Psychiatric Nursing Care Plan

Psychiatric Nursing Care Plan

Interpersonal Process Analysis and Care Plan Assignment-Walden University

Interpersonal Process Analysis and Care Plan Assignment

2 Care plans is for the( week july 16 – july 20 I need to posted the 20 in blackboard )

4 Interpersonal Process analysis are for the week (july 2 -july 6 I need it for july 6 )

Remember the class is Mental Health.

Im going to atach the tempalte and the rubric for those 2 works .

Robert Please reed the rubric for the interpersonal process Is an APA paper.

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NURS 2231L: Psychiatric Nursing Care Plan Template

Student					Date
Instructor					Course
Patient Initials		Date of Admission		Legal Status (Vol, 5150, 5250, Conservatorship)
Patient DOB		Unit
Chronological and Apparent Age		Gender		Ethnicity
Allergies

 

Height/Weight	Temp  (location)	Pulse  (location)	Respiration	Pulse Ox (O2 Sat)	Blood Pressure (location)	Pain Scale 1-10 (location, character, onset)

 

Psychiatric Diagnosis and DSM 5 Diagnostic Criterion	History of Present Psychiatric Illness: Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement
Psychopathology of admitting and/or related psychiatric diagnosisBiophysical and/or related medical diagnosisDescription of how this diagnosis relates to your patientWith APA citations	Erickson’s Developmental StageInclude Rationale Based on the PatientWith APA citations

 

MENTAL STATUS EXAMINATION

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, difficulty understanding 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)

 

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

 

Pertinent Lab Tests Results(normal ranges in parentheses)	Rationale for Abnormals
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
CBC  (WBC with diff, ANC, RBC)
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results(with dates)	Rationale for Abnormals
Substance Abuse and other Addictions(gambling, sex, shopping, smoking)
Type:Amount / Frequency:Duration:Last Used:Withdrawal Symptoms:		Type:Amount / Frequency:Duration:Last Used:Withdrawal Symptoms:
C.A.G.E.  Questionnaire
Have you ever felt you should cut down on your drinking?			Yes  / No
Have people annoyed you by criticizing your drinking?			Yes  / No
Have you ever felt bad or guilty about your drinking?			Yes  / No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?			Yes  / No

 

 

Abnormal Involuntary MovementsCode:  0 = None   1 = Minimal   2 =  Mild   3 = Moderate   4 = Severe
I:  Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)	0      1      2      3      4
II:  Extremity Movements:      Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.     Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot	0      1      2      3      4
III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)	0      1      2      3      4
IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)	0      1      2      3      4
V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)	Yes               No

 

 

 

 

 

 

 

DiagnosisMinimum of 2 NANDA – actual and/or potential.Include etiology and signs and symptoms. *Includedefinition of the nursing diagnoses with APA citations	PlanningOutcome CriteriaMinimum of 2 measureablegoal per diagnosis related to the nursing diagnosis	ImplementationMinimum of 4independent and collaborative nursing intervention include further assessment, intervention, and teaching that is related to the outcome criteria	Rationales for interventions(With APA citations )	EvaluationGoal MetGoal not Met(If not met, what revisions would you make?) How did the patient respond to your interventions
1. Nursing Diagnosis Definition:	1. 2.	1. 2. 3. 4.	1. 2. 3. 4.	1. 2.
2. Nursing Diagnosis Definition:	1. 2.	1. 2. 3. 4.	1. 2. 3. 4.	1. 2.

 

 

MEDICATION LIST

 

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

REFERENCES

PSYCHIATRIC NURSING CARE PLAN TEMPLATE & RUBRIC

Student					Date
Instructor					Course
Patient Initials		Date of Admission		Legal Status (Vol, 5150, 5250, Conservatorship)
Patient DOB		Unit
Chronological and Apparent Age		Gender		Ethnicity
Allergies

 

Height/Weight	Temp  (location)	Pulse  (location)	Respiration	Pulse Ox (O2 Sat)	Blood Pressure (location)	Pain Scale 1-10 (location, character, onset)

 

Psychiatric Diagnosis and DSM 5 Diagnostic Criterion	History of Present Psychiatric Illness: Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement
Psychopathology of admitting and/or related psychiatric diagnosisBiophysical and/or related medical diagnosisDescription of how this diagnosis relates to your patientWith APA citations	Erickson’s Developmental StageInclude Rationale Based on the PatientWith APA citations

 

MENTAL STATUS EXAMINATION

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, difficulty understanding 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)

 

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

 

Pertinent Lab Tests Results(normal ranges in parentheses)	Rationale for Abnormals
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
CBC  (WBC with diff, ANC, RBC)
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results(with dates)	Rationale for Abnormals
Substance Abuse and other Addictions(gambling, sex, shopping, smoking)
Type:Amount / Frequency:Duration:Last Used:Withdrawal Symptoms:		Type:Amount / Frequency:Duration:Last Used:Withdrawal Symptoms:
C.A.G.E.  Questionnaire
Have you ever felt you should cut down on your drinking?			Yes  / No
Have people annoyed you by criticizing your drinking?			Yes  / No
Have you ever felt bad or guilty about your drinking?			Yes  / No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?			Yes  / No

 

 

Abnormal Involuntary MovementsCode:  0 = None   1 = Minimal   2 =  Mild   3 = Moderate   4 = Severe
I:  Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)	0      1      2      3      4
II:  Extremity Movements:      Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.     Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot	0      1      2      3      4
III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)	0      1      2      3      4
IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)	0      1      2      3      4
V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)	Yes               No

Psychiatric Nursing Care Plan

 

 

 

 

Psychiatric Nursing Care Plan

 

DiagnosisMinimum of 2 NANDA – actual and/or potential.Include etiology and signs and symptoms. *Includedefinition of the nursing diagnoses with APA citations	PlanningOutcome CriteriaMinimum of 2 measureablegoal per diagnosis related to the nursing diagnosis	ImplementationMinimum of 4independent and collaborative nursing intervention include further assessment, intervention, and teaching that is related to the outcome criteria	Rationales for interventions(With APA citations )	EvaluationGoal MetGoal not Met(If not met, what revisions would you make?) How did the patient respond to your interventions
1. Nursing Diagnosis Definition:	1. 2.	1. 2. 3. 4.	1. 2. 3. 4.	1. 2.
2. Nursing Diagnosis Definition:	1. 2.	1. 2. 3. 4.	1. 2. 3. 4.	1. 2.

 

 

MEDICATION LIST

Psychiatric Nursing Care Plan

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

 REFERENCES

Psychiatric Nursing Care Plan Rubric 

NAME:                                                                                                                                      COURSE:                                                   DATE:                                                                                                                                             

 

CLIENT INITALS:                                                             CLIENT PSYCHIATRIC DISORDER:                                                                                 

 

CRITERIA	Exemplary4	Proficient 3	Developing2	Ineffective1 – 0	POINTS
Client’s Demographics and Psychiatric Legal Status	Clearly and accurately describes the client’s demographics and psychiatric legal status in detail.	Adequately describes the client demographics and psychiatric legal status with adequate detail.	Vaguely describes the client’s demographics and psychiatric legal status with some detail.	Lack description of the client’s demographics and psychiatric legal status that presents no detail.
Client’s Vital Signs and Allergies	Clearly and accurately documented the client’s vital signs and allergies in full detail.	Adequately documented the client’s vital signs and allergies. Missing few minor details.	Incomplete documentation of the client’s vital signs and allergies.	Fails to document the client’s vital signs and allergies.
History of Present Illness and Diagnostic Criteria	Clearly and accurately describes the client’s history of present illness and diagnostic criteria which clearly supports the chief complaints and presenting signs/symptoms.	Adequately describes the client’s history of present illness and diagnostic criteria which adequately supports the identified chief complaint and presenting signs/symptoms.	Vaguely describes the client’s history of present illness and diagnostic criteria which vaguely supports the identified chief complaint and presenting signs/symptoms.	Lack description of the client’s history of present illness and diagnostic criteria that does not support the identified chief complaint and presenting signs/symptoms.
Psychopathology and biophysical pathology of admitting and/or related psychiatric and medical diagnosis	Clearly and accurately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms.	Adequately identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms.	Vaguely identifies psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms.	Fails to identify psychopathology and biophysical pathology related to the identified diagnostic criterion based on the client’s history and presenting symptoms.	X2

 

 

 

 

CRITERIA	4	3	2	1         –    0	POINTS
Erikson’s Developmental Stages	Clearly and accurately identifies client’s developmental stage with rationales based on the client’s developmental tasks.	Adequately identifies client’s developmental stage with rationales based on the client’s developmental tasks.	Vaguely identifies client’s developmental stage without adequate rationale based on the client’s developmental tasks.	Fail to identify client’s developmental stage and lack rationale based on the client’s developmental tasks.
Mental Status Assessment	Clearly and accurately describes all components of the mental status examination based on the client’s presenting symptoms.	Adequately describes components of the mental status examination based on the client’s presenting symptoms.	Vaguely describes components of the mental status examination based on the client’s presenting symptoms.	Fails to describe any of components of the mental status examination based on the client’s presenting symptoms.	X2
Substance Abuse and other Addictions	Clearly and accurately identifies abused substances and problems associated with substance and other addictions.	Adequately identifies abused substances and problems associated with substance and other addictions.	Vaguely identifies abused substances and problems associated with substance and other addictions.	Fails to identify abused substances and problems associated with substance and other addictions.
Risk Assessment	Clearly and accurately identifies all risk factors related to the client’s history and presenting symptoms.	Adequately identifies some risk factors related to the client’s history and presenting symptoms.	Vaguely identifies risk factors related to the client’s history and presenting symptoms.	Fails to identify any of the risk factors related to the client’s history and presenting symptoms.
Multidisciplinary Client Outcome & Discharge Planning.	Clearly and accurately describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning.	Adequately describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning.	Vaguely describes collaborative issues and concerns related multidisciplinary client outcome and discharge planning.	Fails to describe collaborative issues and concerns related multidisciplinary outcome and discharge planning.
Teaching Assessment and Client Education	Clearly and accurately identifies areas of instructional needs, learning preference and learning barriers. Provided clear and concise client education the will aid in health promotion, health maintenance and self-care activities.	Adequately identifies areas of instructional needs, learning preference and learning barriers. Provided some and adequate client education the will aid in health promotion, health maintenance and self-care activities.	Vaguely identifies areas of instructional needs, learning preference and learning barriers. Provided minimal and vague client education the will aid in health promotion, health maintenance and self-care activities.	Fails to identify areas of instructional needs, learning preference and learning barriers. Did not provide client education the will aid in health promotion, health maintenance and self-care activities.	X2
Pertinent Lab Test& Abnormal Involuntary Movement	Clearly and accurately identifies pertinent laboratory test and abnormal movements related to client’s disease process.	Adequately identifies pertinent laboratory test and abnormal movements related to client’s disease process.	Vaguely identifies pertinent laboratory test and abnormal movements related to client’s disease process.	Fails to identify pertinent laboratory test and abnormal movements related to client’s disease process.
NANDA Nursing Diagnosis (prioritized) Nursing Diagnosis Definition	Both nursing diagnoses are accurate and prioritized per NANDA format with clear etiology and data to support diagnosis. Nursing Diagnosis is consistent and presents correlation from the assessment data based on Gordon’s 11 Functional Health Pattern and Mental Status Examination. Clear and accurate nursing diagnosis definition.	Both nursing diagnoses are adequate and prioritized per NANDA format with sufficient etiology and data to support diagnosis. Nursing Diagnosis is adequate and presents correlation from assessment data based on Gordon’s 11 Functional Health Pattern and Mental Status Examination. Adequate nursing diagnosis definition.	Both nursing diagnosis are vague and not prioritized per NANDA format with vague etiology and unclear correlation from the assessment data that may or may not be classified as nursing diagnosis based on Gordon’s 11 Functional Health Pattern and Mental Status Examination. Inaccurate nursing diagnosis definition.	Both nursing diagnosis are indefinable per NANDA format and does not correlate to support assessment data and cannot be classified as nursing diagnosis based on Gordon’s 11 Functional Health Pattern and Mental Status Examination. Lack nursing diagnosis definition.	X2
Nursing Outcome Criteria	Clearly and accurately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal clearly supports the nursing diagnosis and plan of care. The goals are easily measurable and realistic.	Adequately establishes client’s outcome criteria and can be achieved with nursing assistance. The goal somewhat supports the nursing diagnosis and plan of care. The goals are somewhat measurable and realistic.	Vaguely establishes client’s outcome criteria and may or may not be achieved with nursing assistance. The goals are inconsistent with the nursing diagnosis and plan of care. The goals are vaguely realistic and measurable.	Fails to establish client’s outcome criteria that cannot be met by nursing assistance. The goals lack support and nonspecific from gathered data, Outcome criteria are not realistic and not measurable.	X2
Nursing Intervention Criteria & Rationale	Clearly and accurately Identifies independent nursing interventions criteria with teaching supported by scientific rationale and evidence-based practice.Interventions are always individualized, prioritized, organized, specific and realistic. Nursing actions are always aimed at the client’s goals and directed at the stated health deviation based on nursing assessment and Erickson’s stages of development.	Adequately Identifies nursing interventions with adequate teaching. Scientific rationale is adequately supported by evidence-based practice.Interventions are adequate, individualized, organized, specific and realistic. Interventions can be implemented adequately that is focused on client’s goal and health deviation based on nursing assessment and Erickson’s stages of development.	Vaguely Identifies nursing interventions with unclear teaching. Scientific rationale is vaguely relevant & not supported by evidence-based practice.Interventions are inconsistent, non-specific, disorganized, and not adequately focused on the client’s goal. Interventions are difficult to implement and has weak relationship to nursing diagnosis based on nursing assessment and Erickson’s stages of development.	Fails to identify interventions and teaching. Lack Scientific rationale and is not supported by evidence-based practice.Interventions are non-specific, inappropriate, unrealistic, un-measurable and do not relate to nursing diagnosis. Intervention does do not focus on client goals and/or the stated health deviation based on nursing assessment and Erickson’s stages of development.	X2

 

Evaluation	Skillfully and independently identifies criteria for evaluation. Evaluates effectiveness of interventions and measures goal completion.  Modifies, revises and recommends alternative intervention.	Adequately identifies criteria for evaluation. Adequately determines effectiveness of nursing interventions and measures goal completion with appropriate modification and revisionsto the treatment plan.	Difficulty utilizing criteria for evaluation. Difficulty determining effectiveness of interventions and goal completion. Evaluation vaguely supports if goal is met or not met with inaccurate revisions to the treatment plan.	Does not support nor utilize criteria for evaluation. Does not determine effectiveness of interventions and goal completion. There is a lack of alternative interventions to the treatment plan.	X2
Medications	Clearly and accurately identifies all components of the medication list, including mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client.	Adequately identifies components of the medication list. Adequate description of mechanism of action, purpose, range, side effects, interactions, levels and nursing considerations relevant to the client.	Vaguely identifies components of the medication list. Lack description of mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client.	Fails to identify components of the medication list. Failed to include mechanism of action, purpose, range side effects, interactions, levels and nursing considerations relevant to the client.	X2
General Organization	Accurate APA format, appropriate citations and references,No spelling or grammar errors.	Adequate APA format. Minimal citations and references are appropriate. Few spelling or grammar errors.	Numerous APA format errors, Inaccurate citations and references.Few spelling and grammar errors.	Fails to utilize APA format.No citations or references included numerous spelling and grammar errors.
TOTAL: 100

 

 

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Psychiatric Nursing Care Plan