Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Student
Date
Instructor
Patient Initials
Date of Admission
Patient DOB
Unit
Course
Legal Status
(Vol, 5150, 5250,
Conservatorship)
Chronological and
Apparent Age
Gender
Ethnicity
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
Page 1 of 8
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
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)
Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive,
open and friendly, candid and cooperative,
showed subdued mistrust and hostility, excessive
shyness)
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)
Thought Processes
(loose associations, confabulations, flight of ideas,
Page 2 of 8
MENTAL STATUS EXAMINATION
Appearance
Gait and Motor Coordination
(awkward, staggering, shuffling, rigid, trembling
with intentional movement or at rest),
posture
(slouched, erect),
any noticeable mannerisms or gestures
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.
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)
Hallucinations and Delusions
(presence, absence, denied visual but admitted
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)
Judgment and Insight
(based on explanations of what they did, what
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
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
Pertinent Lab Tests Results
(normal ranges in parentheses)
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
CBC (WBC with diff, ANC, RBC)
Page 3 of 8
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)
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
happened, and if they expected the outcome, good,
poor, fair, strong)
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
Rationale for Abnormals
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results
(with dates)
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Rationale for Abnormals
Substance Abuse and other Addictions
(gambling, sex, shopping, smoking)
Type:
Amount / Frequency:
Duration:
Last Used:
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?
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)?
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,
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
Page 4 of 8
Yes
Yes
Yes
Yes
/ No
/ No
/ No
/ No
0
1
2
3
4
0
1
2
3
4
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)
IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal
movements.)
V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)
Page 5 of 8
0
1
2
3
4
0
1
2
3
4
Yes
No
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Diagnostic
Label
Diagnosis
Minimum of 2 NANDA actual and/or potential.
Include etiology and
signs and symptoms.
*Include
definition of the nursing
diagnoses with APA
citations
1.
Nursing Diagnosis
Definition:
2.
Planning
Outcome Criteria
Minimum of 2
measureable
goal per diagnosis related
to the nursing diagnosis
1.
1.
1.
2.
2.
3.
3.
4.
4.
1.
1.
2.
2.
3.
3.
4.
4.
2.
Page 6 of 8
2.
Signs and
Symptoms
As evidenced by
Implementation
Minimum of 4
independent and collaborative
nursing intervention include further
assessment, intervention, and
teaching that is related to the
outcome criteria
1.
Nursing Diagnosis
Definition:
Contributing
Factors
Related to
Rationales for interventions
(With APA citations )
Evaluation
Goal Met
Goal not Met
(If not met, what revisions
would you make?) How
did the patient respond to
your interventions
1.
2.
1.
2.
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
MEDICATION LIST
Medications
Generic / Trade
Page 7 of 8
Class/Rationale for the
patient
Dose/Route/
Time
(Frequency)
Range /
Therapeutic
Levels
Mechanism of action /
Onset of action
Common side
effects / Food and
drug interaction
Nursing considerations
specific to this patient
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
REFERENCES
Page 8 of 8
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
Student
Date
Instructor
Patient Initials
Date of Admission
Patient DOB
Unit
Course
Legal Status
(Vol, 5150, 5250,
Conservatorship)
Chronological and
Apparent Age
Gender
Ethnicity
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
Page 1 of 13
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
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)
Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive,
open and friendly, candid and cooperative,
showed subdued mistrust and hostility, excessive
shyness)
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)
Thought Processes
(loose associations, confabulations, flight of ideas,
Page 2 of 13
MENTAL STATUS EXAMINATION
Appearance
Gait and Motor Coordination
(awkward, staggering, shuffling, rigid, trembling
with intentional movement or at rest),
posture
(slouched, erect),
any noticeable mannerisms or gestures
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.
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)
Hallucinations and Delusions
(presence, absence, denied visual but admitted
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)
Judgment and Insight
(based on explanations of what they did, what
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
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
Pertinent Lab Tests Results
(normal ranges in parentheses)
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
CBC (WBC with diff, ANC, RBC)
Page 3 of 13
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)
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
happened, and if they expected the outcome, good,
poor, fair, strong)
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
Rationale for Abnormals
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results
(with dates)
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Rationale for Abnormals
Substance Abuse and other Addictions
(gambling, sex, shopping, smoking)
Type:
Amount / Frequency:
Duration:
Last Used:
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?
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)?
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,
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
Page 4 of 13
Yes
Yes
Yes
Yes
/ No
/ No
/ No
/ No
0
1
2
3
4
0
1
2
3
4
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)
IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal
movements.)
V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)
Page 5 of 13
0
1
2
3
4
0
1
2
3
4
Yes
No
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
Diagnostic
Label
Diagnosis
Minimum of 2 NANDA actual and/or potential.
Include etiology and
signs and symptoms.
*Include
definition of the nursing
diagnoses with APA
citations
1.
Nursing Diagnosis
Definition:
2.
Planning
Outcome Criteria
Minimum of 2
measureable
goal per diagnosis related
to the nursing diagnosis
1.
1.
1.
2.
2.
3.
3.
4.
4.
1.
1.
2.
2.
3.
3.
4.
4.
2.
Page 6 of 13
2.
Signs and
Symptoms
As evidenced by
Implementation
Minimum of 4
independent and collaborative
nursing intervention include further
assessment, intervention, and
teaching that is related to the
outcome criteria
1.
Nursing Diagnosis
Definition:
Contributing
Factors
Related to
Rationales for interventions
(With APA citations )
Evaluation
Goal Met
Goal not Met
(If not met, what revisions
would you make?) How
did the patient respond to
your interventions
1.
2.
1.
2.
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
MEDICATION LIST
Medications
Generic / Trade
Page 7 of 13
Class/Rationale for the
patient
Dose/Route/
Time
(Frequency)
Range /
Therapeutic
Levels
Mechanism of action /
Onset of action
Common side
effects / Food and
drug interaction
Nursing considerations
specific to this patient
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
REFERENCES
Page 8 of 13
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
Psychiatric Nursing Care Plan Rubric
NAME:
CLIENT INITALS:
CRITERIA
Client’s Demographics
and Psychiatric Legal
Status
Client’s Vital Signs and
Allergies
History of Present
Illness and Diagnostic
Criteria
Psychopathology and
biophysical pathology
of admitting and/or
related psychiatric and
medical diagnosis
Page 9 of 13
COURSE:
DATE:
CLIENT PSYCHIATRIC DISORDER:
Exemplary
4
Clearly and accurately
describes the client’s
demographics and
psychiatric legal status in
detail.
Clearly and accurately
documented the client’s
vital signs and allergies in
full detail.
Clearly and accurately
describes the client’s
history of present illness
and diagnostic criteria
which clearly supports the
chief complaints and
presenting signs/symptoms.
Proficient
3
Adequately describes the
client demographics and
psychiatric legal status with
adequate detail.
Developing
2
Vaguely describes the
client’s demographics and
psychiatric legal status with
some detail.
Ineffective
1-0
Lack description of the
client’s demographics and
psychiatric legal status that
presents no detail.
Adequately documented
the client’s vital signs and
allergies. Missing few minor
details.
Adequately describes the
client’s history of present
illness and diagnostic
criteria which adequately
supports the identified chief
complaint and presenting
signs/symptoms.
Incomplete documentation
of the client’s vital signs and
allergies.
Fails to document the
client’s vital signs and
allergies.
Vaguely describes the
client’s history of present
illness and diagnostic
criteria which vaguely
supports the identified chief
complaint and presenting
signs/symptoms.
Lack description of the
client’s history of present
illness and diagnostic
criteria that does not
support the identified chief
complaint and presenting
signs/symptoms.
Clearly and accurately
identifies psychopathology
and biophysical pathology
related to the identified
diagnostic criterion based
on the client’s history and
presenting symptoms.
Adequately identifies
psychopathology and
biophysical pathology
related to the identified
diagnostic criterion based
on the client’s history and
presenting symptoms.
Vaguely identifies
psychopathology and
biophysical pathology
related to the identified
diagnostic criterion based
on the client’s history and
presenting symptoms.
Fails to identify
psychopathology and
biophysical pathology
related to the identified
diagnostic criterion based
on the client’s history and
presenting symptoms.
POINTS
X2
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
CRITERIA
Erikson’s
Developmental Stages
Mental Status
Assessment
Substance Abuse and
other Addictions
Risk Assessment
Multidisciplinary Client
Outcome & Discharge
Planning.
Teaching Assessment
and Client Education
Page 10 of 13
4
Clearly and accurately
identifies client’s
developmental stage with
rationales based on the
client’s developmental
tasks.
Clearly and accurately
describes all components of
the mental status
examination based on the
client’s presenting
symptoms.
Clearly and accurately
identifies abused
substances and problems
associated with substance
and other addictions.
Clearly and accurately
identifies all risk factors
related to the client’s
history and presenting
symptoms.
Clearly and accurately
describes collaborative
issues and concerns related
multidisciplinary client
outcome and discharge
planning.
Clearly and accurately
identifies areas of
instructional needs,
learning preference and
learning barriers. Provided
clear and concise client
education the will aid in
3
Adequately identifies
client’s developmental
stage with rationales based
on the client’s
developmental tasks.
2
Vaguely identifies client’s
developmental stage
without adequate rationale
based on the client’s
developmental tasks.
1 - 0
Fail to identify client’s
developmental stage and
lack rationale based on
the client’s
developmental tasks.
POINTS
Adequately describes
components of the mental
status examination based
on the client’s presenting
symptoms.
Vaguely describes
components of the mental
status examination based
on the client’s presenting
symptoms.
X2
Adequately identifies
abused substances and
problems associated with
substance and other
addictions.
Adequately identifies some
risk factors related to the
client’s history and
presenting symptoms.
Vaguely identifies abused
substances and problems
associated with substance
and other addictions.
Fails to describe any of
components of the
mental status
examination based on the
client’s presenting
symptoms.
Fails to identify abused
substances and problems
associated with substance
and other addictions.
Vaguely identifies risk
factors related to the
client’s history and
presenting symptoms.
Fails to identify any of the
risk factors related to the
client’s history and
presenting symptoms.
Adequately describes
collaborative issues and
concerns related
multidisciplinary client
outcome and discharge
planning.
Adequately identifies areas
of instructional needs,
learning preference and
learning barriers. Provided
some and adequate client
education the will aid in
health promotion, health
Vaguely describes
collaborative issues and
concerns related
multidisciplinary client
outcome and discharge
planning.
Vaguely identifies areas of
instructional needs,
learning preference and
learning barriers. Provided
minimal and vague client
education the will aid in
health promotion, health
Fails to describe
collaborative issues and
concerns related
multidisciplinary outcome
and discharge planning.
Fails to identify areas of
instructional needs,
learning preference and
learning barriers. Did not
provide client education
the will aid in health
promotion, health
X2
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
Pertinent Lab Test
& Abnormal
Involuntary Movement
NANDA Nursing
Diagnosis (prioritized)
Nursing Diagnosis
Definition
health promotion, health
maintenance and self-care
activities.
Clearly and accurately
identifies pertinent
laboratory test and
abnormal movements
related to client’s disease
process.
Both nursing diagnoses are
accurate and prioritized per
NANDA format with clear
etiology and data to
support diagnosis. Nursing
Diagnosis is consistent and
presents correlation from
the assessment data based
on Gordon’s 11 Functional
Health Pattern and Mental
Status Examination. Clear
and accurate nursing
diagnosis definition.
Nursing Outcome
Criteria
Clearly and accurately
establishes client’s outcome
criteria and can be achieved
with nursing assistance. The
goal clearly supports the
nursing diagnosis and plan
of care. The goals are easily
measurable and realistic.
Nursing Intervention
Criteria & Rationale
Clearly and accurately
Identifies independent
nursing interventions
Page 11 of 13
maintenance and self-care
activities.
maintenance and self-care
activities.
maintenance and selfcare activities.
Adequately identifies
pertinent laboratory test
and abnormal movements
related to client’s disease
process.
Vaguely identifies pertinent
laboratory test and
abnormal movements
related to client’s disease
process.
Fails to identify pertinent
laboratory test and
abnormal movements
related to client’s disease
process.
Both nursing diagnoses are
adequate and prioritized
per NANDA format with
sufficient etiology and data
to support diagnosis.
Nursing Diagnosis is
adequate and presents
correlation from
assessment data based on
Gordon’s 11 Functional
Health Pattern and Mental
Status Examination.
Adequate nursing diagnosis
definition.
Adequately establishes
client’s outcome criteria
and can be achieved with
nursing assistance. The goal
somewhat supports the
nursing diagnosis and plan
of care. The goals are
somewhat measurable and
realistic.
Both nursing diagnosis are
vague and not prioritized
per NANDA format with
vague etiology and unclear
correlation from the
assessment data that may
or may not be classified as
nursing diagnosis based on
Gordon’s 11 Functional
Health Pattern and Mental
Status Examination.
Inaccurate nursing
diagnosis definition.
Both nursing diagnosis
are indefinable per
NANDA format and does
not correlate to support
assessment data and
cannot be classified as
nursing diagnosis based
on Gordon’s 11
Functional Health Pattern
and Mental Status
Examination. Lack nursing
diagnosis definition.
X2
Vaguely establishes client’s
outcome criteria and may
or may not be achieved
with nursing assistance. The
goals are inconsistent with
the nursing diagnosis and
plan of care. The goals are
vaguely realistic and
measurable.
Fails to establish client’s
outcome criteria that
cannot be met by nursing
assistance. The goals lack
support and nonspecific
from gathered data,
Outcome criteria are not
realistic and not
measurable.
X2
Adequately Identifies
nursing interventions with
adequate teaching.
Vaguely Identifies nursing
interventions with unclear
teaching. Scientific rationale
Fails to identify
interventions and
teaching. Lack Scientific
X2
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
criteria with teaching
supported by scientific
rationale and evidencebased practice.
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
based on nursing
assessment and Erickson’s
stages of development.
Scientific rationale is
adequately supported by
evidence-based practice.
Interventions are adequate,
individualized, organized,
specific and realistic.
Interventions can be
implemented adequately
that is focused on client’s
goal and health deviation
based on nursing
assessment and Erickson’s
stages of development.
is vaguely relevant & not
supported by evidencebased practice.
Interventions are
inconsistent, non-specific,
disorganized, and not
adequately focused on the
client’s goal. Interventions
are difficult to implement
and has weak relationship
to nursing diagnosis based
on nursing assessment and
Erickson’s stages of
development.
rationale and is not
supported by evidencebased practice.
Interventions are nonspecific, inappropriate,
unrealistic, unmeasurable and do not
relate to nursing
diagnosis. Intervention
does do not focus on
client goals and/or the
stated health deviation
based on nursing
assessment and
Erickson’s stages of
development.
Evaluation
Skillfully and independently
identifies criteria for
evaluation. Evaluates
effectiveness of
interventions and measures
goal completion. Modifies,
revises and recommends
alternative intervention.
X2
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.
Difficulty utilizing criteria
for evaluation. Difficulty
determining effectiveness
of interventions and goal
completion. Evaluation
vaguely supports if goal is
met or not met with
inaccurate revisions to the
treatment plan.
Vaguely identifies
components of the
medication list. Lack
description of mechanism
of action, purpose, range
side effects, interactions,
levels and nursing
considerations relevant to
the client.
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.
Medications
Adequately identifies
criteria for evaluation.
Adequately determines
effectiveness of nursing
interventions and measures
goal completion with
appropriate modification
and revisions
to the treatment plan.
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.
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.
X2
Page 12 of 13
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC
General Organization
Accurate APA format,
appropriate citations and
references,
No spelling or grammar
errors.
TOTAL: 100
Additional Comments and Feedback:
Page 13 of 13
Adequate APA format.
Minimal citations and
references are appropriate.
Few spelling or grammar
errors.
Numerous APA format
errors, Inaccurate citations
and references.
Few spelling and grammar
errors.
Fails to utilize APA format.
No citations or references
included numerous spelling
and grammar errors.
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
Student:
Date:
Clinical Instructor:
Name (initials only):
Unit:
Current Legal Status (Vol., 5150, 5250, 30 day, T-Con, LPS-Conservatorship):
Multiaxial Diagnostic System: Axis I (Clinical Disorder):
Axis II (Personality Disorder / Mental Retardation):
Axis III (General Medical Conditions):
Axis IV (Psychosocial and Environmental Problems):
Axis V (Global Assessment of Functioning Scale):
1.
Description of the patient: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization?
Number of days in the hospital? Mental Status, etc.
2.
Description of environmental setting where interaction took place. Explain the reasons for a supportive or
non-supportive environment. (e.g. noise, distractions, light, temperature, etc.)
Page 1 of 3
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
INTERPERSONAL PROCESS ANALYSIS
NAME:
Student:
• Verbal (quotes) and Nonverbal
Communication (behavior, tone of
voice, eye contact, mannerisms, etc.)
• Document at least 5 interactions
• Goal for each interaction (realistic and
measurable)
DATE:
Patient:
Communication Techniques
Verbal (quotes) and
• Identify communication technique
Nonverbal Communication
used then define your communication
(behavior, tone of voice, eye
techniques
contact, mannerisms, etc.) • Was the communication therapeutic or
non- therapeutic?
• Which defense and coping
mechanisms didthe patient use?
Rationale based on your patient.
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Page 2 of 3
Critique and Analysis
(effective or not effective? Could
have said…) Document your
thoughts and feelings during the
interaction.
Was your goal met?
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS TEMPLATE
INTERPERSONAL PROCESS ANALYSIS SUMMARY
1. Evaluation: After analyzing the interaction, provide a description on how the interaction progressed. Identify the reasons for successful process or
unsuccessful process. What did you learn from the interaction with your patient?
2. How did you personally feel about the interaction? What would you change if you had to redo the interaction?
Page 3 of 3
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
Introduction
Interpersonal Process Analysis (IPA) is a way to identify patterns in student and patient communication. It is not
an intake assessment nor question and answer session but a time to listen and demonstrate caring concern,
and a time to recognize and identify a patient’s emerging feelings. IPA is a written record of a segment of the
nurse-patient conversation that reflects as closely as possible the verbal, non-verbal, coping, and defense
mechanisms utilized during the interaction. IPA has some disadvantages because it relies on memory and is
subject to distortions, however, it can be a useful tool for identifying communication patterns. The purpose of
the conversation is to give an opportunity to identify and practice communication strategies correctly. Note that
the goal is not to solve the patient’s problems but to explore and use interactive therapeutic communication.
The student selects goals prior to the interactions that are realistic and measurable. Topics include such areas as
behavioral issues (triggers like getting angry when called or made to feel “stupid”), replacing negative with
positive coping mechanisms (reframing), identification of feelings (hungry, angry, lonely, tired, happy, etc.),
plans for discharge, presence/absence delusions/hallucinations, etc. Therapeutic Communication demonstrates
the use of mostly broad open-ended questions, clarification, confronting, reflecting, empathy, immediacy,
focusing, etc. Identify the techniques used with rationales for use, and the effect of these techniques. Read and
follow guidelines (template and rubric) and chapters on therapeutic communication. Is the patient able to
answer? Are responses congruent with your statements?
Instructions
Select a patient to participate. Do not use a “script” for this interaction. Listen and respond to the patient
without taking notes. Taking notes is distracting for both the student and the patient and the patient may
resent or misunderstand the student’s intent or feel like a project. Write out and analyze a segment of the
nurse-patient interaction using quotation marks around what both you and the patient said. Identify non-verbal
actions such as body position changes, mood/affect changes, or conversation factors (looking down when
discussing an uncomfortable subject). Describe the environmental setting where the interaction took place – did
they contribute to a therapeutic (ease of conversation) or non-therapeutic setting (too cold, smoky, etc.). The
interpretation sections will be completed later because these sections take time and reflection. Utilize ATI or the
textbook for communication and defense/coping strategies.
The selected interaction is based upon the parts of the conversation most meaningful or therapeutic. Allow the
interaction to flow, documented so that the Instructor can easily follow the content. As soon as the interaction is
completed, thank the patient and excuse yourself. Begin to write the conversation verbatim (word for word) to
the best of your recollection. Document both parties’ non-verbal behaviors. During documentation, insert
information about any discontinuity, i.e. “patient needed to get ready for group therapy;” “patient left to use
the bathroom;” or “we agreed to meet up directly after group.” If the student continues a conversation later and
wishes to include parts of both conversations, identify the change or time lapse. (Always account for how an
interaction ended when it is unplanned and abrupt, i.e., “patient stood up and said he didn’t want to talk about
this anymore.”)
Page 1 of 8
Version Update: January 2018
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
Steps:
1. Complete the patient demographic information and the environmental setting. (Was the setting
conducive to talking?). In the patient description section, the patient should be described in such a way
that no one can identify him or her (first and last initials only). Never use patient’s name in your papers.
2. Include grooming, affect, posture, and mood.
3. Quote both sides of the conversation and the non-verbal information. Verbal communication is
concerned with the spoken word, including inflection and tone of voice. Non-verbal communication is
concerned with gestures, body movements, posture and other unspoken forms of relaying ideas and
feelings.
4. Identify student thoughts and feelings during the interaction. For example, “I was feeling nervous and
scared. He had attempted suicide and I didn’t know if what I said would hurt him.” Focus on what is
happening to you and the patient that has communication value.
5. The rest of the template will be completed later with time to analyze. Once all columns are complete,
the student will have gained insight needed to look back and decide if the technique was therapeutic or
non-therapeutic. If the patient responded favorably, yet a non-therapeutic statement was used such as
closed statements (“why did you do that?”), document what could have been said that was more
therapeutic. For example, I could have said, “Tell me more about what happened.”
6. The ability to look back and analyze conversation errors/ non-therapeutic responses is as valuable as
providing therapeutic responses during the conversation and can provide insight into what is customarily
used in your conversations.
7. Complete the type of communication techniques used and identify whether therapeutic or nontherapeutic. (Therapeutic communication is defined as a face-to-face process of interacting, focusing on
advancing the patient’s physical and emotional well-being, and is used to support or inform.)
8. Identify coping or defense mechanisms the patient probably used in this interaction and whether these
were adaptive or maladaptive.
9. Evaluate the effectiveness of this interaction.
a. Evaluate the goals. Are the responses relevant to the goal?
b. Did the patient initiate the conversation or did you?
c. Did you or the patient change the subject due to discomfort with the topic (like self-harm or
abuse)? Did the patient answer you, look away, or hesitate?
d. Were only meaningless/social topics discussed (football teams, music, food, etc.)? Did you use
closed communications, and if so was it because the patient was not cognitively communicative
(Alzheimer, stroke, or dementia patient)? What communication techniques were used the most?
e. Is there congruence between the verbal and nonverbal communications?
f. Interpret behaviors. These relate to the perception of meaning behind the words.
g. Identify feelings involved. When possible, document the reasoning behind the feelings.
h. Identify and evaluate themes and strategies.
i. What did the communication mean to you and the patient? If you were to redo this interaction,
what would you change?
10. These assignments are typed. Extra pages/rows may be added as needed for the conversation. Include a
reference page in APA form.
REV 5/2017
Page 2 of 8
Version Update: January 2018
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
INTERPERSONAL PROCESS ANALYSIS
Student:
Date:
Clinical Instructor:
Name (initials only):
Unit:
Current Legal Status (Vol., 5150, 5250, 30 day, T-Con, LPS-Conservatorship):
Multiaxial Diagnostic System: Axis I (Clinical Disorder):
Axis II (Personality Disorder / Mental Retardation):
Axis III (General Medical Conditions):
Axis IV (Psychosocial and Environmental Problems):
Axis V (Global Assessment of Functioning Scale):
1.
Description of the patient: Age? Sex? Ethnicity? Marital Status? What precipitated hospitalization?
Number of days in the hospital? Mental Status, etc.
2.
Description of environmental setting where interaction took place. Explain the reasons for a supportive or
non-supportive environment. (e.g. noise, distractions, light, temperature, etc.)
Page 3 of 8
Version Update: January 2018
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
INTERPERSONAL PROCESS ANALYSIS
NAME:
Student:
• Verbal (quotes) and Nonverbal
Communication (behavior, tone of
voice, eye contact, mannerisms, etc.)
• Document at least 5 interactions
• Goal for each interaction (realistic and
measurable)
DATE:
Patient:
Communication Techniques
Verbal (quotes) and
• Identify communication technique
Nonverbal Communication
used then define your communication
(behavior, tone of voice, eye
techniques
contact, mannerisms, etc.) • Was the communication therapeutic or
non- therapeutic?
• Which defense and coping
mechanisms didthe patient use?
Rationale based on your patient.
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Goal:
Verbal:
Nonverbal:
Verbal:
Nonverbal:
Page 4 of 8
Version Update: January 2018
Critique and Analysis
(effective or not effective? Could
have said…) Document your
thoughts and feelings during the
interaction.
Was your goal met?
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
INTERPERSONAL PROCESS ANALYSIS SUMMARY
1. Evaluation: After analyzing the interaction, provide a description on how the interaction progressed. Identify the reasons for successful process or
unsuccessful process. What did you learn from the interaction with your patient?
2. How did you personally feel about the interaction? What would you change if you had to redo the interaction?
Page 5 of 8
Version Update: January 2018
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
INTERPERSONAL PROCESS ANALYSIS RUBRIC
Program Learning Outcome #7: Utilize effective communication to interact with patients, families, and the interdisciplinary health team.
Course Learning Outcome #3: Initiate therapeutic nurse-client relationship then analyze verbal and non-verbal interactions, defense mechanisms, and coping
mechanisms.
Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcome.
Environment
Description
Clearly and accurately
describes the environment
with clear detail of where
the interaction took place.
Adequately describes the
environment with
adequate detail where the
interaction took place.
2
(Approaching
Expectations)
Vaguely describes the
environment with some
detail regarding where the
interaction took place.
Client Description
Clearly and accurately
describes the client’s
description in detail.
Adequately describes the
client’s description with
adequate detail.
Vaguely describes the
client’ description with
some detail.
Communication
Goals
Clearly and accurately
identifies realistic and
measurable
communication goals.
Adequately identifies
realistic and measurable
communication goals.
Vaguely identifies realistic
and measurable
communication goals.
Fails to identify to identify
realistic and measurable
communication goals.
Student
Communication
Clearly and accurately
identifies all verbal and
non-verbal
communications.
Adequately identifies
verbal and non-verbal
communications.
Vaguely identifies some,
but not all of the verbal
and non-verbal
communications.
Fails to identify either the
verbal and non-verbal
communications.
CRITERIA
4
(Exceeds Expectations)
3
(Meets Expectations)
Page 6 of 8
Version Update: January 2018
1-0
Score
(Does Not Meet
Expectations)
Lack description of the
environment and presents
no detail of where the
interaction took place.
Lack description of the
client and presents no
detail.
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
CRITERIA
Client
Communication
Communication
Techniques
Defense
Mechanism
Coping
Mechanism
Critique and
Analysis
CRITERIA
4
(Exceeds Expectations)
Clearly and accurately
identifies all verbal and
non-verbal
communications.
Clearly and accurately
identifies therapeutic and
non-therapeutic
communication
techniques. Consistently
able to explain the
rationale for using selected
techniques.
Clearly and accurately
identifies client’s defense
mechanisms.
Clearly and accurately
identifies client’s coping
mechanisms.
3
(Meets Expectations)
Adequately identifies
client’s verbal and nonverbal communications.
Progressively identifies
therapeutic and nontherapeutic
communication
techniques. Progressively
able to explain majority of
the rationale for using
selected techniques.
Progressively identifies
client’s defense
mechanisms.
Progressively identifies
client’s coping
mechanisms.
Clearly and accurately
interprets if the
communication technique
was effective or not.
Clearly interpretation of
thoughts and feelings
regarding statements.
Progressively interprets if
the communication
technique was effective or
not. Identifies
interpretation of thoughts
and feelings regarding
statements.
4
(Exceeds Expectations)
3
(Meets Expectations)
2
(Approaching
Expectations)
Vaguely identifies some
but not all of the client’s
verbal and non-verbal
communications.
Vaguely identifies some,
but not all therapeutic and
non- therapeutic
communication
techniques. Able to
explain some of the
rationale for using
selected techniques.
Vaguely identifies some
but not all defense
mechanisms.
Vaguely identifies some
but not all coping
mechanisms.
Page 7 of 8
Version Update: January 2018
Fails to identify any of the
therapeutic and nontherapeutic
communication
techniques used. Fails to
explain the rationale for
using the selected
communication
techniques.
Score
X2
Fails to identify client’s
defense mechanisms.
X2
Vaguely interprets if the
communication technique
was effective or not.
Vague interpretation of
thoughts and feelings
regarding statements.
2
(Approaching
Expectations)
1-0
(Does Not Meet
Expectations)
Fails to identify either
client’s verbal and nonverbal communications.
Fails to identify client’s
coping mechanisms.
X2
Fails to interpret if the
communication technique
was effective or not. Lack
justification of one’s
analysis and interpretation
of feelings regarding his or
her statements.
1-0
(Does Not Meet
Expectations)
X2
Score
Course: NURS 223L
INTERPERSONAL PROCESS ANALYSIS & RUBRIC
Evaluation
General Organization
Expresses clear and
precise point of view.
Responds strongly
regarding personal
feelings regarding the
interaction.
Accurate APA format,
appropriate citations and
references.
No spelling or grammar
errors.
Progressively expresses
own point of view and
own personal feelings
during the interaction.
Adequate APA format.
Minimal citations and
references are
appropriate.
Few spelling or grammar
errors.
Difficulty expressing own
point of view, vague
response regarding
personal feelings during
the interaction.
Fails to clearly express
own point of view and
describe personal
feelings during the
interaction.
Fails to utilize APA
format.
No citations or
references included
numerous spelling and
grammar errors.
Numerous APA format
errors,
inaccurate citations and
references.
Few spelling and
grammar errors.
X2
Total
STUDENT SIGNATURE:
DATE:
INSTRUCTOR SIGNATURE:
DATE:
COMMENTS:
/64 = %
_______
Page 8 of 8
Version Update: January 2018
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