Student Care Plan

STUDENT CARE PLAN

MENTAL HEALTH

Student: / Date:
Patient/Client Initials: / M/F: / Age:
Dates Cared for: / Rm. #: / Ht:
Date of Admission: / Physician: / Wt:
Medical Diagnosis: / Pertinent Past History: / IBW range:
Surgery (if any) and Date: / Health Insurance: / Allergies:
Marital Status: / Religious Preference: / Tendency Toward:
Erickson’s Developmental Stage: / Occupation: / AEB:

(Two points total)

careplans\careplanmh103.doc

GORDON'S FUNCTIONAL HEALTH PATTERNS

STUDENT ASSESSMENT GUIDE FOR

MENTAL HEALTH PATIENTS

(11 points)

SUBJECTIVEOBJECTIVE

1.HEALTH MAINTENANCE MANAGEMENT

Admit Date

Diagnosis

Axis I

Axis II

Axis III

Axis IV

Axis V

Insurance

Age/Developmental level

Allergies

Perception of overall health status

Risk behaviors

Discharge needs

2.NUTRITION/METABOLIC

Anorexia

Nausea

Height, weight

Recent weight change

Diet type

Vital Signs

3.ELIMINATION

Bladder

Bowel pattern

Last BM

SUBJECTIVEOBJECTIVE

4.ACTIVITY/EXERCISE

Mobility

Assistive equipment

ADL performance

Observed energy e.g., agitated, lethargic

Tremors

Leisure and recreation

5.SLEEP/REST

Usual pattern of sleep

Usual quality and quantity

Most recent pattern

Most recent quality and quantity

6.COGNITIVE/PERCEPTUAL

Cognitive

Judgement

Orientation (3 spheres)

Concentration

Abstraction

Memory recent and remote

Thought Content e.g., suicidal, delusional,

(specify) ideas of reference

Thought Process e.g., flight of ideas, block-

ing, tangential, loose associations

Sensory misinterpretations

Hallucinations (specify)

Illusions

Sensory aids

SUBJECTIVEOBJECTIVE

7.SELF-PERCEPTION/SELF-ESTEEM

Describes attitudes about self and perception of abilities

Subjective

Attitude about self

Impact of illness on self

Desire to change self

Perceived powerlessness

8.ROLE/RELATIONSHIPS

Occupation

Recent change in role

Marital status

Family structure

Family dynamics

9.SEXUALITY

Sexual issues

Impact of illness on sexuality

Menstrual history: children

Self-breast/testicular exams

Practices safe sex

10.COPING/STRESS

Level of anxiety

Affect

Defense mechanisms

Stressors

Usual coping mechanisms

Support systems

Family support

Community resources

SUBJECTIVEOBJECTIVE

11.VALUES/BELIEFS

Spirituality/Religion

Cultural beliefs/practices

Practice of values/beliefs

Advanced Directives

DNR

Sexual preference

careplans\careplanmh103.doc

STUDENT CARE PLAN WORKSHEET – (2 points)

STRENGTHS / WEAKNESSES
Prioritize for Care
Using Maslow’s Hierarchy of Needs / PRIORITIZE THREE AREAS OF CARE
AND STATE EACH PROBLEM AS A
NANDA DIAGNOSIS / RATIONALE FOR PRIORITIZATION OF PROBLEMS / DISCHARGE GOALS
1.
2. / ______
TEACHING NEEDS
______
3.

MEDICATION WORKSHEET - (10 POINTS)

CLASSI-
FICATION / MEDICA-
TION / USUAL
DOSAGE / ROUTE / MECHANISM OF ACTION / DRUG INTERACTIONS / TOXIC/SIDE EFFECTS / NURSING INTERVENTIONS

careplans\careplanmh103.doc

CONCEPT MAP (50 points total)

Include: Pathophysiology, relevant GFHP data collected, medications, lab studies, diagnostic imaging, collaborative care (treatments, diet activity, etc., from physician’s orders) and nursing care including nursing diagnoses, interventions, outcomes, and evaluation. You must include at least 3 nursing diagnoses. You may use more than one sheet of paper.

ARENA ASSESSMENT - (3 points)

How does each arena contribute to physical and psychosocial-spiritual well-being?

A.Agency (4 points)

a.Physical

b.Psychosocial-spiritual

B.Family (4 points)

a.Physical

b.Psychosocial-spiritual

C.Community (Patient’s home community) (4 points)

a.Physical

b.Psychosocial-spiritual

D.Attach a printout of a home page form a website that would benefit this patient. (3 points)

REFERENCE PAGE

careplans\careplanmh103.doc