Trinity Valley Community College
Associate Degree Nursing Program
Level IV –Analysis of a Patient with a Psychiatric Disorder Paper
STUDENT’S NAME:______DATE: ______
PATIENT’s INITIALS:______PATIENT’s AGE: ______PATIENT’s GENDER: ______PATIENT’S MARITAL STATUS: ______
DIAGNOSIS(ES): ______UNIT: ______
FACILITY: ______DATE OF INTERVIEW: ______
INSTRUCTIONS FOR WRITING THE PAPER: Before beginning writing the paper, read all of the components in the rubric below to be included in the analysis. Additionally, include the components cited below in the sequence they are given when writing the paper. A maximum of 7 typed pages is required to be posted on Blackboard when you arrive at the clinical area where you meet with your instructor in the morning of the second week. Do not use the patient’s name or initials in the body of the paper. Additionally, include the checklist page, the reference page, and the AIMS and MSME forms completed on the patient with a score indicated. Use TVCC Modified APA format for writing the paper. When you are writing the paper, begin with the first section of the rubric below for a complete paper and follow segment by segment consecutively until the paper is completed. Partial or insufficient data included in the analysis has the potential to have your paper scored as unacceptable and rewriting it may be necessary. (.25 score increments/decrements will used to determine score)
Concept(s) / Area / Complete / Partial / Insufficient / Points for each area:Clinical Judgment, Safety / Introduction of Patient and concept. / 5 2.5
a. Brief pt. intro. With general appearance, & gender.
b. Admission diagnosis and other diagnosis(es), indicate if illness is acute or chronic, and state agency’s designated pt. acuity level / 2.25 1.25
a. Brief intro. of pt. with main diagnosis(es).
b. Missing is general appearance, other diagnosis(es) if any, and agency acuity level or if the patient’s illness is chronic or acute is not included / 1.00 .25
a. Brief intro. of pt. with general appearance.
b. Scant, insufficient or missing other data. / _____Pts
Clinical Judgment, Safety / Attributes and Antecedents / 6 3
a. Pertinent social & family history; spiritual, cultural, and safety issues are addressed and rationale is given for their being pertinent; b. Presenting AIMS and MMSE scores with summarized results. including relevance for this patient’s diagnosis and acuity level. (Attach scored sheets for MMSE and AIMS to back of paper);
c. Attributes (objective and subjective symptoms/assessment data - including pertinent lab values with norms for lab values in parentheses.
d. antecedents(events leading to this admission) are cited in the paper as well. / 2.75 1
a. Social & family history with spiritual and cultural issues with AIMS and MMSE scores included but relevance to acuity level is not included.
b. Attributes and antecedents are not addressed. / . 75 .25
Very brief social and family history and discussion of spiritual and cultural issues. Other data is scanty, insufficient or missing. / ____pts
Concept based care goals. / Planning and Goal Setting / 6 3
a. Identify inherent concepts with rationale.
b. Identify the clinical goal of the pt’s. treatment team with rationale.
c. indicate pt’s perception of future self goals at 3 mon., 1 yr., & 5 yrs.
d. Give indication of factors that may help or hinder goal attainment with relevance to physical, emotional, social, spiritual, financial, cultural, and lifestyle choices;
e. Determine if goals are realistic and if not cite goals that are more realistic with rationale. / 2.75 1
a. Clinical treatment goals and patients self-goals over time periods are included and discussed with factors which may assist or hinder attainment.
b. Physical, emotional, social, spiritual, financial, cultural, and lifestyle choices are discussed insufficiently
c. If indicated more realistic goals with rationale is omitted. / .75 .25
Treatment goals and self-goals are mentioned only briefly.
Factors which may affect or hinder goal achievement are omitted along with citations of more realistic goals when indicated. / ____pts
Concept Based Care with Evaluation for Effectiveness / Implement-
Ion and Evaluation / 8 4
a. Research the Pt’s diagnosis(es) in 1 textbook and 2 peer reviewed nursing journals and indicate the care of the patient at TSH with care recommended in the literature
1. pharmacologic, treatment (effects, side effects, nursing responsibility.
2.therapies (purpose).
3. pt./family
education
needs.
4. referrals and
support groups. b. Describe a minimum of five evidence-based nursing intervention that would be appropriate for the patient that are recommended in the literature including 1 through 4 above
b. provide results of evaluation for the effectiveness of current nursing interventions and treatment(s).
c. Indicate if the care the patient is receiving at the facility is consistent with the evidence based interventions indicated in the literature
d. provide a summary paragraph and include student’s likely determination of the pt’s prognosis with rationale. / 3.75 1
a. Researched the Pt’s diagnosis(es) in 1 textbook only, compared the care of the patient at TSH with care recommended in the literature
1, 2, 3. pharmacologic, treatment (effects, side effects, nursing responsibility, therapies (purpose), patient education, referrals, support groups, and evidence-based interventions, results of evaluation of current treatment is insufficiently covered or is left out. B.
b. Three or less nursing interventions or treatments with evaluations were included. c. A summary paragraph is included but student’s indication of the pt’s likely prognosis with rationale is omitted. / .75 .25
Pt’s diagnosis in provided but other aspects of care for the pt. is omitted or is insufficiently covered. A very brief summary paragraph is included. / ____pts
Additional written paper requirements / APA format in text references,
reference page, accuracy in spelling and grammar, criteria sheet, length, when due. / 5 2.50
a. APA format with at least three references in narrative (text) and reference page is included.
b. There is accuracy in spelling and grammar. C. The check sheet for professional papers is included along with the criteria for analysis of a patient with a psychiatric disorder sheet.
d. Paper is written succinctly with no more than 7 typed pages.
e. Paper is submitted on Blackboard by the time of arrival on the morning of the second day of clinical. / 2.25 1
a. APA format is partly used with referencing of sources used being limited and sometimes left out.
b. There is accuracy in spelling but grammar accuracy is lacking.
c. The paper goes beyond the maximum number of pages but it is submitted on time. / .75 .25
There is inappropriate use of APA format, the paper does not sufficiently cover the required concepts and nursing judgments. The paper is submitted late. / ____pts
Total Points: ___/30
Instructor Comments:
Instructor: Date: TOAL POINTS______
E: Rev. 11/16 j/Level IV concepts/ Spring 2-17/ TSH