Homework answers / question archive / Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Psychiatric Nursing Care Plan West Coast University Page 1 of 12 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Student Instructor Patient Initials Patient DOB Chronological and Apparent Age Allergies Date Professor Gayane Avagimian K

Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Psychiatric Nursing Care Plan West Coast University Page 1 of 12 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Student Instructor Patient Initials Patient DOB Chronological and Apparent Age Allergies Date Professor Gayane Avagimian K

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Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Psychiatric Nursing Care Plan West Coast University Page 1 of 12 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Student Instructor Patient Initials Patient DOB Chronological and Apparent Age Allergies Date Professor Gayane Avagimian K.Y Date of Admission 11/07/1967 Unit 52 Course Legal Status (Vol, 5150, 5250, Conservatorship) 6/19/19 Mariah East Female 7/20/19 NURS 223L 5250 Korean Gender Ethnicity N.K.A Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure (location) 5’3”/135 lbs 98F (Temporal) 105 16 99 127/80 (Right arm) Psychiatric Diagnosis and DSM 5 Diagnostic Criterion Multiaxial Diagnostic System: Axis I (Clinical Disorder): Paranoid Schizophrenia Axis II (Personality Disorder / Mental Retardation): Paranoid Personality disorder Axis III (General Medical Conditions): N/A Axis IV (Psychosocial and Environmental Problems): Anxiety Axis V (Global Assessment of Functioning Scale): N/A 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 Psych diagnosis: Paranoid schizophrenia Paranoid schizophrenia is a kind of, which means your mind doesn't agree with reality. It affects how you think and behave. This can show up in different ways and at different times, even in the same person. The illness usually starts in late adolescence or young adulthood. Page 2 of 12 Pain Scale 1-10 (location, character, onset) 0 History of Present Psychiatric Illness: Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement The patient is a 52-year-old Korean female. She is unmarried and has no children. The patient was brought on a 5250 call from her sister. The sister called saying that the patient was throwing things around and previously assaulted her mother twice, accusing her of “stealing her boyfriend”. The patient’s sister also said that the patient had kept scratching her left forearm aggressively for a long time. The patient had been in the hospital for eleven days upon our arrival. The patient was calm upon speaking with her. However, when alone, the patient keeps rubbing her arm and has a blunted affect. Erickson’s Developmental Stage Include Rationale Based on the Patient With APA citations Generativity vs. Stagnation The patient is in the “Generativity vs. stagnation” stage because this stage is from 40 to 65 years of age and the patient is 52-years-old. It is the second to last stage of the eight Erikson Developmental stages. This stage exemplifies making a trademark on the world by giving back to it. This can be through raising children, working or giving back to the community. Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE People with paranoid delusions are unreasonably suspicious of others. This Through generativity the patient develops a sense of being a part of the bigger can make it hard for them to hold a job, run errands, have friendships, and picture. In this stage, the patient is trying to find a motive to being successful even go to the doctor. and feeling accomplished. If the patient does not succeed, the patient will tend Although it's a lifelong illness, you can take medicines and find help to stop to feel stagnant and unproductive. That is why success is an important part of symptoms or make them easier to live with. this stage. (McLeod, 2018) Medical diagnosis (cite): No medical diagnosis 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) Presenting Appearance According to the patient’s chart, the patient had poor appetite, no physical deformities, no hearing impairment, did not wear any glasses. The patient did not have any injuries and did not use a cane. She was 5’3” and appeared to be at a healthy weight. Basic Grooming and Hygiene The patient was moderately clean; she had a spaghetti strap and shorts on, which was appropriate for the warm weather. However, the walking was walking barefoot outside which was not appropriate. Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) Page 3 of 12 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 Gait and Motor Coordination The patient’s shuffles her feet a little when she walks. She likes to sit outside in the sun for the majority of the time and only walks to go eat or to go to her room. Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise) Level of Participation in the Program/Activity The patient does not attend group at all. When asked about having any friends in the unit she claims that “there is no time.” When asked to clarify, the patient did not. Posture The patient’s posture is slightly slouched. 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. 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) Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Interpersonal Characteristics and Approach to Evaluation The patient is polite and friendly. She approached me first and began making conversation. However, when she was asked questions, the patient would response with close-ended answers. She dismissed me at one point when we got more personal. However, I tried to approach the patient later that day and she was cooperative but did not want to share her reason for being admitted to the unit. 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) Recall and Memory The patient is able to recall recent and past events. Orientation The patient is alert and oriented to person, place, time, and event. 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 Processes Page 4 of 12 Behavioral Approach The patient is alert. Coping and Stress Tolerance The patient presented palliative coping mechanisms for the majority of the time while speaking to her. Her stress tolerance was moderate because she didn’t want to speak after asking her about why she was admitted. 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) Alertness The patient is alert and slightly distracted about scratching her arm. Coherence The patient’s responses were coherent and for the majority of the time, 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) Hallucinations and Delusions Receptive Language (normal, able to comprehend questions, difficulty understanding questions) Speech The patient exhibits quiet speech. Expressive Language The patient had no problems expressing herself. Receptive Language The patient’s language was normal. 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) Concentration and Attention The patient was not asked to perform any tests that would measure concentration and attention. Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong) Judgement and Insight Course: NURS 223L The patient did not exhibit a specific thought process while speaking to her. PSYCHIATRIC NURSING CARE PLAN TEMPLATE The patient was not experiencing any auditory, visual, and tactile hallucinations while speaking to her. The patient exhibits impaired judgement according to her chart. She claims that her mother wanted to “steal” her boyfriend and attacked her mother. 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) 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) Values and Belief System The patient did not exhibit values and beliefs while speaking to her. 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. Mood The patient exhibited a calm mood. Affect The patient’s affect was blunted. Rapport Initially it was difficult to establish a rapport with the patient because she dismissed me upon asking her about her reason for being admitted to the unit. When attempting to interview the patient again, she did not want to share any personal information regarding her diagnosis but was willing to talk. However, when asking her questions, she answered with close-ended answers. Response to Failure on Test Items The patient was not tested on anything during the interview. Impulsivity The patient’s was not currently impulsive nor did she not use any substances. Anxiety The patient had slight anxiety why being interviewed because she kept changing positions. She would keep scratching her right forearm. Facial and Emotional Expressions The patient did not show much facial and emotional expression. She was neutral throughout the whole interview. Risk Assessment: Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent) Self-Injurious Behavior (cutting, burning) Page 5 of 12 Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program Teaching Assessment and Client / Family Education: (Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Hypersexual, Elopement, Non-adherence to treatment The patient does not have any suicidal ideation, according to her chart. However, she has homicidal ideation towards her mother because she claims that her mother wants to “steal” her boyfriend. She also claimed that is not married or has kids but strangled her mother twice due to her “stealing” boyfriend. The patient cannot return home with her mother due to her homicidal ideation towards her mother. Her mother was previously taking care of her, but her mother left her because she could not handle her anymore, especially since she was attacked by her own mother. Her sister then began to take care of her at her home. While her sister was taking care of her, the patient had a psychotic episode and the sister decided to call and admit her in a mental health facility. 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) Rationale for Abnormals N/A N/A N/A N/A N/A N/A N/A N/A N/A Rationale for Abnormals N/A Type: None Amount / Frequency: Duration: Last Used: Withdrawal Symptoms: Page 6 of 12 The patient must take their medication as prescribed by the doctor which is highly important. It is also important to take the medication concisely to avoid relapse of positive symptoms of schizophrenia. The patient has to make sure to never stop taking the medication abruptly. If the patient feels confused at any point and feels like the medication Is not working, they must contact their doctor immediately for this could signify adverse effects. N/A Substance Abuse and other Addictions (gambling, sex, shopping, smoking) Type: None Amount / Frequency: Duration: Last Used: Withdrawal Symptoms: Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE 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 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 7 of 12 Yes Yes Yes Yes / No / No / No / No 0 1 2 3 4 0 1 2 3 4 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.Impaired verbal communication related to altered perception as evidenced by difficulty in discerning and maintaining the usual communication pattern. Related to Planning Outcome Criteria Minimum of 2 measureable goal per diagnosis related to the nursing diagnosis 1.Patient will express thoughts and feelings in a, logical and goal-oriented manner. 2.Patient will spend at least two to three 5minute sessions with nurse sharing observations in the environment within 3 days. 2. Impaired social interaction related to inadequate emotional responses as evidenced by patient stating, “there is no time for friends.” Page 8 of 12 1.Patient will attend one group activity within 5-7 days. 2.Patient will use appropriate social skills in interactions. 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.Identify the duration of the psychotic medication of the client. 2.Keep voice in a low manner towards the patient. 3. Keep the patient in an stimulifree environment. 4. Use clear, simple words and directions. 1. Assess if the medication has reached therapeutic levels. 2. Identify with the patient symptoms she experiences when she begins to feel anxious around others. As evidenced by Rationales for interventions (With APA citations ) 1. The therapeutic level of the medication may cause the patient to think clearly. 2. A loud voice may cause the patient to obtain increased levels of anxiety. 3. The patient could be triggered by a noises or crowded places. 4. The patient might have trouble processing difficult tasks. (Pinho,2017) 1. Some of the positive symptoms of schizophrenia will be reduces with medication and can facilitate social interactions. 2. Increased anxiety can cause the patient to act out or be violent. 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.Goal partially met because 2.Goal partially met because the patient only spent one 5 minute session with the nurse within the three days. 1. Goal met because the patient participated in group session to color. 2.Goal partially met because the patient use appropriate social skills for Course: NURS 223L Nursing Diagnosis Definition: PSYCHIATRIC NURSING CARE PLAN TEMPLATE 3. Keep the patient in an stimuli3. The patient could be triggered free environment. by a noises or crowded places. 4. Avoid touching the patient. Page 9 of 12 4. The patient might interpret touch in the wrong way. (Pinho,2017) the majority of her time there. Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE MEDICATION LIST Medications Generic / Trade Lorazepam/Ativan Class/Rationale for the patient Benzodiazepine Dose/Route/ Time (Frequency) 1 mg/PO/Q6 PRN Range / Therapeutic Levels 1-3 mg 10 mg/PO/Qday 10-15 mg 15 mg/PO/QHS PRN 7.5-30 mg Amnestic, antianxiety, anticonvulsant, sedative Olanzapine/ Zyprexa Thienobenzodiazepine Antipsychotic Temazepam/ Restoril Benzodiazepine Sedative-hypnotic Page 10 of 12 Mechanism of action / Onset of action Enhances the effect of the inhibitory neurotransmitter gamma-aminobutyric acid on the GABA receptors by binding to a site that is distinct from the GABA binding site in the central nervous system. May achieve antipsychotic effects by antagonizing dopamine and serotonin receptors. Anticholinergic effects may result from competitive binding to and antagonism of the muscarinic receptors M1 through M2. Enhances the effect of the inhibitory neurotransmitter gamma-aminobutyric acid on the GABA receptors by binding to a site that is distinct from the GABA binding site in the central nervous system. Common side effects / Food and drug interaction Drowsiness, dizziness, tiredness, muscle weakness, headache, blurred vision, insomnia, loss of balance or coordination Nursing considerations specific to this patient -Monitor for signs of hypercarbia and hypoxia -After lorazepam administration and may pose a significant risk to patients with congenital heart disease or pulmonary hypertension -Monitor respiratory status and oxygen saturation Weight gain, drowsiness, dizziness, tiredness, speech or memory problems, tremors, numbness, changes in personality, dry mouth, or increased salivation -Monitor blood pressure routinely -Notify MD if patient develops tardive dyskinesia -Monitor blood glucose level routinely because it could increase Dizziness, drowsiness, amnesia, muscle weakness, loss of balance or coordination Headache, blurred vision, depression, nervousness, excitability, irritability, nausea and vomiting, -Give at bed time -Monitor quantity taken or for dependence -Monitor renal and hepatic function -Do not give to pregnant woman Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE stomach discomfort, dry mouth (Learning, 2018) Page 11 of 12 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE References Learning, J. & B. (2018). 2018 Nurses Drug Handbook (17th ed.). Burlington, MA: Jones & Bartlett Learning. Martin, P., BSN, RN. (2019, April 11). 6 Schizophrenia Nursing Care Plans. Retrieved May 5, 2019, from https://nurseslabs.com/schizophrenia-nursing-careplans/#disturbed-thought-process McLeod, S. A. (2018, May 03). Erik Erikson's stages of psychosocial development. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html Pinho, L. M. (2017). Nursing Interventions in Schizophrenia: The Importance of Therapeutic Relationship. Nursing & Care Open Access Journal, 3(6). doi:10.15406/ncoaj.2017.03.00090 Schizophrenia. (2018, April 10). Retrieved from https://www.mayoclinic.org/diseasesconditions/schizophrenia/symptoms-causes/syc-20354443 Page 12 of 12 You are working on an inpatient psychiatric unit and just admitted a 22-year-old male with a diagnosis of schizophrenia, paranoid type. He has been attending the local university and living at home with his parents. He has always been a good student and has been active socially. Last semester his grades began declining, and he became very withdrawn. He spends most of his time along in his room. His grooming has deteriorated; he may go days without bathing. For several weeks before admission he insisted on keeping all of the blinds and curtains in the house closed. For the past 2 days he has refused to eat, saying, “They have contaminated the food.” As you approach him, you note that he appears to be carrying on a conversation with someone, but there is no one there. When you talk to him, he looks around answers in a whisper but gives you like information. Appearance: Disheveled state, refuses to bath Motor: Rigid, tremors noted Level of Participation: lack of motivation, stays in room Characteristic: Friendly, yet guarded VS: BP 135/82, P83, RR 21, SPo2 99%, temp 98.1, pain 0/10 5150 – D/T SI with an active plan Diagnosis: Paranoid Schizophrenia, Depression, Generalized Anxiety and SI. Past drug use: No history of drug use NO LABS Medications: Haloperidol (Haldol) 2mg PO Q6H PRN Lorazepam (Ativan) 4mg PO BID Olanzapine (Zyprexa) 4mg PO Q6H PRN Quetiapine (Seroquel) 50mg PO BID 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