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. 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. 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. 5. 6. 7. 8. Select a client that is not working with another student for this assignment. 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. OBTAIN INSTRUCTOR APPROVAL to use your selected client for the assignment. DO NOT BEGIN TO GATHER DOCUMENTATION UNTIL THIS IS DONE. Make a confidential note of the clients identification numbers for medical records review. 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 clients NANDA diagnoses. Try to implement as many interventions as possible during your clinical time with the client. 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. 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).

2.

3.

10.

2.

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3. 4. 5.

It is due at the time specified by your clinical instructor. DUE:_______________ Note: Do not submit partial or incomplete papers. Sequence Of Pages: (Assemble your paper in this order) Title page Face Sheet

Treatment Plan/Prescribed Treatments

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 . .

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. 2.

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. 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. Potential for Violence is often problem #2. Note: MEDICAL DIAGNOSES AND MEDICAL NANDA DIAGNOSES ARE NOT ACCEPTED AND/OR APPROPRIATE FOR THIS ASSIGNMENT. 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. 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

3. 4. 5. 6.

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Disturbed Sensory Perception: Auditory/Visual Impaired Verbal Communication Self-care Deficit

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NURSING 3 PSYCHIATRIC NURSING CARE PLAN RIVERSIDE COMMUNITY COLLEGE DATE NURSING EDUCATION STUDENT SEMESTER INSTRUCTOR ROTATION
Clients Initials Gender Age Legal Status Admission Date

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

Admitting/Primary Diagnosis Axis 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/Reactions Religious Preference

Ethnicity

Marital Status

Occupation

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

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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 physicians orders) Oxygen: Respiratory Treatment: I.V. Infusion: Diet: Feeding: Bowel/Bladder: Hygiene: Activity: Other:

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PSYCHOSOCIAL HISTORY Include a one-page NARRATIVE summary of the client that addresses the following: a. b. c. d. e. f. Psychiatric diagnoses, age, sex, ethnicity, religion, work history, financial support, etc. Past psychiatric and medical histories Family constellation/friends/support systems/cultural impact Events that led up to this hospitalization Any other pertinent data that helps to assess client Multidisciplinary team input from chart and/or treatment team

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DSM IV TR Criteria For 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 months D: Not due to another psychiatric disorder, or substance abuse. DSM- IV-Criteria Client s/s
1. 2. 3. 4. Delusions Hallucinations Disorganized speech

On admission client believed the CIA was following him Client continues to hear voices telling him hes no good Not observed Not observed Grooming and hygiene are poor, patient must be prompted to perform ADLs. Has not worked in 6 years, receives SSI Family reports that this all started 6 years ago Client denies use of drugs, but UDS on admission revealed amphetamines

Grossly disorganized or catatonic behavior 5. Negative symptoms: affective flattening, alogia, or avolition

B: Social occupational dysfunction C: Duration (some s/s persist for > 6 months) D: Not due to drugs or other psych illness

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.

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Therapeutic Communication Process 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 clients nonverbal communication. State your observations after the clients 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 wont expect each of your responses to be therapeutic, nor will I mark you off if they arent, so long as you recognize what you could have done better.

Therapeutic Communication Example

Student Nurse Client Hi, my name is Cheri, and Im a nursing Yes, I guess so. student. Is it OK if I sit down and talk (looks down at the floor) with you for a few minutes? (T, broad opening, offers self)

How are you feeling today? (T broad opening)

I feel terrible! I hate it here. Id rather be dead! (looks at scar on wrist)

Surely things cant be that badthere are What do you know about how bad I have it? many people in the world who have it Youre just a student nurseyou dont much worse than you. know my life! (NT, false reassurance, rejected clients message) Could have said, It sounds like youre really upset. Tell me about it. (T, reflected patients conversation, general lead.)

Theme: Hopelessness.
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MENTAL STATUS/ASSESSMENT OF PSYCHIATRIC SYMPTOMS

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

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GENERAL APPEARANCE NORMAL for Age/Culture Facial Expressions: Sad Expressionless Hostile Worried Avoids Gaze Dress: Meticulous Clothing, Hygiene Poor Eccentric Seductive

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

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

SENSORIUM NORMAL for Age/Culture Orientation 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 THOUGHT NORMAL 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 Doesnt Know Why He is Here Unmotivated for Treatment

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RN3_14625_7_1_05

ADDITIONAL COMMENTS:

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RN3_14625_7_1_05

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

SevereModerately SevereExtremely Very Mild Not Present Mild Moderate Severe

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.

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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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RN3_14625_8_1_05

Section 2: Psychosocial Assessment

Note: 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 1. Emotional State a.

Related Nursing Diagnoses

Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for

What seems to be the clients mood? -Normal for Age/Culture -Withdrawn -Depressed -Anxious -Fearful -Uncooperative -Flat Affect -Elevated -Euphoric -Expressive -Other How have previous life experiences affected the clients perception of the current health problems?

2.

Clients Life Experience a.

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.

Family a. What is the client and familys 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?

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IV. SELF-ESTEEM: 1. Self-Esteem and Body Image a. How is the clients self-esteem threatened by this illness/admission?

Related Nursing Diagnoses

Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive b. What is the clients perception of body image and how has it changed? Coping, Ineffective Coping, Readiness for Enhanced c. What fears/concerns were expressed by the client that relate to clients Death Anxiety Decisional Conflict (Specify) present illness? Denial, Ineffective Fear Grieving, Anticipatory 2. Culture Grieving, Dysfunctional a. What is the clients ethnic background? Grieving, Dysfunctional, Risk for b. How does culture/language influence communication between client/family Hopelessness Personal Identity, Disturbed and healthcare workers? Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness c. Which communication factors are relevant and why do you think so? Powerlessness, Risk for Rape-Trauma Syndrome (Touch, personal space, eye contact, facial expressions, body language) Rape-Trauma Syndrome, Compound Reaction d. Who seems to be making the healthcare decisions in the family? Rape-Trauma Syndrome, Silent Reaction Relocation Stress Syndrome Relocation Stress Syndrome, Risk for e. Based on your observations, what role does each family member play? Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for f. Who is responsible for care of a sick family member at home? Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic g. What cultural practices related to hospitalization need to be considered? Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, 3. Spirituality Readiness for Enhanced a. What spiritual/religious beliefs does the client express? Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) b. What signs and symptoms if present indicate spiritual distress? Home Maintenance, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced c. What spiritual practices related to hospitalization need to be considered? (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, V. SELF-ACTUALIZATION

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1.

What is the clients/familys current level of understanding of their health/illness problem?

2.

What type of relationship exists with healthcare providers?

Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced

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

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T AC T I S-

herapeutic effect ction ontraindications oxic effects/Side effects nterventions afe dose Time
Med Due

PRESCRIBED MEDICATIONS
Allergies ______________________ MSI minimum safe infusion MSD minimum safe dilution Therapeutic
Effect (T)

Drug Classification/ Medication Generic/Brand Dose/route/interval

Source_________________________________ ___
Action (A)

Contraindications

(C)

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

Interventions (I)

Ordered Date Stop Date

Safe Dose (S) Include MSI/MSD (IV Meds)*

*All meds being titrated (i.e. heparin) state appropriate lab results related to medication administration. W:PSYCHIATRICCAREPLAN:13:1/06 -1919

ADMISSION DATE __________ ADULT LABORATORY/ DIAGNOSTIC TOOL SOURCE:_______________________ Test Range Adm. Date/ Date/ Identify WNL Significance/ Resul Resul Resul Trends t t t WBCs 5,00010,000/ mm3 RBCs 4.2-6.1 x 106/g Hgb 11.5-17.5 g/dl Hct 40-52% MCV MCH MCHC RDW Retic. Platelet Neutrophil s Lymphocy tes Monocyte s Eosinophil s Basophils SODIUM Chloride Potassium CO2 Magnesiu m Calcium INR 90-95 mm3 27-31 g 32-36 g/dl 11%-14.5% 0.5%-3.1% 150,000400,000 mm3 55-70% 20-40% 2-8% 1-4% 0.5-1.0% 135-145 mEq/L 98-106 mEq/L 3.5-5.0 mEq/L 24-30 mEq/L 1.3-2.1 mEq/L 9.0-10.5 mg/dl See lab

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PT
e n a l

PTT
On anticoag.

BUN Creatinine

result 11-12.5 seconds 60-70 seconds 1.5-2.5 x control 10-20 mg/dl

0.5-1.2 mg/dl Test Range Adm. Date/ Date/ Identify Note: Normal value range will vary depending on laboratory WNL Significance/ Trends Resul Resul Resul used.
t t t

Glucose l o o d C h e m. Hgb A1c AST ALT Acid Phosphata se Ammonia LDH Amylase Lipase Phosphoru s Alk. Phos. Total Bilirubin Cholester ol Uric acid Total protein Albumin Globulin Lithium level

70-110 mg/dl 4.4-6.4% 0-35 U/L 4-36 IU/L 0.13-0.63 U/L 80-110 g/dl 100-190 U/L 30-220 U/L 0-160 U/L 3-4.5 mg/dl 30-120 U/L .3-1.0 mg/dl <200 mg/dl 2.7-8.5 mg/dl 6.4-8.3 g/dl 3.5-5.0 g/dl 2.3-3.4 g/dl 0.5- 1.3 mmol/L

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Depakote level Dilantin level

50-100 g/ml 10-20 g/ml

Urine negative Drug screen Urinalysis

Date/Result Date/Results Date/Results Date/Results Color 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_________________________________________________________________________________________

Diagnostic Tests

ABGS

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

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CONCEPT MAP
Developmental Stage ___________________________ Psycho-social Crisis_____________________________

Health-Illness Continuum: Maximum Health Oxygen Needs/Circulation

Health Elimination

Illness

Death Nutrition/Hydration

Psychiatric Diagnoses: Axis I: ___________________________ Axis II: __________________________ Axis III: _________________________ Axis IV: _________________________ Axis V: __________________________ Problem List/Nursing Diagnosis Prioritize according to Maslows Hierarchy 1. _______________________________________

Neurological/ Neurovascular

2. ___________________________________________ 3. ____________________________________ 4. ____________________________________ 5. ____________________________________. Anxiety/Concerns/Fear/Knowledge Needs

Safety/Skin/Wounds Drains/Infections/ Sensory

Love/Belonging/Culture Coping/Body Image Rest/Activity

Comfort/Sexualtity

Psych Care Plan: 8/06

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RCC Nursing Education Programs Nursing Care Plan

Student Name: Client Initials: Admission date: ID: Age: Course: Gender: Date:

Medical Diagnosis:
Nursing Diagnosis
NDX: (Problem)

Desired Outcomes
Goal (Reversal of Problem)

Interventions (I)-Independent (C) - Collaborative

N1-(I) (C)

Rationale & APA Reference

R1-

Evaluation of Interventions
E1-

R/T: (etiology/factor):

Client will (list measurable outcomes; reverse signs and symptoms) 1. N2-(I) (C) R2E2-

AEB: (s/sx; defining characteristics) 1. 2. 3.

2. 3. Evaluation of Outcomes (address each outcome) 1. 2. 3.

N3-(I) (C)

R3-

E3-

*If risk for would exhibit:

NSG CarePlan: 8/06

*Attach 1 M.E.T.H.O.D. Teaching tool for each patient

24

RCC Nursing Education Programs Nursing Care Plan

Student Name: Client Initials: Admission date: ID: Age: Course: Gender: Date:

Medical Diagnosis:
Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference Evaluation of Interventions

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-

NSG CarePlan: 8/06

*Attach 1 M.E.T.H.O.D. Teaching tool for each patient

25

RCC Nursing Education Programs Nursing Care Plan

Student Name: Client Initials: Admission date: ID: Age: Course: Gender: Date:

Medical Diagnosis:
Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference Evaluation of Interventions

N7- (I) (C)

R7-

E7-

N8- (I) (C)

R8-

E8-

N9- (I) (C)

R9-

E9-

NSG CarePlan: 8/06

*Attach 1 M.E.T.H.O.D. Teaching tool for each patient

26

RCC Nursing Education Programs Nursing Care Plan

Student Name: Client Initials: Admission date: ID: Age: Course: Gender: Date:

Medical Diagnosis:
Nursing Diagnosis Desired Outcomes Interventions (I)-Independent (C) - Collaborative Rationale & APA Reference Evaluation of Interventions

NSG CarePlan: 8/06

*Attach 1 M.E.T.H.O.D. Teaching tool for each patient

27

(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/Circulation Breathing Airway Clearance, Ineffective Aspiration, Risk for Breathing Pattern, Ineffective Gas Exchange, Impaired Infection, Risk for Sudden Infant Death Syndrome, Risk for Suffocation, Risk for Ventilation, Impaired, Spontaneous Ventilatory Weaning Response, Dysfunctional Circulation Cardiac Output, Decreased Fluid Balance, Readiness for Enhanced Fluid Volume Deficit Fluid Volume Excess Fluid Volume, Risk for Deficit Fluid Volume, Risk for Imbalanced Tissue Perfusion, Ineffective (specify: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) Neurological/Neurovascular Neurological Confusion, Acute Confusion, Chronic Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Readiness for Enhanced Organized Infant Behavior, Risk for Disorganized Intracranial, Decreased Adaptive Capacity Memory, Impaired Thought Processes, Disturbed Neurovascular Dysreflexia, Autonomic Dysreflexia, Risk for Autonomic Peripheral Neurovascular Dysfunction, Risk for Nutrition/Hydration Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Dentition, Impaired Failure to Thrive, Adult Fluid Volume, Deficit Fluid Volume, Deficit, Risk for Infant Feeding Pattern, Ineffective Nausea Nutrition: Imbalanced, Risk for More Than Body Requirements Nutrition: Imbalanced, Less Than Body Requirements Nutrition: Imbalanced, More Than Body Requirements Nutrition: Readiness for Enhanced Oral Mucous Membranes, Impaired Self-Care Deficit, Feeding Swallowing, Impaired Elimination Bowel Constipation Constipation, Perceived Constipation, Risk for Diarrhea Incontinence, Bowel Nausea Urinary Fluid Volume, Risk for Imbalanced Infection, Risk for Incontinence, Functional Incontinence, Reflex Incontinence, Risk for Urge Incontinence, Stress Incontinence, Total Incontinence, Urge Tissue Perfusion, Ineffective Urinary Elimination, Impaired Urinary Elimination, Readiness for Enhanced Urinary Retention Rest/Activity Activity Intolerance Activity Intolerance, Risk for Disuse Syndrome, Risk for Diversional Activity Deficient Fatigue Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Perioperative Positioning Injury, Risk for Sedentary Lifestyle Sleep Deprivation Sleep Pattern, Disturbed Sleep, Readiness for Enhanced Transfer Ability, Impaired Walking, Impaired Comfort/Sexuality Comfort Pain, Acute Pain, Chronic Sexuality Sexuality Pattern, Ineffective Sexual Dysfunction Safety/Skins/Wounds/Infections/Sensory Temperature Hyperthermia Hypothermia Temperature, Risk for Imbalanced Body Thermoregulation, Ineffective Skin Infection, Risk for Injury, Risk for Latex Allergy Response Latex Allergy Response, Risk for Protection, Ineffective Skin Integrity, Impaired Skin Integrity, Impaired, Risk for Tissue Integrity, Impaired Physical Falls, Risk for Growth, Risk for Disproportional Mobility, Impaired Physical Perioperative Positioning Injury, Risk for Trauma, Risk for Self-Care Deficit, Bathing/Hygiene Self-Care Deficit, Dressing/Grooming Self-Care Deficit, Toileting Surgical Recovery, Delayed Wandering Perception Energy Field, Disturbed Environmental Interpretation Syndrome, Impaired Infant Behavior, Disorganized Infant Behavior, Disorganized, Risk for Infant Behavior, Readiness for Enhanced Organized Poisoning, Risk for Self-Mutilation Self-Mutilation, Risk for Sensory/Perception, Disturbed (specify): Visual, Kinesthetic, Auditory, Gustatory, Tactile, Olfactory Suicide, Risk for Unilateral Neglect Violence, Risk for Other-Directed Violence, Risk for Self-Directed Love/Belonging/Culture/Coping/Body Image Adjustment, Impaired Caregiver Role Strain Caregiver Role Strain, Risk for Communication, Impaired Verbal Communication, Readiness for Enhanced Community Coping, Ineffective Community Coping, Readiness for Enhanced Delayed Development, Risk for Family Coping: Compromised, Ineffective Family Coping: Disabled Family Coping: Readiness for Enhanced Family Processes, Dysfunctional: Alcoholism Family Processes, Interrupted Family Processes, Readiness for Enhanced Growth and Development, Delayed Loneliness, Risk for Parental Role Conflict Parent/Infant/Child Attachment, Impaired, Risk for Parenting, Impaired Parenting, Impaired, Risk for Parenting, Readiness for Enhanced Role Performance, Ineffective Social Interaction, Impaired Social Isolation Violence, Risk for Anxiety Concerns/Fear/Knowledge Needs Self-Esteem Adjustment, Impaired Anxiety Body Image Disturbed Coping, Defensive Coping, Ineffective Coping, Readiness for Enhanced Death Anxiety Decisional Conflict (Specify) Denial, Ineffective Fear Grieving, Anticipatory Grieving, Dysfunctional Grieving, Dysfunctional, Risk for Hopelessness Personal Identity, Disturbed Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Powerlessness Powerlessness, Risk for Rape-Trauma Syndrome Rape-Trauma Syndrome, Compound Reaction Rape-Trauma Syndrome, Silent Reaction Religiosity, Impaired Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem, Situational Low, Risk for Self-Mutilation Self-Mutilation, Risk for Sorrow, Chronic Spiritual Distress Spiritual Distress, Risk for Spiritual Well-Being, Readiness for Enhanced Self-Actualization Health Maintenance, Ineffective Health Seeking Behaviors (Specify) Home Maintenance, Impaired Knowledge, Deficient (Specify) Knowledge, Readiness for Enhanced (Specify) Noncompliance Therapeutic Regimen: Community, Ineffective Management of Therapeutic Regimen: Families, Ineffective Management of Therapeutic Regimen: Management, Effective Therapeutic Regimen: Management, Ineffective Therapeutic Regimen: Management, Readiness for Enhanced

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

PATIENT INITIALS: LEARNERS PRESENT (circle): MEDICAL DIAGNOSES: TECHNIQUES: Discussion Q/A Demos Handout(s) Other __________ Client Family Sig. Other Other __________

Date/ Initial
M (Medications):

Content

Evaluation

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.

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