Lucas Callahan Bipolar Disorder Shadow Health Care Plan
Nursing Diagnosis
Student Response Model Answer Explanation Points Earned
Possibility of harm Possibility of harm The most appropriate diagnosis is “possibility of harm.” At the moment, there are no signs or symptoms indicating impaired thinking or a risk of heart issues for the patient. 0.5 out of 0.5
Signs & Symptoms
Student Response Model Answer Explanation Points Earned
Sleeping less than 3 hours in the last few days Sleeping less than 3 hours in the last few days For Mr. Callahan, “possibility of harm” is the most suitable diagnosis, considering his current manic state. Relevant symptoms include impulsivity, paranoid thoughts, and self-destructive behavior, which put him at risk. Moreover, his high energy and lack of sleep worsen these symptoms, elevating his risk of harm. There’s no current indication of suicidal thoughts or self-harm from Mr. Callahan, so his past suicide attempt doesn’t support the current diagnosis. He isn’t disoriented or experiencing hallucinations either, making these options inappropriate. Additionally, his history of cocaine use doesn’t contribute to the current risk of harm as he’s not under its influence presently. 0.5 out of 0.5
Excessive energy and agitation Excessive energy and agitation Given Mr. Callahan’s situation, “possibility of harm” is the most fitting diagnosis. Symptoms such as impulsivity, paranoid thoughts, and self-destructive behavior align with his current manic state, posing a risk. Moreover, his heightened energy and lack of sleep exacerbate these symptoms, increasing his risk of harm.
There’s no indication of current suicidal thoughts or self-harm, so his past suicide attempt doesn’t support the current diagnosis. He’s not disoriented or hallucinating either, ruling out those possibilities. Additionally, his past cocaine use doesn’t contribute to the current risk of harm as he’s presently sober. Evaluate Mr. Callahan’s readiness for care. . Mr. Callahan, are you prepared to proceed with the care plan? Before implementing interventions, it’s crucial to assess the patient’s readiness to engage in the care plan by evaluating their willingness to listen, learn, and participate.
Based on your presentation today, it seems you’re at risk of harm.
Intervention & Evaluation
2.5 out of 2.5
Student Response Model Answer Explanation Points Earned
Fully Fully The goal of ensuring Mr. Callahan remained free from harm while awaiting psychiatric evaluation has been completely achieved. The interventions chosen helped reduce his risk of harm and ensured safety for everyone, including staff and other patients. Providing him with writing materials kept him occupied. The physical examination revealed no injuries, confirming goal fulfillment. 2.5 out of 2.5
Intervention & Evaluation Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Did you achieve your goal of keeping your patient free from harm until he could be evaluated by a psychiatrist? The aim of preventing harm to the patient until psychiatric evaluation was fully accomplished. The interventions selected effectively reduced the risk of harm. No injuries were detected during the physical examination.
Therefore, the goal was achieved. The objective was to ensure Mr. Callahan remained free from harm until psychiatric evaluation. The chosen interventions successfully mitigated the risk of harm, ensuring safety for both the patient and staff. Providing writing materials kept Mr. Callahan occupied. The physical examination findings confirmed the absence of injuries, thus indicating goal achievement. It’s important to conduct a focused physical exam to verify whether Mr. Callahan has indeed remained free from harm. Trusting the objective data from the exam is crucial for determining goal attainment. Given Mr. Callahan’s manic state, relying solely on his self-report might not be accurate or reliable.
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Lucas Callahan Bipolar Disorder Shadow Health Care Plan
International classification for nursing practice (ICNP) nursing diagnoses (v2019_06_27) [Data set]. (2019). International Council of Nurses (ICN). https://www.icn.ch/what-we-do/projects/ehealth-icnptm/icnp-download
Diagnosis
Student Response | Model Answer | Explanation | Points Earned |
Risk for injury | Risk for injury | “Risk for injury” is the most appropriate diagnosis. The patient currently does not exhibit any signs and symptoms that suggest he has impaired cognition or is at risk for impaired cardiac function. | 0.5 out of 0.5 |
Signs & Symptoms
Student Response | Model Answer | Explanation | Points Earned |
Sleeping 3 hours or fewer in the past few days | Sleeping 3 hours or fewer in the past few days | Because “risk for injury” is the most appropriate diagnosis for Mr. Callahan, the relevant signs and symptoms are those that align with his current manic state and put him at risk for injury, such as his impulse control, paranoid thoughts, and self-destructive behavior. Additionally, his excessive energy and lack of sleep can further exacerbate his other signs and symptoms and increase his risk for injury. Mr. Callahan has not expressed any current suicidal ideation or thoughts of self-harm; therefore, his prior suicide attempt does not support his current diagnosis of “risk for injury.” He is also not currently disoriented or experiencing hallucinations, so these answers would be inappropriate. Additionally, a history of cocaine use would not contribute to his current “risk for injury” as he is not under the influence of any substances at this time. | 0.5 out of 0.5 |
Excessive energy and restlessness | Excessive energy and restlessness | Because “risk for injury” is the most appropriate diagnosis for Mr. Callahan, the relevant signs and symptoms are those that align with his current manic state and put him at risk for injury, such as his impulse control, paranoid thoughts, and self-destructive behavior. Additionally, his excessive energy and lack of sleep can further exacerbate his other signs and symptoms and increase his risk for injury. Mr. Callahan has not expressed any current suicidal ideation or thoughts of self-harm; therefore, his prior suicide attempt does not support his current diagnosis of “risk for injury.” He is also not currently disoriented or experiencing hallucinations, so these answers would be inappropriate. Additionally, a history of cocaine use would not contribute to his current “risk for injury” as he is not under the influence of any substances at this time. |
Evaluate Mr. Callahan’s readiness for care. | . | Mr. Callahan, are you ready to move forward with the care plan? | Before proceeding with interventions, it is important to assess a patient’s readiness to listen, learn, and participate in the care plan. |
Based on your presentation today, I believe you are at risk of injury. |
Intervention & Evaluation
Student Response | Model Answer | Explanation | Points Earned |
Fully | Fully | The goal of having Mr. Callahan remain injury free while he was waiting to be evaluated by a psychiatric provider has been fully met. The selected interventions helped reduce the patient’s risk of injury and keep everyone, including staff and other patients, safe. Additionally, providing Mr. Callahan with writing materials kept him occupied. The data collected through the physical examination determined that Mr. Callahan did not present with any injuries. Your goal has been fully met. | 2.5 out of 2.5 |
Intervention & Evaluation Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt | Student Response | Model Answer | Explanation |
Did you achieve your goal of having your patient remain injury free until he could be evaluated by a psychiatric provider? | The goals of having the patient remain injury free until he was evakuated by a psychiatrist was fuly achieved. The selected intereventions helped reduce risk of injury. The patient did not present with any injuries during physical exam. Therefore, the goal was met. | The goal of having Mr. Callahan remain injury free while he was waiting to be evaluated by a psychiatric provider has been fully met. The selected interventions helped reduce risk of injury and keep both the patient and staff safe. Additionally, providing Mr. Callahan with writing materials kept him occupied. Based on the data collected, Mr. Callahan did not present with any injuries when he was physically examined, so the goal was met. | Given the details of this case, it is important to conduct a focused physical exam to confirm that Mr. Callahan has remained injury free. You can trust the objective data gathered through a physical exam and determine if your goal has truly been met or not. Given Mr. Callahan’s manic state, it would be inappropriate to merely ask him if he had remained injury free, because he may not answer honestly or accurately. |