INSTRUCTIONS: For this case scenario, you will develop a Nursing Care Plan
using SNL, the Standardized Nursing Languages of NANDA, NOC and NIC (NNN).
You will be completing the blank care plan that accompanies this scenario.
• J.S. is a 19 year old college freshman, who was referred from the emergency
room following an overdose of approximately 40 acetaminophen extra strength.
He was cleared medically. He had been in outpatient counseling once a week
since an initial overdose six months ago. Last night the patient was caught shop
lifting and was charged with a crime, and now he has a court date pending. He
was released to his family.
• Shortly after his return home he ingested the tablets. He did not tell anyone
until he was discovered to be vomiting profusely and taken to the emergency
room by his mother. He told the physician that when he took them he wanted to
die. His mood and affect are depressed and blunted. He states his appetite
and sleep have been poor and he believes he has lost 10 pounds over the last
month. He is anhedonic and his grades are dropping due to inability to
concentrate. He is unable to describe any reason for this. He has thought of
suicide in spite of intervention.
• There is no evidence of psychosis or a thought disorder.
• The Functional Health Pattern that is most relevant for J.S. is:
Role/Relationship
Step 1. Choosing the Nursing Diagnosis (es)
The following nursing diagnoses are appropriate for J.S In practice, you may
select additional nursing diagnoses.
• While all of these nursing diagnoses are appropriate, for purposes of this
exercise, let’s use
Risk for violence, self-directed
• On the nursing care plan form, write in the nursing diagnosis, and check the
risk factors (etiology) for J.S.
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Step 2. Choosing the Nursing Outcomes (NOCs)
• The next step is to select nursing outcomes that can best affect this
nursing diagnosis.
Nursing Outcomes
Suicide Self-restraint
Indicators:
• Seeks help when feeling self-destructive
• Verbalizes control of impulses
• Refrains from gathering means for suicide
• Does not require treatment for suicide gestures or attempts.
• Upholds suicide contract
Mood Equilibrium
Indicators:
• Exhibits impulse control
• Reports adequate sleep
• Exhibits concentration
• Reports normal appetite
• Absence of suicide ideation
• Shows interest in surroundings
• Select one of the above listed nursing outcomes for this care plan
exercise, go to the nursing care plan and check the indicators that you
think will best measure your patient’s progress towards the outcome that
your have chosen.
• You will need to RATE your patient’s current status for each indicator.
• Now that you have chosen your outcome for J.S., you will need to select
the interventions that will best meet this outcome.
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Step 3. Choosing the Nursing Interventions
• If you have chosen the NOC, Suicide Self-Restraint, continue
below to select your interventions and activities.
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NIC – Surveillance - Safety Activities (NIC3 pg. 635)
• Monitor patient for • Determine degree of • Provide appropriate level of
alterations in physical surveillance required by supervision/surveillance to
or cognitive function patient, based on level of monitor patient and to
that might lead to functioning and the allow therapeutic actions,
unsafe behavior hazards present in as needed
environment
• Place patient in least • Initiate and maintain • Communicate information
restrictive precaution status for about the patient’s risk to
environment that patient at high risk for other nursing staff
allows for necessary dangers specific to the
level of observation care setting
• Monitor environment
for potential safety
hazards
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The second NIC for the NOC, Mood Equilibrium is Medication Management
Again, select 5 nursing activities that are appropriate for J.S. and write them on
the care plan in the activity column for Medication Management
Congratulations!
You have successfully completed your first nursing care plan using the
standardized nursing language vocabularies of NANDA, NOC, and NIC.
1. If you wish to received CE for this educational activity, please complete the
evaluation form and return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls , 6B12
Ann Arbor, Michigan 48109-0436
2. If you are working with a coordinator please give your quiz, evaluation and
completed nursing care plan to your coordinator.
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Psychiatric Care
NURSING DIAGNOSIS: Patient Name
Defining Characteristics (Signs & Symptoms)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏
Related Factors (Etiology)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏
NOCs (Outcomes)
Measurement Scale Score:
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
Suicide:
5 = Consistently demonstrated
Self ❏ Seeks help when feeling self-destructive
Restraint ❏ Verbalizes control of impulses
❏ Refrains from gathering means for suicide
❏ Does not require treatment for suicide
gestures or attempts
❏ Upholds suicide contract
DATE/TIME
INITIALS
Suicide ❑
Prevention ❑
DATE/TIME
ACTIVITIES: MODIFICATIONS:
❑:
Surveillance - ❏
Safety ❏
DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏
❏
Mood
❏
Management
❏
DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏
❏
Medication
❏
Management
❏
DATE/TIME
OTHER INTERVENTIONS: SIGNATURE BOXES:
• •
• •
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