Psychiatric Care Plans 08

PSYCHIATRIC NURSING MAJOR CARE PLAN ASSIGNMENT

Guidelines:

1. This assignment is much like a Case Study and is intended to be a comprehensive learning experience that synthesizes essential psychiatric and medical/surgical nursing theory. Your finished product will demonstrate mastery of principles needed for nurses working with severely mentally impaired clients.

2. It is similar to other Major Care Plans with face sheet, lab sheets, TACTIS, METHOD, assessment forms, and etc. It is graded using the same tool. Exceptions to the assignment are that it may take the form of a “case study” and will require you to do additional documentation and research on diagnoses that are unique to the psychiatric setting.

3. It must address the needs of one psychiatric client that you select to work with. The patient must be actively delusional and/or hallucinating, and/or on antipsychotic medications. (Remember that you must establish rapport, gain trust, and initiate with the client before you can move in to the “working” phase of the nurse-patient relationship. Use your verbal and non-verbal therapeutic communication skills).

4. Select a client that is not working with another student for this assignment.

5. Try to select a client that is likely to be hospitalized for several more days or weeks. Check with staff to ensure that there are no imminent discharge plans.

6. OBTAIN INSTRUCTOR APPROVAL to use your selected client for the assignment. DO NOT BEGIN TO GATHER DOCUMENTATION UNTIL THIS IS DONE.

7. Make a confidential note of the client’s identification numbers for medical records review.

8. You must ACTIVELY INTERACT with the client frequently over a period of two or more days. (Some fortunate students will be able to work with their client for two weeks in a row). You are expected to select your nursing goals/expected outcomes for the client and attempt to achieve them. (Remember that the client does not have to be exceptionally welcoming or talkative to do this assignment. 9. Identify appropriate nursing interventions for each of your client’s NANDA diagnoses. Try to implement as many interventions as possible during your clinical time with the client.

10. WHAT DIAGNOSES SHOULD YOU LOOK FOR?• Schizophrenia and related psychoses• Schizophreniform• Schizoaffective• Psychosis NOS• Brief Reactive Psychosis• Psychotic Depression; post-partum psychosis• Bipolar, Psychotic, Acute Manic Phase• Psychosis related to Dementia/Organic Pathology• Psychosis related to Substance Use Disorders

I will accept any client willing to talk with you who is on at least 2 psychotropic medications

Format Of The Care Plan:

1. Most parts of the assignment are to be typed. (You may highlight and write directly on forms provided and assessment tools). Your instructor is expecting to see college level work that is neatly and comprehensively done. Use black ink only in areas not typed. Handwriting needs to be easily read. Use APA format.

2. Submit the completed paper in a very small (1/2 inch or less) lightweight three-ring binder. (Second copies are not required unless specifically requested by instructor).

3. It is due at the time specified by your clinical instructor. DUE:_______________

4. Note: Do not submit partial or incomplete papers.

5. Sequence Of Pages: (Assemble your paper in this order)

• Title page• Face Sheet

. Treatment Plan/Prescribed Treatments

W:PSYCHIATRICCAREPLAN:1-2:1/06 -1-

• Psychosocial History. DSM IV TR Comparison Table. Process Recording

• Mental Status Assessment Form

• Brief Psychiatric Rating Scale

• Psychosocial Assessment Form

• Prescribed Medications (TACTIS form)

• Lab Sheet - (Identify abnormals, cite theory and source/page #)

• Psychiatric Concept Map - (Include side effects of medications)

• List of NANDA Diagnoses (Mark all that pertain to client)

• Problems 1 - 3 with defining characteristics, expected outcomes, nursing interventions, evaluations of interventions and evaluation of overall goal attainment. (Met, not met, partial/Continue plan/revise). Be sure to use the AAMT format for each problem: A = Assess/ Monitor for problem; A = Actions/Nursing Interventions for problem; M = Medications for problem/why useful/source/See TACTIS; T = Teach what to the patient/family about the problem?/Why? Source/See METHOD.

• METHOD Sheet (Note: This is to be considered discharge teaching. What information should be given to patient and/or family about each area of METHOD?) Use your own words and language that is appropriate for the patient to understand. DO NOT INCLUDE MORE THEORY HERE. The middle column is for above teaching only.

• Reference Sheet

• Care Plan Evaluation Tool

What Else?

1. The top three of the five NANDA diagnoses/problems are to be fully developed. (See diagnosis box on Concept Map sheet). Be sure to measure your overall goal at the completion of the problem.

2. PROBLEM #1 (AND OFTEN MOST IMPORTANT FOR PSYCHOTIC CLIENTS) IS ALTERED OR DISTURBED THOUGHT PROCESS. Remember that you will give antipsychotics for this problem. Be sure that you consider the side effects of all medications in your plan.

3. Potential for Violence is often problem #2.

4. Note: MEDICAL DIAGNOSES AND MEDICAL NANDA DIAGNOSES ARE NOT ACCEPTED AND/OR APPROPRIATE FOR THIS ASSIGNMENT.

5. You will also need to select two other pertinent diagnoses for your client (to be listed on the Concept Map but not developed). Consider those listed in your textbook and psychiatric care plan books.

6. Summary of required NANDA diagnoses:#1. Disturbed Thought Process (Altered Thinking)#2. Risk for Violence: Self/Others#3. Include psychiatric NANDA diagnosis of your choice:

Recommended selections:• Knowledge deficit/Non-compliance• Ineffective Coping• Disturbed Sensory Perception: Auditory/Visual• Impaired Verbal Communication• Self-care Deficit


NURSING 3PSYCHIATRIC NURSING CARE PLAN

RIVERSIDE COMMUNITY COLLEGE DATE NURSING EDUCATIONSTUDENT SEMESTER INSTRUCTOR ROTATION

Client’s Initials Gender Age Legal Status Admission Date

Presenting Signs/Symptoms (chief complaint and reasons for admission)

Admitting/Primary DiagnosisAxis I: P

S

Axis II:(personality disorder or mental retardation)

Axis III: (medical diagnoses)

Axis IV:(Stressors client is experiencing)

Axis V(Global Assessment of functioning)

Substance Use (Include use of tobacco, alcohol, street drugs, over-the-counter drugs, length of use and time of last use.)

Allergies/ReactionsReligious Preference Ethnicity Marital Status Occupation

Define Axes Diagnoses here as well as research about client’s diagnosis(es) in narrative form.


Therapeutic/Multidisciplinary Treatment Plan: (Textbook) Source (List principles of therapeutic milieu. Also identify other psychiatric health team members and their role in care of your client.)

Prescribed Treatments (as per physician’s orders)

Oxygen:

Respiratory Treatment:

I.V. Infusion:

Diet:

Feeding:

Bowel/Bladder:

Hygiene:

Activity:

Other:


PSYCHOSOCIAL HISTORY

Include a one-page NARRATIVE summary of the client that addresses the following:

a. Psychiatric diagnoses, age, sex, ethnicity, religion, work history, financial support, etc.b. Past psychiatric and medical historiesc. Family constellation/friends/support systems/cultural impactd. Events that led up to this hospitalization e. Any other pertinent data that helps to assess clientf. Multidisciplinary team input from chart and/or treatment team


DSM IV TR CriteriaFor each axis 1 or 2 diagnosis on your client, look up the DSM criteria in your textbook or in the DSM IV TR. List the criteria for that diagnosis, and state whether your client meets each symptom. Then make a final judgment: in your judgment, does the client meet the criteria for this disorder? In many cases, clients will seem fine when you talk to them. You made need to go back and look at the record of the behavior when first admitted. In this case you might say, “Client does not currently appear to be meeting the criteria for schizophrenia at this time. He is currently receiving Risperdal 2 mg. po bid and responding well. But at time of admission client was acutely psychotic, hearing voices and talking to unseen people.”

Criteria for Schizophrenia:A: Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):B: Social /Occupational Dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset…C: Duration: some s/s of the disturbance persist for at least 6 monthsD: Not due to another psychiatric disorder, or substance abuse.DSM- IV-Criteria Client s/s

1. Delusions On admission client believed the CIA was following him

2. Hallucinations Client continues to hear voices telling him he’s no good

3. Disorganized speech Not observed

4. Grossly disorganized or catatonic behavior Not observed

5. Negative symptoms: affective flattening, alogia, or avolition

Grooming and hygiene are poor, patient must be prompted to perform ADLs.

B: Social occupational dysfunction Has not worked in 6 years, receives SSI

C: Duration (some s/s persist for > 6 months) Family reports that this all started 6 years ago

D: Not due to drugs or other psych illness Client denies use of drugs, but UDS on admission revealed amphetamines

Based on my assessment of the client, I believe that he does meet the criteria for schizophrenia. He exhibits 3 of the 5 symptoms for criteria A, has not worked, and has had problems for 6 years. Even though amphetamines were found on the drug screen, client has been inpatient for 3 weeks, and still has some of the same symptoms, including hearing voices.


Therapeutic CommunicationProcess Recording

Directions: Engage in a therapeutic communication session(s) with your client and record what each of you said. This can most easily be done by setting up a 2 column table. After each comment in your column you should analyze whether your communication was therapeutic or nontherapeutic. Use the handout on therapeutic communication to guide you. If your responses are therapeutic, list the technique that you used; if non-therapeutic, state, “I should have said…” Pay special attention to your client’s nonverbal communication. State your observations after the client’s responses. Your process recording should be about 3 pages long. Not all patients will be able to tolerate a conversation that long all at once, so you may come back several times and try to pick up the thread each time. At the end of the session, try to summarize the theme of what the client was trying to say (anger, sadness, blame-shifting, etc).Therapeutic communication is a new language that is not easy to learn. I won’t expect each of your responses to be therapeutic, nor will I mark you off if they aren’t, so long as you recognize what you could have done better. Therapeutic Communication ExampleStudent Nurse Client

Hi, my name is Cheri, and I’m a nursing student. Is it OK if I sit down and talk with you for a few minutes?

(T, broad opening, offers self)

How are you feeling today?

(T broad opening)

Surely things can’t be that bad…there are many people in the world who have it much worse than you.”

(NT, false reassurance, rejected client’s message)

Could have said, “It sounds like you’re really upset. Tell me about it.”

(T, reflected patient’s conversation, general lead.)

Yes, I guess so.

(looks down at the floor)

I feel terrible! I hate it here. I’d rather be dead!

(looks at scar on wrist)

What do you know about how bad I have it? You’re just a student nurse—you don’t know my life!

Theme: Hopelessness.


MENTAL STATUS/ASSESSMENT OF PSYCHIATRIC SYMPTOMS

INSTRUCTIONS: Check box where applicable. If “NORMAL” is checked, go to next section.X

GENERAL APPEARANCE NORMAL for Age/CultureFacial Expressions:

Sad Expressionless Hostile Worried Avoids Gaze

Dress:Meticulous Clothing, Hygiene Poor Eccentric Seductive

MOTOR ACTIVITY NORMAL for Age/Culture

Increased Amount Decreased Amount Agitation Tics Tremor Peculiar Posturing Unusual Gait Repetitive Acts

SPEECH NORMAL for Age/Culture

Excessive Amount Poverty of Pressure of Slowed Loud Soft Mute Slurred Stuttering

INTERVIEW BEHAVIOR NORMAL for Age/Culture

Expansive Suspicious Withdrawn Angry Outbursts Irritable Impulsive Hostile Silly Sensitive Apathetic Evasive Passive Aggressive Naive Overly Dramatic Manipulative Dependent Uncooperative Demanding Negative Callous

FLOW OF THOUGHT NORMAL for Age/Culture

Blocking Circumstantial Tangential Perseveration Flight of Ideas Loose Associations Indecisive Incoherence Neologisms

AFFECT NORMAL for Age/Culture

Inappropriate Labile

Range:Restricted Blunted Flat

MOOD NORMAL for Age/Culture

Elevated Euphoric Expansive

Dysphoric:Depressed Anxious Irritable

SENSORIUM NORMAL for Age/CultureOrientation Impaired:

Time Place Person

Memory:Clouding of Consciousness Inability to Concentrate Amnesia Poor Recent Memory Poor Remote Memory Confabulation

INTELLECT NORMAL for Age/Culture

Above Normal Below Normal Paucity of Knowledge Vocabulary Poor Serial Sevens Done Poorly Poor Abstraction

CONTENT OF THOUGHTNORMAL for Age/Culture

Suicidal Thoughts Suicidal Plans Assaultive Ideas Homicidal Thoughts Homicidal Plans Antisocial Attitudes Suspiciousness Poverty of Content Phobias Obsessions/Compulsions Feelings of Unreality Feels Persecuted Thoughts of Running Away Somatic Complaints Ideas of Guilt Ideas of Hopelessness Ideas of Worthlessness Excessive Religiosity Sexual Preoccupation Blames Others Ideas of Reference Magical Thinking Illogical Thinking

Illusions:Present Mood-Incongruent Auditory Visual Gustatory Olfactory Somatic Tactile

Delusions:Mood-Congruent Mood-Incongruent of Persecution of Grandeur of Reference Somatic Systematized of Being Controlled Bizarre Nihilistic of Poverty Jealousy

INSIGHT AND JUDGMENT NORMAL for Age/Culture

Poor Insight Poor Judgment Unrealistic Regarding Degree of Illness Doesn’t Know Why He is Here Unmotivated for Treatment

ADDITIONAL COMMENTS:

W:PSYCHIATRICCAREPLAN:7:1/06 -8-

BRIEF PSYCHIATRIC RATING SCALE

DIRECTIONS: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom.

Patient Initials ___________ Physician ______________________________ Date

Not

P

rese

nt

Ver

y M

ild

Mil

d

Mod

erat

e

Mod

erat

ely

Sev

ere

Sev

ere

Ext

rem

ely

Sev

ere

SOMATIC CONCERNS preoccupation with physical health, fear of physical illness, hypochondriasis.

ANXIETY worry, fear, over-concern for present or future, uneasiness.

EMOTIONAL WITHDRAWAL lack of spontaneous interaction, isolation, deficiency in relating to others.

CONCEPTUAL DISORGANIZATION thought processes confused, disconnected, disorganized.

GUILT FEELINGS self-blame, shame, remorse for past behavior.

TENSION physical and motor manifestations of nervousness, over-activation, agitation.

MANNERISMS AND POSTURING peculiar, bizarre, unnatural motor behavior (not including tic).

GRANDIOSITY exaggerated self-opinion, arrogance, conviction of unusual power or abilities.

DEPRESSIVE MOOD sorrow, sadness, despondency, pessimism.

HOSTILITY animosity, contempt, belligerence, disdain for others.

SUSPICIOUSNESS mistrust, belief others harbor malicious or discriminatory intent.

HALLUCINATORY BEHAVIOR perceptions without normal stimulus correspondence.

MOTOR RETARDATION slowed, weakened movements or speech, reduced body tone.

UNCOOPERATIVENESS resistance, guardedness, rejection of authority, non-compliant.

UNUSUAL THOUGHT CONTENT unusual, odd, strange, bizarre thought content.

BLUNTED AFFECT reduced emotional tone, reduction in formal intensity of feelings, flatness.

EXCITEMENT emotional tone, agitation, increased reactivity.

DISORIENTATION confusion or lack of proper association for person, place, or time.

Global Assessment Scale (Range 0-100) _________________________________________________________________


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Ma

Section 2: Psychosocial AssessmentNote: It is not appropriate to ask the client direct questions as you would during a history. Information is obtained by observing

verbal and nonverbal behaviors and making inferences as you and the patient work toward accomplishing goals and objectives.

III. LOVE AND BELONGING Related Nursing Diagnoses

1. Emotional Statea. What seems to be the client’s mood? -Normal for Age/Culture

-Withdrawn -Depressed -Anxious -Fearful -Uncooperative -Flat Affect -Elevated -Euphoric -Expressive -Other

2. Client’s Life Experiencea. How have previous life experiences affected the client’s perception of the

current health problems?

b. How has life changed as a result of the current health problem?

c. Describe any signs or symptoms that may indicate actual/potential

physical/emotional abuse.

3. Familya. What is the client and family’s perception of the illness/admission?

b. What evidence indicates that family life has changed?

c. How do family members seem to be coping?

d. What supportive behaviors from family/significant others are evident?

4. Erikson/Newman/Newman Developmental Stage:

a. What task is appropriate for this stage of development?

b. How has this health problem interfered with accomplishing the

development tasks for this client?

c. What evidence indicates negative or positive developmental resolution?

Adjustment, ImpairedCaregiver Role StrainCaregiver Role Strain, Risk forCommunication, Impaired VerbalCommunication, Readiness for EnhancedCommunity Coping, IneffectiveCommunity Coping, Readiness

for EnhancedDelayed Development, Risk forFamily Coping: Compromised, IneffectiveFamily Coping: DisabledFamily Coping: Readiness for EnhancedFamily Processes, Dysfunctional:

AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for EnhancedGrowth and Development, DelayedLoneliness, Risk forParental Role ConflictParent/Infant/Child Attachment,

Impaired, Risk forParenting, ImpairedParenting, Impaired, Risk forRole Performance, IneffectiveSocial Interaction, ImpairedSocial IsolationViolence, Risk for


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IV. SELF-ESTEEM: Related Nursing Diagnoses

1. Self-Esteem and Body Imagea. How is the client’s self-esteem threatened by this illness/admission?

b. What is the client’s perception of body image and how has it changed?

c. What fears/concerns were expressed by the client that relate to client’s

present illness?

2. Culturea. What is the client’s ethnic background? b. How does culture/language influence communication between client/family

and healthcare workers?

c. Which communication factors are relevant and why do you think so?

(Touch, personal space, eye contact, facial expressions, body language)

d. Who seems to be making the healthcare decisions in the family?

e. Based on your observations, what role does each family member play?

f. Who is responsible for care of a sick family member at home?

g. What cultural practices related to hospitalization need to be considered?

3. Spiritualitya. What spiritual/religious beliefs does the client express?

b. What signs and symptoms if present indicate spiritual distress?

c. What spiritual practices related to hospitalization need to be considered?

Self-EsteemAdjustment, ImpairedAnxietyBody Image DisturbedCoping, DefensiveCoping, IneffectiveCoping, Readiness for EnhancedDeath AnxietyDecisional Conflict (Specify)Denial, IneffectiveFearGrieving, AnticipatoryGrieving, DysfunctionalGrieving, Dysfunctional, Risk forHopelessnessPersonal Identity, DisturbedPost-Trauma SyndromePost-Trauma Syndrome, Risk forPowerlessnessPowerlessness, Risk forRape-Trauma SyndromeRape-Trauma Syndrome, Compound

ReactionRape-Trauma Syndrome, Silent ReactionRelocation Stress SyndromeRelocation Stress Syndrome, Risk forSelf-Esteem, Chronic LowSelf-Esteem, Situational LowSelf-Esteem, Situational Low, Risk forSelf-MutilationSelf-Mutilation, Risk forSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well-Being,

Readiness for EnhancedSelf-ActualizationHealth Maintenance, IneffectiveHealth Seeking Behaviors (Specify)Home Maintenance, ImpairedKnowledge, Deficient (Specify)Knowledge, Readiness for Enhanced

(Specify)NoncomplianceTherapeutic Regimen: Community,

Ineffective Management ofTherapeutic Regimen: Families,V. SELF-ACTUALIZATION


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Ineffective Management ofTherapeutic Regimen: Management,

EffectiveTherapeutic Regimen: Management,

IneffectiveTherapeutic Regimen: Management,

Readiness for Enhanced

1. What is the client’s/family’s current level of understanding of their

health/illness problem?

2. What type of relationship exists with healthcare providers?

Education/discharge planning: See M.E.T.H.O.D. attached.


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PRESCRIBED MEDICATIONS

Drug Classification/ MedicationGeneric/BrandDose/route/interval

TimeMedDue

TherapeuticEffect (T)

Action (A) Contraindications(C)

Toxic Effects (T)& Side Effects(include common/life-threatening)

Interventions (I) OrderedDate

Stop Date

Safe Dose (S)IncludeMSI/MSD(IV Meds)*

*All meds being titrated (i.e. heparin) state appropriate lab results related to medication administration.W:PSYCHIATRICCAREPLAN:13:1/06 -13-

Allergies ______________________MSI – minimum safe infusionMSD – minimum safe dilution

T – herapeutic effectA - ctionC – ontraindicationsT – oxic effects/Side effectsI – nterventionsS - afe dose

Source____________________________________

ADMISSION DATE __________ ADULT LABORATORY/ DIAGNOSTIC TOOL SOURCE:_______________________Test Range Adm.

ResultDate/Result

Date/Result

Identify WNL Significance/ Trends

WBCs 5,000-10,000/mm3

RBCs 4.2-6.1 x 106/g

Hgb 11.5-17.5g/dl

Hct 40-52%

MCV 90-95mm3

MCH 27-31 g

MCHC 32-36 g/dl

RDW 11%-14.5%

Retic. 0.5%-3.1%

Platelet 150,000-400,000 mm3

Neutrophils 55-70%

Lymphocytes 20-40%

Monocytes 2-8%

Eosinophils 1-4%

Basophils 0.5-1.0%

SODIUM 135-145 mEq/L

Chloride 98-106 mEq/L

Potassium 3.5-5.0mEq/L

CO2 24-30mEq/L

Magnesium 1.3-2.1 mEq/L

Calcium 9.0-10.5 mg/dl

INR See lab result

PT 11-12.5seconds

PTTOn anticoag.

60-70 seconds1.5-2.5 x control

BUN 10-20 mg/dl

Creatinine 0.5-1.2 mg/dl

Test Range Adm.Result

Date/Result

Date/Result

Identify WNL Significance/ Trends

Glucose 70-110 mg/dl

Hgb A1c 4.4-6.4%


CBC

WBC

Diff

Lytes

Coag

Renal

Blood

Note: Normal value range will vary depending on laboratory used.

AST 0-35 U/L

ALT 4-36 IU/L

Acid Phosphatase

0.13-0.63 U/L

Ammonia 80-110 g/dl

LDH 100-190 U/L

Amylase 30-220 U/L

Lipase 0-160 U/L

Phosphorus 3-4.5 mg/dl

Alk. Phos. 30-120 U/L

Total Bilirubin .3-1.0 mg/dl

Cholesterol <200 mg/dl

Uric acid 2.7-8.5 mg/dl

Total protein 6.4-8.3 g/dl

Albumin 3.5-5.0 g/dl

Globulin 2.3-3.4 g/dl

Lithium level 0.5- 1.3 mmol/L

Depakote level

50-100 g/ml

Dilantin level 10-20 g/ml

Urine Drug screen

negative

Urinalysis Diagnostic Tests ABGSDate/Result Date/Results Date/Results Date/ResultsColor X-rays pH pH Appearance pCO2 pCO2 Spec. gravity pO2 PO2 Protein Nuclear scans B.E B.E. Glucose O2 sat O2 sat Ketones CT/MRI Comments ___________________________Bacteria_________________________ _____________________________Blood________________________ Other _____________________________Other_________________________________________________________________________________________

Note: Normal value range will vary depending on laboratory used.


CONCEPT MAP

Developmental Stage ___________________________ Psycho-social Crisis_____ ________________________

Health-Illness Continuum: Maximum Health Health Illness Death

Oxygen Needs/Circulation Elimination Nutrition/Hydration

Neurological/ Safety/Skin/WoundsNeurovascular Drains/Infections/

Sensory

Anxiety/Concerns/Fear/Knowledge Needs

Love/Belonging/Culture Comfort/SexualtityCoping/Body Image

Rest/Activity

Psych Care Plan: 8/06 -16-

Psychiatric Diagnoses:Axis I: ___________________________Axis II: __________________________Axis III: _________________________Axis IV: _________________________Axis V: __________________________

Problem List/Nursing DiagnosisPrioritize according to Maslow’s Hierarchy1. _______________________________________2. ___________________________________________3. ____________________________________4. ____________________________________5. ____________________________________.

RCC Nursing Education Programs Nursing Care Plan

Student Name: ID: Course: Date:

Client Initials: Admission date: Age: Gender:

Medical Diagnosis:

Nursing Diagnosis Desired Outcomes Interventions (I)-Independent(C) - Collaborative

Rationale & APA Reference Evaluation of Interventions

NDX: (Problem)

R/T: (etiology/factor):

AEB: (s/sx; defining characteristics)

1.

2.

3.

*If ‘risk for’ would exhibit:

Goal (Reversal of Problem)

Client will (list measurable outcomes; reverse signs and symptoms)

1.

2.

3.

Evaluation of Outcomes (address each outcome)1.

2.

3.

N1-(I) (C) R1- E1-

N2-(I) (C) R2- E2-

N3-(I) (C) R3- E3-

NSG CarePlan: 8/06 *Attach 1 M.E.T.H.O.D. Teaching tool for each patient 17




Medical Diagnosis:



Evaluation of Goal:(circle one)

Goal met

Goal not met

Goal partially met

(If goal not met, describe outcomes not met)

Continuation of plan:(circle one)

Continue plan of care

Discontinue plan of care

Revise plan of care

(Explain revisions as needed)

N4-(I) (C) R4- E4-

N5- (I) (C) R5- R5-

N6- (I) (C) R6- E6-





Medical Diagnosis:



N7- (I) (C) R7- E7-

N8- (I) (C) R8- E8-

N9- (I) (C) R9- E9-


(Highlight or underline problems you have chosen. Asterisk all that may pertain to your client.)NURSING DIAGNOSES (NANDA, 2005-2006) GROUPED ACCORDING TO CONCEPTUAL FRAMEWORK

(NOTE: MARK ALL THAT APPLY TO YOUR CLIENT)

Oxygen Needs/CirculationBreathingAirway Clearance, Ineffective Aspiration, Risk forBreathing Pattern, Ineffective Gas Exchange, Impaired Infection, Risk forSudden Infant Death Syndrome, Risk forSuffocation, Risk forVentilation, Impaired, SpontaneousVentilatory Weaning

Response, DysfunctionalCirculation Cardiac Output, DecreasedFluid Balance, Readiness for EnhancedFluid Volume DeficitFluid Volume ExcessFluid Volume, Risk for DeficitFluid Volume, Risk for ImbalancedTissue Perfusion, Ineffective(specify: renal, cerebral,cardiopulmonary, gastrointestinal, peripheral)Neurological/NeurovascularNeurologicalConfusion, AcuteConfusion, ChronicEnvironmental Interpretation Syndrome,

ImpairedInfant Behavior, DisorganizedInfant Behavior, Readiness for

Enhanced OrganizedInfant Behavior, Risk for DisorganizedIntracranial, Decreased Adaptive

CapacityMemory, ImpairedThought Processes, DisturbedNeurovascularDysreflexia, AutonomicDysreflexia, Risk for AutonomicPeripheral Neurovascular Dysfunction,

Risk forNutrition/HydrationBreastfeeding, EffectiveBreastfeeding, IneffectiveBreastfeeding, InterruptedDentition, ImpairedFailure to Thrive, AdultFluid Volume, DeficitFluid Volume, Deficit, Risk forInfant Feeding Pattern, IneffectiveNauseaNutrition: Imbalanced, Risk for

More Than Body RequirementsNutrition: Imbalanced, Less

Than Body RequirementsNutrition: Imbalanced, More

Than Body RequirementsNutrition: Readiness for EnhancedOral Mucous Membranes, ImpairedSelf-Care Deficit, FeedingSwallowing, ImpairedEliminationBowelConstipationConstipation, PerceivedConstipation, Risk forDiarrheaIncontinence, BowelNauseaUrinaryFluid Volume, Risk for ImbalancedInfection, Risk forIncontinence, FunctionalIncontinence, ReflexIncontinence, Risk for UrgeIncontinence, StressIncontinence, Total

Incontinence, UrgeTissue Perfusion, IneffectiveUrinary Elimination, ImpairedUrinary Elimination, Readiness for EnhancedUrinary RetentionRest/ActivityActivity IntoleranceActivity Intolerance, Risk forDisuse Syndrome, Risk forDiversional Activity DeficientFatigueMobility, Impaired BedMobility, Impaired PhysicalMobility, Impaired WheelchairPerioperative Positioning Injury, Risk forSedentary LifestyleSleep DeprivationSleep Pattern, DisturbedSleep, Readiness for EnhancedTransfer Ability, ImpairedWalking, ImpairedComfort/SexualityComfortPain, AcutePain, ChronicSexualitySexuality Pattern, IneffectiveSexual DysfunctionSafety/Skins/Wounds/Infections/SensoryTemperatureHyperthermiaHypothermiaTemperature, Risk for Imbalanced BodyThermoregulation, IneffectiveSkinInfection, Risk forInjury, Risk forLatex Allergy ResponseLatex Allergy Response, Risk forProtection, IneffectiveSkin Integrity, ImpairedSkin Integrity, Impaired, Risk forTissue Integrity, ImpairedPhysicalFalls, Risk forGrowth, Risk for DisproportionalMobility, Impaired PhysicalPerioperative Positioning Injury, Risk forTrauma, Risk forSelf-Care Deficit, Bathing/HygieneSelf-Care Deficit, Dressing/GroomingSelf-Care Deficit, ToiletingSurgical Recovery, DelayedWanderingPerceptionEnergy Field, DisturbedEnvironmental Interpretation Syndrome, ImpairedInfant Behavior, DisorganizedInfant Behavior, Disorganized, Risk forInfant Behavior, Readiness for

Enhanced OrganizedPoisoning, Risk forSelf-Mutilation Self-Mutilation, Risk forSensory/Perception, Disturbed (specify):

Visual, Kinesthetic, Auditory, Gustatory, Tactile, OlfactorySuicide, Risk forUnilateral NeglectViolence, Risk for Other-DirectedViolence, Risk for Self-DirectedLove/Belonging/Culture/Coping/Body ImageAdjustment, ImpairedCaregiver Role StrainCaregiver Role Strain, Risk forCommunication, Impaired VerbalCommunication, Readiness for Enhanced

Community Coping, IneffectiveCommunity Coping, Readiness for EnhancedDelayed Development, Risk forFamily Coping: Compromised, IneffectiveFamily Coping: DisabledFamily Coping: Readiness for EnhancedFamily Processes, Dysfunctional:

AlcoholismFamily Processes, InterruptedFamily Processes, Readiness for EnhancedGrowth and Development, DelayedLoneliness, Risk forParental Role ConflictParent/Infant/Child Attachment,

Impaired, Risk forParenting, ImpairedParenting, Impaired, Risk forParenting, Readiness for EnhancedRole Performance, IneffectiveSocial Interaction, ImpairedSocial IsolationViolence, Risk forAnxiety Concerns/Fear/Knowledge NeedsSelf-EsteemAdjustment, ImpairedAnxietyBody Image DisturbedCoping, DefensiveCoping, IneffectiveCoping, Readiness for EnhancedDeath AnxietyDecisional Conflict (Specify)Denial, IneffectiveFearGrieving, AnticipatoryGrieving, DysfunctionalGrieving, Dysfunctional, Risk forHopelessnessPersonal Identity, DisturbedPost-Trauma SyndromePost-Trauma Syndrome, Risk forPowerlessnessPowerlessness, Risk forRape-Trauma SyndromeRape-Trauma Syndrome, Compound ReactionRape-Trauma Syndrome, Silent ReactionReligiosity, ImpairedReligiosity, Readiness for EnhancedReligiosity, Risk for ImpairedRelocation Stress SyndromeRelocation Stress Syndrome, Risk forSelf-Esteem, Chronic LowSelf-Esteem, Situational LowSelf-Esteem, Situational Low, Risk forSelf-MutilationSelf-Mutilation, Risk forSorrow, ChronicSpiritual DistressSpiritual Distress, Risk forSpiritual Well-Being, Readiness for EnhancedSelf-ActualizationHealth Maintenance, IneffectiveHealth Seeking Behaviors (Specify)Home Maintenance, ImpairedKnowledge, Deficient (Specify)Knowledge, Readiness for Enhanced (Specify)NoncomplianceTherapeutic Regimen: Community, Ineffective

Management ofTherapeutic Regimen: Families, Ineffective

Management ofTherapeutic Regimen: Management, EffectiveTherapeutic Regimen: Management, IneffectiveTherapeutic Regimen: Management,

Readiness for Enhanced


M.E.T.H.O.D. Daily Teaching Plan and Evaluation

PATIENT INITIALS:

LEARNERS PRESENT (circle): Client Family Sig. Other Other __________

MEDICAL DIAGNOSES:

TECHNIQUES: Discussion Q/A Demos Handout(s) Other __________

Date/Initial Content Evaluation

M (Medications):

E (Environment):

T (Treatments):

H (Health knowledge of disease):

O (Outpatient/inpatient referrals): (including resources such as websites and organizations):

D: (Diet):

Schuster, P. (2000). The key to the therapeutic relationship. Philadelphia: FA Davis.Schuster, P. (2002). Concept Mapping: A critical thinking approach to care planning. Philadelphia:

FA Davis.


Psychiatric Care Plans 08

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