WEST COAST UNIVERSITY

Psychiatric / Mental Health Nursing Care Plan

Student / Course / NURS 214L / Date
Instructor
Patient Initials / DOB / Age
Date of Admission / Gender / Ethnicity
Unit / Legal Status (Vol, 5150, 5250, Conservatorship / Allergies

(4pts)

Multiaxial Diagnostic System (3pts)
Axis I: Psychiatric Diagnosis
Axis II: Personality Disorder / Mental Retardation
Axis III: Medical / Physical Problems
Axis IV: Psychosocial and Environmental Problems
Axis V: Global Assessment of Functioning / History of Present Psychiatric Illness: (3pts)
(Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services) / Psychopathology of admitting and/or related psychiatric diagnosis
Describe How does this diagnosis relate to your patient
(With APA citations) (4 pts)
Erickson’s Developmental Stage: (3pts)
Include Rationale
(APA citation) / Self-Perception/Self Concept: (2pts)
(Body comfort, body image, feeling state, attitudes about self, perception of abilities) / Role-Relationship: (2pts)
(Perception of current major roles and responsibilities (e.g., father, husband, occupation); marital status satisfaction with family, work, or social relationships)
Health Perception / Health Management: (2pts)
(Adherence to medication regimen, use of health-promotion activities such as regular exercise and follow-ups) / Value – Belief: (2pts)
(Patterns of values, beliefs (including spiritual, cultural, religious, family), and goals that guide client's choices or decisions that may affect his/her care) / Coping and Stress Tolerance: (2pts)
(Client's usual manner of handling stress, available support systems, perceived ability to control or manage situations).
Nutritional-Metabolic: (2pts)
(Diet, appetite, feeding supplement, swallowing difficulty, chewing difficulty. Condition of skin, teeth, hair, nails, mucous membranes) / Elimination Pattern: (2pts)
(Frequency of bowel movements, voiding pattern, pain on urination, appearance of urine and stool) / Activity-Exercise (2pts) Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and activities of daily living
Risk Assessment: (3pts)
(Suicide history, Self-Injurious Behavior, Hypersexual, Elopement, Fall, Homicidal, Non-adherence to treatment) / Discharge Plans: (2pts)
(Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program) / Sleep-Rest Pattern (2pts) Client’s perception of quality and quantity of sleep and energy, sleep aids, routines client uses for sleep.
Mental Status Examination: (5 pts)
Appearance:
Speech:
Eye Contact:
Behavior & Motor Activity:
Mood & Affect:
Orientation:
Cognitive Functioning
Thought Process:
Thought Content:
Insight:
Judgment:
Level of participation in the program: / Sexuality-Reproductive: (2pts) (Number of children and age. Number of pregnancy and childbirth; difficulties with sexual functioning; satisfaction with sexual relationship). / Teaching Needs and Assessment: (2pts) (document education material provided)
Pertinent lab test (normal ranges in parentheses) & diagnostic reports (with dates) (2pts)
Rationale for Abnormal Labs / Current Prescriber’s Order and Rationale for Orders
(Include diet, test, and treatments) (4pts) / Substance Abuse and other Addictions: (gambling, sex, shopping, smoking) (4 pts)
Amount / Frequency:
Duration:
Last Used:
W/D symptoms:
BAL on admission:
C.A.G.E. score:
VS (3pts) Temp / Pulse / Respiration / Blood Pressure / Pain Scale 1-10 (location, character, onset)
Height: / Weight:
Gordon’s Functional Health Pattern
(3pts) / Nursing Diagnosis
(NANDA) (Actual and/or potential)
Minimum of 2
Include etiology and sign and symptoms
Definition of Nursing Diagnosis
(5pts) / Nursing Outcome Criteria (NOC)
Measureable
Goal during your shift
Minimum 2
(5pts) / Implementations
(Independent and collaborative nursing intervention include further assessment, intervention and teaching)
Minimum 4
(5pts) / Rationale
(Use APA citations) (5pts) / Evaluation
Goal Met
Goal not Met
(If not met, what revisions would you make?)
(5pts)

Medication List (10pts)

Medications
Generic / Trade / Dose/Route/ Time (Frequency) / Class/Rationale for the patient / Range / Therapeutic Levels / Mechanism of action Onset of action / Common side effects / food and drug Interaction / Nursing considerations

Reference:

West Coast University Criteria for Clinical Evaluation

NURS 214L PSYCHIATRIC / MENTAL HEALTH NURSING

Student Learning Outcome: The student will be able to apply nursing care concepts by using Gordon’s Functional Health Pattern in psychiatric clients.

CRITERIA / 1
(63 and below) / 2
(64 – 75) / 3
(76 – 83) / 4
(84 – 90) / 5
(91 – 100)
Assessment and utilizing Gordon’s Functional Health Pattern / Unable to utilize Gordon’s Functional Health Pattern in assessing and planning nursing care for psychiatric clients. / Requires cues, reminders and/or remediation when utilizing Gordon’s Functional Health Pattern in assessing and planning nursing care for psychiatric clients. / Adequate use of Gordon’s Functional Health Pattern in assessing and planning nursing care for psychiatric clients. / Consistently utilize Gordon’s Functional Health Pattern in assessing and planning nursing care for psychiatric clients. / Always utilize Gordon’s Functional Health Pattern confidently and accurately in assessing and planning nursing care of psychiatric clients.
Nursing Diagnosis / Diagnoses do not correlate to gathered assessment data and cannot be classified as nursing diagnosis based on Gordon’s Functional Health Pattern. / Diagnosis presents some correlation from the assessment data that may or may not be classified as nursing diagnosis based on Gordon’s Functional Health Pattern. / Diagnosis is adequate and present correlation from assessment data that can be classified as nursing diagnosis based on Gordon’s Functional Health Pattern. / Diagnosis is consistent and presents correlation from assessment data that can be classified as nursing diagnosis based on Gordon’s Functional Health Pattern. / Diagnosis is always consistent and presents correlation from assessment data that can be classified as nursing diagnosis based on Gordon’s Functional Health Pattern.
Nursing Outcome Criteria / Outcome criteria are unsupported and nonspecific from gathered data, which cannot be met by nursing assistance. Outcome criteria are not measurable and have no time frame. / Outcome criteria present some support from gathered data, which cannot be met with nursing assistance. Outcome criteria are not measurable and have no time frame. / Outcome criteria adequately identifies clients goals which usually match nursing diagnosis, can be met with nursing assistance, measurable and have a time frame / Outcome criteria consistently produces client goals that can be met with nursing assistance, match nursing diagnosis, measurable and have a time frame. / Outcome criteria always establishes client goals, which can be achieved with nursing assistance that clearly matches the nursing diagnosis, are easily measurable and have a time frame.
Nursing Intervention Criteria / Interventions are non-specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Intervention does not focus on client goals and/or the stated health deviation based on Gordon’s Functional Health Pattern and Erickson’s stages of development. / Interventions are inconsistent, non-specific, disorganized, and not adequately focused on client goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis, based on Gordon’s Functional Health Pattern and Erickson’s stages of development. / Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on client’s goal and health deviation, which is based on Gordon’s Functional Health Pattern and Erickson’s stages of development. / Interventions are consistently individualized, prioritized, organized, specific and realistic. Nursing actions are consistently aimed at the client goal and directed at the stated health deviation, which are based on Gordon’s Functional Health Pattern and Erickson’s stages of development. / Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation, which is based on Gordon’s Functional Health Pattern and Erickson’s stages of development.
Evaluation / Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. / Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of interventions and goal completion. / Adequately utilizes criteria for evaluation. Adequately determines effectiveness of interventions and measures goal completion. / Demonstrate consistent progress in identifying and using criteria for evaluation. Determines effectiveness of interventions and measures goal completion. / Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of interventions. Modifies, recommends alternative intervention.

COMMENTS:

STUDENT SIGNATURE: DATE:

INSTRUCTOR SIGNATURE: DATE: