Interpersonal Process analysis and care plan

User Generated

pybrc2011

Health Medical

Description

2 Care plans is for the( week july 16 - july 20 I need to posted the 20 in blackboard )

4 Interpersonal Process analysis are for the week (july 2 -july 6 I need it for july 6 )

Remember the class is Mental Health.

Im going to atach the tempalte and the rubric for those 2 works .

Robert Please reed the rubric for the interpersonal process Is an APA paper .

Unformatted Attachment Preview

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
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

By this, I think my work for this question is done. I will now mark this answer as being the final one. I am also going to reattach all the work I did for you so you have a faster access to them.In total I wrote for your task 2 nursing care plans and 4 interpersonal analysis paper :Nursing Care plans *Nursing Care Plan I - Bipolar Disorder / the paper is about bipolar disorder*Nursing Care Plan II - Schizophrenia / the paper is about unspecified schizophrenia Interpersonal Analysis*Interpersonal Depressive Disorder with psychosis and delusions/analysis of a patient with depressive disorder major form and with episodes of delusions and psychosis*Interpersonal Analysis Depressive form of Bipolar Disorder/analysis of a patient with bipolar disorder but mainly focused on depressive episodes rather than psychosis one.*Interpersonal Analysis Paranoid Schizophrenia/analysis of a patient which high degrees of paranoia mixed with bipolarity disorder.*Interpersonal Analysis Psychosis episodes Bipolar disorder I/the patient has type I bipolar disorder manifested especially through psychosis episodes.-------Please confirm that you got all the files. If you need any changes don't hesitate to text me. Looking forward to hearing from you.

Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE

Student

Date

Instructor
Patient Initials

Course
Legal Status
(Vol, 5150, 5250,
Conservatorship)

Patient DOB
Chronological and
Apparent Age
Allergies

D.I

Date of Admission
4 March 1978

Unit

40 years, looks older than her
real age
She denies any allergies

20/4/2018
Mental Health Unit

7/5/2018
Mental Health

F

Afro American

Gender

Ethnicity

Height/Weight

Temp (location)

Pulse (location)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure
(location)

5’8 / 73 kg

Oral – 98.5

Radial - 88

14

99%

Right hand – 120/70
Left Hand – 120/70

Psychiatric Diagnosis and DSM 5 Diagnostic Criterion

Axis I –Bipolar Disorder
Criteria:
*Recent Major Depressive Episodes
* Previously faced with a mixed or maniac episode at least once
*The mood i not caused by other pathology such as delusional disorder or
schizophrenia.
Axis II – The patient has no personality disorder or mental retardation
Axis III – Hepatitis C
Axis IV – The symptoms are generated when the patient is under severe
stress
Axis V – Currently not determined
(American Psychiatric Association, 2013)
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
Bipolar disorder interferes with the capacity to live a normal life. Most of the
patients face with mood swings and also energy level swings. The two main
Page 1 of 11

Voluntary

Pain Scale 1-10
(location, character,
onset)
No Pain

History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement
The patient presents with an acute episode psychosis and the main signs and
symptoms are represented by suicidal thoughts. The patient tried to cut her
veins but the members of the family saw her.
She was never admitted before this time.

Erickson’s Developmental Stage
Include Rationale Based on the Patient
With APA citations
Stage: Intimacy vs Isolation
This stage occurs between the age of 18 until the age of 40. During this period of

Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE

episodes are represented by the maniac one during which the patient is
irritable, the need of sleep is decreased, more talkative than usually ,
distractible, involved in pleasurable activities which can lead to painful
consequences. On the other hand the depressive episode is represented by
excessive sleeping, feeling fatigue all the time, excessive worrying, though sot
death , weight gain or weight loss.
All these patients are at high risk for psychotic depression which can be
translated by a severe disability to function and integrate in the society.
(Hilty, Leamon, Lim, Kelly, Hales, 2006)

Page 2 of 11

time we get to understand ourselves better and start getting more involved in
an intimately way with the others. If the person is successful in this stage she or
he will feel comfortable and will have a sense of commitment. The opposite
situation will lead to isolation and depression.
Our patient is married, has 2 children and seems to have no major problems in
her family. Because we can state that she is very attached to her family by the
way she described them we can state that she doesn’t want to be insolated from
the loved ones.
(Malone,Liu,Vaillant,Rentz,Waldinger,2016)

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)
BMI- 24,7 (the patient has a normal weight) .
Patient has a broken right leg after falling on the
stairs.
The patient is well groomed and clean (even so,
the family members insist that sometimes they
have to force her to take care of herself)

Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive,
open and friendly, candid and cooperative,
showed subdued mistrust and hostility, excessive
shyness)
The patient is very sociable. She immediately
noticed me when I entered the room and started
talking to me. She was open to answer any of my
questions. From time to time she used vulgar
language.

Recall and Memory
(recalls recent and past events in their personal
history). Recalls three words (e.g., Cadillac,
zebra, and purple)
Orientation
Page 3 of 11

MENTAL STATUS EXAMINATION
Appearance
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)
BMI- 24,7 (the patient has a normal weight) .
Patient has a broken right leg after falling on the
stairs.
The patient is well groomed and clean (even so, the
family members insist that sometimes they have to
force her to take care of herself)

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)
BMI- 24,7 (the patient has a normal weight) .
Patient has a broken right leg after falling on the
stairs.
The patient is well groomed and clean (even so, the
family members insist that sometimes they have to
force her to take care of herself)

Manner and Approach
Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive, open
and friendly, candid and cooperative, showed
subdued mistrust and hostility, excessive shyness)

Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive, open
and friendly, candid and cooperative, showed
subdued mistrust and hostility, excessive shyness)

The patient seemed calm and tended to be
cooperative during our talk.
Coping mechanism: projection . She stated that she
started having this moods after her husband
cheated on her and even though their relationship
still work she thinks that was the cause for her
mood swings.
She understands the fact that she indeed has
problems and needs help.
Orientation, Alertness, and Thought Process
Alertness
(sleepy, alert, dull and uninterested, highly
distractible)
Coherence
(responses were coherent and easy to understand,

The patient spoke at a faster rate than average and
very loudly.
In terms of expressive language and receptive
language the patient showed no signs of deficit.
She was able to fully understand and process my
question and offer a coherent answer.

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)

Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE

(person, place, time, presidents, your name)

Able to recall last presidents.
Able to recall three words ( table, apple, pen).
Able to remember her treatment plan.
Able to remember her date of birth and the one
of her husband
Able to remember my name.
She was oriented to place, time ,person and
situation.

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
Thought process: focused , linear.
The patient doesn’t believe in god and never goes
to the church.

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.
The patient was a little bit irritable but she stated
that this is because she didn’t smoke since
morning.
Page 4 of 11

simplistic and concrete, lacking in necessary detail,
overly detailed and difficult to follow)
She was alert and also oriented.
Coherent in speaking and very easy to understand.

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)

She denies having any delusional thoughts or
hearing voices.
She admits for having suicidal thoughts.
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)
It was easy to establish rapport with the patient. She
was very open and wanted to engage in the
conversation.
During all our talk she used appropriate emotional

Patient was able name the days of the week and the
months.
She showed no signs of difficulties spelling the word
“marble” backward.
No difficulties in spelling the ABC backwards.

Judgment and Insight
(based on explanations of what they did, what
happened, and if they expected the outcome, good,
poor, fair, strong)

The patient shows sings of good judgment. She
wants to follower her treatment in order to be able
to leave the hospital as soon as possible and spend
time with her family.
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)
The patient is aware that it was harder to spell the
ABC backwards.
No signs of impulsivity were seen during the talk.
She didn’t seem to be anxious at all.

Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE

She showed signs of congruent affect.

and also facial expression.
She seems to be optimistic about her recovery.

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

Discharge Plans and Instruction:
Placement, outpatient treatment, partial
hospitalization, sober living, board and care, shelter,
long term care facility, 12 step program

Patient had suicidal thought and she even tried
to cut her wrists but was stopped by her family.
Currently she is adherent to the treatment.
Denies homicidal ideation.

The physician will help determine what is the correct
post-discharge plan for this patient and also advise
about the changes that need to be done.
The treatment will most likely be under the form of a
12 step program.

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)
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results
(with dates)
MRI

Page 5 of 11

Teaching Assessment and Client / Family
Education:
(Disease process, medication, coping, relaxation,
diet, exercise, hygiene)
Include barriers to learning and preferred learning
styles

The patient is open to find out more about her
pathology in order to find out how she can control
her episodes.
Me as a nurse , I was able to deliver her general
information about the condition and what can
cause it.
The preferred learning style in our case was the
verbal one.

Rationale for Abnormals

Normal Values
Normal Values
Normal Values
WBC= 4.5, HB= 13.9
Positive for methamphetamine
Normal TSH, T3 and T4,
Normal AST – 33 ; Normal Albumin - 4
Normal creatinine level 0.88
Below 0.01%
Rationale for Abnormals

No signs of abnormalities

Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE

Substance Abuse and other Addictions
(gambling, sex, shopping, smoking)
Type: Smoking
Type: methamphetamine
Amount / Frequency:1/2 pack /day
Amount / Frequency: Occasionally
Duration: for the last 15 years
Duration: Started 4 years ago
Last Used: this morning
Last Used: Before admission
Withdrawal Symptoms: the need to smoke, difficulties falling asleep,
Withdrawal Symptoms: depression, limbs pain, difficulties falling asleep,
difficulties concentrating , irritability, anxiety(McLaughlin,Dani,De Biasi,2015)
irritability, mood swings, weight gain. (Zorick, Nestor, Miotto, Sugar,
Hellemann, Scanlon, London,2010)
C.A.G.E. Questionnaire
Have you ever felt you should cut down on your drinking?
No
Have people annoyed you by criticizing your drinking?
No
Have you ever felt bad or guilty about your drinking?
No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
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,
grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and
out of mouth)

0

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
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 6 of 11

0
0
Yes

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
1.7At risk for injury

Nursing Diagnosis
Definition:” Vulnerable
for injury as a result of
environmental
conditions interacting
with the individual’s
adaptive and defensive
resources, which may
compromise health.
(Ackley,2013)

Related to

Planning
Outcome Criteria
Minimum of 2
measureable
goal per diagnosis related
to the nursing diagnosis

Contributing
Factors

Implementation
Minimum of 4
independent and collaborative
nursing intervention include further
assessment, intervention, and
teaching that is related to the
outcome criteria

1.The patient will
announce the staff
members encase she has
thoughts to harm herself
again

1. Assess the risk of suicide

2. The patient will try to
avoid using items that
could be used for harming
herself

3. Ensure a safe environment which
reduces the risk for possible selfharming

2. Provide supervision for the
patient so she can be observed full
time

4. Try to set limits in terms of
behaviors that can be destructive
on the others.

As evidenced by

Rationales for interventions
(With APA citations )

1. The patient will sign a contract
in which she will state that she will
take full responsibility of what
happened and that she will avoid
doing it again.
2. Access to products that can be
seen as weapon can lead to serious
consequences during the episodes
the patient might suffer.
3. Emotional ventilation can
reduce the number of trigger
factors.
4. In case the patient is not able to
control her behavior , limits will be
established in terms of visitors in
order to ensure that both the
patient and the visitors are safe.

Page 7 of 11

Signs and
Symptoms

Evaluation
Goal Met
Goal not Met
(If not met, what revisions
would you make?) How
did the patient respond to
your interventions

1.
In our case the goal was
met and the patient
responded well to the
interventions presented.

Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE

2.Disturbed thoughts

Nursing Diagnosis
Definition:” The state in
which an individual
experiences a disruption
in such mental activities
as conscious thought,
reality orientation,
problem-solving,
judgment, and
comprehension related
to coping, personality,
and/or mental disorder.
(Ackley,2013)

1. Patients need to
demonstrate that she is in
a stable mood and that
she is able to take care of
herself.
2. The patient will come
with two coping skills that
will have the role of
lowering the risk for
suicidal thoughts and
other manifestations.

1. Help the patient become more
optimistic
2. Teach the person how to discover
different efficient coping skills such
as sharing their emotions and asking
for help
3. Encourage the patient to
determine the current trigger
factors so they can focus on solving
them.
4. Encourage healthy habits in
terms of diet, sleep and daily
activities.

1. If the ...


Anonymous
Just what I needed…Fantastic!

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Related Tags