MENTAL HEALTH NURSING CARE PLAN

NUR 318 FALL 2023

Student: ______________________________________________ Date: __________________________
Instructor: __________________________________ Client Name: ________________________ DOB: ____________ Age:
___________
ALLERGIES: ________N/A___________________ Religion: ____N/A_________ Marital Status: __Divorced_______
Psychiatrist Diagnosis: _____ Bipolar Disorder
________________________________________________________________________________________________________
Psychiatrist History: Known Bipolar Disorder patient on Olanzapine 10mg and Lithium 800mg
daily._____________________________________________________________________________________________________
Medical History: ________________Uses substance and alcohol
________________________________________________________________________________________
Medications: Olanzapine 10mg and Lithium 800mg
___________________________________________________________________________________________________________

Summary of presenting problem (SBAR type information) includes subjective and objective data:
Background:
Olanzapine 10 mg and Lithium 800 mg are prescribed for him to manage his bipolar disorder.
Anthony has been using alcohol and marijuana, and such behavior intensifies the manic symptoms. The one event that eventually
led to his. the current review happened as he was intoxicated and led to about $100,000 worth of property destruction.
He blames his dependence on substances on the side effects of taking prescription drugs, such as obesity.
Anthony was divorced, but he gained more frequent visits with his children.
He holds a steady job in construction, but he is worried about losing his employment due to occasional missed shifts.

Assessment (Subjective and Objective Data):
Subjective Data:
Anthony says that he uses substances like alcohol and marijuana for self-medication and to counteract the side effects of his
syndrome.
He admits he had manic episodes in the past the latest one resulted in property damages.
Objective Data:
Anthony looks messy and anxious upon observation.
There is evidence in his employment history that he has missed work shifts.
He is taking the prescribed drugs, which include lithium and olanzapine, according to medical records.
There is evidence of legal involvement stemming from the property damages incident.

Nursing Diagnosis Goals Interventions Rationale Outcomes
1 (Physiological)
Imbalanced Nutrition:
Less than Body
Requirements related to
poor dietary choices due
to medication side
effects and substance
use.

Improve Anthony's
nutritional intake and
address the weight gain
concern.
Assist Anthony in
managing the side
effects of his
medication.

Collaborate with a
dietitian to assess
Anthony's dietary habits
and develop a
customized nutrition
plan that addresses his
weight concerns while
maintaining the efficacy
of his medications.

A personalized nutrition
plan can help address
Anthony's concerns
about weight gain while
ensuring he receives the
necessary nutrients.
Regular monitoring can
help identify any

Anthony maintains a
stable weight without
experiencing the
negative side effects of
his medication.
Anthony demonstrates
an understanding of the
importance of a

Monitor Anthony's
weight, nutritional
status, and any adverse
effects of his
medications closely, and
provide education on
the importance of
maintaining a balanced
diet alongside his
medication.

adverse effects early,
and education will
empower Anthony to
make informed choices
about his medication
and diet.

balanced diet while
taking his medications.

2. Psychological
Ineffective Coping

Assist Anthony in
developing healthier
coping mechanisms to
reduce substance use.
Help Anthony manage
his bipolar disorder
more effectively.

One-on-one counseling
and psychoeducation:
Provide individual
counseling sessions to
help Anthony identify
and develop alternative
coping strategies, such
as mindfulness, stress
management, and
relaxation techniques.
Collaborate with a
psychiatrist: Work with
a psychiatrist to
evaluate the
effectiveness of

Healthier coping