Development Stage (Erikson): Give the stage and rationale for your evaluation

                      Rasmussen University – Mental Health Care Plan                                                         
A. Patient identifiers:

Age:                   Gender:                   Ht:               Wt.             Code Status:

Isolation:

Development Stage (Erikson): Give the stage and rationale for your evaluation

 

 

Health Status  
Date of admission:

Activity level:                                                                Diet:

Fall risk (indicate reason)

 

Client’s description of health status

 

 

 

Allergies: (include type of reaction)

 

 

 

Reason for admission:

 

 

 

 

 

Past medical history that relates to admission:

Socio-cultural Orientation  
Cultural and Ethnic Background with current practices:

 

Socialization:

 

Family system: (Support system)

 

Spiritual:

 

Occupation: (across the lifespan)

 

Patterns of living: (define past and current)

 

Barriers to independent living:

 

 

 

Healthcare systems elements (continued)                      ALLERGIES:
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.

                                 DEFINE 1:  What the medications Mechanism of Action AND 2: Why the patient is taking the medication?

Medication                                    Classification                              Dosage                                          Rationale                                                    Possible negative outcomes

 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       
 

 

       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychiatric Diagnosis and DSM 5 Diagnostic Criteria History of Present Psychiatric Illness

(Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONCEPT MAP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis

Problem statement: (NANDA)

 

Related to: (What is happening in the body to cause the issue?)

 

Manifested by: (Specific symptoms)

 

 

 

  General Appearance  
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) Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), any noticeable mannerisms or gestures Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise)
     
  Manner and Approach  
Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) 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)

Receptive Language (normal, able to comprehend questions,

     
  Orientation, Alertness, and Thought Process  
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) 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) 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)
     
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 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) Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)
     

 

 

  Mood and Affect  
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. 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)
     

 

Lab Range Value Reason Obtained
 

 

     
 

 

     
 

 

     
 

 

     
 

 

     

 

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

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

 
NRS DX:

Problem Statement:

 

 

 

 

 

R/T: (What is the cause of the symptom?)

 

 

 

Manifested by: (specific symptoms)

 

 

 

 

 

Short term goal:  Create a SMART goal that relates to hospital stay.

Long term goal:  Create a SMART goal that is appropriate for discharge.

 

This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)

 

 

Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) Was it met or not met there is no partially met.

References: