WEST COAST UNIVERSITY

Psychiatric / Mental Health Nursing Care Plan

Student / Course / NURS 214L / Date
Instructor
Patient Initials / DOB / Age
DOA / Gender
Unit / Legal Status (Vol, 5150, 5250, Conservatorship / Allergies
Language / Ethnicity / Marital Satus
Occupation / Education
Admission Diagnosis (3pts)
Axis I
Axis II
Axis III
Axis IV
Axis V / History of Present Psychiatric Illness
(presenting signs & symptoms/diagnostic reports)Previous Psychiatric Admission / Outpatient Mental Health Services) (3pts) / Reason for Hospitalization (Client’s own words) 2pts
Erickson’s Developmental Stage with Rationale (2pts)
(APA citation) / Family concerns. Cultural issues and religious affiliation that may affect his/her care: (2pts) / Psychosocial Considerations (Living Arrangements & Support System)
(2pts)
Psychopathology of admitting and/or related medical diagnosis
Describe How does this diagnosis relate to your patient
(with APA citations) (3 pts) / Past Medical History
Past Surgical History (Concurrent, onset, dates) (2pts)
Date not found please state so / Pertinent lab test (normal ranges in parentheses) & diagnostic reports (with dates) (2pts)
Rationale for Abnormal Labs
Discharge Plans (2pts) / Collaborative Problems
Current Prescriber’s Order
(include diet, test, and treatments) (2pts) / Rationale for Orders
(with APA citations) (2pts)
Risk Assessment (Suicide, Self-Injurious Behavior, Hypersexual, Elopement, Fall, Homicidal, Non-adherence to treatment) (3) / Current Stressors: (2 pts) / Substance Abuse (Addiction): (5 pts)
Amount / Frequency:
Duration:
Last Used:
W/D symptoms:
BAL:
CAGE:
Mental Status Examination: (5 pts)
Appearance:
Speech:
Eye Contact:
Behavior & Motor Activity:
Mood & Affect:
Orientation:
Intellectual Functioning:
Cognitive Functioning:
Thought Process:
Thought Content:
Insight:
Judgement: / Level of Participation in the Unit: (2) / Teaching Needs and Assessment (document education material provided): (2)
Nutritional Status (2): / Elimination Pattern (2): / Activity-Exercise-Sleep-Rest Pattern (2):
Identify Potential Health Deviations
(“At Risk for…” nursing dx) (3pts) / Related Factors
(of “at risk” condition, signs and symptoms should they manifest) (3pts) / Interventions (at least two each)
(Independent Nursing Functions) (3pts)
Functional Health Pattern
(4pts) / Nursing Diagnosis
(NANDA)
(AT LEAST 2)
Definition of Nursing Diagnosis
(4pts) / Planning
(outcome/goal)
Nursing Outcome Criteria (NOC)
Measureable
Goal during your shift
7A-7P
(4pts) / Implementations
(Independent and collaborative nursing intervention include further assessment, intervention and teaching)
Minimum 4
(4pts) / Rationale
(use APA citations) (4pts) / Evaluation
Goal Met
Goal not Met
(If not met, what revisions would you make?)
(4pts)
VS (4pts) Temp / Pulse / Respiration / Blood Pressure / Pain Scale 1-10
Height: / Weight:

Current Medications (10pts)

Medications
Generic / Trade / Dose/Route/ Time (Frequency) / Class/Rationale for the patient / Range / Therapeutic Levels / Mechanism of action Onset of action / Common side effects / food and drug Interaction / Nursing considerations