Psychiatric Mental Health Nursing Care Plan
NURS 223L NURS 223L: PSYCHIATRIC MENTAL HEALTH NURSING CARE PLAN Student Date Instructor Patient Initials Legal Status Date of Admission Unit (Vol, 5150, 5250, Conservatorship) Allergies Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure (location) Pain Scale 1-10 (location, character, onset) Psychiatric Diagnosis and DSM 5 Diagnostic Criterion History of Present Psychiatric Illness: Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement Psychopathology of admitting and/or related psychiatric diagnosis Biophysical and/or related medical diagnosis Description of how this diagnosis relates to your patient With APA citations Erickson’s Developmental Stage Include Rationale Based on the Patient With APA citations West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 1 Page 1 NURS 223L MENTAL STATUS EXAMINATION Presenting Appearance (nutritional status, physical deformities, hearing impaired, glasses, injuries, cane) Basic Grooming and Hygiene (clean, disheveled and whether it is appropriate attire for the weather) Appearance Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), any noticeable mannerisms or gestures Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) Manner and Approach Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing). Coping and stress tolerance. Recall and Memory (recalls recent and past events in their personal history). Recalls three words (e.g., Cadillac, zebra, and purple) Orientation (person, place, time, presidents, your name) Orientation, Alertness, and Thought Process Alertness (sleepy, alert, dull and uninterested, highly distractible) Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow) Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise) Speech (normal rate and volume, pressured, slow, loud, quiet, impoverished) Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling) Receptive Language (normal, able to comprehend questions, difficulty understanding questions) Concentration and Attention (naming the days of the week or months of the year in reverse order, spelling the word “world”, their own last name, or the ABC’s backwards) West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 2 Page 2 NURS 223L Thought Processes (loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization). Values and belief system Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry). Affect or how they felt at a given moment (comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation. Risk Assessment: Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent) Self-Injurious Behavior (cutting, burning) Hypersexual, Elopement, Non-adherence to treatment Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications) Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong) Mood and Affect: Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset) Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic) Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program Response to Failure on Test Items (unaware, frustrated, anxious, obsessed, unaffected) Impulsivity (poor, effected by substance use) Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it) Teaching Assessment and Client / Family Education: (Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 3 Page 3 NURS 223L Pertinent Lab Tests Results specically for your patient (normal ranges in parentheses) Rationale for Abnormal Lab Values Valproic Acid (50 – 120 mcg/mL) Lithium (0.5 – 1.2 mEq/L) Carbamazepine (5 – 12 mcg/mL) CBC (WBC with diff, ANC, RBC) Amylase Thyroid Panel Liver Function (AST/ALT, LHD, Albumin, Bilirubin) Kidney Function (BUN, creatinine) Blood Alcohol Level / UDS Diagnostic Test Results (with dates) Rationale for Abnormal Substance Abuse and other Addictions (gambling, sex, shopping, smoking) Type: Type: Amount / Frequency: Amount / Frequency: Duration: Duration: Last Used: Last Used: Withdrawal Symptoms: Withdrawal Symptoms: C.A.G.E. Questionnaire Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 4 Yes / No Yes / No Page 4 NURS 223L Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? Yes / No Yes / No Abnormal Involuntary Movements Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe I: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling, 0 1 2 3 4 0 1 2 3 4 III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations) 0 1 2 3 4 IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.) 0 1 2 3 4 grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth) II: Extremity Movements: Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements. Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot V: Dental Status: (Current problems with teeth and/or dentures/Endentia?) Yes West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 5 Page 5 No NURS 223L Assessment (recognize cues) Filter information from different sources (i.e. signs and sx, health history, environment Analysis (analyze cues) Link recognized cues to a client’s clinical presentation and establishing probable client needs, concerns, or problems. Planning Implementation (Generate Solutions) Identify expected outcomes and related nursing interventions . (prioritize hypotheses) Establish priorities of care based on the client’s health problems (take action) Implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore health Evaluation (Evaluate Outcomes) Evaluate a client’s response to nursing interventions and reach a nursing judgement regarding the extent to which outcomes have been met West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 6 Page 6 NURS 223L MEDICATION LIST Medications Generic / Trade Class/Rationale for the patient Dose/Route/ Time (Frequency) Range / Therapeutic Levels in needed/ Labs needed Mechanism of Action Common side effects / Adverse effects West Coast University Care Plan Template Revision Date: March 2022 Revision Date: Month, Year December 2021 Page 7 Nursing considerations specific to this patient Page 7 NURS 223L Reference: West Coast University Care Plan Template Revision Date: August 2022 Page 8 NURS 223L Psychiatric / Mental Health Nursing Care Plan Rubric NAME: CLIENT INITALS: CRITERIA Psychopathology of admitting and/or related psychiatric diagnosis Recognize Cues (Assessment) COURSE: DATE: CLIENT PSYCHIATRIC DISORDER: Exemplary 4 Clearly and accurately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion that is based presenting symptoms, including demographics and psychiatric legal status in detail Clearly and accurately recognizes cues and filters information from different sources such as: a. signs and symptoms b. history of present illness c. environment d. vital signs e. labs f. developmental stage g. side effects h. mental status i. risk factors j. substance abuse k. change in condition Proficient 3 Adequately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Developing 2 Vaguely identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Ineffective 1-0 Fails to identify psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms. Adequately recognizes cues and filters information from different sources such as: a. signs and symptoms b. history of present illness c. environment d. vital signs e. labs f. developmental stage g. side effects h. mental status i. risk factors j. substance abuse k. change in condition Vaguely recognizes cues and filters information from different sources. Vaguely identifies relevant information related to the client’s condition that is relevant to the subjective and objective data. Fails to recognize cues nor filter information from different sources. Unable to identify relevant information related to the client’s condition. West Coast University Care Plan Template Revision Date: August 2022 Page 9 POINTS NURS 223L Analyze Cues (Analysis) Clearly and accurately analyzes cues and link to the client’s clinical presentation by establishing probable client needs, concerns, or problems. Accurately compares client findings to evidence-based resources to standards of care and analyzes expected and unexpected findings in health data. Clearly anticipates illness and wellness progression and identifies client problems as it relates to health alterations and prioritizes data that is of immediate concern. Accurately analyzes client needs, identifies potential complications, and identifies pathophysiology as it relates to the clinical presentation. Adequately analyzes cues and link to the client’s clinical presentation by establishing probable client needs, concerns, or problems. Adequately compares client findings to evidence-based resources to standards of care and analyzes expected and unexpected findings in health data. Adequately anticipates illness and wellness progression and identifies client problems as it relates to health alterations and prioritizes data that is of immediate concern. Adequately analyzes client needs, identifies potential complications, identifies pathophysiology as it relates to the clinical presentation. Vaguely analyzes cues and link to the client’s clinical presentation by establishing probable client needs, concerns, or problems. Struggles on how to compare client findings to evidencebased resources to standards of care. Difficulty analyzing expected and unexpected findings in health data. Difficulty with illness and wellness progression as it relates to health alterations. Difficulty with prioritizing data that is of immediate concern and client needs. Struggles with identifying potential complications and pathophysiology as it relates to clinical presentation. Unable to analyze cues and link to the client’s clinical presentation by establishing probable client needs, concerns, or problems. Unable to compare client findings to evidence-based resources to standards of care. Unable to prioritize data that is of immediate concern and client needs. Unable to identify potential as it relates to clinical presentation. Prioritize Hypothesis (Analysis) Clearly and accurately establishes priorities of care based on the client’s analysis of health problems and changes (i.e. environmental factors, risk assessment, urgency, signs / symptoms, lab values etc.). Clearly and accurately identifies Adequately establishes priorities of care based on the client’s analysis of health problems and changes (i.e. environmental factors, risk assessment, urgency, signs / symptoms, lab values etc.). Vaguely establishes priorities of care based on the client’s analysis of health problems and changes (i.e. environmental factors, risk assessment, urgency, signs / symptoms, lab values etc.). Unable to establish priorities of care based on the client’s analysis of health problems and changes Adequately identifies expected outcomes and related nursing interventions to ensure client’s needs are met. Able to collaborate with the health care team and Vaguely identifies expected outcomes and related nursing interventions to ensure client’s needs are met. Struggles with collaborating with the health Unable to identify expected outcomes and related nursing interventions to ensure client’s needs are met. Unable to collaborate Generate Solutions (Planning) expected outcomes and related nursing interventions to ensure client’s needs are met. Able to collaborate with the health care West Coast University Care Plan Template Revision Date: August 2022 Page 10 NURS 223L Take Action (Implementation) Teaching Assessment and Client Education Evaluate Outcomes (Evaluation) team and client to establish client outcomes and the plan of care. The goal clearly supports the plan of care easily measurable and realistic. client to establish client outcomes and the plan of care. The goal care team and client to establish outcomes. The goal vaguely with the health care team and client. The goal does adequately supports the plan of care and measurable and realistic. supports the plan of care and somewhat measurable and realistic. not support the plan of care and is not measurable and realistic. Clearly and accurately implements appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore health. Clearly provided clear instructional needs, learning preference, identify learning barriers and provided clear, concise instructional needs that will aid in health promotion and health. Skillfully and independently evaluates a client’s response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met. Modifies, revises and recommends alternative intervention. Adequately implements Vaguely implements appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore health. Adequately provided clear instructional needs, learning preference, identify learning barriers and provided adequate concise instructional needs that will aid in health promotion and health. appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore health. Vaguely provided instructional needs and learning preferences. Unable to implement interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore health. Unable to provide instructional needs and learning preference. Adequately evaluates a client’s response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met. Adequately modifies, revises and recommends alternative intervention. Difficulty evaluating the client’s response to nursing interventions to reach a nursing judgment at the extent to which outcomes have been met. Difficulty determining effectiveness of interventions, outcome and goal completion. Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. There is a lack of alternative interventions to the treatment plan. West Coast University Care Plan Template Revision Date: August 2022 Page 11 NURS 223L CRITERIA 4 3 2 Medications Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client. General Organization Accurate APA format, appropriate citations and references, No spelling or grammar errors. Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client. Adequate APA format. Minimal citations and references are appropriate. Few spelling or grammar errors. Vaguely identifies components of the medication list. Lack full description of mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client. Numerous APA format errors, Inaccurate citations and references. Few spelling and grammar errors. 1 – 0 Fails to identify components of the medication list. Failed to include mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client. Fails to utilize APA format. No citations or references included numerous spelling and grammar errors. TOTAL: Additional Comments and Feedback: West Coast University Care Plan Template Revision Date: August 2022 Page 12 POINTS
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