NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE

Sample Answer for NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Included After Question

NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE

Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE

Patient Initials Date of Admission Patient DOB Unit Course Legal Status (Vol, 5150, 5250, Conservatorship) 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 diagnosis Biophysical and/or related medical diagnosis Description of how this diagnosis relates to your patient With APA citations Erickson’s Developmental Stage Include Rationale Based on the Patient With APA citations

A Sample Answer For the Assignment: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE

Title: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE

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Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE 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) Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) 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) Thought Processes (loose associations, confabulations, flight of ideas,

Page 2 of 8 MENTAL STATUS EXAMINATION

Appearance Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), any noticeable mannerisms or gestures Manner and Approach 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. Orientation, Alertness, and Thought Process 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) Hallucinations and Delusions (presence, absence, denied visual but admitted Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise) 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) 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) Judgment and Insight (based on explanations of what they did, what Course:

NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization). Values and belief system 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. 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 Pertinent Lab Tests Results (normal ranges in parentheses) Valproic Acid (50 – 120 mcg/mL) Lithium (0.5 – 1.2 mEq/L) Carbamazepine (5 – 12 mcg/mL) CBC (WBC with diff, ANC, RBC) Page 3 of 8 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) Mood and Affect: 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) Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program happened, and if they expected the outcome, good, poor, fair, strong) 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) Teaching Assessment and Client / Family Education: (Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles Rationale for Abnormals

Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Urine Drug Screen Thyroid Panel Liver Function (AST/ALT, LHD, Albumin, Bilirubin) Kidney Function (BUN, creatinine) Blood Alcohol Level Diagnostic Test Results (with dates) Type: Amount / Frequency: Duration: Last Used: Withdrawal Symptoms: Rationale for Abnormals Substance Abuse and other Addictions (gambling, sex, shopping, smoking) Type: Amount / Frequency: Duration: Last Used: Withdrawal Symptoms: C.A.G.E. Questionnaire Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? Abnormal Involuntary Movements Code: 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) 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 Page 4 of 8 Yes Yes Yes Yes / No / No / No / No 0 1 2 3 4 0 1 2 3 4

Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations) IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.) V: Dental Status: (Current problems with teeth and/or dentures/Endentia?) Page 5 of 8 0 1 2 3 4 0 1 2 3 4 Yes No

Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Diagnostic Label Diagnosis Minimum of 2 NANDA actual and/or potential. Include etiology and signs and symptoms. *Include definition of the nursing diagnoses with APA citations 1. Nursing Diagnosis Definition: 2. Planning Outcome Criteria Minimum of 2 measureable goal per diagnosis related to the nursing diagnosis 1. 1. 1. 2. 2. 3. 3. 4. 4. 1. 1. 2. 2. 3. 3. 4. 4. 2. Page 6 of 8 2. Signs and Symptoms As evidenced by Implementation Minimum of 4 independent and collaborative nursing intervention include further assessment, intervention, and teaching that is related to the outcome criteria 1. Nursing Diagnosis Definition: Contributing Factors Related to Rationales for interventions (With APA citations ) Evaluation Goal Met Goal not Met (If not met, what revisions would you make?) How did the patient respond to your interventions 1. 2. 1. 2. Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE MEDICATION LIST Medications Generic / Trade Page 7 of 8 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 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE REFERENCES Page 8 of 8 Home Insert Draw Design Ldyuul ICICILIULJ WUM Calibri (Bod… 10.5 A A Aav E AL 1 ARE v AaBbCcDE آیت اللا Sensitivity Normal Styles Pane Paste B. 1 U v ab X, x? AvDA Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise) 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) Appearance Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), any noticeable mannerisms or gestures Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) Manner and Approach 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 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) 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) Judgment and Insight (based on explanations of what they did, what Hallucinations and Delusions (presence, absence, denied visual but admitted Thought Processes (loose associations, confabulations, flight of ideas, 122% Es Page 2 of 8 0 Focus Home Insert Draw Design Layout References Mailings Review View Table Design Layout Share O Comments X Calibri (Bod… V 10.5 v A A Aav vvs ALT AaBb CcDdE Paste B I Uab X, X A V pv A MINT av Normal Styles Pane Sensitivity Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Student Date Instructor Patient Initials Date of Admission Course Legal Status (Vol, 5150, 5250, Conservatorship) Patient DOB Unit Gender Ethnicity Chronological and Apparent Age 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 diagnosis Biophysical and/or related medical diagnosis Description of how this diagnosis relates to your patient With APA citations Erickson’s Developmental Stage Include Rationale Based on the Patient With APA citations Paste B I U v ab X, Ava Av Tili v av V Normal Styles Pane Sensitivity delusions, reports of experiences of depersonalization) Values and belief system associated with the use of substances, denied while taking medications) 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. Mood and Affect: 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) Discharge Plans and Instruction: Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program 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 Teaching Assessment and Client / Family Education: (Disease process, medication, coping, relaxation, diet, exercise, hygiene) Include barriers to learning and preferred learning styles Rationale for Abnormals Pertinent Lab Tests Results (normal ranges in parentheses) Valproic Acid (50 – 120 mcg/mL) Lithium (0.5 – 1.2 mg/L) Carbamazepine (5 – 12 mcg/mL) CBC (WBC with diff, ANC, RBC) Page 3 of 8 + 122% Focus 1090 words [ English (United States)

Grid View

	Excellent	Good	Fair	Poor
Main Posting	45 (45%) – 50 (50%) Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources. Supported by at least three current, credible sources. Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	40 (40%) – 44 (44%) Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module. At least 75% of post has exceptional depth and breadth. Supported by at least three credible sources. Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.	35 (35%) – 39 (39%) Responds to some of the discussion question(s). One or two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Post is cited with two credible sources. Written somewhat concisely; may contain more than two spelling or grammatical errors. Contains some APA formatting errors.	0 (0%) – 34 (34%) Does not respond to the discussion question(s) adequately. Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible sources. Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Post: Timeliness	10 (10%) – 10 (10%) Posts main post by day 3.	0 (0%) – 0 (0%)	0 (0%) – 0 (0%)	0 (0%) – 0 (0%) Does not post by day 3.
First Response	17 (17%) – 18 (18%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	15 (15%) – 16 (16%) Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	13 (13%) – 14 (14%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	0 (0%) – 12 (12%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Second Response	16 (16%) – 17 (17%) Response exhibits synthesis, critical thinking, and application to practice settings. Responds fully to questions posed by faculty. Provides clear, concise opinions and ideas that are supported by at least two scholarly sources. Demonstrates synthesis and understanding of learning objectives. Communication is professional and respectful to colleagues. Responses to faculty questions are fully answered, if posed. Response is effectively written in standard, edited English.	14 (14%) – 15 (15%) Response exhibits critical thinking and application to practice settings. Communication is professional and respectful to colleagues. Responses to faculty questions are answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	12 (12%) – 13 (13%) Response is on topic and may have some depth. Responses posted in the discussion may lack effective professional communication. Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.	0 (0%) – 11 (11%) Response may not be on topic and lacks depth. Responses posted in the discussion lack effective professional communication. Responses to faculty questions are missing. No credible sources are cited.
Participation	5 (5%) – 5 (5%) Meets requirements for participation by posting on three different days.	0 (0%) – 0 (0%)	0 (0%) – 0 (0%)	0 (0%) – 0 (0%) Does not meet requirements for participation by posting on 3 different days.
Total Points: 100

As we begin this session, I would like to take this opportunity to clarify my expectations for this course:

Please note that GCU Online weeks run from Thursday (Day 1) through Wednesday (Day 7).

Course Room Etiquette:

It is my expectation that all learners will respect the thoughts and ideas presented in the discussions.
All postings should be presented in a respectful, professional manner. Remember – different points of view add richness and depth to the course!

Office Hours:

My office hours vary so feel free to shoot me an email at [email protected] or my office phone is 602.639.6517 and I will get back to you within one business day or as soon as possible.
Phone appointments can be scheduled as well. Send me an email and the best time to call you, along with your phone number to make an appointment.
I welcome all inquiries and questions as we spend this term together. My preference is that everyone utilizes the Questions to Instructor forum. In the event your question is of a personal nature, please feel free to post in the Individual Questions for Instructor forumI will respond to all posts or emails within 24 or sooner.

Late Policy and Grading Policy

Discussion questions:

I do not mark off for late DQ’s.
I would rather you take the time to read the materials and respond to the DQ’s in a scholarly way, demonstrating your understanding of the materials.
I will not accept any DQ submissions after day 7, 11:59 PM (AZ Time) of the week.
Individual written assignments – due by 11:59 PM AZ Time Zone on the due dates indicated for each class deliverable.

Assignments:

Assignments turned in after their specified due dates are subject to a late penalty of -10%, each day late, of the available credit. Please refer to the student academic handbook and GCU policy.
Any activity or assignment submitted after the due date will be subject to GCU’s late policy
Extenuating circumstances may justify exceptions, which are at my sole discretion. If an extenuating circumstance should arise, please contact me privately as soon as possible.
No assignments can be accepted for grading after midnight on the final day of class.
All assignments will be graded in accordance with the Assignment Grading Rubrics

Participation

Participation in each week’s Discussion Board forum accounts for a large percentage of your final grade in this course.
Please review the Course Syllabus for a comprehensive overview of course deliverables and the value associated with each.
It is my expectation that each of you will substantially contribute to the course discussion forums and respond to the posts of at least three other learners.
A substantive post should be at least 200 words. Responses such as “great posts” or “I agree” do notmeet the active engagement expectation.
Please feel free to draw on personal examples as you develop your responses to the Discussion Questions but you do need to demonstrate your understanding of the materials.
I do expect outside sources as well as class materials to formulate your post.
APA format is not necessary for DQ responses, but I do expect a proper citation for references.
Please use peer-related journals found through the GCU library and/or class materials to formulate your answers. Do not try to “Google” DQ’s as I am looking for class materials and examples from the weekly materials.
I will not accept responses that are from Wikipedia, Business com, or other popular business websites. You will not receive credit for generic web searches – this does not demonstrate graduate-level research.
Stay away from the use of personal pronouns when writing.As a graduate student, you are expected to write based on research and gathering of facts. Demonstrating your understanding of the materials is what you will be graded on. You will be marked down for lack of evidence to support your ideas.

Plagiarism

Plagiarism is the act of claiming credit for another’s work, accomplishments, or ideas without appropriate acknowledgment of the source of the information by including in-text citations and references.
This course requires the utilization of APA format for all course deliverables as noted in the course syllabus.
Whether this happens deliberately or inadvertently, whenever plagiarism has occurred, you have committed a Code of Conduct violation.
Please review your LopesWrite report prior to final submission.
Every act of plagiarism, no matter the severity, must be reported to the GCU administration (this includes your DQ’s, posts to your peers, and your papers).

Plagiarism includes:

Representing the ideas, expressions, or materials of another without due credit.
Paraphrasing or condensing ideas from another person’s work without proper citation and referencing.
Failing to document direct quotations without proper citation and referencing.
Depending upon the amount, severity, and frequency of the plagiarism that is committed, students may receive in-class penalties that range from coaching (for a minor omission), -20% grade penalties for resubmission, or zero credit for a specific assignment. University-level penalties may also occur, including suspension or even expulsion from the University.
If you are at all uncertain about what constitutes plagiarism, you should review the resources available in the Student Success Center. Also, please review the University’s policies about plagiarism which are covered in more detail in the GCU Catalog and the Student Handbook.
We will be utilizing the GCU APA Style Guide 7th edition located in the Student Success Center > The Writing Center for all course deliverables.

LopesWrite

All course assignments must be uploaded to the specific Module Assignment Drop Box, and also submitted to LopesWrite every week.
Please ensure that your assignment is uploaded to both locations under the Assignments DropBox. Detailed instructions for using LopesWrite are located in the Student Success Center.

Assignment Submissions

Please note that Microsoft Office is the software requirement at GCU.
I can open Word files or any file that is saved with a .rtf (Rich Text Format) extension. I am unable to open .wps files.
If you are using a “.wps” word processor, please save your files using the .rtf extension that is available from the drop-down box before uploading your files to the Assignment Drop Box.

Grade of Incomplete

The final grade of Incomplete is granted at the discretion of the instructor; however, students must meet certain specific criteria before this grade accommodation is even possible to consider.
The grade of Incomplete is reserved for times when students experience a serious extenuating circumstance or a crisis during the last week of class which prevents the completion of course requirements before the close of the grading period. Students also must pass the course at the time the request is made.
Please contact me personally if you are having difficulties in meeting course requirements or class deadlines during our time together. In addition, if you are experiencing personal challenges or difficulties, it is best to contact the Academic Counselor so that you can discuss the options that might be available to you, as well as each option’s academic and financial repercussions.

Grade Disputes

If you have any questions about a grade you have earned on an individual assignment or activity, please get in touch with mepersonally for further clarification.
While I have made every attempt to grade you fairly, on occasion a misunderstanding may occur, so please allow me the opportunity to learn your perspective if you believe this has occurred. Together, we should be able to resolve grading issues on individual assignments.
However, after we have discussed individual assignments’ point scores, if you still believe that the final grade you have earned at the end of the course is not commensurate with the quality of work you produced for this class, there is a formal Grade Grievance procedurewhich is outlined in the GCU Catalog and Student Handbook.