’s assaultive behavior.

C.

Other legal treatment modalities 1. Psychiatrist will seek court approval for use of psychosurgery to control pt.’s unremitting assaultive behavior.


Implementation of other treatment plans (This step is optional; instead, this information may be included in the problem description.) 1. Staff will implement treatment of Problem 1.1 Psychotic Symptoms to reduce the level of Bill’s paranoia. 2. Staff will implement treatment of Problem 1.1 Depressive Symptoms to relieve the depression that is driving Angela’s suicidal impulses.

3–14


Individual Problem Plans (Frequent Entries) INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.1 Threatening and Assaultive


Nursing Diagnosis: Risk for Violence: Other-Directed Grieving; Hopelessness; Powerlessness

Date: 01/15/03



• •

Onset of symptoms and chronicity

• • • • • •

Characteristics, frequency, intensity, and variance of threats and assaults

Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor frustration tolerance) Response to previous and current treatments and expected response to any proposed treatments Current level of threats and assaults Barriers to treatment, such as poor insight into the need for treatment, including meds Presence or need for psychotropic medication guardianship, guardianship of person and/or estate Current level of symptoms and activity level, including frequency of attendance at therapeutic activities

2.

Make sure that the above relate to goals and treatment modalities.

3.

The description and treatment of any psychotic or depressive symptoms that may be driving pt.’s hostility should be addressed in Problem Area 1 Psychological Impairment.


Target Date

Date/Status*

1. Pt. will be free of assaults for a ___-week/-month period. 2. Pt. will be free of vicious assaults for a ___-week/month period. 3. Pt. will be free of threatening behavior at least ___ days a week for ___ month(s). 4. Pt. will not act in response to any paranoid delusions or command hallucinations for a ___-week/month period. 5. Pt. will be free of command hallucinations telling him or her to assault others for a ___-week/month period. 6. Pt. will not fail to accept redirection by staff when demonstrating hostile or threatening behavior for a ____-week/month period. 7. Pt. will watch video(s) or read pamphlet(s) on anger management entitled ______________________________________________. 8. Pt. will not allow the provocation or intrusiveness of other pts. to escalate him or her to threatening or assaultive behavior for a ___-week/month period. 9. Pt. will be able to identify feelings of anger and frustration as they occur, AEB pt. coming to staff for support rather than threatening or assaulting for a ___-week/month period. 10. Pt.’s score on the Kennedy Axis V for Violence will improve from the current score of ___ to ___. 11. Pt.’s score on the Kennedy NOSIE Irritability will improve from the current score of ___ to ___.





3–15

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to monitor any changes in intensity of agitation and out-of-control behavior. This will allow the psychiatrist to assess the need for special precautions and level of privileges and to prescribe treatment with antipsychotic meds such as __________________, beta-blockers such as ____________________, anticonvulsants such as ____________, lithium, or other meds such as __________________. Lab will be as ordered, including blood levels. Victor Dyson, MD

Social Work: 1. Social worker will meet with pt. for ___ minutes at least ___ times weekly/monthly to help pt. understand how his or her violent behavior acts as a barrier to discharge. Brenda St. Martin, MSW

Psychology (or Social Work): 1. Psychologist (or social worker) will meet one-to-one with pt. for ___ minutes at least ___ time(s) monthly in supportive, problem-solving, cognitive therapy to reduce or redirect pt.’s anger, impulsivity, and frustration. 2. Psychologist (or social worker) will lead group (e.g., anger management group) weekly to help pt. recognize anger and learn methods for reducing and or more appropriately expressing anger. Susan Green, Psychologist Brenda St. Martin, MSW

Rehab: 1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ times weekly/monthly to review and revise his or her daily treatment schedule, will refer pt. to appropriate groups, and will work to improve his or her frustration tolerance. 2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about risk factors and how to avoid them. See weekly schedule for programs. Jane Hoover, Rehab

Nursing Care Plan: 1. Nsg. staff will be alert to pt.’s expressions of anger and frustration and will assist pt. in dealing with these in an appropriate, nonthreatening manner. 2. Nsg. staff will immediately redirect pt. from hostile, angry, or threatening behavior and will discuss appropriate alternatives to cope with anger and frustration. 3. Nsg. staff will question pt. directly at least ___ time(s) each shift/day/week to determine whether pt. has any impulses to threaten or assault others. 4. If there are concerns about the pt.’s safe behavior, nsg. staff will have pt. verbally contract for safety each time pt. goes off the ward. If needed, nsg. staff will escort pt. to off-ward groups, programs, and other activities. If it is felt that pt. will threaten or assault someone, nsg. staff may restrict pt. to the ward and place him or her on Special Precautions until the psychiatrist can evaluate him or her. 5. Nsg. staff will meet with pt. for ___ minutes at least ___ weekly/monthly to educate pt. about the consequences of violent behavior and about alternative methods to cope with anger and frustration. Marilyn Davis, RN


3–16


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.2 Suicidal and Self-Abusive

Name: Smith, Jane ID #: Area:

Nursing Diagnosis: Risk for Violence: Self-Directed

Date: 01/15/03



• • • • • •

Onset of symptoms and chronicity Precipitants (e.g., depression, losses, substance abuse, command hallucinations) Characteristics, frequency, intensity, and variance of suicidal threats, attempts, self-abusive behavior Response to previous and current treatments and expected response to any proposed treatments Current level of suicidal threats, attempts, self-abusive behavior Barriers to treatment, such as hopelessness about outcome of treatment, poor self-esteem, poor motivation, lethargy

2.


3.

The description and treatment of any psychotic or depressive symptoms that may be driving pt.’s hostility, should be addressed in Problem Area 1 Psychological Impairment.


Target Date

Date/Status*

1. Pt. will be free of suicidal attempts for a ___-week/month period. 2. Pt. will be free of suicidal ideation for a ___-week/month period. 3. Pt. will be free of suicidal ideation and self-abusive impulses at least ___ day(s) a week for ___ month(s). 4. Pt. will be free of command hallucinations telling him or her to commit suicide for a ___-week/month period. 5. Pt. will be able to identify feelings of hopelessness, helplessness, and frustration as they occur, AEB pt. coming to staff for support rather than attempting to hurt self for a ___-week/month period. 6. Pt. will be able to express an understanding of the connection between his or her feelings of hopelessness and helplessness and pt.’s suicidal impulses. 7. Pt. will learn more appropriate methods to get needed attention (such as verbalizing feelings or asking for attention) other than cutting self for a ___-week/month period. 8. Pt.’s score on the Kennedy Axis V for Violence will improve from the current score of __ to ___.





3–17

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to monitor any changes in intensity of suicidal/self-abusive impulses. This monitoring will allow the psychiatrist to assess the need for special precautions and to prescribe treatment with antidepressant meds such as _______________________ or other meds such as _________________. Lab will be as ordered, including antidepressant levels. Victor Dyson, MD

Social Work: 1. Social worker will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to help pt. understand how his or her suicidal/self-abusive behaviors act as a barrier to discharge. Brenda St. Martin, MSW

Psychology (or Social Work): 1. Psychologist (or social worker) will meet one-to-one with pt. for ___ minutes at least ___ time(s) weekly/monthly in supportive, problem-solving, cognitive therapy to reduce pt.’s suicidal/self-abusive impulses. 2. Psychologist (or social worker) will lead group (e.g., suicidal prevention group or DBT group) weekly to help pt. reduce feelings of hopelessness and helplessness and/or more effectively deal with stress, problems, and losses. Susan Green, Psychologist Brenda St. Martin, MSW

Rehab: 1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s) weekly/monthly to review and revise pt.’s daily treatment schedule and will refer pt. to appropriate groups to work to improve his or her self-esteem/frustration tolerance. 2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about risk factors and how to avoid them. See weekly schedule for programs. Jane Hoover, Rehab

Nursing Care Plan: 1. Nsg. staff will be alert to pt.’s suicidal ideation and self-abusive impulses and will assist pt. to deal with these in an appropriate, safe manner. 2. Nsg. staff will immediately redirect pt. from self-abusive behavior and discuss appropriate alternative means to cope or get attention. 3. Nsg. staff will escort pt. to off-ward groups, programs, and other activities to ensure that pt. does not attempt to harm self. 4. Nsg. staff will question pt. directly at least ___ time/s each shift/day/week to determine whether pt. has any impulse to harm self. 5. If there are any concerns about pt. attempting to hurt self, at a minimum, nsg. staff will have pt. verbally contract for safety each time he or she goes off the ward. For safety reasons, pt. may be restricted to the ward and placed on special precautions until psychiatrist can evaluate pt. 6. Nsg. staff will meet with pt. for ___ minutes at least ____ time/s weekly/monthly to educate pt. about the consequences of self-abusive behavior and about alternative means to cope or get attention. Marilyn Davis, RN


Notes


3–19

Sample Individual Problem Plans CONTENTS Suicidal Ideation and Attempts .............................................................................................................. 3–20 Suicidal Attempts.................................................................................................................................... 3–22 Anger and Explosiveness ........................................................................................................................ 3–24 Threatening and Assaultive Behavior..................................................................................................... 3–26 Homicidal Threat .................................................................................................................................... 3–28 Violence Secondary to Paranoia............................................................................................................. 3–30 Sexually Assaultive Behavior................................................................................................................... 3–32 Stalking Behavior.................................................................................................................................... 3–34

3–20


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.1 Suicidal Ideation and Attempts

Name: Jones, Gerald ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a long history of attention-seeking suicidal ideation and dangerous suicidal attempts, including attempts to hang himself, suffocate himself with a plastic bag, and, recently, to poison himself by drinking an insecticide. Precipitants to suicidal attempts include 1) improvement with associated increased cognitive ability to appreciate the tragedy of his illness and difficulties making real progress (“reality depression”) and 2) desire to escape tormenting auditory hallucinations. Treatment should emphasize controlling hallucinations and helping pt. to accept slow, gradual improvements in his progress toward goals. In the past, focusing on suicidal ideation has increased pt.’s attention-seeking gestures. Implement treatment of Problem 1.1 Psychotic and Depressive Symptoms, including regular and prn meds to reduce the level of tormenting hallucinations.


Target Date

1. Pt. will demonstrate behavioral control, such that there is no evidence of suicidal ideation or attempts for 6 months.

01/15/04

2. Pt. will verbalize self-worth and express realistic hopes for his future consistently for 6 months.

01/15/04

3. Pt. will be free of any suicidal ideation or attempts during 2 weeks of overnight passes to a halfway house in the community.

01/15/04


Target Date

1. Upon inquiry, pt. will verbalize content of hallucinations, particularly tormenting or self-destructive hallucinations, consistently for 3 months.

07/15/03

2. Pt. will consistently approach staff to seek help when he feels suicidal or when he is tormented by auditory hallucinations for 3 months.

07/15/03

3. Pt. will not use suicidal ideation to receive extra attention or to avoid participation in treatment for 3 months.

07/15/03

4. Pt. will demonstrate a realistic orientation to his progress by identifying practical steps toward his goal of discharge and acting on them, consistently for 3 months.

10/15/03

Date/Status*

Date/Status*





3–21

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for at least 1½ hours a month to assess pt.’s response to treatment, including monitoring any changes in intensity of suicidal ideation, place pt. on special precautions as needed, and allow increased privileges when pt. is assessed to be safe. Victor Dyson, MD

Psychology: 1. Psychologist will meet with pt. for 45 minutes once weekly to discuss connections between daily behavior (being out of bed, attending program) and progress toward pt.’s goals, including discharge. 2. Staff will encourage pt. to inform staff of suicidal feelings when they occur and to help pt. learn interventions, such as 1) focusing on his realistic goals (e.g., passes with family, shopping trips, and discharge planning), 2) focusing on ward activities, and 3) focusing on his assets and accomplishments (e.g., hobbies, program attendance, relatives who care for him, memories of happy experiences). Susan Green, Psychologist

Social Work: 1. Social worker will meet with pt. for ½ hour once weekly to evaluate pt.’s readiness for discharge. 2. Social worker will consistently offer pt. the opportunity for treatment planning involvement. Brenda St. Martin, MSW

Nursing Care Plan: 1. Nsg. staff will observe pt. for early signs of agitation and tormenting hallucinations. If present, staff will inquire about reasons for distress, including content of hallucinations. Nsg. staff will express understanding of pt.’s distress and suggest interventions to reduce hallucinations, such as 1) redirecting into activity (e.g., program), 2) substituting stimulation (e.g., listening to the radio headset), or 3) requesting prn med. 2. On observing any signs of suicidal intent, nsg. staff will assess dangerousness and ask pt. for verbal or written contract stating that he will be able to maintain control over impulses to hurt himself. 3. Nsg. staff will continue to monitor pt. for changes in suicidal intent and will institute special suicidal precautions as necessary. 4. Nsg. staff will notify psychiatrist as needed of any significant change in pt.’s level of dangerousness. 5. Nsg. staff will encourage pt. to recognize and express self-worth (e.g., compliment him when he improves his appearance). Ronald Donahue, RN Å Nsg. Staff

Rehab: 1. Rehab staff will meet with pt. for at least ½ hour once a week to review and revise his daily program schedule and refer him to appropriate groups to improve his self-esteem, coping skills, and frustration tolerance. 2. Rehab staff will ensure that pt. is actively engaged in creative art therapy, an area of strength for pt. Albert Sanchez, Rehab


3–22


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.2 Suicidal Attempts

Name: Brandt, Jennifer ID #: Area:


Date: 01/15/03

Problem Description: Two weeks following the loss of her job, pt. was found by neighbors with her wrist deeply cut. Pt. required 3 days of medical hospitalization for treatment of blood loss and nerve injuries sustained during the suicidal attempt; however, there appears to have been no permanent functional damage. She felt that she would not be able to get another job. She felt that suicide was the only way to avoid her mounting bills and problems. Pt. now denies suicidal ideation; however, she is felt to still be a serious risk of a suicidal attempt. In the past, pt. had attempted suicide twice before by taking overdoses. The previous attempts were also associated with difficulty coping with stress in her life. Implement treatment of Problem 1.1 Depressive Symptoms, including meds to reduce the level of hopelessness and helplessness.


Target Date

1. Pt. will be free of suicidal ideation and self-destructive behavior for 3 months.

04/15/03

2. K Axis score on Violence will improve from a current score of 40 to at least 60.

04/15/03


Target Date

1. Upon inquiry, pt. will attempt to accurately express the presence or absence of suicidal impulses consistently for 3 weeks.

02/15/03

2. Pt. will be free of suicidal ideation or acts of self-abuse for 3 weeks.

02/15/03

3. Pt. will cooperate so that she completes the assessment of her work skills and interests.

02/15/03

Date/Status*

Date/Status*





3–23

Date: 01/15/03


Date/Status*

Social Work: 1. Staff will provide family counseling to help pt.’s family understand her suicidal attempts and help them to cope with fears that she will again attempt suicide. Brenda St. Martin, MSW

Psychology: 1. Psychologist will meet with pt. for 1 hour once a week 1) to help pt. understand the association between her hopelessness and helplessness and her suicidal attempts, 2) to help pt. to verbalize her self-destructive thoughts rather than acting on them, 3) to help her reduce feelings of hopelessness and helplessness, and 4) to help her more effectively deal with stress in her life. 2. Staff will use psychological testing to help assess pt.’s level of dangerousness. Susan Green, Psychologist

Rehab: 1. Staff will assess pt.’s skills and work interests to determine whether pt. has a problem that would interfere with her getting and keeping a job. 2. Staff will assign pt. to appropriate groups to work to improve her self-esteem and selfconfidence, including suicidal prevention group. Jane Hoover, Rehab

Nursing Care Plan: 1. Nsg. staff will provide pt. with a safe, secure environment with special monitoring as necessary. 2. Nsg. staff will observe pt. for signs that she is becoming self-destructive, such as becoming withdrawn and verbalizing hopelessness. 3. Even when pt. is doing well, nsg. staff will provide pt. with regular one-to-one support and reassurance at least once each shift. Ronald Donahue, RN Å Nsg. Staff


3–24


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.3 Anger and Explosiveness

Name: Parker, Janet ID #: Area:

Nursing Diagnosis: Risk for Other-Directed Violence

Date: 01/15/03

Problem Description: Pt. has a long history of poor control over hostile impulses. Currently she is often angry, hostile, and threatening; however, it has been more than 6 months since pt. was physically assaultive. Pt. is very likely to become angry when demands are placed on her, especially concerning programs or her meds. She generally takes her anger out on others; however, she has a history of breaking a window when angry, resulting in a serious laceration of her hand. Pt. has been treated with a number of meds with some degree of success.


Target Date

1. Pt. will demonstrate a maximum of one explosive, threatening episode for 3 months.

07/15/03

2. Pt.’s Kennedy Axis V score for Violence will improve from a current score of 50 to 60.

07/15/03


Target Date

1. Pt. will show a maximum of one episode of inappropriate expression of anger (e.g., verbal threats, screaming, demanding behavior) per week for 1 month.

04/15/03

2. Pt. will continue to be free of physically aggressive and selfabusive behavior.

Ongoing

3. Pt. will learn appropriate alternative ways to express anger and frustration, including seeking out staff to talk about situations that cause her to get angry, consistently for 1 month.

04/15/03

Date/Status*

Date/Status*





3–25

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will prescribe meds to help control anger and hostility, such as Clozaril, Depakote, lithium, beta-blockers, and the like. Victor Dyson, MD

Social Work: 1. Social worker will meet with pt. one-to-one weekly to give pt. the opportunity to discuss personal issues. Brenda St. Martin, MSW

Psychology: 1. Psychologist will encourage pt. to appropriately verbalize anger to staff. 2. Psychologist will lead pt. in relaxation exercises. 3. Psychologist will assess pt.’s appropriateness for referral to the DTB Program. Joseph LeBlanc, Psychologist

Rehab: 1. Staff will train pt. to improve frustration tolerance via involvement in groups such as anger management group. 2. Staff will provide pt. with opportunities to feel empowered (i.e., give her choices as to the activities she would like to pursue). Albert Sanchez, Rehab

Nursing Care Plan: 1. Nsg. staff will be alert to pt.’s expressions of anger and hostility and will assist her with expressing these in an appropriate, nonthreatening manner. 2. Nsg. staff will provide positive verbal reinforcement for appropriate expression of anger, frustration, and the like. 3. Nsg. staff will meet with pt. for 20 minutes twice weekly to educate her about the consequences of her hostility toward others and about alternative methods to cope with her hostility. Marilyn Davis, RN Å Nsg. Staff


3–26


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.4 Threatening and Assaultive Behavior



Date: 01/15/03

Problem Description: Pt. has a long history of being assaultive and threatening. The assaultiveness has been reduced to about once a month. Generally the assaults are no more than pushing someone or hitting someone on the arm; however, about a year ago he attacked and injured an attendant. The assaultiveness is associated with periods of being angry and irritable. Recently the pt. has been moderately angry and irritable because of conflicts with his family. Implement treatment of Problem 1.1 Psychotic Symptoms to reduce paranoid feelings.


Target Date

1. Assaultive behavior will decrease to no more than once during 6 months.

01/15/04

2. Kennedy Axis V score for Violence will improve from a current score of 50 to 60.

01/15/04


Target Date

1. Pt. will spontaneously verbalize any thoughts of hurting others rather than assaulting anyone, consistently for 3 months.

07/15/03

2. Pt. will be able to converse with staff for 10 minutes each shift without threatening or attempting to assault staff for 1 month.

04/15/03

3. Pt. will be able to tolerate the frustration of cooperating with ward routine with a maximum of one disruptive episode per waking shift for 3 months.

07/15/03

Date/Status*

Date/Status*





3–27

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will restrict pt. to supervised privileges for at least 1 week if he is assaultive to others. 2. Psychiatrist will administer meds as prescribed to reduce pt.’s anger and irritability. Victor Dyson, MD

Psychology: 1. Psychologist will discuss with pt. the association between pt.’s paranoia and assaultiveness. 2. Psychologist will discuss with pt. Stress Reduction Training and will initiate it if appropriate. Susan Green, Psychologist

Nursing Care Plan: 1. Nsg. staff will observe pt. for signs that he is becoming assaultive, such as becoming angry or irritable. 2. Nsg. staff will encourage pt. to verbalize his agitation rather than becoming oppositional or threatening. 3. If needed, nsg. staff will offer pt. prn meds to relieve irritability and acute explosive episodes. 4. Nsg. staff will redirect pt. to a quiet area if he becomes agitated or threatening. 5. Nsg. staff will provide positive feedback to pt. for appropriate control of his hostile impulses. 6. Even when pt. is doing well, nsg. staff will provide him with regular one-to-one support and reassurance at least once each shift. Ronald Donahue, RN Å Nsg. Staff


3–28


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.5 Homicidal Threat

Name: Stewart, Allen ID #: Area:


Date: 01/15/03

Problem Description: In August 2001, pt. made an attempt to kill his mother. At that time, pt. had a knife at his mother’s throat, but was pulled away by his brother. Since August 2001, patient has continued to make threats to kill his mother; however, since the attempt in August 2001, he has not had the opportunity to harm his mother. Currently pt. is supervised whenever he is off the ward; there is a restraining order to prevent him from going to the area where his mother lives. Implement treatment of Problem 1.1 Psychotic Symptoms and Problem 3.1 Anger and Explosiveness to help reduce the danger toward pt.’s mother.


Target Date

1. Upon inquiry, pt. will accurately express the absence of homicidal thoughts toward his mother for 6 months.

01/15/04

2. Pt. will be free of any homicidal impulses toward his mother for 6 months.

01/15/04


Target Date

1. Upon inquiry, pt. will accurately express either the presence or absence of homicidal thoughts toward his mother consistently for 3 months.

07/15/03

2. Pt. will approach staff when he is having homicidal thoughts toward his mother consistently for 3 months.

07/15/03

3. Pt. will not attempt to act on his impulses to hurt his mother for 3 months.

07/15/03

4. Pt. will be able to go on independent privileges for 3 months without any evidence that he is having any impulses to hurt his mother.

10/15/03

Date/Status*

Date/Status*





3–29

Date: 01/15/03


Date/Status*

Nursing Care Plan: 1. Nsg. staff will provide safe, secure environment using staff supervision and special precautions as needed. 2. Nsg. staff will monitor pt. for signs of agitation and anger that may be directed toward his mother. 3. Nsg. staff will ask pt. directly at least once each shift whether he is having any impulses to hurt anyone, including his mother. 4. Nsg. staff will work with pt. and the rest of the team to protect pt.’s mother from pt.’s homicidal impulses. Linda Larkin, RN Å Nsg. Staff

Social Work: 1. Social worker will maintain contact with his mother to clarify any conflicts that she may have with pt. and discuss possible resolution. 2. Social worker will keep pt.’s mother informed of any potential danger from pt. as indicated under the hospital duty-to-warn policy. Roger Sing, MSW


3–30


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.6 Violence Secondary to Paranoia

Name: Bell, Howard ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a long history of assaultive, threatening behavior in association with paranoid thoughts. Pt. has had an ongoing fascination with weapons and police work. Prior to the current hospitalization, pt. threatened his father with a knife because he felt that his father was conspiring with the Mafia to have him assassinated. Implement treatment of Problem 1.1 Psychotic Symptoms to reduce pt.’s level of paranoia.


Target Date

1. Pt. will be free of threatening and assaultive behavior for 3 months.

10/15/03

2. Pt.’s Kennedy Axis V score for Violence will improve from a current score of 40 to 60.

10/15/03


Target Date

1. Pt.’s home will be free of any weapons for at least 3 months.

07/15/03

2. Pt. will be free of threatening and assaultive behavior for 3 months.

07/15/03

3. Pt. will express an understanding of the connection between his paranoia and his assaultiveness consistently for 3 months.

07/15/03

4. Pt. will agree not to attempt to purchase weapons consistently for 3 months.

07/15/03

Date/Status*

Date/Status*





3–31

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for at least 1½ hours a month to monitor any changes in his violent impulses to make decisions concerning the need for special precautions and level of privileges and to prescribe prn meds to help control angry impulses. Victor Dyson, MD

Social Work: 1. Social worker will provide family counseling for 1 hour twice monthly to help pt.’s family understand and learn to cope with pt.’s hostile, threatening episodes. 2. Social worker will encourage family members to remove all weapons from their home. Roger Sing, MSW

Psychology: 1. Psychologist will provide one-to-one therapy for 1 hour once weekly to help pt. understand the association between his paranoia, hostility, weapons, and dangerousness. 2. Psychologist will encourage pt. to verbalize his hostile impulses rather than assaulting others. 3. Psychologist will use psychological testing to help assess pt.’s level of dangerousness. Joseph LeBlanc, Psychologist

Nursing Care Plan: 1. Nsg. staff will provide a safe, secure environment with special monitoring as necessary. 2. Nsg. staff will observe pt. for signs that he is becoming hostile, paranoid, or agitated. 3. When pt. is becoming hostile, paranoid, or agitated, nsg. staff should give him support and reassurance by expressing acceptance of his emotional distress. 4. Nsg. staff should avoid arguments with pt. about his paranoid thinking. 5. Nsg. staff should administer prn meds as needed for agitation. 6. Nsg. staff should administer regular meds as outlined under Problem 1.1 Psychotic Symptoms. 7. Even when pt. is doing well, nsg. staff will provide him with regular one-to-one support and reassurance at least once each shift. Ronald Donahue, RN


3–32


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.7 Sexually Assaultive Behavior

Name: Jones, Stanley ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a long history of inappropriate sexual behaviors, including public nudity, sexually inappropriate touching of females, and masturbating in public. Pt.’s sexually assaultive behavior appeared to be under fairly good control; however, recently pt. began openly masturbating in front of the social worker while having an individual therapy session in her office. Pt. barred her from leaving the room until he had reached a climax. This attack was felt to have been more of an inappropriate attempt at sexual gratification, rather than an act of hostility. Pt. appears to have very little insight into the hostile, frightening nature of his acts toward females. Pt. has been resistive to taking meds to help control his sexual impulses.


1. Pt. will be free of sexually assaultive episodes for 6 months.


Target Date

Date/Status*

01/15/04

Target Date

1. Pt. will be free of sexually assaultive episodes for 3 months.

07/15/03

2. Pt. will express a willingness to explore the possibility of a trial on meds to help control his sexual impulses consistently for 3 months.

07/15/03

3. Pt. will cooperate with treatments to lower his libido AEB his frequency of masturbating decreasing from twice a day to no more than twice a week for 3 months.

10/15/03

Date/Status*





3–33

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will activate an assessment process for transfer to the Intensive Treatment Unit in the event of further sexually assaultive behavior. 2. Psychiatrist will encourage pt. to consider a trial on an SSRI, such as Paxil, or hormonal treatment, such as Depo-Provera, to help pt. maintain better control over his sexual impulses. Virginia Coleman, MD

Rehab/Psychology: 1. Staff will initiate cognitive-behavioral training for socially appropriate responses to women in a variety of heterosexual situations, using modeling and role-playing. 2. Psychologist will help pt. to understand the legal consequences of sexually assaultive behavior. Joseph LeBlanc, Psychologist Albert Sanchez, Rehab

Nursing Care Plan: 1. Nsg. staff will closely observe pt. for signs of inappropriate sexual or assaultive behavior. 2. Nsg. staff will educate pt. concerning the risks and benefits of various meds that might be considered to help him to better control his sexual impulses. Marilyn Davis, RN Å Nsg. Staff


3–34


INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.8 Stalking Behavior

Name: Drago, Charles ID #: Area:


Date: 01/15/03

Problem Description: Patient has been obsessed with one of the social workers at the hospital (Anne Stevens) since 12/01. He has been making threatening comments to her by letter, calling her at home, and waiting for her outside her office and by her car. Patient appears to have no insight into the threatening nature of his acts. Currently, he seems less preoccupied by this social worker and less convinced that they share something special; however, these thoughts do occur at times. In the past, pt. has not been able to have any significant relationship with a member of the opposite sex.


Target Date

1. Pt. will not harm anyone, including Anne Stevens, for 6 months.

01/15/04

2. Pt. will not demonstrate stalking behavior for 6 months.

01/15/04


Target Date

1. Pt. will not harm anyone, including Anne Stevens, for 3 months.

07/15/03

2. Pt. will not demonstrate stalking behavior for 3 months.

07/15/03

3. Pt. will not make any threats toward anyone for 3 months.

07/15/03

4. Pt. will be able to demonstrate a focus away from Anne Stevens AEB his not making any plans to attempt to contact Anne or send her a gift for 3 months.

07/15/03

5. Pt. will be able to pass by Anne when on privileges without making an attempt to get Anne’s attention for 3 months.

10/15/03

Date/Status*

Date/Status*





3–35

Date: 01/15/03


Date/Status*

Nursing Care Plan: 1. Nsg. staff will notify Anne Stevens of any changes in pt.’s privilege status or passes. 2. Nsg. staff will notify Anne Stevens, Department of Mental Health Police, police department from his area, state police, District Attorney’s office, pt.’s next of kin, and the hospital’s chief operating officer (Virginia Day) if pt. escapes. 3. Nsg. staff will place duty-to-warn label on the cover of pt.’s chart so all staff will be aware of the need to warn. Marilyn Davis, RN Å Nsg. Staff

Psychology: 1. Psychologist will meet one-to-one with pt. for 1 hour weekly in cognitive therapy to help pt. resolve his obsession with Anne Stevens. 2. Psychologist will lead the sex offenders group once weekly to help pt. gain insight into the inappropriateness of his behaviors through the group process, as well as to help him understand the legal consequences of his stalking behaviors. Joseph LeBlanc, Psychologist


Notes

ADL–OCCUPATIONAL SKILLS (Problem Area 4)

4–1


ADL–Occupational Skills (Problem Area 4)

4–3

ADL–OCCUPATIONAL SKILLS (Problem Area 4) CONTENTS Kennedy Axis V for ADL–Occupational Skills............................................................................................ 4–4 This rating scale can be used to measure the outcome of treatment. It also helps to define which problems fit into the category of ADL–Occupational Skills and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 4–5 Examples of problem names and descriptions that may relate to ADL–Occupational Skills are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 4–6 Examples of strengths that may be related to treatment and discharge in the area of ADL–Occupational Skills are listed here.

Goals ......................................................................................................................................................... 4–6 Examples of treatment goals that may relate to problems in the area of ADL–Occupational Skills are listed here.

Treatment Modalities ............................................................................................................................... 4–8 Examples of treatment modalities that may relate to problems in the area of ADL–Occupational Skills are listed here.

Sample Individual Problem Plans ........................................................................................................... 4–13 A wide range of Individual Problem Plans relating to ADL–Occupational Skills are included here.

4–4


Kennedy Axis V—ADL–Occupational Skills 100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those expected of a successful college graduate. 90 Good skills in all ADL–occupational activities; no more than average difficulties with any work assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school graduate. 80 No more than slight impairment in occupational skills or skills in school; has slight difficulty performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork assignments; slight impairment in workmanship. 70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following instructions, workmanship is somewhat sloppy), but generally functioning fairly well. 60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed; however, has trouble carrying through assignments; some difficulty problem solving or following instructions; some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home or apartment). 50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call. 40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any significant period or do routine housework due to poor work skills; failing in school due to poor academic skills); needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food restaurant; poor understanding of how to budget money. 30 No job and unable to independently maintain a home due to serious impairment in skills needed to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call, follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs (e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire alarm; difficulty finding way back from short errands. 20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from short errands). 10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete most tasks even with constant supervision; may even have to be physically assisted to complete a task, including eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support (e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately respond to a fire alarm. NR Not rated



II.

ADL–Occupational Skill Deficits Problems A.

Broad skill deficits 1. Skill deficits secondary to mental retardation 2. Skill deficits secondary to dementia 3. Inability to deal with abstract thoughts or ideas 4. Confusion and disorientation due to organic impairment 5. Poor memory 6. Poor insight and judgment due to organic factors 7. Poor insight due to limited intellect 8. Institutionalized

B.

Specific skill deficits 1. Needs to improve money management skills 2. Has difficulty completing tasks 3. Requires frequent prompts to complete tasks 4. Has poor personal hygiene due to a lack of personal hygiene skills 5. Lacks adequate nutritional skills 6. Needs to take better care of personal clothing 7. Needs to take better care of immediate living space 8. Has sloppy workmanship due to lack of skills 9. Is unable to find way back from short errands 10. Has difficulty feeding or dressing self 11. Wets or soils clothes or bedding due to lack of ability to use the toilet

C.

Other 1. No examples given

Poor ADL Skills Often Associated With Dangerousness A.

General 1. Lacks ability to perform self-preservation skills 2. Lacks basic life survival skills 3. Is unable to care for self 4. Has dependent patient status 5. Appears incapable of recognizing dangers

B.

Specific 1. Eats in a manner that would lead to choking 2. Has hazardous smoking habits 3. Walks in front of cars due to a lack of understanding of the danger 4. Wanders away

4–5

4–6



ADL–Occupational Strengths A. B. C. D. E. F. G. H. I.

Has average or above average intellectual ability Is able to read and write Is a high school or college graduate Is capable of independent living Is independent in personal care Has a job to return to Is able to successfully work in full-time competitive employment for more than 1 year Has technical or vocational skills for a job Other strengths

Goals I.

Expected Improvements in Skills and Symptoms A.

II.

Skills that pt. will learn 1. Pt. will learn to make his or her bed AEB making the bed without supervision for 2 weeks. 2. Pt. will be able to complete his or her daily personal hygiene without guidance or instructions for 2 weeks. 3. Pt. will learn to use the ashtray three out of five times he or she smokes for 1 month. 4. Pt. will be able to consistently dress self without having to be told what to put on for 1 month. 5. Pt. will learn to do simple tasks around the ward AEB mopping the floor without supervision for 1 month. 6. Pt. will be able to consistently carry out three-step tasks without guidance or instructions for 1 month. 7. Pt. will learn to do complicated multistep tasks AEB preparing a meal without supervision at least 3 days a week for 1 month. 8. Pt. will learn to handle his or her own funds such that pt. retains sufficient money (when working) to meet daily purchasing needs for 2 months. 9. Pt. will demonstrate sufficient ability to function in areas of ADLs to warrant discharge home with parent for 3 months.


Pt. will become more aware of ADL limitations AEB asking for help in areas where needed for 1 month.

III. Participation in Groups, Program Activities, and Such A. B. C.

Pt. will participate in on-ward group activities for 5 minutes a day for 1 month. Pt. will attend morning ward meetings twice per week for 1 month. Pt. will attend one off-ward group activity per week for 4 weeks.


Medication and laboratory work 1. Pt. will consistently discuss the benefits of taking his or her psychotropic meds as prescribed for 1 month. 2. Pt. will express the benefits of taking meds as prescribed consistently for 1 month. 3. Pt. will take psychotropic meds as prescribed for 3 months.


V.

4–7

B.

Treatment planning 1. Pt. will cooperate with at least one treatment team member in the treatment planning process for 1 month. 2. Pt. will cooperate with treatment plans, such as IQ testing and vocational evaluations. 3. Pt. will consistently accept realistic plans for employment for 3 months.

C.

Program activities 1. Pt. will gain insight into the need to attend program, AEB being able to consistently explain the reasons for attending, for 1 month. 2. Pt.’s level of compliance will improve such that pt. will attend art therapy class twice a week for 1 month. 3. Pt. will attend the programs recommended by the treatment plan on a regular basis for 1 month.

D.

Consequences of pt.’s actions 1. Pt. will demonstrate an understanding of his or her progress by being able to consistently explain, for 1 month, the connections among— a. Dressing and attending to personal hygiene and being able to go to activities off the ward, b. Working in a prevocational program and getting a job in the community, c. Failing to learn basic ADL skills and receiving continued care at the hospital, and d. Failing to learn basic occupational skills and being unable to get a job.


Assessments 1. Staff will complete rehabilitation assessment for appropriate day-program referral. 2. Pt. will cooperate so that rehab staff can assess the degree to which apathy, lack of motivation, or poor focal attention obscure ADL skills. 3. Pt. will cooperate so that psychological testing can be completed.

B.

Evaluations to R/O various diagnoses 1. Staff will complete evaluation to R/O mental retardation. 2. Staff will complete evaluation to R/O thought disorder.


Kennedy Axis V 1. Pt.’s Kennedy Axis V score for ADL–Occupational Skills will improve from a current score of 30 to 40.

B.

Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE) 1. Pt.’s K NOSIE score on Social Competency will improve from a current score of +10 to +28. 2. Pt.’s K NOSIE score on Personal Neatness will improve from a current score of +10 to +18.

C.

Comprehensive Occupational Therapy Evaluation (COTE) 1. Pt.’s COTE score will improve from a current score of _____ to _____.


Staff will maintain a safe, secure environment for (dependent) pt. while attempting to maximize his or her functional ability.

4–8



II.

Verbal Treatment Modalities (emphasize verbal interactions) A.

Support and reassurance 1. Even when pt. is doing well in the development of his or her occupational skills, staff will provide pt. with regular one-to-one support and reassurance.

B.

Cognitive refocusing (redirect focus toward reality and realistic self-appraisal) 1. When pt. is able to handle increased periods of pt. wage program and maintain reasonable periods of focused activity, staff will refer pt. to day program to continue work on focused, purposeful activity. 2. Staff will focus pt. away from plans based on his or her psychotic thinking to realistic, achievable occupational goals.

C.

Psychotherapy 1. Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better cope with problems on the job.


Positive reinforcement 1. Nsg. staff will encourage pt. and provide verbal praise for performing on-ward work activities. 2. Staff will reinforce with positive verbal praise pt.’s positive behaviors, such as following through with daily ADL requirements. 3. Staff will give pt. encouragement for completion of multistep tasks in the absence of ritualistic or other bizarre behavior. 4. Staff will spend one-to-one time daily to encourage pt.’s participation in vocational groups. 5. Nsg. staff will accompany pt. into the bathroom to encourage and reinforce appropriate personal hygiene habits. 6. Staff will give pt. one extra cigarette as a reward for learning the steps of a fairly complicated multistep task. 7. Staff will positively reinforce pt. with canteen and cafeteria privileges for regular attendance at the vocational training group.

B.

Negative reinforcement (including discouragement, restriction, and withholding of reinforcement) 1. Pt. will be restricted to supervised privileges for 24 hours when pt. fails to attend the vocational training group. 2. Independent privileges will be held if pt. has sloppy inappropriate dress, has not taken care of his or her dorm area, or has not attended to personal hygiene.

C.

Extinction 1. Nsg. staff will limit their interactions with pt. when he or she fails to work on learning how to do multistep tasks, such as making the bed and washing clothes.

D.

Shaping and modeling 1. Staff will provide daily modeling of ADL tasks, such as making the bed, choosing clothes, setting the table, and such. 2. Work supervisor and co-workers will provide modeling to improve desired work skills, such as filing and using the copier. 3. Staff will provide primary and secondary positive reinforcers for incremental increases in level of vocational skills. 4. Staff will refer pt. to day programming for involvement in tasks that require gradually increasing skill levels. 5. Nsg. staff will engage pt. in joint tasks around the ward with some of the higher-functioning pts.


4–9

E.

Channeling energies 1. Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help pt. channel potentially aggressive behavior into work. 2. Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help divert pt.’s energies into acceptable channels to reduce chronic hypersexual arousal and associated sexual assaults.

F.

Task simplification (reduce confusion and frustration by simplifying tasks and providing consistency and assistance) 1. Staff will offer verbal prompts and physical assistance needed to enable pt. to complete basic ADLs. 2. Staff will use the same person as consistently as possible for redirection. 3. All staff will redirect pt. to go to his or her contact for all general questions and requests. 4. Contact will instruct pt. to write down the job steps, and, when appropriate, contact will direct pt. to those written steps. 5. Staff will have clothes and self-care items set up and ready before it is time for the ADL activities. 6. Staff will break tasks down into small, concrete, realistic steps to reduce the level of frustration and disorganization. 7. Staff will break down the steps of treatment into small, understandable goals reachable by pt. 8. Staff will redirect pt. away from decisions, plans, and actions that are grossly unrealistic or overly complicated for pt.


Family treatment modalities 1. Staff will encourage family involvement in support of pt.’s job plans. 2. Staff will provide family therapy to explore reasons within pt.’s family members for their desire for pt. to fail at independent employment.

B.

Religious treatment modalities 1. Provide religious counseling to help pt. learn how to use religious resources to get a volunteer job where pt. can practice and improve work skills. 2. Pt. will do volunteer work for 2 hours 5 days weekly at the church lunch program to improve pt.’s work skills.

C.

Other modalities 1. Group therapy a. Group therapy will facilitate discussions of job-related problems. 2.

Psychodrama a. Role-playing for 1 hour once weekly will assist pt. in dealing with situational conflicts on the job. b. Role-playing for 1 hour once weekly will teach pt. how to act during a job interview.

3.

Rehabilitation a. Staff will provide weekly counseling to identify work goals, to identify deficits in work skills, and to develop plans for education and training needed to meet goals. b. Staff will involve pt. in the on-ward rehabilitation group at least once weekly. c. Staff will involve pt. in money management group for 1 hour once weekly, including community banking. d. Assigned staff will redirect this dependent pt. away from decisions, plans, and actions that place pt. in danger.

4–10



V.

A.

Stimulus reduction 1. Rehab training should be in a quiet area because of pt.’s easy distractibility.

B.

Protective procedures (including special observations) 1. Staff will provide safe, secure environment with special monitoring as necessary. 2. Staff will confine pt. to Privilege Level IV (cafeteria and supervised privileges) because of pt.’s very impaired ADL skills, including difficulty crossing streets. 3. Staff will follow hospital procedures for dependent pt. status. 4. Pt. will not be allowed access to cigarettes or matches because of hazardous smoking habits.

C.



Medication 1. Staff will administer meds as prescribed. 2. Staff will use prn meds to relieve pt. from acute episodes of tormenting hallucinations so pt. can participate in prevocational training.

B.

Other medical treatment modalities 1. Staff will provide a wheelchair to increase pt.’s ability to participate in prevocational training.


Mental illness 1. Staff will discuss with pt. ways of coping with mental illness while working.

B.

Medication 1. Staff will discuss the risks and benefits of meds with the pt. and family. 2. Staff will discuss one-to-one the need to take meds as prescribed, including how meds can facilitate pt.’s ability to participate in vocational programs. 3. Staff will show concrete benefits of taking meds (e.g., “You are able to stay focused and, therefore, better able to benefit from vocational training,” “You are less paranoid on the job; therefore, you are able to participate in on-the-job training”).

C.

Benefits and consequences of behaviors 1. Staff will discuss connections between daily appropriate behavior (e.g., being out of bed, attending job training) and realistic progress toward pt.’s goals (full-time competitive employment). 2. To help pt. understand the consequences of his or her actions, staff will verbally outline for pt., once each morning, the steps necessary to obtain gratification (e.g., pt. must get dressed and attend to personal hygiene to go to prevocational training; next, pt. must graduate from prevocational training before he or she can get a part-time job in the hospital canteen). 3. Staff will demonstrate to pt. benefits of being able to count money. 4. At least once weekly, staff will discuss the benefits of neatness and generally good personal hygiene.

D.



4–11


Rehabilitation assessment 1. Staff will assess pt.’s work preferences and work skills. 2. Staff will assess pt.’s areas of greatest interests and motivation to begin occupational training congruent with pt.’s interests. 3. Rehab staff will assess the degree that apathy, lack of motivation, and poor focal attention obscure ADL skills. 4. Staff will refer pt. to occupational therapist for formal assessment of ADL skills and interests. 5. Pt. will participate in trial job period to assess pt.’s job skills. 6. Staff will use work hardening (slowly increasing hours and difficulty of task) to determine endurance and skill level.

B.

Psychological tests (and other formal verbal tests) 1. Staff will conduct psychological testing to determine pt.’s ability to engage in treatment, including job training.

C.

Psychiatric evaluations 1. Staff will conduct psychotropic medication evaluation to assess the potential for medication to facilitate pt.’s ability to learn new ADL skills. 2. Staff will conduct psychiatric evaluation to assess the degree that side effects of pt.’s psychotropic medication might be impairing pt.’s ADL skills. 3. Staff will provide neuropsychiatric consultation to assess the degree that factors related to pt.’s abnormal EEG might impair job performance.

D.

Medical tests and evaluations 1. Staff will conduct medical tests and evaluations as needed to R/O factors that might impair pt.’s ADL skills or ability to gain new skills.

E.

Other evaluations and assessments 1. Nsg. staff will observe pt. doing on-ward tasks to assess pt.’s level of ADL skills. 2. Staff will test pt.’s ability to find his or her way around the hospital. 3. Nsg. staff will test pt.’s ability to respond to a fire alarm. 4. Nsg. staff will complete “emergency fact sheet” on this dependent pt.


Commitment 1. Psychiatrist will seek court commitment under Sections 7 and 8 for a period up to 6 months because of pt.’s inability to care for self because of limited ADL skills.

B.

Guardianship 1. Psychiatrist will seek permanent legal guardian to make decisions for pt. related to his or her medical and psychiatric condition and estate.


Treatment of problems affecting ADL–occupational skills (This step is optional; instead, this information may be included in the problem description.) 1. Staff will treat pt.’s lack of motivation to get out of bed and attend to personal hygiene, as indicated under Problem 1.1 Psychotic Symptoms. 2. Staff, as indicated, will treat pt.’s marked lack of motivation and apathy under Problem 1.2 Lack of Motivation. 3. Staff will treat pt.’s problems with interpersonal relations on the job as indicated under Problem 2.1 Poor Social Skills.

Notes


4–13

Sample Individual Problem Plans CONTENTS Impaired ADL Skills ................................................................................................................................. 4–14 Impaired ADL Skills (Deferred)............................................................................................................... 4–16 Poor Work Skills ...................................................................................................................................... 4–18 Dependent Patient ................................................................................................................................. 4–20 Hazardous Smoking Habits .................................................................................................................... 4–22

4–14


INDIVIDUAL PROBLEM PLAN Problem # and Name: 4.1 Impaired ADL Skills

Name: Jackson, Kenneth ID #: Area:

Nursing Diagnosis: Self-Care Deficit

Date: 01/15/03

Problem Description: Pt. has a history of many years of severe impairment of ADL skills due to long stays in institutions. Pt. needs constant supervision to complete almost any task (e.g., dressing, preparing a simple meal, and returning from short errands). Implement treatment of withdrawn apathetic behavior and poor focal attention under Problem 1.1 Psychotic Symptoms and Problem 1.2 Poor Focal Attention.


Target Date

1.

Pt. will be able to perform basic ADLs without supervision four of five mornings (i.e., dressing, grooming, showering, and morning housekeeping activities).

01/15/04

2.

Pt.’s Kennedy Axis V score for ADL–Occupational Skills will improve from a current score of 20 to 30.

01/15/04


Target Date

1.

Pt. will ask for things that he needs for his morning routine about 50% of the time for 1 month.

07/15/03

2.

Pt. will be able to independently dress himself four mornings a week for 1 month.

10/15/03

Date/Status*

Date/Status*





4–15

Date: 01/15/03


Date/Status*

Rehab/Nursing Care Plan: 1.

Staff will prepare the environment before the time of the ADL activities (e.g., have clothes and self-care utensils ready).

2.

Staff will provide one-to-one modeling of ADL tasks (e.g., making his bed, choosing clothes, and looking for utensils).

3.

Staff will encourage and praise pt. for successful completion of various ADL tasks.

Albert Sanchez, Rehab Marilyn Davis, RN Å Nsg. Staff


4–16


INDIVIDUAL PROBLEM PLAN Problem # and Name: 4.2 Impaired ADL Skills

Name: Raphael, Linda ID #: Area:

Nursing Diagnosis: Impaired Home Maintenance

Date: 01/15/03

Problem Description: Pt. has marked impaired ADL skills and needs supervision to perform even basic self-care skills; however, the impairment appears to be mostly due to her apathy and disorganized thinking. With encouragement, she is able to perform basic ADLs in self-care and housekeeping, such as preparing a small, simple meal, sewing on buttons, or mending a tear. Implement treatment of apathy and disorganized thinking under Problem 1.1 Psychotic Symptoms.


Target Date

Date/Status*

Target Date

Date/Status*

Deferred: Due to a high level of psychotic symptoms, pt. is currently not using the ADL skills she already possesses. This problem plan will be activated when pt.’s psychotic process is under better control.






4–17

Date: 01/15/03


Date/Status*

Psychiatry:

Social Work:

Psychology:

Rehab:

Nursing Care Plan:


4–18


INDIVIDUAL PROBLEM PLAN Problem # and Name: 4.3 Poor Work Skills

Name: Titus, Kevin ID #: Area:

Nursing Diagnosis: Deficient Knowledge

Date: 01/15/03

Problem Description: Pt. has held three jobs in the past 6 years; however, he was unable to keep any of the jobs for more than 1 month. He was fired from one job for poor performance and quit the other two jobs because he “didn’t like them.” Pt. appears to lack many of the basic skills necessary to keep a job. Pt. has difficulty following instructions and difficulty performing somewhat complicated tasks, such as running the copier, filing, and stocking shelves. Pt. also has difficulty taking public transportation and is unable to drive a car. Implement treatment of Problems 1.2 Lack of Motivation and 1.3 Poor Focal Attention.


Target Date

1.

Pt. will get and keep a part-time job (l6 to 20 hours per week) in a competitive work environment for at least 6 months.

01/15/04

2.

Pt.’s Kennedy Axis V score for ADL–Occupational Skills will improve from a current score of 50 to 60.

01/15/04


Target Date

1.

Staff will identify areas of deficits in work skills.

02/15/03

2.

Pt. will be able to file 50 letters with no more than one misfile.

04/15/03

3.

Pt. will be able to copy standard size, single-sided letters with no significant difficulty for 2 weeks.

04/15/03

4.

Pt. will work 10 hours per week in a work program of his choice and will keep the job for at least 1 month.

07/15/03

Date/Status*

Date/Status*





4–19

Date: 01/15/03


Date/Status*

Rehab: 1.

Pt. will participate in weekly individual and group counseling to identify deficits in work adjustment in order to— a. Address deficits in work skills b. Identify and plan for vocational goals c. Determine education and training needed to meet goals

2.

Staff will identify job interests to help pt. choose an appropriate work program to increase the probability of pt. keeping a job and developing needed work skills. a. Pt. will complete interest testing to aid in vocational decision making. b. Pt. will participate in a 2-week trial in a job of his choice for situational assessment. c. Individual vocational rehab counselor will assign work according to pt.’s choice. d. Vocational rehab counselor will monitor, address, and document work adjustment issues on a daily basis.

3.

Work supervisor and peers will use role modeling and verbal praise to increase desired work behaviors, such as using the copier and filing correspondence.

4.

Staff will use work hardening (slowly increasing hours and difficulty of task) to determine pt.’s endurance and skill level.

Jane Hoover, Rehab


4–20


INDIVIDUAL PROBLEM PLAN Problem # and Name: 4.4 Dependent Patient

Name: Dodge, Patricia ID #: Area:

Nursing Diagnosis: Deficient Knowledge

Date: 01/15/03

Problem Description: Pt. is generally unable to find her way around the hospital. If lost, it is felt that she may not be able to identify herself or tell where she is from. It is feared that if given the opportunity she may wander away from the hospital. Pt. appears to be able to safely cross streets; however, it is believed she is vulnerable to advances of strangers. Without supervision, pt. does not respond to emergencies, such as fire alarms. Implement treatment of Problem 2.1 Poor Social Skills.


Target Date

1.

Pt. will be able to function so that she will no longer require a dependent patient status.

01/15/05

2.

Pt. will be able to identify herself and her ward location consistently once per day for 3 months.

01/15/04


Target Date

1.

Pt. will be able to identify herself and her location once per day for 1 month.

07/15/03

2.

Pt. will be able to lead staff to the hospital store and back to the ward three times weekly for 1 month.

07/15/03

3.

Pt. will be able to go to and return from the hospital store independently and consistently for 3 months.

01/15/04

Date/Status*

Date/Status*





4–21

Date: 01/15/03


Date/Status*


Nsg. staff will maintain a safe, secure environment while attempting to maximize pt.’s functional ability.

2.

Nsg. staff will follow hospital procedure for dependent patients, including labeling the outside of pt.’s chart, notifying the proper authorities if pt. is missing, and the like.

3.

Nsg. staff will ensure that pt. wears an identification bracelet or tag at all times.

4.

Pt. contact will conduct off-ward training trips twice daily to teach pt. the route to the hospital store and back.

5.

Pt. contact will spend 5 to 10 minutes per shift working with pt. to self-identify and to give correct ward address.



4–22


INDIVIDUAL PROBLEM PLAN Problem # and Name: 4.5 Hazardous Smoking Habits

Name: Saxon, Howard ID #: Area:

Nursing Diagnosis: Ineffective Health Maintenance

Date: 01/15/03

Problem Description: Pt. has been a careless smoker for years. He often burns holes in his clothes, thus posing a health hazard.


1.

Pt.’s smoking will improve such that he will be able to go for 6 months without burning holes in his clothes.


Target Date

Date/Status*

01/15/04

Target Date

1.

Pt. will use ashtray three out of five times he smokes without staff cues for 1 month.

04/15/03

2.

Pt.’s smoking will improve such that he will be able to wear one set of clothes each day for 1 month without burning holes in them.

04/15/03

3.

Pt.’s smoking will improve such that he will be able to go for 3 months without burning holes in his clothes.

07/15/03

Date/Status*





4–23

Date: 01/15/03


Date/Status*


Nsg. staff will reinforce the need for and use of an ashtray each time a cigarette is given.

2.

Nsg. staff will remind patient not to burn holes in his clothes.

3.

If patient does not use an ashtray or if he reports for the next scheduled cigarette with a hole in his clothes, his cigarettes will be withheld for 1 hour.

4.

If cigarettes are withheld, nsg. staff will explain why they are being held and will remind pt. what smoking behaviors are necessary to continue hourly cigarette schedule.

5.

Nsg. staff will educate pt. for ½ hour once weekly to help pt. understand the dangers associated with his careless use of cigarettes.



Notes

SUBSTANCE ABUSE (Problem Area 5)

5–1


Substance Abuse (Problem Area 5)

5–3

SUBSTANCE ABUSE (Problem Area 5) CONTENTS Kennedy Axis V for Substance Abuse ....................................................................................................... 5–4 This rating scale can be used to measure the outcome of treatment. It also helps to define which problems fit into the category of Substance Abuse and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 5–5 Examples of problem names and descriptions that may relate to Substance Abuse are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 5–5 Examples of strengths that may be related to treatment and discharge in the area of Sobriety are listed here.

Goals ......................................................................................................................................................... 5–5 Examples of treatment goals that may relate to problems in the area of Substance Abuse are listed here.

Treatment Modalities ............................................................................................................................... 5–7 Examples of treatment modalities that may relate to problems in the area of Substance Abuse are listed here.

Individual Problem Plan (Frequent Entries) ........................................................................................... 5–12 An Individual Problem Plan that contains examples of information that is frequently entered into Individual Problem Plans relating to Substance Abuse is included here.

Sample Individual Problem Plans ........................................................................................................... 5–15 A wide range of Individual Problem Plans relating to Substance Abuse are included here.

5–4


Kennedy Axis V—Substance Abuse 100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone who is totally free of problems with substance abuse. No symptoms. 90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and minimal, if any, treatment needed to maintain sobriety. 80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse (e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety with minimal treatment needed to maintain sobriety. 70 Mild impairment in social, occupational, or school functioning due to substance abuse, but generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy smoker; unable to quit cigarettes despite numerous attempts. 60 Moderate difficulty in social, occupational, or school functioning because of substance abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week; occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust), Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.

50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance abuse; moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing substances despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol or marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions; moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than cigarettes) is beginning to cause some medical complications.

40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety. 30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious neglect of children due to substance abuse. 20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin, or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs into his/her veins more than twice a day.

10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in frequent medical hospitalizations; life-threatening neglect of children due to substance abuse. NR Not rated


5–5


II.

Substance Abuse Problems (alcohol, drugs, or both) A.

Examples 1. Abuse of drugs, cigarettes, or alcohol 2. Lack of insight into acute and chronic alcoholism 3. Inability to quit the use of drugs, cigarettes, or alcohol despite desire to do so 4. Addiction to caffeine

B.

Other 1. Addiction to drinking excessive fluids (this problem is often included under Problem 1.1 Polydipsia, Problem 6.1 Hyponatremia Secondary to Polydipsia, or both)

Problems Associated With Substance Abuse (substance abuse often leads to other acute or chronic problems that might be addressed under their particular problem area[s]) A.

Examples 1. Continued abuse of drugs, cigarettes, or alcohol despite acute or chronic medical problems caused by them 2. Inability to quit cigarettes despite physical damage from cigarettes 3. Multiple accidental overdoses of drugs or alcohol 4. Hypomania triggered by excessive caffeine intake 5. Depression and suicidal ideation secondary to chronic alcohol abuse


Substance Abuse Strengths (sobriety) A. B. C. D.

No significant problem with drugs or alcohol Recently able to attain 10 years of sobriety Has strong moral and ethical beliefs against use of drugs or alcohol Other strengths

Goals I.


Evidence of increasing control over substance abuse 1. Pt. will attend one off-ward independent activity per week for 1 month without abusing drugs or alcohol. 2. Pt. will engage in one independent off-ward social activity with a peer once per week for 1 month without abusing drugs or alcohol. 3. Pt. will use his or her independent privileges for 1 month without abusing drugs or alcohol. 4. Pt. will not abuse drugs or alcohol for 3 months when pt. is on pass or AWA (away without authorization) from the hospital. 5. Pt. will be free of abuse of drugs or alcohol for 3 months despite the opportunity to use them. 6. Pt. will continue to avoid use of drugs or alcohol. 7. Pt. will stop smoking for 1 month. 8. Pt. will consistently eat meals and snacks that are less likely to be associated with past patterns of use of cigarettes or alcohol for 3 months.

5–6

II.


Reporting of Symptoms A. B. C.

Pt. will consistently discuss with staff his or her impulse to use drugs or alcohol for 1 month. Pt. will consistently disclose to staff occasions on which pt. broke his or her agreement not to abuse drugs or alcohol for 3 months. Pt. will agree to sign a contract that pt. will not abuse alcohol when on pass.

III. Participation in Groups, Program Activities, and the Like A. B.

Pt. will attend the programs recommended by the treatment plan, including AA meetings, 4 out of 5 weekdays for 3 months. Pt. will participate in weekly AA and substance abuse discussion groups within the hospital for 1 month.


V.

A.

Medication and laboratory work 1. Pt. will discuss the benefits of taking psychotropic meds as prescribed. 2. Pt. will express an understanding of the benefits of taking psychotropic meds as a means of decreasing his or her impulses to use narcotics. 3. Pt. will take psychotropic meds as prescribed for 3 months. 4. Pt. will cooperate with spot checks of urine for toxicology screen, if substance abuse is suspected, for 3 months.

B.

Treatment planning 1. Pt. will cooperate with at least one treatment team member in the treatment planning process consistently for 1 month. 2. Pt. will be willing to participate in the evaluation process. 3. Pt. will explore potential resources and support systems available in the community. 4. Pt. will verbalize that participation in the work program will help to improve self-esteem, reduce boredom, and channel excess energy away from alcohol.

C.

Program activities 1. Pt. will verbalize the benefits of attending program activities.

D.

Consequences of actions 1. Pt. will be able to verbalize an understanding of the connections among the following: a. Continued drug or alcohol abuse and continued deterioration of one’s lifestyle and rejection by family and friends; b. Continued abuse of illegal drugs and continued conflicts with the law; c. Continued abuse and neglect of basic health needs and reoccurring physical illnesses; d. Substance abuse, AIDS, and other serious health problems; e. Substance abuse and inability to retain a job; and f. Alcohol abuse and worsening of depression.


Assessments 1. Pt. will cooperate with the evaluation process. 2. Pt. will consistently cooperate with urine toxicology screens when substance abuse is suspected for 3 months. 3. Pt. will complete rehabilitation assessment for appropriate day-program referral.

B.

Evaluations to R/O that psychiatric illnesses are self-medicated or caused by substance abuse 1. Pt. will cooperate with complete evaluation to R/O depression secondary to alcoholism. 2. Pt. will cooperate with the assessment to help R/O pt.’s self-medicating an anxiety disorder with street drugs.


5–7


Kennedy Axis V 1. Pt.’s Kennedy Axis V score for Substance Abuse will improve from a current score of 50 to 70.

VII. Miscellaneous A. B.

Pt. will seek a discharge environment free of street drugs and alcohol. Pt. will work for a company that stresses employee health, including smoking cessation and abstinence of alcohol for those with an alcohol problem.


Verbal Treatment Modalities (emphasize verbal interactions) A.

Support and reassurance 1. Staff will provide one-to-one supportive, problem-solving therapy to help pt. learn to cope with life without resorting to drug abuse. 2. Staff will provide one-to-one support when pt. presents as calm and clear but despairing. 3. Staff will provide one-to-one contact with pt. with needed support and reassurance to give pt. a sense that people care for pt. 4. Nsg. staff will provide episodic one-to-one contact to give a sense that pt. is receiving attention. 5. Staff will provide one-to-one interactions to help build a trusting relationship between pt. and staff. 6. Staff will express understanding of pt.’s distress and suggest interventions when pt. is suffering from severe anxiety and depression. 7. Nsg. staff will provide pt. with regular one-to-one support and reassurance at least once each shift, even when pt. is doing well.

B.

Cognitive refocusing (redirect focus away from things that support substance abuse and toward things that support sobriety) 1. Psychologist will meet with pt. once a week to direct pt. toward considering methods other than drinking for dealing with depression and anxiety. 2. Staff will help pt. recognize and express self-worth (e.g., compliment pt. when his or her appearance improves to bolster self-esteem and engage pt. in activities that pt. can succeed in and feel comfortable doing without needing alcohol). 3. Staff will maximize structured activities to minimize preoccupation with drugs and to help pt. stay focused on alternative behaviors. This refocusing can be done by maximizing pt.’s involvement in structured day programs, including open workshop, patient wage program, leisure interest group, and community meeting.

C.

Psychotherapy 1. Staff will provide pt. with one-to-one, insight-oriented psychotherapy once a week to help pt. uncover the reasons why he or she turns to alcohol to cope with problems. 2. Psychologist will provide supportive, problem-solving psychotherapy to help pt. find alternatives to substance abuse for coping with life’s problems.

5–8

II.



Positive reinforcement 1. Ward staff will encourage and give verbal praise for pt.’s involvement in non-drug-related social activities. 2. Staff will provide ongoing verbal reinforcement for pt.’s decision to stop drinking. 3. Staff will reinforce with positive verbal praise pt.’s positive behaviors, such as taking on responsibilities and attempting self-discipline. 4. Staff will positively reinforce pt. with trips to the canteen for involvement in the treatment planning process. 5. Nsg. staff will provide frequent encouragement for pt. to attend to personal hygiene and appearance.

B.

Negative reinforcement (including discouragement, restriction, and withholding of reinforcers) 1. Staff will restrict pt. to supervised privileges for 1 week if pt. returns from AWA intoxicated. Restriction will be only 3 days if there is no evidence of intoxication. 2. Staff will discourage pt. from talking about “war stories” from his or her life of drug use on the streets. 3. Staff will restrict pt. to supervised privileges for at least 1 week while his or her commitment to abstinence is assessed when pt. is found to be abusing drugs or alcohol.

C.

Extinction 1. Nsg. staff members will limit their interactions with pt. when pt. fails to work on means of controlling impulses to abuse drugs and alcohol.

D.

Shaping and modeling 1. Pt. will use the “buddy” system to provide a model of non–drug use for pt. to follow.

E.

Channeling energies 1. Pt. will be placed in a job as a salesperson at a retail store to divert pt.’s hyperactivity and high level of energy from drug dealing to more socially acceptable behaviors. 2. Staff will encourage pt. to spontaneously report urges to drink and will discuss alternatives to help manage these urges.

F.

Task simplification (reduce confusion and frustration by simplifying tasks and providing consistency and assistance) 1. Staff will use the same person as consistently as possible for redirection and support. 2. Substance abuse counselor will break down the steps of reaching and maintaining sobriety into small, understandable goals reachable by pt.


Family treatment modalities 1. Staff will provide family therapy to explore family’s continued financial support of pt.’s drug use.

B.

Substance abuse groups, agencies, and help programs 1. Staff will encourage pt. to attend a substance abuse treatment program once per week. 2. Staff will encourage pt. to attend a relapse prevention group once weekly. 3. Staff will refer pt. to the AA meeting in the hospital. 4. Staff will refer pt. to the Narcotics Anonymous group in town. 5. Staff will refer pt.’s spouse to an Al-Anon family group. 6. Staff will give pt. an appointment with a community self-help group to help pt. with his or her commitment to stay off cigarettes.

C.

Religious treatment modalities 1. Provide religious services to enhance pt.’s self-esteem and feelings of meaning and community. 2. Provide religious counseling to help pt. explore moral issues related to abusing his or her body through the use of drugs and alcohol.


D.

5–9

Other modalities 1. Psychodrama a. Staff will use psychodrama to assist pt. to be able to say “No” when pressured by peers to use drugs. 2.

Termination a. Pt. will be terminated from the program if, after 1 week, pt. shows no significant motivation for change. b. Pt will be readmitted when his or her drug lifestyle is painful enough for pt. to want to change.

3.

Significant other a. Staff will explore whether a significant other, such as pt.’s fiancé(e), will help pt. follow through with a commitment to stopping drinking.


V.

A.

Stimulus reduction 1. Staff will restrict pt. from associates and areas that have triggered drug use in the past. 2. Staff will work at identifying and reducing triggering cues. 3. Dietitian will work with pt. to identify eating habits that trigger smoking (or drinking). 4. Staff will work with pt. for 1 hour once weekly to reduce cues that trigger substance abuse.

B.

Protective procedures (including special observations) 1. Staff will provide a safe, secure, drug-free environment with special monitoring as necessary. 2. Staff will provide a drug-free environment by— a. Having the pt. remain on the locked section of the Detox Unit until pt. has better control of his or her urges to abuse drugs and alcohol; b. Supervising visits and searching pt. for drugs and drug utensils when pt. returns from any unsupervised, off-ward activity; c. Monitoring pt.’s phone calls and screening the pt.’s letters to ensure that pt. does not attempt to get someone to bring drugs onto the ward; d. Performing unannounced drug toxicology screens, randomly and when substance abuse is suspected.

C.


Medical Treatments A.

Medication 1. Staff will gradually reduce medication doses as prescribed to detox pt. off drugs and alcohol. 2. Staff will administer vitamin supplement as prescribed. 3. Staff will place pt. on methadone maintenance. 4. Staff will place pt. on Antabuse (disulfiram) to help prevent relapse back into alcohol use. 5. Staff will place pt. on nicotine gum or nicotine patch to reduce craving for cigarettes.

B.

Other medical treatments 1. Pt. will get a physical exam and an individualized program of physical fitness to help improve health awareness and self-esteem.

5–10



Mental illness 1. Staff will discuss with pt. his or her addiction to drugs and alcohol. 2. Staff will discuss with pt.’s family the nature of pt.’s addiction and the fact that pt. will not be able to stop the abuse of drugs by himself or herself.

B.

Medication 1. Staff will discuss with pt. the process of detoxification using methadone. 2. Staff will discuss with the pt. and family the use of drugs like methadone and Antabuse (disulfiram) in an aftercare program.

C.

Benefits and consequences of behaviors 1. Staff will discuss with pt. the association between substance abuse and worsening of hallucinations and assaultiveness. 2. Staff will give pt. concrete examples of the effects of continued drug abuse (e.g., “Your probation officer will revoke your probation if he or she learns of your continued drug abuse,” “You are starting to show evidence of liver and brain damage secondary to alcohol abuse that will worsen if abuse of alcohol is continued,” “Your depression is worsened by your chronic use of alcohol,” and the like). 3. Staff will work with pt. to help pt. have a clearer understanding of the effects alcohol has on behavior.

D.



Psychological tests (and other formal verbal tests) 1. Staff will conduct psychological testing for addictive profile. 2. Staff will conduct neuropsychological testing to R/O organic brain damage secondary to alcohol and drug abuse.

B.

Psychiatric evaluations 1. Staff will conduct a psychiatric diagnostic evaluation to R/O an underlying psychiatric illness that pt. is self-medicating with drug abuse. 2. Staff will conduct a psychiatric evaluation to help determine whether pt. would be better treated in a psychiatric facility or in a drug treatment program.

C.

Medical tests and evaluations 1. Urine toxicology screen 2. Blood screen for liver disease 3. Blood screen for venereal disease a. Blood screen for syphilis b. Blood screen for AIDS 4.

D.

GC (gonococcus) smear to rule out gonorrhea

Other evaluations and assessments 1. Staff will conduct a one-to-one weekly interview to identify stimuli of substance abuse. 2. Staff will conduct a one-to-one weekly interview to determine the nature of pt.’s anxiety about going into a drug treatment facility. 3. Social worker will investigate the availability and appropriateness of drug treatment programs in the area. 4. Staff will assess pt.’s areas of greatest interests and motivation to begin structured activities congruent with pt.’s interests. 5. Social worker will interview family members to assess their ability to communicate with each other and to identify family interactions that may contribute to pt.’s alcoholism.


5–11


Court commitment 1. Staff will initiate petition for mandatory substance abuse treatment.


Treatment of related problems (This is optional and can be included with the treatment modalities or in the problem description.) 1. Staff will treat the hopelessness and despair associated with pt.’s alcoholism as indicated under Problem 1.1 Depressive Symptoms. 2. Staff will treat pt.’s chronic hepatitis as outlined under Problem 6.1 Chronic Hepatitis.

5–12


Individual Problem Plan (Frequent Entries) INDIVIDUAL PROBLEM PLAN Problem # and Name: 5.1 Substance Abuse


Nursing Diagnosis: Ineffective Coping, Related to Substance Abuse

Date: 01/15/03



• • •

Onset of symptoms and chronicity

• • •

Response to previous and current treatments and expected response to any proposed treatments

Precipitants (e.g., lifestyle, peer pressure, depression, anxiety, losses, other stress, boredom) Characteristics, frequency, intensity, and variance of substance abuse behavior, including types, quantities, and frequency of use of drugs or alcohol Current level of substance abuse, urges to abuse substances, preoccupation with substance abuse Barriers to treatment, such as minimizing one’s problem with substance abuse, poor motivation

2.


3.

The description and treatment of any depressive or anxious symptoms that may be driving pt.’s impulses to abuse drugs or alcohol should be addressed in Problem Area 1 Psychological Impairment and violence secondary to substance abuse in Problem Area 3 Violence.


Target Date

Date/Status*

1. Pt. will be free of substance abuse for ___ week(s)/month(s). 2. Pt. will be able to go on off-grounds privileges on a regular basis without using/abusing drugs/alcohol for ___ week(s)/month(s). 3. Pt. will participate in substance abuse meetings ___ time(s) a week/month for ___ week(s)/month(s). 4. Pt. will complete steps _____ of the 12-step AA program. 5. Pt. will exhibit diminished denial and minimization AEB being able to admit that drugs or alcohol are a problem in pt.’s life consistently for a ___ -week/-month period. 6. Pt. will watch video(s) or read pamphlet(s) on substance abuse titled __________________________________________________. 7. In substance abuse groups, pt. will be able to express an understanding as to how substance abuse can 1) interfere with job and functioning, 2) lead to assaultive or suicidal behavior, 3) force one into criminal activity, and 4) adversely affect one’s mental and/or physical health. 8. Pt. will work with a significant other for at least ___ week(s)/month(s) to help ensure that pt. will follow through with treatment and abstinence. 9. Pt. will consistently agree to spot checks of urine for toxicology screen if substance abuse is suspected for ___ week(s)/month(s). 10. Pt. will be able to express an understanding of the connection between his or her depression, stress, or losses and substance abuse. 11. Pt.’s score on the Kennedy Axis V for Substance Abuse will improve from a current score of ___ to ___.





5–13

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to monitor any changes in intensity of impulses to abuse drugs/alcohol and to prescribe treatments that may help reduce the craving or sense of need for drugs/alcohol such as ___________________________. Labs as ordered, including urine toxicology screens. Virginia Coleman, MD

Social Work: 1. Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to help pt. understand how his or her impulses to abuse drugs or alcohol act as a barrier to pt.’s discharge. Brenda St. Martin, MSW

Psychology (or Social Work): 1. Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___ time(s) weekly/monthly in alcohol counseling to reduce pt.’s craving or sense of need for drugs/alcohol. 2. Psychologist (social worker) will lead group (e.g., substance abuse relapse prevention group) weekly to help reduce pt.’s craving or sense of need for drugs or alcohol and more effectively deal with pt.’s stress, problems, and losses. Susan Green, Psychologist Brenda St. Martin, MSW

Rehab: 1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s) weekly/monthly to review and revise pt.’s daily treatment schedule and will refer pt. to appropriate groups working to improve his or her problem with drugs/alcohol. 2. Pt. will attend AA/Narcotics Anonymous meetings ___ time(s) a week/month to learn more about substance abuse risk factors and how to avoid them. See weekly schedule for substance abuse programs. Jane Hoover, Rehab

Nursing Care Plan: 1. Nsg. staff will be alert to any evidence of intoxication or withdrawal and report any significant findings to the psychiatrist or physician. 2. Nsg. staff will obtain urine toxicology screen or do Breathalyzer test if substance abuse is suspected. 3. Nsg. staff will be alert to pt.’s impulses to abuse drugs or alcohol and med-seeking behavior and will assist pt. in dealing with these in an appropriate, sober manner. 4. Nsg. staff will give encouragement and verbal praise for pt.’s involvement in non-drugrelated social activities. 5. Nsg. staff will escort pt. to off-ward groups, programs, and other activities to ensure pt. does not attempt to abuse drugs or alcohol. 6. Nsg. staff will question pt. directly at least ____ time(s) each shift/day/week to determine whether pt. has any impulses to abuse drugs/alcohol. 7. Nsg. staff will meet with pt. for ___ minutes at least ____ time(s) weekly/monthly to educate pt. about the consequences of substance abuse and about alternative means of relating to others, coping, or dealing with stress. Marilyn Davis, RN


Notes


5–15

Sample Individual Problem Plans CONTENTS Polysubstance Abuse .............................................................................................................................. 5–16 Substance Abuse, Mixed......................................................................................................................... 5–18 Nicotine Dependence ............................................................................................................................. 5–20

5–16


INDIVIDUAL PROBLEM PLAN Problem # and Name: 5.1 Polysubstance Abuse

Name: Graves, Gail ID #: Area:

Nursing Diagnosis: Risk for Injury

Date: 01/15/03

Problem Description: Pt. has a history of several years of abusing substances, including alcohol, marijuana, and cocaine. At first, patient denied abuse of drugs and alcohol; however, her extensive substance abuse problem quickly became apparent. Abuse of drugs and alcohol appears to pervade her thinking and behavior. When given privileges, pt. would frequently go AWA to get alcohol. During these periods, pt. places herself in potentially dangerous situations. Staff feels that if given the opportunity, pt. would abuse drugs and alcohol on a daily basis. Pt.’s driver’s license was revoked last year because of driving under the influence. In part, pt.’s substance abuse is seen as a method of blocking out her feelings of low self-esteem. She has not used any drugs IV. Pt.’s low self-esteem, which appears to be a factor in her substance abuse, will be treated as indicated under Problem Area 1.1 Depressive Symptoms.


Target Date

1. Pt. will be able to go on off-grounds privileges on a regular basis without abusing drugs or alcohol for 3 months.

07/15/03

2. The pt.’s Kennedy Axis V score for Substance Abuse will improve from a current score of 35 to 55.

07/15/03


Target Date

1. Pt. will accurately discuss with staff her impulses to use drugs and alcohol for 1 month.

04/15/03

2. Pt. will participate twice weekly in AA and substance abuse discussion groups within the hospital for 1 month.

04/15/03

3. Pt. will be able to go on independent privileges on the hospital grounds for 1 month without going AWA to get drugs or alcohol.

04/15/03

Date/Status*

Date/Status*





5–17

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for at least 1½ hours each month to monitor any changes in intensity of impulses to abuse drugs and alcohol. 2. Staff will consider prescribing medication to reduce craving for substance abuse, such as naltrexone. 3. Psychiatrist will order urine toxicology screens to help ensure that pt. is not abusing substances. 4. Pt. will be restricted to supervised privileges for 1 week if she returns to the ward intoxicated or if she has a positive urine toxicology screen. During that period, staff will reassess pt.’s commitment to sobriety, the treatment plan, and her level of dangerousness in the community. Victor Dyson, MD

Psychology: 1. Psychologist will meet one-to-one with pt. to direct her toward methods other than substance abuse for relieving her depression and anxiety. 2. Staff will refer pt. to and encourage her to attend AA meetings and substance abuse disorders group at least twice weekly in the hospital. Joseph LeBlanc, Psychologist

Rehab: 1. Pt. will work in hospital cafe 4 hours each workday to help pt. stay focused on alternatives to substance abuse and to improve her self-esteem. 2. Rehab staff will lead the relapse prevention group for 1 hour weekly to help pt. learn about substance abuse risk factors and how to avoid them. Jane Hoover, Rehab

Nursing Care Plan: 1. Nsg. staff will provide encouragement and verbal praise for pt.’s involvement in nondrug-related social activities. 2. Nsg. staff will be alert to any evidence of intoxication, obtain urine toxicology screens if substance abuse is suspected, and report any significant finding to the attending psychiatrist. 3. Nsg. staff will meet with pt. for ½ hour once weekly to educate her about the consequences of substance abuse and about alternative means of coping with stress and her low self-esteem. Marilyn Davis, RN Å Nsg. Staff


5–18


INDIVIDUAL PROBLEM PLAN Problem # and Name: 5.2 Substance Abuse, Mixed

Name: Zachary, Maurice ID #: Area:

Nursing Diagnosis: Risk for Injury

Date: 01/15/03

Problem Description: Pt. was recently transferred from our Psychiatric Acute Treatment Unit to our Substance Abuse Treatment Unit. Pt. began abusing alcohol and marijuana around age 15. His episodic but persistent abuse of alcohol and marijuana invariably leads to a worsening of his psychiatric symptoms. This abuse clearly impairs his functioning in his community residence and his day treatment program. This abuse has led to multiple psychiatric hospitalizations, including the present.


1. Patient will not abuse drugs or alcohol for 6 months.


Target Date

Date/Status*

01/15/04

Target Date

1. Pt. will acquire a willingness to examine substance abuse as a problem in his life as demonstrated by independent participation in a multifaceted educational and treatment program for 1 month.

04/15/03

2. Pt. will be able to consistently verbalize an understanding of how substance abuse interferes with his daily functioning for 3 months.

07/15/03

3. Pt. will be free of drugs and alcohol for 3 months.

07/15/03

Date/Status*





5–19

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will lead medication and mental illness education group weekly to help pt. to learn about the interaction between mental illness and substance abuse disorder. 2. Psychiatrist will monitor and document episodes of substance abuse and provide medical/detox interventions as ordered. Victor Dyson, MD

Social Work: 1. Social worker will lead weekly community transition group to help pt. develop plans around living in the community and to identify support systems and resources that he can use when he is out of the hospital. Brenda St. Martin, MSW

Psychology/Social Work: 1. Psychologist and social worker will lead twice-weekly on-ward substance abuse group to help pt. learn about problems created by substance abuse and to develop supports, strategies, and alternatives to substance abuse. 2. Psychologist and social worker will lead weekly relapse prevention group for pt. to learn ways of preventing relapse of both mental illness and substance abuse. Joseph LeBlanc, Psychologist Brenda St. Martin, MSW

Nursing Care Plan: 1. Nsg. staff will offer ongoing feedback and support for pt.’s decision to attain and maintain abstinence. 2. Nsg. staff will encourage pt.’s attendance at substance abuse groups, including AA meetings, twice weekly in the hospital and once weekly in the community. 3. Contact person will keep track of pt.’s attendance at program activities. 4. Nsg. staff will escort pt. as needed to off-ward groups to ensure that he does not attempt to use marijuana or alcohol. Ronald Donahue, RN Å Nsg. Staff


5–20


INDIVIDUAL PROBLEM PLAN Problem # and Name: 5.3 Nicotine Dependence

Name: Drake, Dawn ID #: Area:

Nursing Diagnosis: Ineffective Health Maintenance

Date: 01/15/03

Problem Description: Pt. has been smoking one to two packs of cigarettes per day for the past 10 years. Pt. has recently begun to experience shortness of breath. Pt. has also begun to experience a persistent, dry cough, and she occasionally experiences upset stomach and chest tightness on days when her smoking is especially heavy (two packs per day). Pt. has expressed a strong desire to cut down or stop smoking, but past attempts have been unsuccessful.


1. Pt. will cease cigarette smoking AEB continuous abstinence from all tobacco products for 3 months.


Target Date

Date/Status*

07/15/03

Target Date

1. Pt. will begin eating meals and snacks that are less likely to be connected with previous patterns of smoking for 1 month.

04/15/03

2. Pt. will increase her interest in and awareness of health issues AEB her participation in an exercise group three times a week for 1 month.

04/15/03

3. Pt. will work with a significant other for at least 1 month to help ensure that she will follow through with stopping smoking.

04/15/03

4. Pt. will stop smoking for 1 month.

04/15/03

Date/Status*





5–21

Date: 01/15/03


Date/Status*

Psychiatry: 1. Psychiatrist will meet with pt. for 15 minutes once weekly to assess any changes in pt.’s craving for cigarettes and to prescribe treatments, such as nicotine gum or nicotine patch, that will help to reduce episodes of cigarette craving. Victor Dyson, MD

Psychology: 1. Psychologist will meet with pt. for ½ hour once a week to identify sources of potential relapse (e.g., cues and triggers for smoking) and to develop coping strategies to reduce risks of returning to smoking. 2. Psychologist will run the clinic self-help group, where pt. can obtain further information regarding the problems associated with cigarette smoking and also obtain peer reinforcement around the decision to stop smoking and to not restart. Joseph LeBlanc, Psychologist

Social Work: 1. Staff will explore whether a significant other, such as her fiancé, will help pt. follow through with her commitment to stop smoking. Brenda St. Martin, MSW

Rehab: 1. Staff will work with pt. to plan and implement an individualized program to focus on good health maintenance, including physical fitness exercises and smoking cessation. Jane Hoover, Rehab

Nursing Care Plan: 1. Nsg. staff will encourage pt. to participate in the clinic self-help group. 2. Nsg. staff will give encouragement and verbal praise for pt.’s involvement in nonsmoking-related social activities. 3. Nsg. staff will question pt. directly every day to determine whether she is losing control of cravings to smoke and report any significant worsening to the psychiatrist. 4. Nsg. staff will lead the on-ward smoking cessation group for ½ hour once weekly to educate pt. about the health consequences of smoking and to help pt. develop strategies for avoiding smoking. Marilyn Davis, RN

Dietitian: 1. Dietitian will work with pt. to identify eating habits that trigger smoking. As the triggers are identified, the dietitian will help pt. develop eating habits that are less connected with previous patterns of cigarette smoking. Louise Tallo, Dietitian


Notes

MEDICAL IMPAIRMENT (Problem Area 6)

6–1


Medical Impairment (Problem Area 6)

6–3

MEDICAL IMPAIRMENT (Problem Area 6) CONTENTS Kennedy Axis V for Medical Impairment.................................................................................................. 6–4 This rating scale can be used to measure the outcome of treatment. It also helps to define the problems that fit into the category of Medical Impairment and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 6–5 Examples of problem names and descriptions that may relate to Medical Impairment are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 6–6 Examples of strengths that may be related to treatment and discharge in the area of Medical Strengths are listed here.

Goals ......................................................................................................................................................... 6–6 Examples of treatment goals that may relate to problems in the area of Medical Impairment are listed here.

Treatment Modalities ............................................................................................................................... 6–8 Examples of treatment modalities that may relate to problems in the area of Medical Impairment are listed here.

Individual Problem Plan (Frequent Entries) ........................................................................................... 6–12 An Individual Problem Plan, containing examples of information frequently entered into Individual Problem Plans relating to Medical Impairment, is included here.

Sample Individual Problem Plans ........................................................................................................... 6–15 A wide range of individual problem plans relating to Medical Impairment are included here.

6–4


Kennedy Axis V—Medical Impairment 100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms. 90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally needs over-the-counter medication. 80 If medical problems are present, they are transient and cause minimal impairment in social, occupational, or school functioning; somewhat more than average missing of work or school due to medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to organic problems.

70 Mild medical problems which may cause some difficulty in social, occupational, or school functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia; epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a year; takes prescription medication on a daily basis.

60 Moderate difficulty in social, occupational, or school functioning due to medical problems; missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma, moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g., injections, blood levels, nebulizer, physical therapy); needs bladder bag.

50 Serious impairment in social, occupational, or school functioning due to medical problems; serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.

40 Major impairment in several areas (such as work or school or family relations) because of medical problems; missing about 2 months a year or more from work or school due to medical problems; medical problems result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems. 30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart, lung, kidney, liver); on dialysis for kidney failure. 20 Major medical problems confine him/her to bed all of the time and intensive, continuous medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart, lung, kidney, liver); quadriplegic. 10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma. NR Not rated


6–5


II.

Medical Problems Often Seen in Psychiatric Patients A.

General medical problems 1. Angina 2. Hypertension 3. Endocarditis 4. Duodenal ulcer 5. Diabetes mellitus 6. Hypoglycemia 7. Asthma 8. Seizure disorder 9. Temporal lobe epilepsy 10. AIDS 11. Positive TB skin test 12. Migraine headaches 13. Acne 14. Allergy to penicillin

B.

Psychiatric illness sequelae (secondary to overdoses, self-inflicted cuts, gunshot wounds, jumping from high places, substance abuse, and the like) 1. Organic brain dysfunction 2. Atonic bladder with associated incontinence 3. Paralysis 4. Laceration of wrist 5. Fracture 6. Malnutrition secondary to anorexia 7. Fluid and electrolyte problems secondary to polydipsia 8. Chronic obstructive pulmonary disease 9. Cirrhosis 10. Hepatitis 11. Chronic pancreatitis 12. Frostbite 13. Bed sores 14. Poor health maintenance

C.

Psychotropic medication side effects 1. Tardive dyskinesia 2. EPS (extrapyramidal side effects) 3. Akathisia 4. Hypothyroidism secondary to lithium 5. Constipation 6. Renal dysfunction secondary to lithium 7. Agranulocytosis secondary to Clozaril (clozapine) 8. Postural hypotension 9. Tachycardia 10. Dysphagia 11. Marked weight gain 12. Diabetes mellitus associated with use of Zyprexa (olanzapine)

Special Medical Status A. B. C. D. E.

Pt. Pt. Pt. Pt. Pt.

is pregnant. uses birth control. has a single kidney. is a carrier of an unexpressed genetic disease. has mitral valve prolapse.

6–6


III. Dental Problems A. B. C. D.

Multiple caries Abscessed tooth Gingivitis Poor dental maintenance


Medical Strengths A. B. C. D. E. F. G. H.

Pt. Pt. Pt. Pt. Pt. Pt. Pt. Pt.

has good physical health. has no more than minor medical problems. exercises on a regular basis. is health-conscious. sticks to a very healthy diet. practices a healthy lifestyle. practices safe sex. has other medical strengths.

Goals I.


Medical problems secondary to psychotropic medications 1. Pt.’s akathisia will improve so that pt. will be able to consistently sit through ½-hour groups for 1 month. 2. Pt. will show no worsening or some remission of tardive dyskinesia for 6 months. 3. Pt. will cooperate with the reduction of antipsychotic medication to the lowest reasonable dose to minimize danger of tardive dyskinesia for 3 months. 4. Pt. will return to euthyroid state (hypothyroidism secondary to lithium). 5. Malignant neuroleptic syndrome will resolve.

B.

General medical problems 1. Pt.’s cholesterol will be reduced to below 200. 2. Pt.’s incidence of acne eruptions will reduce AEB pt.’s face appearing significantly clearer for 1 month. 3. Pt.’s blood pressure will be maintained at a safe level for 3 months. 4. Pt. FBS will be maintained within the normal range for 6 months. 5. Pt. will have a realistic goal of no further weight gain for 3 months, even though pt. is significantly obese because of a lack of insight and a lack of motivation. 6. Pt. will maintain present optimal bladder function (considering the organic impairment of pt.’s bladder). 7. Pt. will have no episodes of shortness of breath for 3 months. 8. Pt. will have no further deterioration in respiratory function AEB no deterioration in pt.’s pulmonary function studies for 6 months. 9. Pt. will be free from poor skin integrity for 6 months. 10. Pt’s infections will heal without complications. 11. Pt.’s right foot will be free from infection for 6 months. 12. Pt. will continue to be free of seizures with treatment for 6 months. 13. Pt. will be free of pain and complications of hemorrhoids for 3 months. 14. Pt. will consistently report any incidences of falling for 3 months.


II.

6–7

Reporting of Symptoms A. B. C.

Pt. will report headaches or changes in symptoms consistently for 1 month. Pt. will report any change or discomfort for 1 month. Pt. will report any reoccurrence of bleeding for 3 months.

III. Participation in Groups, Program Activities, and the Like A. B. C.

Pt. will participate in the physical therapy program once weekly for 1 month. Pt. will attend speech therapy sessions twice weekly for 1 month. Pt. will cooperate with dental work for the next three scheduled appointments.


V.

A.

Medication and laboratory work 1. Pt. will discuss the benefits of taking psychotropic meds as prescribed. 2. Pt. will express the benefits of taking meds as prescribed. 3. Pt. will take meds as prescribed for 3 months. 4. Pt. will comply with blood work for 3 months.

B.

Treatment planning 1. Pt. will consistently cooperate with at least one treatment team member in the treatment planning process for 1 month. 2. Pt. will cooperate with the treatment plan to restrict fluid intake for 1 week. 3. Pt. will demonstrate cooperation with all aspects of the treatment plan for 1 month.

C.

Program activities 1. Pt. will express the benefits of attending the physical therapy program.


Assessments 1. Pt. will cooperate with the evaluation process for 2 weeks. 2. Pt. will cooperate to complete the physical therapy assessment. 3. Pt. will cooperate so that staff can determine the level of nursing care required for placement in the community.

B.

Evaluations to R/O various diagnoses 1. Pt. will cooperate with the complete evaluation to R/O seizure disorder.

C.

Laboratory tests 1. Pt. will cooperate to complete the comprehensive laboratory screen. 2. Pt. will cooperate to complete the EEG and CT scan. 3. Pt. will cooperate to complete the ECG.


AIMS and AIMS Plus EPS exams 1. Pt. will show no deterioration in tardive dyskinesia as measured by monthly AIMS Plus EPS exam for 6 months. 2. Pt.’s akathisia will improve as demonstrated in next month’s AIMS Plus EPS exam.

B.

Mini-Mental State 1. Pt.’s score on the Mini-Mental State will improve from a current score of 12 to 18.

C.

Laboratory tests 1. Pt.’s FBS will remain WNL for 3 months. 2. Pt.’s thyroid function will remain WNL for 6 months.

6–8


VII. Miscellaneous A. B.

Pt. will cooperate so that he or she can remain in an environment that protects the pt. during the healing process. Pt. will cooperate with the competency assessment to determine whether pt. is able to make competent decisions about medical treatments.

Treatment Modalities Because of the extremely broad range of the category Medical Impairment, only a brief outline of treatment modalities is presented here. This outline focuses on the psychiatric aspects of the medical treatments. Additional examples of treatment modalities for Medical Impairment are included on the sample Individual Problem Plans for Medical Impairment.

I.


II.

Support and reassurance 1. Medical staff will work on a one-to-one relationship with pt. to increase trust. 2. Nsg. staff will provide pt. with needed one-to-one support and reassurance that people are concerned about pt.’s health and well-being. 3. Rehab staff will work with pt. one-to-one to help pt. accept the significant residual impairment following pt.’s stroke. 4. Psychologist will meet with pt. one-to-one to enhance pt.’s self-esteem and feelings of meaning and community to offset pt.’s despair following a diagnosis of late-stage ovarian cancer.


Positive reinforcement 1. Nsg. staff will give pt. positive feedback and encouragement for appropriate statements and decisions concerning pt.’s physical health. 2. Staff will encourage pt.’s independence by giving pt. as much decision-making power as possible. 3. Psychologist will encourage pt. to be involved in the treatment planning process.


Family treatment modalities 1. Social worker will provide family therapy to help improve family’s willingness to help pt. follow through with medical treatments.

B.

Religious treatment modalities 1. Pt. will receive religious counseling for support and hope concerning pt.’s left-sided paralysis. 2. Pt. will receive religious counseling to provide a religious perspective on the prognosis that pt. is likely to die from cancer within 3 months. 3. Pt. will receive religious counseling to help pt. objectively examine belief that his or her medical illness is a punishment for sins.

C.

Other modalities 1. Group therapy a. Group therapy will be used to facilitate discussion of pt.’s medical problems. 2.

Psychodrama a. Role-playing will be used to help reduce pt.’s anxiety about talking about his or her illness, including the prognosis.


6–9


V.

A.

Stimulus reduction 1. Staff will redirect pt. from triggering events or overstimulating areas to reduce stress that may worsen pt.’s physical symptoms. 2. Sound-absorbing material will be added to pt.’s dorm area to help reduce noise. 3. Nsg. staff will redirect other pts. from yelling, talking loudly, or playing their radios too loudly near patient, to help pt. relax while healing.

B.

Protective procedures (including special observations) 1. Staff will provide an environment that protects pt. during the healing process. 2. Staff will keep pt. away from street drugs and alcohol to prevent further physical damage. At the same time, pt. will be treated for substance abuse in the hope that pt. will abstain from substance abuse once there is an opportunity to use drugs. 3. Staff will employ escape precautions. 4. Staff will monitor pt. closely to ensure that he doesn’t pick at sutures or wander off the ward.

C.

Other milieu treatment modalities 1. Pt. will be placed in an environment in which pt.’s physical handicap will not be a significant barrier to functioning.


Medication 1. Internist will prescribe meds as indicated for pt.’s physical illness. 2. Nsg. staff will give pt. prn meds to relieve acute exacerbations of illness. 3. Psychiatrist will reduce antipsychotic meds to the lowest reasonable dose to minimize danger of tardive dyskinesia.

B.

Other medical treatment modalities 1. Surgery 2. Radiation therapy 3. Physical therapy 4. Chiropractic treatments 5. Miscellaneous a. Acupuncture b. Exercise as tolerated


Medical illness 1. Nsg. staff will educate pt. about ways to cope with medical illness. 2. Nsg. staff will meet with the pt. and family once weekly for ½ hour to teach them ways to recognize signs of deterioration and other medical dangers. 3. Internist will discuss with the pt. and family the nature of pt.’s medical illness and the prognosis.

B.

Medication 1. Nsg. staff will educate pt. about the risks and benefits of meds. 2. Nsg. staff will show pt. concrete benefits of taking meds (e.g., “The infection is clearing,” “You are looking less pale,” “Your breathing is a lot less labored”). 3. Pt.’s nurse or internist will discuss with pt.’s family the reasons pt. needs to take meds.

6–10


C.

Benefits and consequences of behaviors 1. Nsg. staff will discuss connections between daily appropriate attention to pt.’s medical care and progress toward recovery from medical illness. 2. Social worker will discuss with pt.’s family members the benefits of their visits and support.

D.

Miscellaneous patient and family education 1. Nsg. staff will involve pt.’s family members in a psychoeducational program to improve their ability to cope with pt.’s medical illness. 2. Pt. will receive education to help pt. understand and deal with the long-term aspects of the illness. 3. Nsg. staff will provide education to help pt. understand, recognize, and reduce some of the underlying causes of the illness. 4. Staff will schedule pt. for an appointment for counseling in family planning. 5. Staff will encourage pt. to become involved in a sex education program that addresses pt.’s needs. 6. Nsg. staff will educate pt. about pregnancy and delivery, including prenatal care and signs and symptoms of labor.


Psychological tests (and other formal verbal tests) 1. Psychologist will perform psychological testing to determine pt.’s ability to engage in treatment and to cope with serious illness. 2. Staff will conduct neuropsychological testing to monitor for further deterioration in pt.’s mental functioning.

B.

Psychiatric evaluations 1. Staff will conduct a psychiatric diagnostic evaluation. 2. Psychiatrist will perform a psychopharmacological assessment. 3. Psychiatrist will perform an AIMS or AIMS Plus EPS exam every 6 months. 4. Staff will measure EPS weekly using the AIMS Plus EPS to observe for reductions in pt.’s EPS as Risperdal is decreased.

C.

Medical/laboratory tests and evaluations 1. Internist will order needed urine tests and blood work. 2. Psychiatrist will order blood levels to help determine medication compliance. 3. Staff will monitor blood levels to determine whether meds are in the therapeutic range. 4. Pt. will have EEG to R/O temporal lobe epilepsy. 5. Pt. will have chest X ray to R/O pneumonia. 6. Pt. will have CT scan to R/O organic etiology. 7. Nsg. staff will record pt.’s seizures on the seizure flow chart.

D.

Religious evaluations and assessments 1. Pt. will receive a religious assessment to determine whether religion will be an asset to pt.’s recovery from illness. 2. Pt. will receive an assessment to determine whether pt. sees self as being punished by getting this illness and, if so, how religious/spiritual counseling can help reduce the guilt and improve pt.’s compliance with treatment.

E.

Other evaluations and assessments 1. Rehab staff will assess pt.’s areas of interests and motivation to begin structured activities congruent with pt.’s interests. 2. Social worker will interview family members to assess their ability to communicate with each other and to give needed support to pt. during cancer treatments. 3. Psychiatrist will refer pt. to Movement Disorder Clinic to further assess and treat pt.’s tardive dyskinesia.



Medical guardianship 1. Psychiatrist will seek a medical guardianship to obtain permission for the needed surgery.


No examples given

6–11

6–12


Individual Problem Plan (Frequent Entries) INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.0 Health Maintenance



Date: 01/15/03


Enter any significant medical history, unless it is addressed under a separate problem.

2.

List any active or significant medical problems and any meds or treatment the pt. is taking, such as prophylactic meds, multivitamins, aspirin, and such.

3.

List minor problems (such as acne, constipation, indigestion, mild obesity, mild hyperlipidemia, mild dysphagia, mild hyponatremia, mild dehydration, mild hypertension).

4.

List any special treatments needed to maintain pt.’s health.

5.

List any dietary requirements.

6.

List any allergies.

7.

If the treatment of a particular medical problem is very complicated, use a separate problem plan to address that problem, such as an active breast cancer, severe diabetes, severe obesity, severe dysphagia, severe chronic obstructive pulmonary disease (COPD), or difficult-to-manage seizure disorder.

Goal(s) (Discharge Criteria) (Please number all goals.)

1.

Pt. will continue to maintain an optimal level of health while hospitalized, AEB compliance with all prescribed meds, lab work, and treatments for pt.’s medical problems.

2.

Pt. will maintain an optimal level of wellness, AEB compliance with all prescribed meds, lab work, and treatments for pt.’s medical problems for ____ month(s).

3.

Pt. will comply with meds, treatments, and diagnostic tests for pt.’s medical problems for ____ month(s).

4.

Pt. will perform good basic facial cleansing daily with one verbal prompt for ____ month(s).

5.

Pt.’s [cholesterol, weight, sodium, BP] will improve from a current ____ to ____.

6.

Pt. will have no more than one seizure per year.

7.

Pt.’s fasting blood glucose level will be maintained for ____ week(s)/month(s) in the following range: ________________

8.

Pt. will comply with a [whole, chopped, ground] diet with no choking episodes for ____ month(s).

9.

Pt.’s score on the Kennedy Axis V for Medical Impairment will improve from the current score of ____ to ____.

10.

Pt.’s score on the Kennedy Axis V for Medical Impairment will be maintained at ____.

Target Date

Date/Status*

Ongoing

Ongoing





6–13

Date: 01/15/03


Date/Status*

Medical: 1.

Physician will assess [acne, constipation, indigestion, mild hyperlipidemia, mild obesity, mild dysphagia, mild hyponatremia, mild dehydration, mild hypertension, mild diabetes, mild ___________________] and make appropriate treatment recommendations.

2.

Physician will order and/or perform the following health measures: a. Annual physical exam b. Annual Mantoux test c. Baseline ECG and chest X ray and follow-up as needed d. Routine screen for hepatitis e. Routine dental checks f. Podiatry consults g. Follow-up exams with dermatology as needed



Nsg. staff will monitor pt. daily and follow up on any signs and symptoms of illness.

2.

Nsg. staff will administer all prescribed meds and treatments as ordered and will document pt.’s compliance.

3.

Nsg. staff will assess and document pt.’s level of understanding of prescribed treatment and provide necessary teaching at pt.’s level of understanding.

4.

Nsg. staff will prompt pt. to comply with treatments, lab work, and any other medical procedures. If needed, nsg. staff will support and accompany pt. to procedures. Staff will offer praise for compliance and will document compliance.

5.

Nsg. staff will prompt pt. to attend to basic daily personal hygiene, including bathing, facial cleansing, shaving, combing hair, brushing teeth, and putting on clean clothes. Staff will offer praise for compliance.

6.

Nsg. staff will weigh pt. q____________, take BP and pulse q_______________, and report any significant changes to physician.

7.

Nsg. staff will monitor pt.’s fluid and food intake and urine output and will report any significant changes to physician.

8.

Nsg. staff will encourage pt. to eat a [healthy-heart, low-fat, low-cholesterol, low-salt, high-fiber, low- or high-calorie], [whole, chopped, ground] diet and increase or decrease fluid intake to prevent [constipation, hyponatremia, dehydration], promote a healthy heart, reduce or gain weight, or maintain good health.

9.

Nsg. staff will indicate in the record pt.’s allergies to ________________________.

Marilyn Davis, RN


Notes


6–15

Sample Individual Problem Plans CONTENTS Hypertension .......................................................................................................................................... 6–16 Chronic Obstructive Pulmonary Disease ................................................................................................ 6–18 Diabetes Mellitus .................................................................................................................................... 6–20 Elevated Cholesterol ............................................................................................................................... 6–22 Hypothyroidism Secondary to Lithium................................................................................................... 6–24 Seizure Disorder ..................................................................................................................................... 6–26 Hyponatremia Secondary to Polydipsia ................................................................................................. 6–28 Kidney Dysfunction Secondary to Lithium . ........................................................................................... 6–30 Dysphagia ............................................................................................................................................... 6–32 EPS (Extrapyramidal Side Effects) .......................................................................................................... 6–34 Akathisia ................................................................................................................................................. 6–36 Tardive Dyskinesia .................................................................................................................................. 6–38 Family Planning ...................................................................................................................................... 6–40 Family Planning ...................................................................................................................................... 6–42 Pregnancy ............................................................................................................................................... 6–44

6–16


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.1 Hypertension

Name: Scott, Daniel ID #: Area:


Date: 01/15/03

Problem Description: Pt. has had hypertension for the last several years. His hypertension has been well controlled with a combination of diet, exercise, and meds. This has led to a resolution of pt.’s mild obesity. There is no history of alcohol abuse or cigarette use. Pt.’s family history is strongly positive for hypertension and heart disease. Pt.’s cholesterol and triglycerides are WNL.


1.

Maintain blood pressure WNL.


1.

Pt. will be able to verbalize a reasonable understanding of hypertension and its treatment.

Target Date

Date/Status*

Ongoing

Target Date

Date/Status*

Ongoing





6–17

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will prescribe antihypertensives and diuretics.

2.

Internist will order blood work, including potassium and cholesterol levels.

3.

Internist will order a low-cholesterol, low-salt diet and weight control.

4.

Internist will determine level of exercise pt. can safely tolerate.

5.

Internist will order aspirin 1 po daily as a prophylactic against an MI.

Donald Mason, MD

Dietitian: 1.

Dietitian will meet with pt. once a week to help pt. continue with his healthy-heart, low-sodium diet.

2.

Dietitian will help pt. monitor calories to help ensure that pt. maintains his weight loss.

Sandra Anderson, Dietitian

Rehab: 1.

Rehab counselor will arrange a regular exercise program for pt. that he can safely tolerate.



Nsg. staff will monitor vital signs monthly.

2.

Nsg. staff will make ongoing observations of skin color, swelling, and temp. for evidence of edema or peripheral vascular disease.

3.

Nsg. staff will continue to educate pt. to help him understand, recognize, and continue to reduce some of the underlying risk factors, such as lack of exercise, poor diet, and psychological stress.

4.

Nsg. staff will ensure that pt. has routine follow-ups with the internist.



6–18


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.2 Chronic Obstructive Pulmonary Disease Nursing Diagnosis: Impaired Gas Exchange

Name: Johnson, Tiffany ID #: Area: Date: 01/15/03

Problem Description: Pt. has long-standing history of cigarette use (one to two packs a day). Six months ago, she was diagnosed as having COPD secondary to cigarette smoking. To prevent further deterioration in her respiratory status, she stopped smoking at that time; however, at times, pt. appears to have difficulty maintaining her abstinence from cigarettes. At present, pt. walks freely about the ward with no significant evidence of shortness of breath; however, pt. has great difficulty walking up a flight of stairs. Over the last few months, pt.’s pulse ox has been around 94%.


Target Date

1.

Pt. will maintain patency of bronchial airways and facilitate reasonable exchange of C02/02, AEB no deterioration in her pulmonary function studies for 6 months.

01/15/04

2.

Pt.’s pulse ox will be maintained at 94% or greater for 3 months.

Ongoing


1.

Pt. will be able to verbalize a reasonable understanding of her illness and the long-term importance of treatment, including continued abstinence from smoking.

Target Date

Date/Status*

Date/Status*

04/15/03





6–19

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will prescribe bronchodilators, such as albuterol, and other respiratory meds as ordered.

Margaret Patel, MD

Rehab: 1.

Rehab staff will provide activities as tolerated and provide an opportunity for rest as needed.



Nsg. staff will make ongoing observations for evidence of respiratory distress, including changes in pt.’s skin color.

2.

Nsg. staff will assess pt.’s breath sounds weekly, as well as when she is showing any respiratory distress.

3.

Nsg. staff will use the pulse oximeter to measure pt.’s blood oxygenation (pulse ox) once daily.

4.

Nsg. staff will notify pt.’s internist of any significant change in pt.’s pulmonary function.

5.

Nsg. staff will schedule pt. for routine follow-up at Pulmonary Clinic.

6.

Nsg. staff will encourage pt. to breathe deeply and to have a reasonable fluid intake.

7.

Nsg. staff will educate pt. to help her understand, recognize, and attempt to reduce some of the underlying risk factors, such as smoking, air pollution, allergies (including high pollen count), lack of exercise, and dehydration.

8.

Nsg. staff will educate pt. to help her understand and deal with the long-term aspects of her COPD.



6–20


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.3 Diabetes Mellitus

Name: Costello, Roger ID #: Area:

Nursing Diagnosis: Risk for Elevated Blood Sugar

Date: 01/15/03

Problem Description: Pt. is a 48-year-old man who has had diabetes for the last 10 years. There is no known etiology of his diabetes, other than having a family history that is strongly positive for adult-onset diabetes. When first diagnosed, his diabetes was controlled with diet and low doses of oral hypoglycemics. However, for the last few years, pt. has required insulin to control his blood sugar. Currently, pt.’s diabetes is well controlled with diet and insulin; however, pt. does not appear to have a good understanding of his diabetes and its possible complications.


Target Date

1.

Pt. will maintain good control of his diabetes, AEB normal blood sugars, including absence of hyperglycemic and hypoglycemic episodes, for 6 months.

Ongoing

2.

Pt. will consistently verbalize an understanding that treatment of his diabetes will help prevent the development of diabetic complications, such as recurrent cellulitis of his feet, diabetic retinopathy, cataracts, and diabetic nephropathy, for 6 months.

01/15/04


1.

Pt. will consistently verbalize an understanding of the risk factors associated with diabetes mellitus and an understanding of the treatment modalities for 3 months.

Target Date

Date/Status*

Date/Status*

07/15/03





6–21

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will order blood sugar levels, including finger-stick blood sugar levels.

2.

Based on pt.’s blood sugar levels, internist will make needed adjustments in pt.’s regular insulin dosage and adjust pt.’s Insulin Sliding Scale as needed.

3.

Internist will order periodic complete blood workup; urinalysis, including sugar and acetone levels; ECG; and chest X ray.

4.

Internist will treat any diabetic complications as they occur.

Margaret Patel, MD


Nsg. staff will monitor pt. for evidence that he is developing diabetic complications.

2.

Nsg. staff will monitor pt.’s finger-stick blood sugars and make adjustments in his insulin according to pt.’s Insulin Sliding Scale.

3.

Nsg. staff will monitor pt.’s weight and BP once a month.

4.

Nsg. staff will monitor pt.’s physical activity.

5.

Nsg. staff will run diabetic group 45 minutes per week for pt. education with regard to the diabetic condition, nutrition, insulin, and risk factors and complications associated with diabetes and insulin.

6.

Nsg. staff will ensure that pt. is seen in Podiatry Clinic at least once q 3 months.


Dietitian: 1.

Dietitian will provide dietary consultation as needed to maintain pt. on an antidiabetic diet with enough calories to meet daily demands as per physical activity, height, and weight.



6–22


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.4 Elevated Cholesterol

Name: Schwartz, Ronald ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a history of elevated cholesterol that was first detected in 07/02. Pt.’s cholesterol level at that time was 276. Pt.’s diet was very high in cholesterol and saturated fats. Nursing attempts to get pt. to stick to a low-cholesterol diet led to a reduction of pt.’s cholesterol level to around 240. Currently it is felt that pt. could benefit from cholesterol-lowering meds, in addition to continuing his diet. Pt. does not have a good understanding of the relationship between cholesterol and heart disease. Pt.’s family history is strongly positive for cardiovascular disease. Pt.’s mother also has elevated cholesterol.


1.

Pt. will achieve and maintain normal blood cholesterol level for at least 3 months.


Target Date

Date/Status*

07/15/03

Target Date

1.

Pt. will be able to consistently verbalize a reasonable understanding of the relationship between blood cholesterol and heart disease for 1 month.

04/15/03

2.

Pt. will be able to consistently identify and avoid foods high in cholesterol and saturated fats for 1 month.

04/15/03

3.

Pt.’s blood cholesterol will be decreased to less than 200 for 1 month.

04/15/03

Date/Status*





6–23

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will order periodic blood cholesterol levels and lipid profiles.

2.

Internist will order a dietary consult for follow-up of pt.’s low-fat, low-cholesterol diet.

3.

Internist will prescribe cholesterol-lowering meds, such as niacin (vitamin B3), Lipitor (atorvastatin calcium), or Zocor (simvastatin).

Donald Mason, MD

Dietitian: 1.

Dietitian will educate pt. on how to identify and avoid foods that are high in cholesterol and saturated fats, as well as how to identify foods that are a part of a low-fat, low-cholesterol diet.



Nsg. staff will educate pt. as to the importance of dietary compliance and help him limit his intake of foods that are high in cholesterol and saturated fats.

Marilyn Davis, RN


6–24


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.5 Hypothyroidism Secondary to Lithium Nursing Diagnosis: Risk for Endocrine Imbalance

Name: Russell, Maria ID #: Area: Date: 01/15/03

Problem Description: Pt. has been on lithium for many years with associated hypothyroidism. Endocrinology workup diagnosed the problem as hypothyroidism secondary to lithium. Pt. is on thyroid replacement meds (Synthroid) and is currently euthyroid. She does not have a goiter. Pt.’s psychiatric symptoms are clearly improved by lithium, and alternatives to lithium are less effective. At times, pt. is reluctant to take her Synthroid because she has experienced very few symptoms of hypothyroidism; therefore, she often argues that she does not have any problems with her thyroid function.


1.

Pt. will remain in a euthyroid state for 6 months.


Target Date

Date/Status*

Ongoing

Target Date

1.

Pt. will cooperate with treatment so that complications associated with hypothyroidism will be prevented.

Ongoing

2.

Pt. will consistently verbalize an understanding of her need to take her meds for 3 months.

07/15/03

Date/Status*





6–25

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will order periodic follow-up by the Endocrine Clinic as needed.

2.

Internist will order blood thyroid function studies as needed.

3.

Internist will prescribe thyroid replacement medication, such as Synthroid, and adjust the dose based on pt.’s thyroid function studies.

Margaret Patel, MD


Nsg. staff will educate pt. for ½ hour once weekly to help pt. understand the need to take her thyroid replacement meds.

2.

Nsg. staff will monitor pt. for evidence of hyperthyroidism and inform pt.’s internist of any significant findings.



6–26


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.6 Seizure Disorder

Name: Harrison, Henry ID #: Area:

Nursing Diagnosis: Risk for Seizures

Date: 01/15/03

Problem Description: Pt. has had seizures since age 12, including grand mal seizures that occurred 1 to 2 times a month. The seizure activity was present at the same frequency for years despite various attempts to reduce the frequency. EEGs revealed multiple epileptic foci. Over the last few years, using a combination of anticonvulsants, the frequency of seizures has stabilized at the current level of less than once every 6 months. At times in the past, pt. was reluctant to take his anticonvulsants; however, currently he appears to have a fairly good understanding of the need to continue his anticonvulsants.


1.

Pt. will have no more than 1 seizure q 6 months.


Target Date

Date/Status*

Ongoing

Target Date

1.

Pt. will have no more than 1 seizure q 3 months.

Ongoing

2.

Pt. will be compliant with his taking his anticonvulsants for 3 months.

Ongoing

3.

Pt. will consistently verbalize an understanding of his seizure disorder and the need to take his meds for 3 months.

Ongoing

Date/Status*





6–27

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will prescribe anticonvulsants, such as Depakote (divalproex sodium) and Neurontin (gabapentin).

2.

Internist will order periodic serum blood levels, such as Depakote (divalproex sodium) levels.

3.

Internist will refer pt. for follow-up appointments as needed with a neurologist.

Margaret Patel, MD


Nsg. staff will lead seizure group once per week to help pt. maintain an understanding of his seizure disorder and the need to take his meds.

2.

Nsg. staff will keep a flow sheet on the frequency of pt.’s seizures and will inform the internist of any increase in the frequency of pt.’s seizures.

Linda Larkin, RN


6–28


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.7 Hyponatremia Secondary to Polydipsia Nursing Diagnosis: Excess Fluid Volume

Name: Drago, Evelyn ID #: Area: Date: 01/15/03

Problem Description: Pt. has a long history of drinking water and other fluids to a dangerous excess, which results in electrolyte imbalances. There appears to be no organic basis for the polydipsia. Two years ago, this resulted in seizures when her blood Na+ dropped to 124 (pt. has a seizure disorder that is well controlled by anticonvulsants when pt.’s Na+ is above 130). Through monitoring and encouraging pt. to limit her fluid intake, pt. has not had seizures for years. With monitoring, including twice-weekly Na+ levels, her Na+ is generally 134 or greater. Because of drops in her Na+ below 130, she requires one-to-one monitoring once or twice every 6 months. Pt. appears to have a reasonable understanding of the risk factors associated with polydipsia and the treatment modalities; however, she constantly complains of being thirsty.


Target Date

1.

Pt. will maintain a Na+ of 130 or greater so that she will not require one-to-one monitoring for 6 months.

01/15/04

2.

Pt.’s Na+ levels will be maintained at an “acceptable” level (134 or greater) for 6 months.

01/15/04


Target Date

1.

Pt.’s Na+ levels will be maintained at an “acceptable” level (134 or greater) for 3 months.

07/15/03

2.

Pt. will not gain 8 pounds or more during a 24-hour period for 3 months.

07/15/03

Date/Status*

Date/Status*





6–29

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will order electrolytes twice weekly—daily if Na+ falls below 130.

2.

Internist will restrict pt. to the ward and place pt. on one-to-one monitoring if Na+ falls below 130.

Margaret Patel, MD


Nsg. staff will encourage pt. to limit her fluid intake and to eat solid foods and foods high in Na+.

2.

Nsg. staff will weigh pt. bid.

3.

Nsg. staff will restrict pt. to the ward if pt. gains 8 pounds during a 12-hour period and will have a blood Na+ drawn immediately.

4.

Nsg. staff will restrict pt. to the ward, place pt. on one-to-one monitoring, and restrict pt.’s fluid intake to 2000 cc/24 hrs if Na+ falls below 130.

5.

When pt. is restricted to the ward, nsg. staff will maintain intake/output records and pt.’s Na+ level will be drawn q day.

6.

Nsg. staff will provide positive reenforcement when pt. is able to maintain her blood Na+ level at 134 or greater.



6–30


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.8 Kidney Dysfunction Secondary to Lithium Nursing Diagnosis: Impaired Urinary Elimination

Name: Bryant, Harriet ID #: Area: Date: 01/15/03

Problem Description: During a period of dehydration in association with a weight reduction diet, pt. developed lithium toxicity. Pt. had been toxic once before in the past, in association with skipping blood lithium levels. During the toxic episode, pt. was immediately taken off the lithium. Following the toxic episode, it was noted that pt. had developed diabetes insipidus secondary to lithium toxicity. Pt. is currently off lithium, and fortunately her diabetes insipidus is expected to resolve. Pt.’s manic, aggressive behavior is being reasonably well controlled with a mood stabilizer, Depakote. There are no plans at present to restart lithium because of pt.’s difficulty following up with her diet and blood tests required for lithium.


Target Date

1.

Pt.’s kidney function will return to normal AEB normal blood Na+, BUN, and creatinine levels and normal urine specific gravity for 6 months.

01/15/04

2.

Pt.’s manic and aggressive behaviors will be reasonably well controlled without having to restart pt. on lithium for 6 months.

01/15/04


1.

Pt. will have a normal blood Na+, BUN, and creatinine for 3 months.

Target Date

Date/Status*

Date/Status*

07/15/03





6–31

Date: 01/15/03


Date/Status*

Internist: 1.

Internist will get nephrology consults as needed.

2.

Internist will monitor progress of diabetes insipidus and check for evidence of renal failure with monthly electrolytes, BUN, and creatinine.

3.

Internist will order weekly urine specific gravity checks.

4.

Internist will order meds such as hydrochlorothiazide to assist kidney function.

Margaret Patel, MD


Nsg. staff will ensure that pt. has adequate fluid intake to keep up with fluid loss.

2.

Nsg. staff will use an intake and output chart to monitor pt.’s fluid intake.


Dietitian: 1.

Dietitian will provide dietary consult if pt. decides to go on another weight-reduction diet.



6–32


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.9 Dysphagia

Name: Frantz, Marshall ID #: Area:

Nursing Diagnosis: Impaired Swallowing

Date: 01/15/03

Problem Description: Pt. has been noted to have difficulty swallowing, which appears to have been worsened by the use of neuroleptic meds. Pt. eats very rapidly, and his chewing is very inefficient. Yesterday he choked on a meatball. The nurse had to perform the Heimlich maneuver to open his airway. AIMS Plus EPS exam reveals a significant amount of EPS. Pt.’s mental status has clearly benefited from the use of neuroleptic meds.


Target Date

1.

Pt. will maintain normal nutrition through efficient chewing and swallowing of a regular diet as measured by his maintaining his present weight for 6 months.

01/15/04

2.

Pt. will be free of any further choking episodes for 1 year.

01/15/04


Target Date

1.

Pt. will be free of any further choking episodes for 3 months.

07/15/03

2.

Pt. will be able to experience a reduction in EPS AEB a reduction in the tightness in his neck and the stiffness in his arms for 3 months.

07/15/03

3.

Pt. will demonstrate a slowing in his eating and an increased efficiency in chewing of his food for 3 months.

07/15/03

4.

Pt. will be switched from a chopped diet back to a regular diet when he is determined to be able to safely eat a regular diet.

07/15/03

Date/Status*

Date/Status*





6–33

Date: 01/15/03


Date/Status*

Psychiatrist: 1.

Psychiatrist will treat pt.’s EPS with a reduction in pt.’s neuroleptic meds; a change to another neuroleptic, such as Zyprexa; or a prescription for an antidyskinetic, such as Cogentin.

2.

Psychiatrist will do an AIMS Plus EPS evaluation in 2 weeks following the above med changes.

3.

Psychiatrist will refer pt. to Dysphagia Clinic for possible modified barium swallow to more fully assess pt.’s dysphagia.



Nsg. staff will provide one-to-one monitoring during meals by staff trained in Heimlich maneuver.

2.

Nsg. staff will educate pt. on avoiding hard or dry foods and alternating bites of food with fluids.


Dietitian: 1.

Dietitian will provide pt. with a chopped diet.

2.

Dietitian will evaluate and educate pt. in weekly one-to-one meetings concerning his eating habits and the relationship to choking.



6–34


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.10 EPS (Extrapyramidal Side Effects)

Name: Walsh, Ruth ID #: Area:

Nursing Diagnosis: Impaired Physical Mobility

Date: 01/15/03

Problem Description: Pt. complains of stiffness of extremities. Exam reveals bradykinesia, left greater than right, cogwheel rigidity of wrists and elbows, left greater than right 4 to 6 Hz hand tremor, shuffling gait, diminished arm swing, and foreflexed posture consistent with neuroleptic-induced extrapyramidal side effects (pseudo-Parkinsonism). These findings were not present before reinitiation of neuroleptic treatment 6 months ago. Parkinsonism may be associated with increased falling risk in this pt. Pt. is currently on Risperdal (risperidone) 6 mg bid. Maintenance dose in the community had been 4 mg bid. The pt.’s psychotic symptoms have responded well to Risperdal, but she is known to decompensate rapidly when off neuroleptics.


1.

Pt. will have control of psychotic symptoms with least possible extrapyramidal side effects for 3 months.


Target Date

Date/Status*

07/15/03

Target Date

1.

Pt. will continue to be free from episodes of falling.

Ongoing

2.

Pt. will express a feeling of a reduction in the sensation of stiffness without a worsening of her psychotic symptoms for 1 month.

04/15/03

3.

Pt.’s score on the AIMS Plus EPS (EPS Section) will decrease from current 12 to 6 or less, without a worsening of her psychotic symptoms (i.e., without a decrease in her Kennedy Axis V score for Psychological Impairment).

04/15/03

Date/Status*





6–35

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will reduce Risperdal from 6 mg bid to 4 mg bid and begin Cogentin 1 mg po bid. Increase Cogentin by 1 mg/day every 3 days until rigidity and shuffling improve or until 6 mg/day is reached. Further changes in meds as ordered.

2.

If above interventions fail to reduce EPS in 1 month, psychiatrist will consider changing pt. to a neuroleptic less likely to cause EPS, such as Zyprexa (olanzapine).


Psychology: 1.

Kennedy Axis V rating prior to Risperdal reduction and then monthly to capture any deterioration in pt.’s mental status in association with the medication adjustment.



Nsg. staff will make ongoing mental status evaluations to observe for any deterioration with decrement in Risperdal dosage.

2.

Nsg. staff will make weekly measurements using the AIMS Plus EPS exam to observe for reductions in pt.’s EPS during the period of Risperdal reduction.



6–36


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.11 Akathisia

Name: Gumble, Vincent ID #: Area:

Nursing Diagnosis: Impaired Physical Mobility

Date: 01/15/03

Problem Description: Pt. complains of restlessness with difficulty sitting through 30-minute groups, sitting through meals, watching TV, or calming down to go to sleep. Examination reveals no evidence of Parkinsonism or dystonia, but there is ongoing motor restlessness with leg rubbing and rocking when seated, shifting from foot to foot when asked to stand still, and a tendency to pace rapidly in the hallways. Low-potency antipsychotics and atypical antipsychotics have not been as effective as Haldol (haloperidol) in controlling pt.’s psychotic symptoms. It is felt that reasonable control may be maintained on a lower dose of Haldol. Also, pt.’s akathisia is suspected to be contributing to the appearance of greater severity of his psychosis.


1.

Pt. will be able to maintain good control of his psychotic symptoms with minimal akathisia for 1 month.


1.

Pt. will be able to sit through meals and 30-minute groups consistently for 2 weeks.

Target Date

Date/Status*

04/15/03

Target Date

Date/Status*

03/15/03





6–37

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will rate the Kennedy Axis V before Haldol reduction and then weekly to observe for any deterioration in pt.’s mental status in association with the medication adjustment.

2.

Psychiatrist will slowly reduce Haldol and give entire dose at HS.

3.

Psychiatrist will make ongoing observations for changes in pt.’s akathisia during the period of Haldol reduction.

4.

Psychiatrist will make weekly measurements of akathisia using the AIMS Plus EPS to observe for reductions in pt.’s akathisia during the period of Haldol reduction.

5.

Psychiatrist will make ongoing mental status evaluations to observe for any deterioration with the medication adjustments.

6.

Once pt. is medically cleared and if akathisia continues, psychiatrist will consider starting pt. on a trial of beta-blockers, such as Inderal.


Internist: 1.

Internist will medically clear pt. for possible use of beta-blockers.

Margaret Patel, MD


Nsg. staff will make ongoing assessments of pt.’s akathisia and mental status, especially when administering his meds.

2.

Nsg. staff will report to the psychiatrist any significant changes in pt.’s akathisia or mental status.



6–38


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.12 Tardive Dyskinesia (TD)

Name: Danavich, Debra ID #: Area:

Nursing Diagnosis: Impaired Physical Mobility Date: 01/15/03

Problem Description: AIMS exam about 2 weeks ago revealed moderate choreoathetoid movement of tongue and distal extremities consistent with TD. Previous AIMS exams did not meet the criteria for TD. Several weeks before the current AIMS exam, pt.’s Haldol was decreased; therefore, the current increase in the AIMS score may represent a withdrawal emergent syndrome. In the past, pt. has decompensated when Haldol was decreased to levels significantly lower than she is currently on. Pt. has a general understanding of the risks associated with tardive dyskinesia and continued use of Haldol. She agrees to continue Haldol at a reduced dose, despite the risks. She is also willing to supplement the Haldol with Zyprexa (olanzapine), which may be less likely to worsen her TD. It is hoped that the Zyprexa can be used to replace the Haldol.


Target Date

1.

Pt. will be able to demonstrate control of her psychotic symptoms with the lowest reasonable neuroleptic dosage and, if possible, use neuroleptics that are less likely to cause TD for 3 months.

07/15/03

2.

Pt. will show no worsening of her dyskinetic movements for 3 months.

07/15/03


1.

Pt. will show no worsening of her dyskinetic movements for 1 month.

Target Date

Date/Status*

Date/Status*

04/15/03





6–39

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will decrease Haldol as Zyprexa is added to pt.’s treatment regimen.

2.

To R/O TD versus withdrawal emergent syndrome, psychiatrist will repeat AIMS exam q month to determine whether pt.’s dyskinetic movements resolve consistent with withdrawal emergent syndrome or persist consistent with TD.

3.

If pt. continues to meet AIMS criteria for TD more than 3 months after the reduction of Haldol dosage, psychiatrist will refer pt. to Movement Disorder Clinic for consideration of alternative drug treatment strategies aimed at a reduction of dyskinesia.

4.

If pt.’s AIMS scores worsen after 3 months, psychiatrist will consider a trial of clozapine.

5.

Pt. will be prescribed vitamin E to help minimize tardive dyskinesia.



6–40


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.13 Family Planning

Name: Lampson, Angela ID #: Area:

Nursing Diagnosis: Ineffective Health Maintenance Date: 01/15/03

Problem Description: Pt. is a 32-year-old, twice-divorced mother of three children. All her children are in foster care. She remains sexually active with various partners of the opposite sex and is requesting birth control. She does not want any more children at this time. She has never practiced birth control and is not sure which method is right for her lifestyle.


Target Date

1.

Pt. will faithfully adhere to her birth control program for 3 months.

07/15/03

2.

Pt. will consistently express an understanding of the need to immediately contact her physician with any symptoms of sexually transmitted diseases (STDs) for 3 months.

07/15/03


Target Date

1.

Pt. will cooperate with a gynecological exam.

02/15/03

2.

Pt. will be able to express a reasonable understanding of birth control, including risks and benefits, for 1 month.

03/15/03

3.

Pt. will have an awareness of the risks associated with multiple sexual partners for 1 month.

03/15/03

4.

Pt. will express an awareness of STDs, including symptoms that require medical attention.

03/15/03

5.

Pt. will choose a contraceptive method that fits her lifestyle and meets her needs.

03/15/03

Date/Status*

Date/Status*





6–41

Date: 01/15/03


Date/Status*


Nsg. staff will schedule appointment for gynecological exam.

2.

Family planning counselor will provide pt. with literature on family planning and meet weekly with pt. for ½ hour for at least 2 weeks to educate pt. about the following: a. The available birth control methods, including risks and benefits b. STDs and symptoms and when to seek help from her physician

3.

At the end of the educational program, counselor will schedule an appointment for an additional ½ hour to assist pt. in choosing a suitable birth control method.

4.

Nsg. staff will schedule pt. for follow-up appointments at the family planning clinic in the hospital. At discharge, a follow-up appointment will be scheduled at her local family planning clinic.

Ronald Donahue, RN Linda Larkin, RN (Family Planning Counselor)


6–42


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.14 Family Planning

Name: Lang, Dorothy ID #: Area:

Nursing Diagnosis: Ineffective Health Maintenance Date: 01/15/03

Problem Description: Pt. is a 26-year-old, twice-divorced mother of three children. One of her children has been adopted and two are in foster care. She has had two abortions. She remains sexually active with various partners of the opposite sex. She is refusing birth control and is anxious to have more children. Pt. appears to have a lot of fantasies and misunderstandings concerning sexual relationships and having children. Pt.’s sexual behavior appears to be related to her loneliness and dependency needs. Also, she does not understand the risks of STDs.


Target Date

1.

Pt. will be able to express a reasonably informed understanding of her sexual behavior consistently for 3 months.

07/15/03

2.

Pt. will recognize her loneliness and dependency needs and identify more appropriate ways of dealing with them consistently for 3 months.

07/15/03


Target Date

1.

Pt. will begin to develop a trusting relationship with her counselor.

02/15/03

2.

Pt. will begin verbalizing in one-to-one therapy her thoughts, feelings, and fantasies about having children consistently for 1 month.

04/15/03

3.

In one-to-one therapy, Pt. will explore positive and negative aspects of her relationships with men, including identification of needs satisfied, consistently for 1 month.

04/15/03

4.

Pt. will accept family planning counseling, including counseling on the risk of STDs.

04/15/03

5.

Pt. will begin to participate in a sex education program.

04/15/03

Date/Status*

Date/Status*





6–43

Date: 01/15/03


Date/Status*

Psychology: 1.

Psychologist will schedule meetings with pt. initially for 15 minutes twice a week; meetings will be increased to ½ hour as psychologist develops a therapeutic relationship with pt.

2.

Psychologist will gradually explore pt.’s fantasies around pregnancy and child rearing and assist pt. in understanding the realities of pregnancy and child rearing.

3.

Psychologist will assist pt. with identifying needs met by her sexual behavior and help pt. explore alternative means of meeting her needs.

4.

Psychologist will encourage pt. to enroll in the weekly women’s group.

5.

Psychologist will encourage pt. to become involved in a sex education program that addresses her needs and encourage pt. to work with the Family Planning Counselor.


Rehab: 1.

Rehab counselor will lead the weekly women’s group to help pt. explore positive and negative aspects of her relationships with men.

Jane Hoover, Rehab


Family planning counselor will make pt. aware that family planning counseling is available and encourage pt.’s participation.

2.

Family planning counselor will provide family planning counseling for ½ hour once weekly when pt. is agreeable.

Linda Larkin, RN (Family Planning Counselor)


6–44


INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.15 Pregnancy

Name: Duncan, Helen ID #: Area:


Date: 01/15/03

Problem Description: Pt. is a 28-year-old single female who is here in the hospital in her last trimester of her first pregnancy. She carries a diagnosis of schizophrenia and has a history of multiple psychiatric admissions. She has not been going for prenatal care, is not taking her antipsychotic meds, and is floridly psychotic. She denies that she is pregnant. The paternity of the child is unknown. Pt.’s mother is her legal guardian, and her mother wishes to care for the baby once it is born. Staff feels that pt.’s mother can provide a healthy, nurturing environment for the baby, as well as allow pt., when she is doing well, to have an ongoing relationship with her baby.


Target Date

1.

Pt. will safely deliver a full-term, healthy baby.

04/15/03

2.

Pt. will concur with the need to place her baby in the care of her mother until she can safely care for her baby.

04/15/03


Target Date

1.

Pt. will see an obstetrician as soon as possible.

01/29/03

2.

Pt. will cooperate with and will receive adequate nutrition, rest, and exercise.

02/15/03

3.

Pt. will acknowledge her pregnancy.

02/15/03

4.

Pt. will verbalize an understanding of the need for prenatal care and verbalize an awareness of the signs and symptoms of labor.

02/15/03

Date/Status*

Date/Status*





6–45

Date: 01/15/03


Date/Status*

Social Work/Nursing: 1.

Staff will discuss with pt. and her mother the placement of pt.’s infant with pt.’s mother.

Brenda St. Martin, MSW, and Linda Larkin, OBS Primary Nurse


Nsg. staff will maintain pt. in an environment that is safe for her and her unborn child.

2.

Nsg. staff will develop a trusting relationship with pt. to get pt. to cooperate with prenatal care.

3.

Nsg. staff will monitor nutrition, elimination, rest, and activity; staff will report any difficulties to the obstetrician.

Ronald Donahue, RN Å Nsg. Staff 4.

Nsg. staff will meet with pt. for ½ hour once weekly to provide education about pregnancy and delivery, including signs and symptoms of labor.

Linda Larkin, RN, OBS Primary Nurse 5.

Nsg. staff will be educated to the signs and symptoms of labor so they can monitor these signs and symptoms on a daily basis, as well as review them with pt.

Linda Larkin, OBS Primary Nurse Å Nsg. Staff 6.

Staff will collaborate to determine when pt. will be transferred to the Maternity Ward.

Ronald Donahue, RN Linda Larkin, OBS Primary Nurse 7.

As pt.’s due date approaches, check pt. every 15 minutes for evidence of labor.


Other: 1.

Treatment outlined in Problem 1.1 Psychotic Symptoms, including a low-dose antipsychotic med that is medically cleared and recommended by pt.’s psychiatrist and obstetrician following a discussion of the risks and benefits with pt. and her guardian.

Staff as indicated


Notes

ANCILLARY IMPAIRMENT (Problem Area 7)

7–1


Ancillary Impairment (Problem Area 7)

7–3

ANCILLARY IMPAIRMENT (Problem Area 7) CONTENTS Kennedy Axis V for Ancillary Impairment ................................................................................................ 7–4 This rating scale can be used to measure the outcome of treatment. It also helps to define the problems that fit into the category of Ancillary Impairment and can be helpful in composing a short description of each problem.

Problem Names and Descriptions ............................................................................................................ 7–5 Examples of problem names and descriptions that may relate to Ancillary Impairment are listed here. These examples can be used to develop the Problem List and to help compose a short description of each problem.

Strengths .................................................................................................................................................. 7–5 Examples of strengths that may be related to treatment and discharge in the area of Ancillary Strengths are listed here.

Goals ......................................................................................................................................................... 7–6 Examples of treatment goals that may relate to problems in the area of Ancillary Impairment are listed here.

Treatment Modalities ............................................................................................................................... 7–7 Examples of treatment modalities that may relate to problems in the area of Ancillary Impairment are listed here.

Individual Problem Plan (Frequent Entries) ............................................................................................. 7–8 An Individual Problem Plan containing examples of information relating to Ancillary Impairment is included here.

Sample Individual Problem Plans ........................................................................................................... 7–11 A wide range of Individual Problem Plans relating to Ancillary Impairment are included here.

7–4


Kennedy Axis V—Ancillary Impairment 100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood, home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe environment. No significant ancillary problems or symptoms. 90 Good life situation; has few if any ancillary problems; no more than minor problems with living environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet his/her needs, rare late payment on a bill, rare parking or traffic ticket. 80 If ancillary problems are present, they are transient and cause no more than minimal difficulty with his/her living situation, financial resources, or the law; somewhat more than average problems with his/her living environment, financial resources, or legal problems.

70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal violence in his/her environment; however, generally safe living situation. 60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards; evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing, defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for competency to make decisions concerning person, estate, and/or treatment. 50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for placement. 40 Major problems with living situation, finances, and/or the law; some real danger of being physically injured in his/her environment; evaluation and/or disposition is being made for very violent criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson). 30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate physical injuries from violence in his/her environment. 20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing or because of high level of violence in his/her environment; evaluation and/or disposition is being made for extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).

10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment; evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone, very viciously harming or very viciously raping a child, arson with intent of hurting others). NR Not rated



Ancillary Problems A.

Placement difficulties 1. Homelessness 2. Alienation of halfway house staff members 3. Ambivalence about leaving the hospital 4. Appropriate placement not available 5. Placement blocked by unresolved legal difficulties

B.

Financial problems 1. No means of support 2. Debts beyond ability to pay 3. Overwhelming credit card debt 4. Social Security Disability Income (SSDI) benefits needed

C.

Legal difficulties 1. Court report 2. Court assessment of competency 3. Court permission for forcing medication 4. Court review of use of antipsychotic meds 5. Court review of use of an experimental drug 6. Court review of psychosurgery 7. Criminal charges 8. Guardian is not properly handling pt.’s money 9. Divorce

D.

Data collection 1. Insufficient database 2. No information available on pt.’s psychiatric history 3. No information available on pt.’s current housing or legal status

E.

Other ancillary problems 1. Dangerous homeless situation 2. High level of violence in pt.’s environment 3. No stable residence 4. Abusive spouse 5. Target of a stalker


Ancillary Strengths A. B. C. D. E. F. G. H. I. J. K. L.

Community placement to return to Safe environment to return to Supportive family or friend who is actively involved in pt.’s care Good community support network Good religious support system Economic security Financial resources for basic needs Private insurance SSDI in place Guardianship in place for psychotropic meds Guardianship in place for person and estate Other ancillary strengths

7–5

7–6


Goals I.

II.

Expected Improvements A.

Placement 1. Pt. will be able to demonstrate basic community living skills, including the ability to use public transportation, budget money, shop for food, and prepare a meal, for 3 months. 2. Pt. will be able to verbalize fears and ambivalence about moving into a community residence. 3. Pt. will go on a “no-strings-attached” tour of prospective halfway houses. 4. Pt. will be able to consistently express an understanding of the benefits of going into a halfway house for 1 month. 5. Pt. will be able to begin the process of slow transition to a community setting without serious regression. 6. Pt. will be able to successfully go to the community day program two times a week for 1 month. 7. Pt. will be placed in a structured residential setting without serious regression during the transition. 8. Pt. will be able to transition from a locked ward to an unlocked, open ward. 9. Pt. will reduce dependency on his or her mother to the point that pt. will begin to discuss community residential alternatives to being discharged to live with mother. 10. Pt. will express an understanding of the fact that pt. can benefit from discharge to a halfway house rather than return to mother’s home. 11. Pt. will be discharged to the appropriately supervised residential setting. 12. Pt. will improve so that court approval can be obtained for discharge to a halfway house.

B.

Financial 1. Pt. will begin getting SSDI benefits as a step toward being able to move out of the homeless shelter. 2. Pt. will be able to get a job that will provide the income necessary to stabilize pt.’s life to live outside of the hospital. 3. Pt. will cooperate with social worker on ways to get credit card debt under control.

C.

Legal 1. Pt. will cooperate so that the information needed to complete the mandated court evaluation can be gathered. 2. Pt. will show up for the court hearing. 3. Pt. will have a permanent legal guardian appointed by the court for financial, medical, and psychiatric concerns. 4. Pt. will consistently maintain communication with the guardian for 3 months. 5. Pt. will consistently cooperate with the lawyer in gathering the necessary information for pt.’s upcoming divorce, for 1 month. 6. Pt. will consistently cooperate with the lawyer in pt.’s defense against the charge of attempted murder for 3 months.

D.

Other 1. No examples given.


Pt. will discuss fears about leaving the hospital.

III. Participation in Groups, Program Activities, and the Like A. B.

Pt. will participate in discharge transition group. Pt. will participate in the abused spouses group.


7–7


V.

A.

Medication and laboratory work 1. Pt. will discuss the benefits of taking meds. 2. Pt. will express the benefits of taking meds. 3. Pt. will take meds as prescribed. 4. Pt. will go for follow-up lab tests in the community.

B.

Treatment planning 1. Pt. will cooperate with at least one treatment team member in the treatment planning process. 2. Pt. will be willing to participate in the court evaluation process as laid out in pt.’s treatment plan.

C.

Program activities 1. Pt. will express the benefits of attending community transition group meetings. 2. Pt. will consistently agree to go for follow-up at the community clinic.

D.

Consequences of pt.’s actions 1. Pt. will demonstrate a realistic orientation toward progress such that pt. understands and explains the connections among— a. Failure to work with the lawyer and legal setbacks b. Alienation of community staff and difficulty transitioning into the community c. Inconsistent program attendance, recurring setbacks, and continued care at the hospital d. Failure to follow through with the terms of pt.’s probation and a return to jail

Diagnostic Tests and Evaluations A. B. C.

Pt. will cooperate with the evaluation of the nature of pt.’s anxiety about discharge. Pt. will cooperate with the competency exam. Pt. will cooperate with the treatment team to gather the information necessary to complete mandated court evaluation.


Kennedy Axis V subscale for Ancillary Impairment will improve from a current score of 40 to 60.

VII. Miscellaneous A. B. C. D.

Once level of care has been determined, pt. will give staff permission to determine the availability of appropriate discharge placement. Pt. will allow the community case manager to be involved in the discharge planning process. Pt. will cooperate with determining who would be best to act as pt.’s guardian. Pt. will demonstrate motivation for discharge by advocating for self with case management about the fact that an appropriate placement is lacking, despite pt.’s readiness to function in a community residence.

Treatment Modalities Because of the extremely diverse nature of the category of Ancillary Impairment, no listing of treatment modality examples is included. However, some examples of treatment modalities for Ancillary Impairment are included in the samples of Individual Problem Plans at the end of this section on Ancillary Impairment. Also, the categories of treatment modalities presented in previous sections should generally apply to the treatment of Ancillary Impairment.

7–8


Individual Problem Plan (Frequent Entries) INDIVIDUAL PROBLEM PLAN Problem # and Name: 7.1 Court Evaluation (for criminal behavior) Nursing Diagnosis: Ineffective Community Coping

Name: Smith, John ID #: Area: Date: 01/15/03



• • •

Description and date of alleged crime

• • • • •

Motive (e.g., anger, jealousy, revenge, monetary gain, sexual gratification)

Type of court evaluation (e.g., competency to stand trial, criminal responsibility) Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor frustration tolerance, poor impulse control, antisocial personality characteristics, pedophilia) Brief description of criminal history (e.g., frequency and characteristics of crimes) Outcome of previous court evaluations Current potential for repeating the alleged crime Barriers to the evaluation (e.g., unwillingness to cooperate, poor or distorted memory for the event, lack of witnesses or other corroborating information)

2.

Make sure that the description relates to goals and treatment modalities.

3.

Address the description and treatment of associated problems that may have led to pt.’s alleged crime in the appropriate problem area, such as Problem Area 1 Psychological Impairment, Problem Area 3 Violence, or Problem Area 5 Substance Abuse.

Goal(s) (Discharge Criteria) (Please number all goals.)

1.

Pt. will consistently cooperate with the assessment process for ___ week(s).

2.

Pt. will provide the necessary information to complete the court evaluation.

3.

Pt. will cooperate with the forensic evaluation so that it can be completed by the target date.

4.

Pt. will consistently provide necessary information to complete the Forensic Evaluation for ____ week(s).

5.

Pt. will be able to express some understanding that he or she has committed a crime and needs to act to defend self in court for ____ week(s).

6.

Pt. will cooperate with efforts to regain competency to stand trial for ____ week(s).

7.

Pt. will regain competency to stand trial AEB working with the attorney and demonstrate an understanding of the charges and the role of court members for ____ week(s).

Target Date

Date/Status*





7–9

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Psychiatrist will discuss case with the forensic team, including diagnosis, medication, laboratory findings, physical findings, and follow-up psychiatric treatment recommendations.

Victor Dyson, MD

Social Work: 1.

Social worker will discuss with the forensic team issues related to environmental or social precipitants of the alleged crime and aftercare treatment services.



Psychologist will discuss psychological testing with the forensic team.


Rehab: 1.

Rehab staff will discuss with the forensic team issues relating to how pt. is doing in scheduled program groups.

Jane Hoover, Rehab


Nsg. staff will discuss with the forensic team issues relating to pt.’s behavior on the ward and any medical issues.

Marilyn Davis, RN

Forensic Team: 1.

Forensic team will gather the necessary information from the pt. and treatment team members to complete the court-ordered forensic report.

Madison Yu, PhD, Forensic Team Leader


Notes


7–11

Sample Individual Problem Plans CONTENTS Placement ............................................................................................................................................... 7–12 Homelessness.......................................................................................................................................... 7–14 Court Evaluation ..................................................................................................................................... 7–16 Court Assessment of Competency.......................................................................................................... 7–18

7–12


INDIVIDUAL PROBLEM PLAN Problem # and Name: 7.1 Placement

Name: Marco, Anne ID #: Area:

Nursing Diagnosis: Ineffective Community Coping

Date: 01/15/03

Problem Description: In the past, pt. has resided in single rooms and shelters. Historically, she abuses alcohol and behaves inappropriately in the community. With the assistance of friends, she has been able to function fairly well in the community; however, these friends are unable to provide pt. with regular support and care. When they are not available, she places herself in dangerous situations. Her friends are encouraging her to consider living in a community residential program. She has historically rejected community residential programs.


1.

Pt. will be discharged to a safe, appropriate setting.


Target Date

Date/Status*

07/15/03

Target Date

1.

Pt. will go on a tour of residential placements with “no strings attached.”

03/15/03

2.

Pt. will be able to carry on a reasonable discussion concerning possible community residential placement consistently for 1 month.

04/15/03

3.

If pt. decides to live in a community residential program, she will be tentatively accepted by a community residential program that is acceptable to her.

05/15/03

4.

If agreeable to pt., she will begin transitioning into a residential program, including going for overnight visits.

06/15/03

Date/Status*





7–13

Date: 01/15/03


Date/Status*

Social Work: 1.

Hold one-to-one session twice weekly to discuss and address placement issues with the pt.

2.

Continue to explore supervised community residential placement, as well as alternatives to supervised community residential placement.

3.

Coordinate with pt. and community resources, including significant others, if a reasonable placement plan can be agreed on.

4.

Arrange for residential tours, interviews, and the like.

5.

Plan for community day-program involvement.

Roger Sing, MSW

Rehab: 1.

Assess pt.’s ability to live outside of the hospital.

John Loudon, Rehab


7–14


INDIVIDUAL PROBLEM PLAN Problem # and Name: 7.2 Homelessness

Name: Wolfe, Nicholas ID #: Area:


Date: 01/15/03

Problem Description: Pt. has a long history of homelessness, which began sometime before his first psychiatric hospitalization in his late teens. He has no family support and has used alcohol and drugs when living on the streets. When not living on the streets, he is in a shelter, a psychiatric hospital, or jail for minor legal offenses. He has refused previous attempts to refer him to a community residence. Last winter, pt. had to be treated for medical problems suffered after exposure to the severe weather conditions. Pt.’s judgment is increasingly impaired and he is increasingly making irrational plans to continue living on the streets. If brought to the court, it is very unlikely that the court would honor pt.’s request to be discharged to the streets.


1.

Pt. will be discharged to a community residential setting after successfully completing 1 week of overnights.


Target Date

Date/Status*

05/15/03

Target Date

1.

Pt. will agree to work with his social worker and community case manager concerning discharge plans.

02/15/03

2.

Pt. will agree to visit the community residences available in his placement area.

03/15/03

3.

Pt. will be able to express at least three advantages to living in a community residence.

03/15/03

4.

Pt. will agree to be referred to a community residence of his choice in his placement area.

04/15/03

Date/Status*





7–15

Date: 01/15/03


Date/Status*

Social Work: 1.

Social worker will meet with pt. at least 1 hour weekly to discuss discharge plans, including the advantages of moving from the streets into a community residence.

2.

Social worker will arrange visits with pt. to appropriate community residences.


Social Work/Case Management: 1.

Social worker will assist pt. in establishing relationships in the community (e.g., staff and residents in the community day program and the community residential program).

2.

Case manager will arrange for residential tours, interviews, and the like.

Brenda St. Martin, MSW Richard Sullivan, Community Case Manager

Other: 1.

Continue treatment of pt.’s mental illness as outlined in other sections of this treatment plan.

Staff as indicated


7–16


INDIVIDUAL PROBLEM PLAN Problem # and Name: 7.3 Court Evaluation

Name: Robinson, James ID #: Area:


Date: 01/15/03

Problem Description: Pt. faces criminal charges, including assault and battery, attempt to commit murder, and assault and battery with a dangerous weapon. Pt. was committed for evaluation of competency to stand trial and criminal responsibility at the time of the alleged crime. Commitment expires on 02/15/03.


1.

Pt. will return to court with completed court-mandated evaluation.


Target Date

Date/Status*

02/15/03

Target Date

1.

Pt. will cooperate so that the treatment team can begin to gather the information necessary to complete the court evaluation.

01/22/03

2.

Pt. will cooperate so that the forensic team can complete the first draft of the court report.

02/07/03

Date/Status*





7–17

Date: 01/15/03


Date/Status*

Social Work: 1.

Staff will obtain community records, including police report and report from community psychiatrist.


Treatment Team Evaluators: 1.

Staff will give pt. Lambe warning that information obtained in the course of this evaluation will be used as part of the evaluation to be sent to court.

2.

Staff will complete psychosocial, psychological, psychiatric, and nursing databases.

Discipline-Specific Evaluating Staff


Nsg. staff will discuss with the forensic team issues related to pt.’s behavior on the ward, including any medical issues.


Forensic Team: 1.

Staff will gather the necessary information from the pt. and treatment team members to complete the court-ordered forensic report.

2.

Forensic team will present the report to the court and testify, if necessary.

Madison Yu, PhD, Forensic Team Leader


7–18


INDIVIDUAL PROBLEM PLAN Problem # and Name: 7.4 Court Assessment of Competency

Name: Ball, Paula ID #: Area:


Date: 01/15/03

Problem Description: Pt. appears to be incompetent. She needs to have the courts declare her incompetent and appoint a guardian. Pt. has a long history of being unable to care for herself. Her insight and judgment are markedly impaired. She appears unable to make competent decisions concerning her money and medical care. She is also unable to make rational statements as to why she needs to be in the hospital. Pt.’s mother appears to be a good candidate for pt.’s legal guardian.


1.

Pt.’s mother will be appointed permanent legal guardian, including having the right to consent to pt.’s medical treatment and the right to commit pt. to a mental institution.


Target Date

Date/Status*

04/15/03

Target Date

1.

Pt. will cooperate so that the competency report can be completed for court.

02/15/03

2.

Pt. will cooperate so that everything is ready for the court hearing, including a court date.

03/15/03

Date/Status*





7–19

Date: 01/15/03


Date/Status*

Psychiatry: 1.

Staff will complete report on pt.’s competency to care for herself, her ability to make decisions concerning medical treatment, and her ability to make decisions concerning committing herself to a mental institution.

2.

Staff will testify in court as to pt.’s competency.

Victor Dyson, MD

Psychology: 1.

Psychologist will perform psychological testing to assess depressive cognition.

2.

Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive, problem-solving therapy to improve pt.’s mood and help her function, even if depressive symptoms persist.


Social Work: 1.

Staff will discuss with pt.’s mother the issues surrounding her seeking legal guardianship of pt. and the responsibilities associated with being assigned legal guardianship of the pt.

2.

Staff will assist the legal office in obtaining necessary paperwork from pt.’s mother and from pt.’s record.

Roger Sing, MSW


Notes

BLANK FORMS

BF–1


Blank Forms

BF–3

BLANK FORMS CONTENTS Master Treatment Plan........................................................................................................................... BF–5 Problem List .................................................................................................................................................. BF–5 Strengths/Discharge Plan/Diagnosis ............................................................................................................. BF–6 Individual Problem Plan................................................................................................................................ BF–7 Signature Page ............................................................................................................................................... BF–9

Treatment Plan Review......................................................................................................................... BF–11

Notes

Blank Forms

BF–5

Name:


Problem List

ID #:

Area: Name of Facility Date:

Date of Admission: Problem Number

Problem Name

Discharge Barrier*




BF–6


Name:


ID #:

Strengths/Discharge Plan/Diagnosis

Area:

Date: Patient’s Strengths (related to treatment and discharge):


Psychiatric Diagnosis (DSM-IV-TR): AXIS I: AXIS II: AXIS III: AXIS IV:


AXIS V:

PSY =

SOC =

GAF Equivalent =

VIO =

ADL =

SAb =

MED =


Significant changes have been made in the diagnosis and those changes have been documented on the Treatment Plan Review dated: / / / / / / / /___

Blank Forms

INDIVIDUAL PROBLEM PLAN Problem # and Name:

BF–7

Name: ID #: Area:

Nursing Diagnosis:

Date:

Problem Description:



Target Date

Date/Status*

Target Date

Date/Status*


BF–8



Continued on Problem #: ________

Date: ________


Date/Status*


Blank Forms


Signature Page

BF–9

Name:

ID #:

Area: Name of Facility Date: Patient Participation in Treatment Planning (check as appropriate): Contributed to goals and plan Aware of plan content Present at team meeting Refused to participate Unable to participate Refused to sign plan




Staff Members’ Comments (optional):


Date:

Print Name:

Nurse:

Date:

Print Name:

Social worker:

Date:

Print Name:

Psychologist:

Date:

Print Name:

Rehabilitation:

Date:

Print Name:

Other:

Date:

Print Name:


Notes

Blank Forms

Treatment Plan Review Including Review of MASTER TREATMENT PLAN & NURSING CARE PLAN

Name of Facility

BF–11

Name: ID #: Area: Date:

1. Changes in Psychiatric Diagnosis (DSM-IV-TR): AXIS I: AXIS II: AXIS III: 2. Changes in Problem List:

3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:

Check if review is continued on reverse [ ]

BF–12


MASTER TREATMENT PLAN AND NURSING CARE PLAN REVIEW Continued 4. Changes in Treatment Plan Goals and/or Modalities:

5. Reasons for Continued Hospitalization:

6. Discharge Planning Update:

7. Continuation/Comments:

8. Level of Care: Active Treatment [ ] Extended [ ]

Awaiting SNF [ ]


Date:

Print Name:

Nurse:

Date:

Print Name:

Social worker:

Date:

Print Name:

Psychologist:

Date:

Print Name:

Rehabilitation:

Date:

Print Name:

Other:

Date:

Print Name:


Date:

Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.

QUESTIONNAIRES

Q–1


Questionnaires

Q–3

QUESTIONNAIRES CONTENTS Overview and Use of Questionnaires ...................................................................................................... Q–4 References and Acknowledgments ......................................................................................................... Q–4 Kennedy Axis V ........................................................................................................................................ Q–5 Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)............................................. Q–17 AIMS Plus EPS (Abnormal Involuntary Movement Scale Plus Extrapyramidal Side Effects)................ Q–19

Q–4


Overview and Use of Questionnaires The questionnaires in this manual have been developed to make them useful and practical in clinical, nonresearch settings. Many questionnaires are developed for research purposes and are only tangentially useful in nonresearch settings. Complex administration, scoring, and interpretation methods may be necessary for research purposes; however, this often makes such questionnaires of little use to the harried clinician. Details on the Kennedy Axis V (K Axis) and the Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE) are included in the companion book Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning. This companion book also acts as a training manual for both the Kennedy Axis V and the Kennedy NOSIE. Progress notes are often the standard for measuring outcome in clinical practice, not formal research instruments. The use of questionnaires should be based on whether they can improve on or add to the information manageability of progress notes. These improvements have to be gained without unduly taxing staff time and resources. The major difference between the Abnormal Involuntary Movement Scale Plus EPS (AIMS Plus EPS) and the original AIMS is that in addition to measuring evidence of tardive dyskinesia, the AIMS Plus EPS also measures extrapyramidal side effects (EPS). There is tremendous overlap between the physical exam used to assess involuntary movements and that used to assess EPS. Therefore, for clinical purposes and ease of documentation, both are included on the AIMS Plus EPS. If questionnaires are used to follow up treatment, predicted scores should be included on the treatment plan as goals. However, these scores should be used along with other measurable clinical outcomes. As shown earlier in this manual, these questionnaires can easily be integrated into the format of a goal. For example, The score on the K Axis subscale for Psychological Impairment will improve from a current score of 40 to 60. The score on the K NOSIE for Irritability will improve from the current score of –12 to –6.

References and Acknowledgments Dr. Kennedy is the author of the Kennedy Axis V and Kennedy NOSIE. These instruments are introduced in Kennedy JA: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning. Washington, DC, American Psychiatric Publishing, 2003

The Kennedy Axis V and the Kennedy NOSIE are not in the public domain. For details on how to obtain a licensing agreement to use the Kennedy Axis V or the Kennedy NOSIE questionnaires, please contact James A. Kennedy, MD, or go online to www.kennedymd.com. Dr. Kennedy, in conjunction with the Massachusetts State Medical Record Committee, developed the AIMS Plus EPS. It was introduced in Kennedy JA: Fundamentals of Psychiatric Treatment Planning. Washington, DC, American Psychiatric Press, 1992

The AIMS and the AIMS Plus EPS are both in the public domain. The AIMS was developed at the National Institute of Mental Health: National Institute of Mental Health, Alcohol Drug Abuse and Mental Health Administration: Abnormal Involuntary Movement Scale. Washington, DC, U.S. Department of Health, Education and Welfare, 1974

Questionnaires

Q–5


Questionnaires

Q–7

Instruction Sheet What Is the Kennedy Axis V (K Axis)? The K Axis consists of seven subscales for Axis V: Psychological Impairment, Social Skills, Violence, ADL– Occupational Skills, Substance Abuse, Medical Impairment, and Ancillary Impairment. These subscales capture the clinician’s impression of the individual’s overall level of functioning during the previous week (longer if significant, e.g., suicidal attempts). In addition to an individual score for each of the subscales, clinicians can generate a patient profile using the K Axis, as well as a score equivalent to the GAF. The K Axis is useful for developing Problem Lists, planning treatment, measuring its impact, and predicting outcome. Note: If needed, each subscale can stand alone and act as an individual questionnaire.

Using the Kennedy Axis V to Create Equivalents to the GAF Scale

• •

GAF Equivalent (GAF Eq): Add the first four subscales and divide by four to give a score that is roughly equivalent to a score from the GAF Scale. This score should ensure that the major areas of functioning are not overlooked when rating the patient. Dangerousness Level (DL): The DL is roughly equivalent to the GAF’s measure of dangerousness. The numbers used to derive the DL are on the scoring sheet directly below each subscale score. The lowest of these numbers becomes the DL. If the DL is 50 or less, it is often associated with the need for very high intensity outpatient care, residential care, or even hospitalization.

Choosing Current, Discharge, and Highest Level of Functioning Ratings

• • •

The current rating should be based on the level of functioning at the time of the evaluation and is most reflective of the current need for treatment or care. The discharge rating should be based on the level of functioning at the time of discharge and, when compared with the admission rating, is most reflective of the impact of treatment. The highest level of functioning should be based on the highest level of functioning that lasted for at least a few months during the last year. This score may be very predictive of outcome.

Using “Best Fit” to Capture the Clinical Impression The rating choice should be guided by the best fit for the client, even though some of the thinking or behaviors at that level may not be characteristic of the client. The anchor points only serve as aids and are not required for a specific rating. Ultimately, the clinical impression is the determinant of the score, and the best fit should guide one to that score rather than a particular anchor point.

Using Each Subscale to Measure Multiple Factors In each subscale, rate the factor that causes the most impairment. On the Violence subscale, the best fit should be based on suicidal factors for the suicidal client and on factors related to assaultiveness for the assaultive client. On the Substance Abuse subscale, the best fit should be based on use of alcohol for the alcoholic patient and use of drugs for the patient who abuses drugs. Impairments in multiple factors should help confirm a lower rating. Factors that relate to being withdrawn or showing lack of interest or poor motivation should be rated under Psychological Impairment rather than under Social Skills or ADL–Occupational Skills.

Measuring the Effects of Treatment, Stress, Physical Limitations, and the Like

•

•

The presence or absence of support, medication, other treatments, or even severe stress generally should not affect the rating, unless it is covering up skills. The rating should be based on the level of functioning, and no adjustment should be made for the presence or absence of these factors. Do not factor out the effects of treatment, even if the patient may drop out of treatment. The effect of physical/environmental limitations generally should be factored out of the rating. For example, factor out not abusing drugs or not assaulting others due to being incarcerated or physically restrained; factor out not being socially active or employed due to physical constraints of being in a wheelchair or confined to bed. Rate how functional or dysfunctional a client would be if given reasonable opportunity—that is, do not let physical barriers cover up skills or violence.

Q–8


Kennedy Axis V—Psychological Impairment

(Problem Area 1)

100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems never seem to lead to any significant anxiety or depression. No symptoms. 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday problems or concerns. 80 If symptoms are present, they are transient and expected reaction to psychosocial stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The stress is too much”); not considered to have mental problems by those who know him/her.

70

Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally functioning fairly well; however, those who know him/her well might express some concerns about his/her mental state.

60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others; to those who know him/her well it is clear that he/she has mental problems. 50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety attacks, moderately guarded, mild but definite manic syndrome). 40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however, probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have mental problems. 30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications; inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job, home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children. 20 Thinking and communication are generally grossly impaired; manic excitement or catatonia; largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe food off shirt; smears feces for bizarre, delusional reasons). 10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a few seconds; chronic, self-induced vomiting has led to a very life-threatening situation. NR

Not rated

Questionnaires

Kennedy Axis V—Social Skills

Q–9

(Problem Area 2)

100 Superior social skills, sought out by others because of his/her outstanding social/communication skills, has many friends and no difficulty making new friends. No symptoms. 90

Good social skills, no difficulty being pleasant and engaging, good communication skills, socially

effective.

80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships. 70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally functioning fairly well, has some meaningful interpersonal relationships. 60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of problems with social skills; communications are understandable but vague. 50 Serious impairment in social skills; has no friends because of clearly impaired social skills; however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear difficulty; frequently intrusive; inappropriate, nonsexual touching. 40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others; great difficulty recognizing that his/her sexual advances are not welcome. 30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how to share with others, and/or how to show sympathy toward others; conversations with others are grossly inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual touching, and the like. 20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing of feces or making sexual advances toward young children; however, may have some understanding that such behavior is inappropriate. 10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others); extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social situations). NR

Not rated

Q–10


Kennedy Axis V—Violence

(Problem Area 3)

100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to any inappropriate anger, frustration, or conflicts. No symptoms. 90 No significant evidence of violence to self or others; generally satisfied with life, no more than everyday problems or conflicts (e.g., an occasional argument with family members). 80 No more than slight problems with anger and irritability; if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild anger after family argument); no suicidal ideation. 70

Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior; thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning; severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant problems with violence or self-harm.

60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with violence. 50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or others; however, some precautions including close observation may be indicated. 40 Major problems with anger and irritability; some real danger of hurting self or others; violent outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual; occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others; set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or two minor fires. 30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met; suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or restraints may be necessary to prevent serious harm to self or others. 20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone; attempted to very violently harm or violently rape someone within the last month; constant suicidal preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal attempts without clear expectation of death within the last month; close observation to prevent harm to self or others may be required 1 or 2 days a week. 10 Persistent danger of severely hurting self or others; attempted to kill someone within the last month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of death; little or no control of impulses to hurt self or others; expressing loss of control of command hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within the last 2 years. NR

Not rated

Questionnaires

Kennedy Axis V—ADL–Occupational Skills

Q–11

(Problem Area 4)

100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those expected of a successful college graduate. 90 Good skills in all ADL–occupational activities; no more than average difficulties with any work assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school graduate. 80 No more than slight impairment in occupational skills or skills in school; has slight difficulty performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork assignments; slight impairment in workmanship. 70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following instructions, workmanship is somewhat sloppy), but generally functioning fairly well. 60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed; however, has trouble carrying through assignments; some difficulty problem solving or following instructions; some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home or apartment). 50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call. 40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any significant period or do routine housework due to poor work skills; failing in school due to poor academic skills); needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food restaurant; poor understanding of how to budget money. 30 No job and unable to independently maintain a home due to serious impairment in skills needed to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call, follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs (e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire alarm; difficulty finding way back from short errands. 20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from short errands). 10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete most tasks even with constant supervision; may even have to be physically assisted to complete a task, including eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support (e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately respond to a fire alarm. NR

Not rated

Q–12


Kennedy Axis V—Substance Abuse

(Problem Area 5)

100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone who is totally free of problems with substance abuse. No symptoms. 90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and minimal, if any, treatment needed to maintain sobriety. 80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse (e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety with minimal treatment needed to maintain sobriety. 70 Mild impairment in social, occupational, or school functioning due to substance abuse, but generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy smoker; unable to quit cigarettes despite numerous attempts. 60 Moderate difficulty in social, occupational, or school functioning because of substance abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week; occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust), Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.

50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance abuse; moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing substances despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol or marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions; moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than cigarettes) is beginning to cause some medical complications.

40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety. 30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious neglect of children due to substance abuse. 20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin, or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs into his/her veins more than twice a day.

10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in frequent medical hospitalizations; life-threatening neglect of children due to substance abuse. NR

Not rated

Questionnaires

Kennedy Axis V—Medical Impairment

Q–13

(Problem Area 6)

100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms. 90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally needs over-the-counter medication. 80 If medical problems are present, they are transient and cause minimal impairment in social, occupational, or school functioning; somewhat more than average missing of work or school due to medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to organic problems.

70 Mild medical problems which may cause some difficulty in social, occupational, or school functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia; epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a year; takes prescription medication on a daily basis.

60 Moderate difficulty in social, occupational, or school functioning due to medical problems; missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma, moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g., injections, blood levels, nebulizer, physical therapy); needs bladder bag.

50 Serious impairment in social, occupational, or school functioning due to medical problems; serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.

40 Major impairment in several areas (such as work or school or family relations) because of medical problems; missing about 2 months a year or more from work or school due to medical problems; medical problems result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems. 30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart, lung, kidney, liver); on dialysis for kidney failure. 20 Major medical problems confine him/her to bed all of the time and intensive, continuous medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart, lung, kidney, liver); quadriplegic. 10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma. NR

Not rated

Q–14


Kennedy Axis V—Ancillary Impairment

(Problem Area 7)

100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood, home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe environment. No significant ancillary problems or symptoms. 90 Good life situation; has few if any ancillary problems; no more than minor problems with living environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet his/her needs, rare late payment on a bill, rare parking or traffic ticket. 80 If ancillary problems are present, they are transient and cause no more than minimal difficulty with his/her living situation, financial resources, or the law; somewhat more than average problems with his/her living environment, financial resources, or legal problems.

70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal violence in his/her environment; however, generally safe living situation. 60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards; evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing, defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for competency to make decisions concerning person, estate, and/or treatment. 50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for placement. 40 Major problems with living situation, finances, and/or the law; some real danger of being physically injured in his/her environment; evaluation and/or disposition is being made for very violent criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson). 30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate physical injuries from violence in his/her environment. 20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing or because of high level of violence in his/her environment; evaluation and/or disposition is being made for extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).

10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment; evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone, very viciously harming or very viciously raping a child, arson with intent of hurting others). NR

Not rated

Questionnaires

Q–15

Kennedy Axis V: Scoring Sheet Name:

© 1986–2003

#:

Age:


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 50 40 35 25 15 5 Primarily (check one):

Not Impaired___

Antisocially Impaired___

Other Impairment___

Both___

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 Primarily (check one):

Nonviolent___

Violent to Self___

Violent to Others___

Violent to Self and Others___

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 50 40 35 25 15 5

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 45 40 35 30 25 20 15 10 5 100 95 90 85 80 75 70 65 60 55 50 Primarily (check one):

Nonabuser___

Alcohol Abuser___

Drug Abuser___

Both___

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 50 40 35 25 15 5

7. Ancillary Impairment (optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50

GAF Equivalent:

#1

+ #2

+ #3

+ #4

=

/

4

=


Date:

Notes

Questionnaires

Q–17

Kennedy Nurses’ Observation Scale for Inpatient Evaluation

Kennedy NOSIE or K NOSIE Copyright © 1985–2003 James A. Kennedy, MD Patient’s Name: _______________________________________________ #: ______________________ Date: ____/____/____ Name and Title of Rater: _______________________________________________________________________________________ Note: Closely follow The Guide to the Kennedy NOSIE by James A. Kennedy, MD (available at www.kennedymd.com), to significantly improve the reliability and validity of your ratings.

1.

Social Competence

Never

Sometimes

Often

Usually

Always

A.

Refuses to do the ordinary things expected of him/her

–0

–1

–2

–3

–4

B.

Has trouble remembering

–0

–1

–2

–3

–4

C.

Has to be reminded what to do

–0

–1

–2

–3

–4

D.

Has to be told to follow hospital routine

–0

–1

–2

–3

–4

E.

Has difficulty completing even simple tasks on his/her own

–0

–1

–2

–3

–4

Never

Sometimes

Often

Usually

Always

Sec. #1: –______

2.

Social Interest A.

Shows interest in activities around him/her

+0

+1

+2

+3

+4

B.

Tries to be friendly with others

+0

+1

+2

+3

+4

C.

Laughs or smiles at funny comments or events

+0

+1

+2

+3

+4

D.

Starts up a conversation with others

+0

+1

+2

+3

+4

E.

Talks about his/her interests

+0

+1

+2

+3

+4

Never

Sometimes

Often

Usually

Always

Sec. #2: +______

3.

Personal Neatness A.

Is sloppy

–0

–1

–2

–3

–4

B.

Keeps clothes neat

+0

+1

+2

+3

+4

C.

Is messy in eating habits

–0

–1

–2

–3

–4

D.

Keeps self clean

+0

+1

+2

+3

+4

Sec. #3: ______ Subtotal: ______

Transfer subtotal to the back

Å

Enter Licensing Agreement Number Here:

Based on NOSIE–30 (Gilbert Honigfeld, Roderic D. Gillis, and C. James Klett: “NOSIE-30: A Treatment-Sensitive Ward Behavior Scale.” Psychological Reports 19:180–182, 1966).

Q–18


Kennedy NOSIE (Page 2 of 2) 4.

Irritability

Never

Sometimes

Often

Usually

Always

A.

Is impatient

–0

–1

–2

–3

–4

B.

Gets angry or annoyed easily

–0

–1

–2

–3

–4

C.

Becomes easily upset if something doesn’t suit him/her

–0

–1

–2

–3

–4

D.

Is irritable and grouchy

–0

–1

–2

–3

–4

E.

Is quick to fly off the handle

–0

–1

–2

–3

–4

Never

Sometimes

Often

Usually

Always

–1

–2

–3

–4

Sec. #4: –______

5.

Manifest Psychosis A.

Hears things that are not there

–0

B.

Sees things that are not there

–0

–1

–2

–3

–4

C.

Talks, mutters, or mumbles to self

–0

–1

–2

–3

–4

D.

Giggles or smiles to self without any apparent reason

–0

–1

–2

–3

–4

Never

Sometimes

Often

Usually

Always

Sec. #5: –______

6.

Motor Retardation A.

Sits, unless directed into activity

–0

–1

–2

–3

–4

B.

Sleeps, unless directed into activity

–0

–1

–2

–3

–4

C.

Is slow moving and sluggish

–0

–1

–2

–3

–4

Sec. #6: –______

Final Scoring Section I. Subtotal from front: II. Subtotal from back: III. Kennedy NOSIE total:

– (Range –76 to +28) (–76 ÄDysfunctional –––– FunctionalÅ +28)

Rating for last 3 days ________ or typical 3-day period during the last 2 weeks ________

Questionnaires

AIMS Plus EPS Abnormal Involuntary Movement Scale Plus Extrapyramidal Side Effects Scale

Q–19

Name: Hosp #: Ward: Date:

Instructions: Rate highest severity observed. Rate movements that occur upon activation one less than those observed spontaneously. Code:

0 = None; 1 = Minimal, may be extreme normal; 2 = Mild; 3 = Moderate; 4 = Severe (circle the appropriate rating below).

Tardive Dyskinesia (Do not include tremors.) 1.

Muscles of facial expression _________________________________________________________ 0

1

2

3

4

1

2

3

4

1

2

3

4

e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling, grimacing

2.

Lips and perioral area _______________________________________________________________ 0 e.g., puckering, pouting, smacking

3.

Jaw _________________________________________________________________________________ 0 e.g., biting, clenching, chewing, mouth opening, lateral movement

4.

Tongue______________________________________________________________________________ 0

1

2

3

4

5.

Upper extremities (arms, wrists, hands, fingers)________________________________________ 0

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

include choreic movements (e.g., rapid, objectively purposeless, irregular, spontaneous), athetoid movements (e.g., slow, irregular, complex, serpentine)

6.

Lower extremities (legs, knees, ankles, toes) ___________________________________________ 0 e.g., irregular lateral knee movement, irregular foot or heel movements

7.

Trunk movements (neck, shoulders, hips) _____________________________________________ 0 e.g., irregular rocking, twisting, or squirming or pelvic gyrations

TD Total: Extrapyramidal Side Effects 1.

Dystonia ____________________________________________________________________________ 0 e.g., persistent spasm usually of the eyes, face, neck, or back muscles (this results in persistent abnormal positioning of one or more extremities or of the face, neck, or trunk)

2.

Parkinsonism _______________________________________________________________________ 0 e.g., bradykinesia (decreased movement), shuffling gait, masklike facies, resting tremor, drooling

3.

Akathisia ____________________________________________________________________________ 0 e.g., restlessness, pacing, rocking, inability to sit still

4.

Rigidity _____________________________________________________________________________ 0 e.g., increased muscle tone with continuous passive resistance to movement, cogwheel rigidity

5.

Parkinsonian tremor ________________________________________________________________ 0 e.g., slow, rhythmic, present at rest (pill rolling)

6.

Akinesia_____________________________________________________________________________ 0 decreased motor movements often associated with weakness, decreased spontaneous movements, and paresthesias

EPS Total: Comments:

Examiner: _________________________________________________________________

Date: ___________

Q–20


Examination Procedure Either before or after completing the examination procedure, observe the patient unobtrusively, at rest (e.g., in waiting room). The chair to be used in this examination should be a hard, firm one without arms.

1.

Ask patient whether there is anything in his or her mouth (such as gum or candy) and if there is, to remove it.

2.

Ask patient about the current condition of his or her teeth. Ask if patient wears dentures. Do teeth or dentures bother patient now?

3.

Ask patient whether he or she notices any movements in mouth, face, hands, or feet. If yes, ask patient to describe and to what extent they currently bother patient or interfere with activities.

4.

Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire body for movements while in this position.)

5.

Ask patient to sit with hands hanging unsupported. If male, between legs, if female and wearing a dress, hanging over knees. (Observe hands and other body areas.)

6.

Ask patient to open mouth. (Observe abnormalities of tongue movement.)

7.

Ask patient to protrude tongue. (Observe abnormalities of tongue movement.) Do this twice.

8.

Ask patient to top thumb with each finger, as rapidly as possible for 10 to 15 seconds; separately with right hand, then with left hand. (Observe facial and leg movements.)*

9.

Flex and extend patient’s left and right arms, one at a time.

10. 11.

Ask patient to stand up. (Observe in profile. Observe all body areas again, hips included.) Ask patient to extend both arms outstretched in front with palms down. (Observe trunk, legs, and mouth.)*

12.

Have patient walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice.

*Activated movements.

APPENDIX

A–1


Appendix

A–3

APPENDIX CONTENTS Focused Master Treatment Plans .............................................................................................................A–5 Rating Master Treatment Plans..............................................................................................................A–20 Rating Master Treatment Plans (Spreadsheet) ......................................................................................A–27 Nursing Diagnoses..................................................................................................................................A–28

Notes

Appendix

A–5

Focused Master Treatment Plans Joseph L. Black, MD ,∗ suggests using focused Master Treatment Plans when there is a fairly specific comprehensive rehabilitation goal (long-term goal) that is the focus of hospitalization. That comprehensive rehabilitation goal should also be associated with a target date that the patient can realistically attain in 30 days or less. Such focused treatment plans may be useful in a wide range of treatment and evaluation settings, such as the following:

• • • •

Treatment for acute detoxification Treatment for acute psychotic decompensation Treatment to restore competency to stand trial Evaluation of criminal responsibility

In such cases, Dr. Black recommends having one comprehensive rehabilitation goal for most, if not all, of the active problems. For example, when a patient has been admitted from the courts for restoration of competency to stand trial, the comprehensive rehabilitation goal might be as follows: Patient will return to the 15th Judicial District Court of Parker County upon demonstrating a rational and factual understanding of the proceedings against him and sufficient ability to consult with a reasonable degree of rational understanding. In these focused Master Treatment Plans, Dr. Black suggests that one should attempt to defer most, if not all, active problems that are not directly related to the comprehensive rehabilitation goal. These deferred problems would be addressed after the comprehensive rehabilitation goal has been attained and the patient has been discharged, transferred, or returned to court. In these focused Master Treatment Plans, the patient should be expected to respond to treatment for the active problems in a relatively short period of time, usually less than 30 days. Generally, the longer the treatment that is needed, the more difficult it becomes to defer other active problems and to focus on the comprehensive rehabilitation goal. Clearly, treatment for some active problems, especially a medical problem such as diabetes or seizures, cannot be deferred. On the following pages, Dr. Black presents a Kennedy Axis V rating and a focused Master Treatment Plan for a patient, John Lightfoot, who was committed for treatment to restore competency to stand trial.

∗

Joseph L. Black, MD: “Inpatient Treatment Plan Based on Functional Outcomes Measurement” (Session 6, #18), American Psychiatric Association Institute on Psychiatric Services, Innovative Programs, Orlando, FL, October 12, 2001.

A–6


Kennedy Axis V: Scoring Sheet Name: John Lightfoot

© 1986–2003

#: F02845

Age:

24


ÄÄ FUNCTIONAL

DYSFUNCTIONAL ÅÅ

1. Psychological Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Not Impaired___ Antisocially Impaired___ Other Impairment X Both___ Primarily (check one): Major psychological impairment AEB auditory and visual hallucinations, delusions of grandeur, and impaired judgment and insight.

2. Social Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 70 65 65 60 55 45 40 30 25 20 15 5 50 Major impairment in social relationships as evidenced by insensitivity to the feelings and needs of others and aggressive, intrusive behaviors.

3. Violence 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 X 15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonviolent___ Violent to Self___ Violent to Others X Primarily (check one): Frequently violent. Pt. is in real danger of hurting others and destroying property.

Violent to Self and Others___

4. ADL–Occupational Skills 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Moderate difficulty in occupational and school functioning.

5. Substance Abuse 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Nonabuser___ Alcohol Abuser___ Drug Abuser X Both___ Primarily (check one): Pt.’s behavior is considerably influenced by substance abuse, namely his frequent use of Peyote.

6. Medical Impairment 100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 90 85 80 75 75 70 70 65 60 55 55 40 35 25 15 5 50 Mild medical problems that may cause some difficulty in social, occupational, or school functioning, including his need to take prescription meds on a daily basis and his need for periodic medical follow-up.

7. Ancillary Impairment (Optional) 100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___ 100 95 90 85 80 75 70 65 60 55 45 40 35 30 25 20 15 10 5 50 Major problems with the law AEB his having been found incompetent to stand trial on a charge of aggravated assault with a deadly weapon and a charge of theft greater than $20,000.

GAF Equivalent:

#1

40

+ #2

40

+ #3

20

+ #4

60


Joseph Black, M.D.

= 160 /

4

=

40

20 Date:

01/05/03

Appendix

A–7

Name: Lightfoot, John


Problem List

ID #: F02845

North Texas State Hospital

Area: Spruce Unit

Name of Facility Date: 01/15/03

Date of Admission: 01/03/03 Problem Number

Problem Name

Discharge Barrier*


1.1

Psychotic Symptoms

Yes

01/15/03 Active

2.1

Impaired Social Skills

Yes

01/15/03 Active

3.1

Assaultive Behavior

Yes

01/15/03 Active

4.1

Impaired Occupational Skills

No

01/15/03 Deferred

5.1

Peyote Abuse

No

01/15/03 Deferred

6.0

Health Maintenance

No

01/15/03 Active

6.0a

Rule Out Seizure Disorder

No

01/15/03 Active

7.0

Court Evaluation

Yes

01/15/03 Active



A–8




ID #: F02845

Strengths/Discharge Plan/Diagnosis

Area: Spruce Unit

Date: 01/15/03 Patient’s Strengths (related to treatment and discharge):

• • • • • • • • •

Interests: horseback riding and Native American cultures and ceremonies Good verbal skills Fluent in both English and Comanche languages; also speaks Spanish and Cheyenne No self-abusive or suicidal thoughts or behaviors Average intelligence Has a driver’s license, though currently suspended due to driving while intoxicated Has worked in competitive employment as a laborer for up to 6 months Fairly good physical health Supportive family when he is not abusing drugs


John Lightfoot will return to the 15th Judicial District Court of Parker County upon demonstrating a rational and factual understanding of the proceedings against him and sufficient ability to consult with a reasonable degree of rational understanding. Discharge Coordinated By: Juan Sanchez, MSW

Anticipated Discharge Date: 02/05/03

Psychiatric Diagnosis (DSM-IV-TR): AXIS I:

Substance-induced mood disorder with manic features Substance-induced psychotic disorder with delusions and hallucinations Hallucinogen dependence (peyote) in a controlled environment Adult antisocial behavior

AXIS II:

No diagnosis

AXIS III:

No diagnosis

AXIS IV:


AXIS V:

PSY =

40

SOC =

GAF Equivalent =

40 40

40

VIO =

20

ADL =

60

SAb =


30

MED =

70

20

Significant changes have been made in the diagnosis and those changes have been documented on the Treatment Plan Review dated: / / / / / / / /__

Appendix

INDIVIDUAL PROBLEM PLAN Problem # and Name: 1.1 Psychotic Symptoms

A–9

Name: Lightfoot, John ID #: F02845 Area: Spruce Unit

Nursing Diagnosis: Disturbed Thought Processes

Date: 01/15/03

Problem Description: Off and on since 2000, John has had major psychological impairment AEB auditory and visual hallucinations, delusions of grandeur, and poor judgment and insight. Recently he has reported that he had a vision in which the Great Spirit appointed him as the leader of his people. Pt. has also made statements to the effect that local laws do not apply to him. He has been observed by staff to sit motionless for 12 or more hours as if he were in a trance. John’s poor focal attention, poor judgment, and poor insight impair his taking medication as prescribed.


1.

John Lightfoot will return to the 15th Judicial District Court of Parker County upon demonstrating a rational and factual understanding of the proceedings against him and sufficient ability to consult with a reasonable degree of rational understanding.


Target Date

Date/Status*

02/05/03

Target Date

1.

John will learn to communicate in a rational, coherent, and logical manner, AEB being able to engage in a 10-minute conversation with staff five times a week for 1 week.

01/29/03

2.

John will seek out his unit advisor to get his needs met and to discuss issues regarding his treatment daily for 1 week.

01/22/03

3.

John will be able to name pertinent information regarding his medication, including its effect on psychotic symptoms, consistently for 1 week.

01/22/03

4.

John will accept prescribed medication and necessary lab work for 2 weeks.

01/29/03

Date/Status*


A–10




Date: 01/15/03

TREATMENT MODALITIES (Include the modality, time period, and frequency. Also include the individual responsible and discipline. Please number all modalities.) 1.

Date/Status*

Psychoactive meds per Dr. Black’s order by licensed vocational nurse (LVN) supervised by the RN under the direction of the Nurse Manager.

Joseph Black, MD Marilyn Davis, RN 2.

Unit advisor will talk with John for 2 hours per week.

Jane Hoover, Rehab 3.

Medication education group with LVN will meet with pt. 2 hours per week.

Marilyn Davis, RN 4.

The case coordinator will correspond with mental health assistant and primary correspondent, once John signs consent, in order to facilitate aftercare planning.

Juan Sanchez, MSW (Case Coordinator)


Appendix

INDIVIDUAL PROBLEM PLAN Problem # and Name: 2.1 Impaired Social Skills

A–11


Nursing Diagnosis: Impaired Social Interactions

Date: 01/15/03

Problem Description: John has major impairment in social relations AEB his insensitivity to the feelings and needs of others and his aggressive, intrusive behaviors.


1.



Target Date

Date/Status*

02/05/03

Target Date

1.

John will learn to interact with others in a socially appropriate manner, AEB not demonstrating any aggressive, intrusive behaviors toward others for 2 weeks.

01/29/03

2.

John will be able to learn to consistently identify for 1 week at least three socially inappropriate behaviors that have led to conflicts with others and placed him at risk of losing self-control.

01/29/03

3.

John will be able to verbalize an adequate understanding of the positive aspects, values, beliefs, cultural links, attitudes, similarities, and differences in both North American and his own culture and will be able to apply these concepts to increase selfesteem and identity.

01/29/03

4.

John will be able to engage in empathetic conversations with his family consistently for 2 weeks.

02/05/03

Date/Status*


A–12




Date: 01/15/03


Date/Status*

Pt. will participate in on-unit psychosocial rehab group (Social Skills Group) 2 hours per week.


Pt. will participate in on-unit psychosocial rehab group (Relating Alternatives Group) 2 hours per week.


Pt. will participate in on-unit psychosocial rehab group (Cultural Awareness Group) 1 hour twice per week.

Juan Sanchez, MSW Å Roger Sing, MSW 4.

Pt. will participate in Problem-Solving Group with his family 1 hour per week.

Juan Sanchez, MSW


Appendix

INDIVIDUAL PROBLEM PLAN Problem # and Name: 3.1 Assaultive Behavior

A–13



Date: 01/15/03

Problem Description: John has a history of aggressive and assaultive behavior. He is a known gang member; he is reputed to be a gang leader. Currently he is frequently violent. He is felt to be in real danger of hurting others and destroying property.


Target Date

1.


02/05/03

2.

John’s K Axis score for Violence will improve from his current score of 20 to a score of 60.

02/05/03


Target Date

1.

John will demonstrate the ability to resolve conflicts and respond to stressors in a proper manner by using clinical time-out and discussions with staff consistently for 1 week.

01/29/03

2.

John will learn alternative coping mechanisms to relieve stress, rather than acting out against others, AEB not being threatening or assaultive for 2 weeks.

01/29/03

Date/Status*

Date/Status*


A–14




Date: 01/15/03


Date/Status*

Psychoactive meds will be administered per Dr. Black’s order by the LVN/RN supervised by the RN under the direction of the nurse manager.

Joseph Black, MD Marilyn Davis, RN 2.

Pt. will participate in on-unit psychosocial rehab group (Stress and Anger Management Group) 2 hours per week.



Appendix

INDIVIDUAL PROBLEM PLAN Problem # and Name: 6.0 Health Maintenance

A–15



Date: 01/15/03

Problem Description: Pt. has mild medical problems, including his need to take prescription meds on a daily basis and his need for periodic medical follow-up. Pt. may have impairment of conscious awareness due to a seizure disorder.


1.

John will continue to maintain an optimal level of health while hospitalized, AEB compliance with all prescribed meds, lab work, and treatments for his medical problems.


1.

Target Date

Date/Status*

Ongoing

Target Date

Date/Status*

Same as long-term goal.


A–16




Date: 01/15/03


Date/Status*

Medical: 1.

Doctor will work up John for the possibility of a seizure disorder, including EEG and referral to Neurology Clinic, and will make appropriate treatment recommendations.

Joseph Black, MD Virginia Coleman, MD


Nsg. staff will monitor John daily and follow up on any signs and symptoms of illness.

2.

Nsg. staff will administer all prescribed medication and treatments as ordered and will document John’s compliance.

3.

Nsg. staff will assess and document pt.’s level of understanding of prescribed treatment and provide necessary teaching at John’s level of understanding.

4.

Nsg. staff will prompt John to comply with treatments, lab work, and any other medical procedures. If needed, nsg. staff will support and accompany John to procedures. Staff will offer praise for compliance and will document compliance.

Marilyn Davis, RN


Appendix

INDIVIDUAL PROBLEM PLAN Problem # and Name: 7.0 Court Evaluation

A–17



Date: 01/15/03

Problem Description: John was referred to North Texas State Hospital–Vernon pursuant to Article 46.02 Section 5(a) of the Texas Code of Criminal Procedure after he was found incompetent to stand trial on charges of aggravated assault with a deadly weapon (to wit: lance, revolver, and scalping knife) and of theft greater than $20,000 (horses and cattle) out of the 15th District Court of Parker County, Texas. When local examiners evaluated him, pt. sat motionless, stared straight ahead, and refused to speak. He was subsequently found incompetent to stand trial.


1.



Target Date

Date/Status*

02/05/03

Target Date

1.

John will demonstrate an ability to work with his attorney in preparation of his defense and will display a factual knowledge of the court system.

02/05/03

2.

John will be able to assist in his defense as determined by no observations or self-reported statements that reflect poor reality contact or lack of knowledge of the court processes.

02/05/03

Date/Status*


A–18




Date: 01/15/03


Date/Status*

The treatment team will meet with John as a part of the competency training group for 2 hours per week.

Joseph Black, MD, Team Leader 2.

Pt. will receive counseling with case coordinator 1 hour per week to reinforce realitybased statements that promote competency and discourage those that do not.

Juan Sanchez, MSW, Case Coordinator


Appendix

A–19



ID #: F02845

Signature Page Area: Spruce Unit Name of Facility Date: 01/15/03 Patient Participation in Treatment Planning (check as appropriate): Contributed to goals and plan Aware of plan content Present at team meeting Refused to participate Unable to participate Refused to sign plan


X X



Staff Members’ Comments (optional): John is very resistive to treatment. At times he sits motionless for 12 or more hours, as if he were in a trance.


Joseph Black, MD

Date:

01/15/03

Print Name:

Joseph Black, MD

Nurse:

Marilyn Davis, RN

Date:

01/15/03

Print Name:

Marilyn Davis, RN

Social worker:

-XDQ6DQFKH]06:

Date:

01/15/03

Print Name:

Juan Sanchez, MSW

Psychologist:

Joseph LeBlanc, PhD

Date:

01/15/03

Print Name:

Joseph LeBlanc, PhD

Rehabilitation:

Jane Hoover, Rehab

Date:

01/15/03

Print Name:

Jane Hoover, Rehab

Other:

Date:

Print Name:


A–20


Rating Master Treatment Plans Based on the Kennedy Treatment Planning System Instructions This system for rating Master Treatment Plans uses the following rating scale: NA 0 1 2 3

= = = = =

Not applicable Absent Unacceptable Mild to moderate problems Acceptable to excellent

Rate the 10 sections of a Master Treatment Plan: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Problem List Strengths Discharge plan Psychiatric diagnosis Problem description Long-term goals Short-term goals Treatment modalities Changes in goal status and treatment modalities Signature page

Determine the score for each section: 1. 2. 3. 4.

Rate each applicable component in that section. Add the scores of each component that was rated. Divide that total score by the number of rated components. Round off this number to the nearest whole number.

Record the score for each section on the summary sheet. Determine the plan rating as follows: 1. 2. 3.

Add the scores for each section rated. Divide that total score by the number of sections rated. Round off this number to the first decimal place.

A set of blank Master Treatment Plan Rating Forms follows.

Appendix

A–21

SUMMARY SHEET Master Treatment Plan Rating Form © 2003 James A. Kennedy, MD Patient’s Name:

ID#:

Rater’s Name:

Date of Plan:

Section

Rating

Date of Rating:

Comments

1. Problem List

2. Strengths

3. Discharge plan

4. Psychiatric diagnosis

5. Problem description

6. Long-term goals

7. Short-term goals

8. Tx modalities

9. Signature page 10. Goals and Tx modalities status changes

Total Comments:

________ ÷ (# of Items Rated) = Plan Rating:

A–22


Master Treatment Plan Rating Form © 1998–2003 James A. Kennedy, MD Patient’s Name:

ID#:

Rater’s Name:

Date of Plan:

NA 0 1 2 3

= = = = =

Date of Rating:

Not applicable Absent Unacceptable Mild to moderate problems Acceptable to excellent

Start Rating Here (Enter section rating on summary sheet.)

PROBLEM LIST 1. Problem List

Rating

Comments

Problem number

Problem name

Discharge barrier

Date established and status

Date changed and status

Missing problems or placed in wrong problem area

Missing Individual Problem Plans

Total

________ ÷ (# of Items Rated) = Section Rating:

Appendix

STRENGTHS/DISCHARGE CRITERIA/DIAGNOSIS 2. Strengths

Rating

Comments

Related to treatment and discharge Covers Kennedy strength areas Includes interests

Total

3. Discharge Plan

_____ ÷ (# of Items Rated) = Section Rating:

Rating

Comments

Discharge environment Criteria for discharge Target discharge date Discharge coordinator

Total

4. Psychiatric Diagnosis (DSM-IV-TR)


Rating

Comments

Axis I Axis II Axis III Axis IV (ancillary impairment) Axis V (GAF-Eq)

Total


A–23

A–24


INDIVIDUAL PROBLEM PLANS 5. Problem Description

Rating

Comments

Onset of problem indicated Description of symptoms Current severity of symptoms indicated Measurability of current severity of symptoms

Total

6. Long-Term Goals


Rating

Comments

Target behaviors indicated Behaviors observable/ measurable Frequency and time interval indicated Goals relate to problem description, short-term goals, and Tx modalities Target dates present and reasonable Dated and numbered

Total


Appendix

INDIVIDUAL PROBLEM PLANS 7. Short-Term Goals

Continued

Rating

Comments

Target behaviors indicated Behaviors observable/ measurable Frequency and time interval indicated Goals relate to problem description, long-term goals, and Tx modalities Target dates present and reasonable Dated and numbered

Total

8. Treatment Modalities


Rating

Comments

Relevant disciplines are included Modality, time period, and frequency are included Related to problem description and goals Individual responsible is identified Dated and numbered

Total


A–25

A–26


SIGNATURE PAGE 9. Signature Page

Rating

Comments

Plan signed by team members Patient involvement indicated Patient/guardian signed plan or absence explained Sources of new entries are identifiable

Total


PLAN GOALS AND TREATMENT MODALITIES STATUS CHANGES 10. Goals and Tx Modalities Status Changes

Rating

Comments

If goal changed, new status and date are indicated Line drawn through changed goals New goals added as needed Expired target dates are updated Modalities are updated as needed New modalities are added as needed

Total


Appendix

A–27

Rating Master Treatment Plans Example of a Summary of Results Using a Spreadsheet

Inpt./ Outpt.

P. List

Stgths.

D/C Crit.

Dx.

Albert Smith

Inpt.

3

3

3

3

3

3

David Jones

Outpt.

3

3

1

3

3

George Jones

Outpt.

3

3

3

3

Inpt.

2

3

2

3

Michael Jones

Outpt.

3

3

1

Linda Jones

Outpt.

1

3

2

Robert Jones

Outpt.

3

3

1

Name

Mary Jones

Prob. D. Ltg. Stg.

Tx. Mod.

Sig.

Total

Plan Rating

3

3

3

27

3.0

3

3

3

3

25

2.7

2

3

2

2

2

3

3

25

2.7

2

3

3

22

2.4

3

3

2

3

3

2

3

1

22

2.4

3

2

3

2

21

2.3

3

2

2

2

2

3

21

2.3

Chgs.*

Janet Jones

Inpt.

2

3

0

2

2

2

2

3

1

17

1.8

Alice Jones

Inpt.

1

3

1

3

1

1

1

1

3

15

1.7

William Jones

Inpt.

1

0

1

3

0

3

2

2

2

14

1.6

Brenda Jones

Inpt. AVERAGE =

1

0

0

0

0

3

2

3

3

12

1.3

2.1

2.5

1.4

2.5

1.9

2.5

2.1

2.6

2.5

20.1

2.2

*This spreadsheet represents ratings of just-completed Master Treatment Plans and, therefore, does not include ratings of subsequent changes (Chgs.) in Goals and Modalities.

A–28


Nursing Diagnoses The following pages list nursing diagnoses from Nursing Diagnoses: Definitions and Classifications∗ that have been categorized according to the Kennedy Axis V subscale areas. This reference should help nurses to locate the appropriate nursing diagnosis when incorporating the Nursing Care Plan into the Master Treatment Plan. This categorization system has been reviewed by Rose Mary Carroll-Johnson, MN, RN, editor, Nursing Diagnosis: The International Journal of Nursing Language and Classification. Many of the nursing diagnoses fit into more than one subscale area; therefore, notes in italics help to separate many of the nursing diagnoses into two or more subscale areas. For example, Activity Intolerance is included under the subscale areas of Psychological Impairment and Medical Impairment. Its inclusion under Psychological Impairment is clarified as “Activity Intolerance (related to Psy. Factors)” and its inclusion under Medical Impairment is clarified as “Activity Intolerance (related to Medical Factors).” When using the nursing diagnosis, it is not necessary to include the additions to the nursing diagnoses. Also, some nursing diagnoses may extend into subscale areas that have not been indicated. This categorization includes only what is felt to be the most likely area or areas that pertain. This is a guideline; you must use your own clinical judgment when choosing a particular nursing diagnosis, that is, when pairing a nursing diagnosis to a particular problem name in the Individual Problem Plan section of the Master Treatment Plan or Nursing Care Plan. “Health Maintenance” is commonly used as a problem name in treatment planning to allow clinicians to list treatments that are intended to maintain good or optimal physical health, even when the patient does not have any significant medical problems. There was no equivalent nursing diagnosis to pair with Health Maintenance; therefore, it was added to NANDA’s list. As described earlier, it is set in italics to indicate that it is not an official NANDA-approved nursing diagnosis.

∗

Nursing Diagnoses: Definitions and Classifications 2001–2002. Philadelphia, PA, North American Nursing Diagnosis Association, 2001.

Appendix

NANDA’S Nursing Diagnoses Categorized by the Kennedy Axis V 1. Psychological Impairment Activity Intolerance (related to Psy. Factors) Activity Intolerance, Risk for (related to Psy. Factors) Adaptive Capacity, Decreased Intracranial Adjustment, Impaired Anxiety Anxiety, Death Body Image, Disturbed Confusion, Acute (related to Psy. Factors) Constipation, Perceived Coping, Defensive Coping, Ineffective (related to Psy. Factors) Decisional Conflict Denial, Ineffective Development, Risk for Delayed (related to Psy. Factors) Diversional Activity, Deficient Failure to Thrive, Adult Falls, Risk for (related to Psy. Factors) Fatigue Fear Fluid Volume, Deficient (related to Psy. Factors) Fluid Volume, Deficient, Risk for (related to Psy. Factors) Fluid Volume, Excess (related to Psy. Factors) Fluid Volume, Imbalance, Risk for (related to Psy. Factors) Grieving, Anticipatory Grieving, Dysfunctional Growth and Development, Delayed (related to Psy. Factors) Growth, Disproportionate, Risk for Altered (related to Psy. Factors) Health-Seeking Behaviors, Impaired (related to Psy. Factors) Hopelessness Incontinence, Urinary, Functional Injury, Risk for (related to Psy. Factors) Loneliness, Risk for Memory, Impaired (related to Psy. Factors) Noncompliance Nutrition, Imbalanced: Less Than Body Requirements (related to Psy. Factors) Nutrition, Imbalanced: More Than Body Requirements (related to Psy. Factors) Nutrition, Imbalanced: Risk for More Than Body Requirements (related to Psy. Factors) Pain, Acute (related to Psy. Factors) Pain, Chronic (related to Psy. Factors) Personal Identity, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Rape-Trauma Syndrome, Compound Reaction Rape-Trauma Syndrome, Silent Reaction Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Role Performance, Ineffective

Additions to NANDA’s nursing diagnoses are in italics.

A–29

A–30


Self-Care Deficit, Bathing/Hygiene (related to Psy. Factors) Self-Care Deficit, Dressing/Grooming (related to Psy. Factors) Self-Care Deficit, Feeding (related to Psy. Factors) Self-Care Deficit, Toileting (related to Psy. Factors) Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for Sensory Perception, Disturbed (related to Psy. Factors) Sexual Dysfunction (related to Psy. Factors) Sexuality Patterns, Ineffective Sleep Deprivation Sleep Pattern, Disturbed Social Interaction, Impaired (related to Psy. Factors) Social Isolation Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Suffocation, Risk for (related to Psy. Factors) Thought Processes, Disturbed (related to Psy. Factors) Ventilatory Weaning Response, Dysfunctional (related to Psy. Factors) Wandering (related to Psy. Factors)

2. Social Skills Communication, Verbal, Impaired Injury, Risk for (related to Social Skills Deficits) Social Interaction, Impaired (related to Social Skills Deficits)

3. Violence Falls, Risk for (related to Violence to Self) Injury, Risk for (related to Violence to Self) Self-Mutilation Self-Mutilation, Risk for Suicide, Risk for Violence: Other-Directed, Risk for Violence: Self-Directed, Risk for

4. ADL–Occupational Skills Breastfeeding, Ineffective (related to ADL Skills Deficits) Breastfeeding, Interrupted (related to ADL Skills Deficits) Confusion, Chronic (related to Retardation/Dementia) Environmental Interpretation Syndrome, Impaired Falls, Risk for (related to ADL Skills Deficits) Health Maintenance, Ineffective Health-Seeking Behavior, Impaired (related to ADL Skills Deficits) Home Maintenance, Impaired Injury, Risk for (related to ADL Skills Deficits) Knowledge, Deficient Memory, Impaired (related to Retardation/Dementia) Poisoning, Risk for (related to ADL Skills Deficits) Self-Care Deficit, Bathing/Hygiene (related to ADL Skills Deficits) Self-Care Deficit, Dressing/Grooming (related to ADL Skills Deficits) Self-Care Deficit, Feeding (related to ADL Skills Deficits) Self-Care Deficit, Toileting (related to ADL Skills Deficits) Suffocation, Risk for (related to ADL Skills Deficits) Therapeutic Regimen Management, Effective


Appendix

Therapeutic Regimen Management, Ineffective Thought Processes, Disturbed (related to Retardation/Dementia) Trauma, Risk for (related to ADL Skills Deficits) Wandering (related to Retardation/Dementia)

5. Substance Abuse Confusion, Acute (related to Substance Abuse) Confusion, Chronic (related to Substance Abuse) Coping, Ineffective (related to Substance Abuse) Development, Risk for Delayed (related to Substance Abuse) Falls, Risk for (related to Substance Abuse) Family Processes, Dysfunctional: Alcoholism Health Maintenance, Ineffective (related to Substance Abuse) Injury, Risk for (related to Substance Abuse) Protection, Ineffective (related to Substance Abuse) Sensory Perception, Disturbed (related to Substance Abuse) Thought Processes, Disturbed (related to Substance Abuse)

6. Medical Impairment Activity Intolerance (related to Medical Factors) Activity Intolerance, Risk for (related to Medical Factors) Airway Clearance, Ineffective Aspiration, Risk for Body Temperature, Risk for Imbalanced Breathing Pattern, Ineffective Breastfeeding, Effective Breastfeeding, Ineffective (related to Medical Factors) Breastfeeding, Interrupted (related to Medical Factors) Cardiac Output, Decreased Confusion, Acute (related to Medical Factors) Confusion, Chronic (related to Medical Factors) Constipation Constipation, Risk of Dentition, Impaired Development, Risk for Delayed (related to Medical Factors) Diarrhea Disuse Syndrome, Risk for Dysreflexia, Autonomic Dysreflexia, Risk for Autonomic Falls, Risk for (related to Medical Factors) Fluid Volume, Deficient (related to Medical Factors) Fluid Volume, Deficient, Risk for (related to Medical Factors) Fluid Volume, Excess (related to Medical Factors) Fluid Volume, Imbalanced, Risk for (related to Medical Factors) Gas Exchange, Impaired Growth and Development, Delayed (related to Medical Factors) Health Maintenance Health Maintenance, Enhanced Health Seeking Behaviors (enhanced) Hyperthermia Hypothermia Incontinence, Bowel Incontinence, Urinary, Reflex Incontinence, Urinary, Risk for Urge Incontinence, Urinary, Stress Incontinence, Urinary, Total


A–31

A–32


Incontinence, Urinary, Urge Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced Organized Infant Feeding Pattern, Ineffective Infection, Risk for (related to Medical Factors) Latex Allergy Response Latex Allergy Response, Risk for (related to Medical Factors) Mobility, Impaired, Bed Mobility, Impaired, Physical Mobility, Impaired, Wheelchair Nausea Neglect, Unilateral Nutrition, Imbalanced: Less Than Body Requirements (related to Medical Factors) Nutrition, Imbalanced: More Than Body Requirements (related to Medical Factors) Nutrition, Imbalanced: Risk for More Than Body Requirements (related to Medical Factors) Oral Mucous Membrane, Impaired Pain, Chronic (related to Medical Factors) Peripheral Neurovascular Dysfunction, Risk for Protection, Ineffective (related to Medical Factors) Sensory Perception, Disturbed (related to Medical Factors) Sexual Dysfunction (related to Medical Factors) Skin Integrity, Impaired Skin Integrity, Impaired, Risk for Suffocation, Risk for (related to Medical Factors) Surgical Recovery, Delayed Swallowing, Impaired Thermoregulation, Ineffective Thought Processes, Disturbed (related to Medical Factors) Tissue Integrity, Impaired Tissue Perfusion, Ineffective Transfer Ability, Impaired Urinary Elimination, Impaired Urinary Retention Ventilation, Impaired Spontaneous Ventilatory Weaning Response, Dysfunctional (related to Medical Factors) Walking, Impaired

7. Ancillary Impairment Breastfeeding, Interrupted (related to Environmental Factors) Caregiver Role Strain Caregiver Role Strain, Risk of Conflict, Parental Role Coping, Community, Ineffective Coping, Community, Readiness for Enhanced Coping, Compromised Family Coping, Disabled Family Coping, Readiness for Enhanced Family Development, Risk for Delayed (related to Environmental Factors) Energy Field, Disturbed Falls, Risk for (related to Environmental Factors) Family Process, Interrupted Growth and Development, Delayed (related to Environmental Factors) Growth, Disproportionate, Risk for Altered (related to Environmental Factors) Infection, Risk for (related to Environmental Factors) Injury, Risk for (related to Environmental Factors) Injury, Risk for, Perioperative Positioning


Appendix

Latex Allergy Response, Risk for (related to Environmental Factors) Therapeutic Regimen Management, Community, Ineffective Therapeutic Regimen Management, Family, Ineffective Parent/Infant/Child Attachment, Risk for Impaired Parenting, Impaired Parenting, Impaired, Risk for Poisoning, Risk for (related to Environmental Factors) Suffocation, Risk for (related to Environmental Factors) Trauma, Risk for (related to Environmental Factors) Ventilatory Weaning Response, Dysfunctional (related to Environmental Factors)


A–33

Notes

Fundamentals of Psychiatric Treatment Planning, Second Edition

Psychiatric Rehabilitation, Second Edition

Atlas of Psychiatric Pharmacotherapy, Second Edition

Lubrication Fundamentals, Second Edition

Healthcare Strategic Planning, Second Edition

Business Resumption Planning, Second Edition

Handbook of Epilepsy Treatment, Second Edition

Lens Design Fundamentals, Second Edition

Fundamentals of Geomorphology (Fundamentals of Physical Geography) - Second Edition

Consumer Credit Fundamentals, Second Edition

Fundamentals of Matrix Computations, Second Edition

Fundamentals of Esthetic Implant Dentistry, Second Edition

Fundamentals of English Grammar Workbook, Second Edition

Fundamentals of Soil Ecology, Second Edition

Fundamentals of Environmental Chemistry, Second Edition

Fundamentals of English Grammar Workbook, Second Edition

Fundamentals of Renewable Energy Processes, Second Edition

Fundamentals of Environmental Chemistry, Second Edition

Fundamentals And Applications of Microfluidics, Second Edition

Fundamentals of Biological Wastewater Treatment

Fundamentals of Biological Wastewater Treatment

Congenital Clubfoot: Fundamentals of Treatment

Addiction Treatment: A Strengths Perspective , Second Edition

Industrial Waste Treatment Handbook, Second Edition

Site Planning and Design Handbook, Second Edition

Childhood Obesity Prevention and Treatment, Second Edition

Fish Disease: Diagnosis and Treatment, Second Edition

Process Planning and Cost Estimation, Second Edition

Fundamentals of Psychiatric Treatment Planning, Second Edition

Psychiatric Rehabilitation, Second Edition

Atlas of Psychiatric Pharmacotherapy, Second Edition

Lubrication Fundamentals, Second Edition

Healthcare Strategic Planning, Second Edition

Business Resumption Planning, Second Edition

Handbook of Epilepsy Treatment, Second Edition

Lens Design Fundamentals, Second Edition

Fundamentals of Geomorphology (Fundamentals of Physical Geography) - Second Edition

Consumer Credit Fundamentals, Second Edition

Fundamentals of Matrix Computations, Second Edition

Fundamentals of Esthetic Implant Dentistry, Second Edition

Fundamentals of English Grammar Workbook, Second Edition

Fundamentals of Soil Ecology, Second Edition

Fundamentals of Environmental Chemistry, Second Edition

Fundamentals of English Grammar Workbook, Second Edition

Fundamentals of Renewable Energy Processes, Second Edition

Fundamentals of Environmental Chemistry, Second Edition

Fundamentals And Applications of Microfluidics, Second Edition

Fundamentals of Biological Wastewater Treatment

Fundamentals of Biological Wastewater Treatment

Congenital Clubfoot: Fundamentals of Treatment

Addiction Treatment: A Strengths Perspective , Second Edition

Industrial Waste Treatment Handbook, Second Edition

Site Planning and Design Handbook, Second Edition

Childhood Obesity Prevention and Treatment, Second Edition

Fish Disease: Diagnosis and Treatment, Second Edition

Process Planning and Cost Estimation, Second Edition

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