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Clinical Assignment Packet for Mental Health Nursing

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Contents:Clinical LimitationsMedication Knowledge BaseRequired AssignmentsClinical Reflective JournalTherapeutic Communication DefinitionsMental Status ExamMental Health Nursing AssessmentMedication Preparation Log (MPL)Interaction Process Recording (IPR) InstructionsIPR Cover Sheet, Analysis and EvaluationNursing Care Plan Forms **Please note that additional care plan information/forms are available as a separate document on the LRC website.

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Limitations to Clinical Practice

During this clinical rotation, students may, with preceptors’ consent and supervision, assume responsibility for all the nursing activities within the preceptors’ roles. The following are exceptions to this rule.

Students may not do the following:

1. Witness any consent forms or advance directive forms.2. Administer any medications in the mental health setting.3. Perform any task that requires certification or advanced instruction (i.e., arterial blood

gas (ABG) puncture, chemotherapy, removal of central venous catheter, interpretation/monitoring of EKGs).

4. Take physician orders either verbally or by phone. 5. Transcribe physician orders.6. Initiate invasive monitoring.7. Regulated epidural analgesia.8. Remove epidural catheters.9. Remove surgically inserted drains and/or tubes (e.g. Jackson-Pratt drains, Hemovac

drains) without direct supervision by a Registered Nurse.10. Solely monitor patient during and following conscious sedation.11. Witness wasting or the sign out controlled medications in Accudose, Pyxis or Meditrol

medication delivery systems.12. Perform end of shift controlled medication count (if applicable). 13. Have controlled medication keys in their possession (if applicable).14. Verify blood products and/or witness blood administration forms.15. Perform any invasive procedure on each other in any setting (i.e., injections,

catheterization, IV starts).16. Perform any task during a code situation, except those skills learned in BLS.17. Interventions that the facility restricts the student from performing.18. Any skill/procedure that has not been covered in a nursing lab.19. Any task outside the RN scope of practice as identified by facility.

Any questions regarding specific procedures or responsibilities should be directed to the Denver School of Nursing faculty. Students are expected to maintain standards of care of the facility and function within the scope of their knowledge, skills, and abilities.

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Medication Knowledge Base

Drug required knowledge is mandatory for each medication prescribed for each assigned patient. Students will not be administering medications to patients in this clinical experience.

If you can memorize and retain information without writing it down, you may do this, but you may not pass medications without this knowledge at hand – use of reference materials at the cart side or at the PYXIS is time prohibitive and must be a rare back-up system.

Student must be prepared to recite required knowledge base (as outlined below) at med-cart or PYXIS as requested by instructor.

Using a drug knowledge tool is useful in review for future clinical rotations and for NCLEX

review and to prepare for different patients.

Medication knowledge base MUST include the MINIMAL information as reflected on the following page-Medication Preparation Log (MPL)

‘Must know’ could be ‘Take pulse’ for drugs affecting heart rate or rhythm, ‘Take BP’ for drugs affecting BP, ‘Check K+’ before administering potassium supplements, ‘Check BG’ for insulin or other drugs affecting BG, etc.

Required Assignments

ADN: 1 Complete Mental Health Nursing Assessment, including the Medication Preparation Log 2 Interpersonal Process Recordings (IPR) 1 Nursing care plan with at least one nursing diagnosis Weekly journaling, per instructor preference Students MUST do Reflective Logs in evaluation packets

BSN: 2 Complete Mental Health Nursing Assessments, including the Medication Preparation Logs 2 Interpersonal Process Recordings (IPR) 1 Nursing care plan with at least two nursing diagnoses Weekly journaling, per instructor preference Students MUST do Reflective Logs in evaluation packets

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Clinical Reflective Journal – Optional

Personal Journal:Students will submit a daily journal to their clinical supervisor on the clinical day designated by the clinical supervisor. A sheet of single paper or a non-spiral notebook may be used.This is a tool designed for a personal inner journey rather than a reporting of what you have observed or done. It is a journal of your thoughts and feelings about your clinical experiences.This is confidential between your instructor and you and you may receive feedback. It is hoped that the reflections and insight one develops as a result of the journal will foster personal and professional growth.

Suggestions for beginning journal:1 – What was the high point of my day? Low point?2 – Was I in disagreement with anyone? How did I handle it?3 – What changes did I make in my thinking or behavior?4 – How could I improve my day?5 – What has been on my mind today?6 – What are two choices I made today?7 – What did I procrastinate on today?8 – What feelings did I identify today?9 – Say one positive thing about yourself for today.10 – What happened to me was…………………..11 – What this means to me is……………………12 – For the first time I now understand………..13 – I still question………………………………..14 – Other

Journal Goals: Students are expected to submit 2 personal daily goals in their journal. Goals should be evaluated in writing at the conclusion of the day prior to submitting the journal on the following day.

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Therapeutic Communication DefinitionsCommunication: Transaction between sender and receiverNon-verbal: Physical appearance/dress, body movement & posture, touch, facial expressions, eye movements, vocal cues

Therapeutic Communication TechniquesSilence: give time to collect thoughts, consider other concernsAccepting: conveys attitude of reception and regardGiving Recognition: acknowledge and indicate awareness (commend strengths)Offering Self: making one’s self available on unconditional basis (increases self-worth)Broad Openings: allows client initiative to introduce topic of concern (client role)Offer General Leads: offers client the encouragement to continuePlacing the Event in Time or Sequence: clarifies event in time perspectiveMaking Observations: verbalizing what is observed or perceived (client behavior)Encouraging Perception Description: ask client to verbalize what perceived-hallucinationEncourage Comparison: ask client to compare similarity and difference-reoccur/changeRestate: repeat main idea of what client said (client can clarify or continue on)Reflect: questions and feelings referred back to client to recognize/accept own viewFocusing: taking notice of a single idea or word (don’t use if client is anxious)Exploring: delve further into subject (helpful if client tends to be superficial in communication)Seek Clarification/Validation: strive to explain the vague or incomprehensiblePresent Reality: when client has misperception, nurse indicates perception of situationVoicing Doubt: expressing uncertainty of reality of client’s perception (delusions)Verbalizing the Implied: put into words what client has implied or said indirectlyAttempt to Translate Words into Feelings: find clues to feelings expressed indirectly Formulate Plan of Action: when client has a plan of action for stressful situation, it may prevent anger or anxiety form escalating into unmanageable levelActive Listening: sit facing client, open posture, lean forward, eye contact, relaxFeedback: descriptive of behavior, specific rather than general, directed toward what can be changed, impart information not advice, well-timed (early after behavior)

Non-Therapeutic Communication Techniques (Blocks)

Giving reassurance Rejecting Giving approval/disapproval Agreeing/disagreeing

Giving advice Probing Requesting an Explanation Defending

Using Denial Interpreting Stereotype Comments Belittling Feelings

Indicating Existence of an External Power Introducing an Unrelated Topic

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The mental status examination is a process wherein a clinician systematically examines an individual’s mental functioning. Each area of function is considered separately.

Appearance: This category covers the physical aspects of the individuals. Include: Physical appearance, height and weight, how person is dressed and groomed, dominant attitude during interview, such as degree of poise or comfort, degree of anxiety, and how anxiety is expressed.

Behavior: How does the person move and the position in which he/she holds body. Noteabnormal tics, movement disorders, and degree of movement.

Speech: Separate speech from content of thought. Note volume, rate of flow of speech(fast, slow, halting, extremely loud). Include mannerisms, accent, stress or lack of it, hesitations, stuttering. Use descriptive words like garrulous, monotonous, loud or emotional.

Mood/Affect: Affect is the outward show of emotion. Can vary thru depression, elation, anger, and normality, but if the overall sense from the examination is depressed, depressed is the word to describe the mood. Mood is the general pervasive emotional state as reported by client. Range describes if the person shows a full or even expanded range or if the affect is blunted or restricted. Include cultural considerations. Consider appropriateness of affect – is the emotion consistent with the topic being discussed. A client with inappropriate affect may cry when talking about a parking ticket and show little or no emotion when discussing the death of a loved one.

Thought: Thought is divided into process, the way a person thinks, and content. What he/she thinks.Process: The rate of thoughts, how they flow and are connected. A formal

thought disorder comprises processes such as pressured thoughts, (excessively rapid), flight of ideas, thought blocking (speech is halted), disconnected thoughts (loosening of association, derailment), tangentiality, circumstantial thoughts (over inclusive and slow to get to the point), word salad (nonsensical responses), punning (talking in riddles), poverty of speech (limited content).

Content: Includes those things discussed in the interview and the person’s beliefs. May have preoccupying thoughts – ideas of reference, obsessions, ruminations or phobias. The person may have delusions of control, thought insertion, broadcast, or delusions – persecutory, grandiose, religious, reference, somatic, morbid jealousy. For example, a depressed person may have delusions of hopelessness, helplessness or worthlessness.

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Perceptions: Covers sensory areas and describes distortions such as illusions, delusions or hallucinations. Describe the nature of the experience in detail. Auditory hallucinations (hearing voices) is more common in schizophrenics, visual disturbances are more common in organic problems. In addition, there are gustatory, olfactory, tactile, somatic, and kinesthetic hallucinations. Depersonalization (the person feels unreal) are described here.

Ask “do you hear voices when no one else is around?” “Do you see things such as ghosts, spirits, or angels?” Ask if the voices are commanding the person to do anything, particularly homicidal or suicidal acts. Hallucinations can be in the form of a running commentary. If the voices command a person to do something, does the person obey the instructions or ignore them. Sometimes hallucinations are not well-formed voices or objects – persons may hear bells ringing, knocking at the door, banging sounds in his ears, or see vague things like halos or colors which are difficult to describe.

Note how persons cope with the hallucinations and whether they are pleasant, unpleasant or terrifying. Comment on the hallucinatory behavior, such as person looking back repeatedly, gesturing or engaged in self-talk. To determine if the person is having delusions, ask do you feel you have some special power or abilities? Does the radio or TV give them special messages? Does the person have thoughts that other people think are strange?

Obsessions and compulsions: Is the person afraid of dirt? Does he wash his hands frequently or wash hands repeatedly.

Phobias: Does the person have any fear, such as animals, heights, snakes, crowds, etc.

Preoccupations: Ask about ideas about the person’s body: He may believe he is changing or has changed, that his elimination functions, sexual functions, or digestive functions work in different or bizarre ways.

Cognition: Look at areas of abstract thought which declines or is absent in a number of conditions such as schizophrenia or dementia, level of general education and intelligence, degree of concentration.

Consciousness: Level of conscious state is assessed, whether it is steady, fluctuating, cloudy, or clear. Rate: 1=coma 2=stuporous 3=lethargic/evidence of drowsiness 4=alert.

Orientation: Ask if the person knows the time and date, place, person (who he/she is), and the situation the person is in.

Memory: Memory is tested by looking for immediate recall. Give the client 3 unrelated words (yellow, fox, Chicago) and ask him to repeat them. In 5 minutes ask the

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person to repeat them again. Do not tell the person that you will ask them to repeat them in 5 minutes. (You need to write them down so you remember.)

Recent recall: What did the person eat two meals ago?Remote memory: When and where was the person born? Where did he go to high school?Confabulation: Filling in memory lapses by guessing or making up events. Persons may do this if they cannot remember – if this occurs, just note it. You might have to check information with outside sources for verification. You can test for confabulation by asking if the person has seen you before – the person who confabulates may fabricate details of a meeting which did not take place.

Concentration and Attention:May be impaired for a variety of reasons: cognitive disorder, anxiety, depression,internal stimuli. Ask the person to subtract 7 from 100 and keep subtracting 7 from the answer (serial 7s). Average time to complete is 90 seconds. Note the person’s response to the task: irritability, frequent hesitation, or questioning. Four or more errors is considered marginal; 7 or more indicates a poor performance. If the person cannot begin the task, start at 50 and subtract 3s. If he is unable to do that, have him count backward from 10. He is not to use paper to complete the task.

Others: Dreams: Are there dreams, how often, how vivid, any repetitive dreams, nightmares? What is the content of dreams.

Déjà vu: Sensation of having been in situations similar to the present one.

Presence of suicidal/homicidal thoughts. Must inquire about specific plans,suicide notes, impulse control. If positive, will he contract for safety?

Ask if person has any thoughts of wanting to hurt anyone, wishing someone was dead? If yes, ask about specific plans.

Intellectual Functioning:General knowledge: Who is the President, name 5 last presidents.What is happening in the world? (war, economy). Name 5 majorUS cities. If you go to McDonalds and buy 2 hamburgers for 70 cents each and pay $2, how much change will you get back? Or, how muchis a quarter, dime, nickel and penny?

Math calculations: Ask basic math problems: 4+6 or 13-8.Complex: Add 14+17.

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Ability to abstract:Determine similarities

How are an orange and a pear alike? Good answer = fruit, Poor answer = round.

How are a fly and a tree alike? Good answer = alive, Poor answer = nothing

How are a train and car alike?Good answer = modes of transportation, Poor answer = they both have wheels

Proverbs Ask “what does it mean to say: Don’t count your chickens before they are

hatched? Good answer = Don’t plan on future gains before they happen. Poor answer = chickens are little.

Judgment and Insight:Evaluate judgment with person’s response to: “What would you do if you were in a crowded theatre and smelled smoke?”“What would you do if you found an addressed, stamped envelope lying in the street?”

Insight: How does the person perceive his present problem? “How did things come to be this way?

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Mental Health Nursing Assessment

Student’s Name: __________________________________ Date: ____________________________

I. Client AssessmentA. Client’s Demographic Data

Client’s initials: _____ Client’s Age: ____ Client location/room: ___________________Admit date: ________ Gender: ________ Marital Status: _______ Children: ________Career: ___________________ Last worked: ___________ Education: _____________Cultural background: ________________________ Primary language: ______________Spiritual belief/Religion: ___________________________________________________Legal status: _____________ Privileges: _______________ Precautions: ____________Living arrangements: ________________________ ADLs: _______________________Family/community supports: ________________________________________________Erikson’s developmental stage: ______________________________________________

B. DSM-IV-TR Admitting DiagnosesAxis I- (Admitting psychiatric disorder(s)): ____________________________________Axis II- (Personality disorder(s) or DD: _______________________________________Axis III- (General medical diagnoses): ________________________________________Axis IV- (Psychosocial/environmental factors): _________________________________Axis V- (GAF Score):______________________________________________________

C. Psychopathology Leading to Current Admission(Behavior, thought processes, dysfunction, crisis event, and past history or mental illness or addictions)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

D. Contributing History or Events (i.e., social, cultural, family, etc.)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. Discharge Plan____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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II. Mental Status Exam Flow SheetA. Identifying Data

Client initials: ____________ Living arrangements: ________________________Gender: _________________ Religious preference: ________________________Age: ____________________ Allergies: _________________________________Race/Culture: _____________ Special diet: _______________________________Occupation: _______________ Chief complaints: ___________________________Significant Other: __________ Medical diagnoses: __________________________

B. General Description1. Appearance

Grooming/dress: _________________ Hair color/texture: ______________Hygiene: _______________________ Scars/tattoos: __________________Posture: ________________________ Appears age?: __________________Height/weight: ___________________ Level of eye contact: ____________

2. Motor activityTremors: ________________________ Rigidity: ______________________Tics/movements: __________________ Gait: _________________________Mannerisms: _____________________ Echopraxia: ___________________Restlessness: _____________________ Psychomotor retardation: _________Aggressiveness: ___________________ Range of motion: _______________

3. Speech patternsSlow or rapid pattern: _______________ Volume: ______________________Pressured speech: __________________ Speech impediment: _____________Intonation: _______________________ Aphasia: ______________________

4. General attitudeCooperative/uncooperative: ___________ Interest/apathy: _________________Friendly/hostile/defensive: ____________ Guarded/suspicious: _____________

C. Emotions1. MoodSad: ___________ Depressed: _____________ Despairing: ____________________Irritable: ________ Anxious: ______________ Elated: _______________________Euphoric: _______ Fearful: _______________ Guilty: _______________________Labile: __________2. AffectCongruence with mood: ____________________________________________________Constricted or blunted: _____________________________________________________Flat: ____________________________________________________________________Appropriate or inappropriate: ________________________________________________

D. Thought Processes1. Form of thoughtFlight of ideas: __________________________ Associative looseness: ______________

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13 of 31Circumstantiality: ________________________ Tangentiality: ____________________Neologisms: ____________________________ Concrete thinking: ________________Clang associations: _______________________ Word salad: _____________________Perseveration: ___________________________ Able to concentrate: _______________Echolalia: ______________________________ Mutism: _________________________Poverty of Speech: _______________________ Attention span: ___________________

2. Content of thoughtDelsusions: persecutory: __________ Grandiose: __________ Reference: _________

Control: _____________ Somatic: ____________ Nihilistic: _________Suicidal/homicidal ideas: ___________________________________________________Obsessions: _____________________________________________________________Paranoia/suspiciousness: ___________________________________________________Magical thinking: _________________________________________________________Religiosity: ______________________________________________________________Phobias: ________________________________________________________________Poverty of content: ________________________________________________________

E. Perceptual DisturbancesHallucinations: Auditory: __________________ Visual: ____________________

Tactile: ____________________ Olfactory: _________________Gustatory: __________________

Illusions:Depersonalization: ________________________________________________________Derealization: ____________________________________________________________

F. Sensory and Cognitive AbilityLevel of alertness/consciousnessOrientation: Memory:Time: ____________________________ Recent: _____________________________Place: ____________________________ Remote: ____________________________Person: ___________________________ Confabulation: _______________________Circumstances: _____________________ Capacity/abstract thought: ______________

G. Impulse ControlAbility to control impulses related to the following:Aggression: ________________________ Guilt: ______________________________Hostility: __________________________ Affection: ___________________________Fear: ______________________________ Sexual feelings: ______________________

H. Judgment and InsightAbility to solve problemsAbility to make decisionsKnowledge about self: awareness of limitations, awareness of consequences of actions, awareness of illnessAdaptive/maladaptive use of coping strategies and ego defense mechanisms.

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Laboratory DataStudents MAY NOT use the term WNL or chart by exception on this form. Write normal value range, exact value for patient, and indicate if this is normal, high, or low. Sodium White Blood Cells

Potassium Red Blood Cells

Chloride Hemoglobin

Glucose Hematocrit

Blood Urea Nitrogen Total Bilirubin

Creatinine AST

Calcium ALT

Magnesium Alkaline Phosphatase

Phosphorous Lithium/Depakote/Tegretol Level

Total Protein TSH

Albumin UA

Pre-Albumin Drug Toxicology

Cortisol Level

What information can you obtain from these lab values? Why is this information important for this specific patient?

Pathophysiology: Briefly summarize significant psychiatric/mental health problems, linking to medical co-morbidities as applicable.

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Medication Preparation Log (MPL)

Student Name: _______________________________________ Clinical Rotation Date: ___________________________

Patient Identifier:

Code Status:

Allergies:

Diagnosis:

Relevant Medical/Surgical History:

Drug (Generic/Trade)Pt. Dose/ Normal Range Route Frequency Classification

Reason pt. receiving RX Top 4 Side Effects

Nrsg Implications/ MUST KNOW

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Drug (Generic/Trade)Pt. Dose/ Normal Range Route Frequency Classification

Reason pt. receiving RX Top 4 Side Effects

Nrsg Implications/ MUST KNOW

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18 of 31Interaction Process Recording Instructions

The purpose of the Interactive Process Recording (IPR) is to demonstrate the student’s skills in understanding and refining therapeutic interactions as part of the nurse-client relationship. The analysis of interactions with the patient promotes the student’s ability to use the key therapeutic tool, the use of self, to facilitate growth in the nurse-client relationship. The IPR assists the student to recognize personal feelings, actions and interactions throughout the orientation, working, and termination phases of the relationship and to identify areas needing improvement. Must have a minimum of 15 interchanges of interaction.

Instructions for Completing IPR Form

A. Cover Sheet

B. Dialogue/Analysis1. Place all statements and nonverbal communications in the column under interaction. Statements

by the student and client are to be recorded verbatim – for example: “and then she just passed away.”

2. Student analysis columna. Enter the type of therapeutic technique used. “Silence” whether it was Therapeutic (T) or

Non-therapeutic (N).b. Student rationale – to allow the patient more time to think about the death of his mother –

and your thoughts about the client’s response. He seemed close to tears and I felt uncomfortable that I may have to see him cry. I did well not talking – I wanted to say something like I felt sad when my grandmother died, but I didn’t – I allowed him the time he needed to process his feelings.

c. Alternative statement (2) and for each (N) response.3. Client analysis column

a. Analysis of client’s thoughts, feelings and response – possibly looking for approval from student.

b. Anxiety level – rate none, mild, moderate, severe or panic. May also use 0, +1, +2, +3, +4.

c. Labile defense mechanisms (2 required). If none, state none seen.

C. Evaluation Sheet

D. Basic Script for Opening“Hello, I am a nursing student at ____________. I would like to talk with you for about 20 minutes about some concerns or issues you may have which are related to the reasons you are here for treatment.” When client agrees, say: “Anything we talk about is confidential.” If the patient is unsure of where to start, use the following: “Tell me about the goals you are working on for your treatment plan.”

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1. Be direct in asking the patient to talk with you. Nurse counseling is a legitimate role and nurses should be comfortable with it.

2. Utilize seating arrangement to facilitate the IPR.3. Take a deep breath and set yourself before you start.4. Use who, what, where, and when to follow up client statements as appropriate.5. Avoid use of why and how statements.6. Avoid jargon, euphemisms, slang and figures of speech, may be misunderstood.7. Do not over-sympathize with the client about problems of living in the hospital.8. Do not agree with “you know”. Clarify what they mean.9. When the client uses psychiatric terms, ask what they mean by them.10. Avoid close-ended questions.11. Don’t get into the physical nursing role when counseling (i.e., “Do you need to lie down?”).12. Do not tell the client how he should feel.13. Do not use judgmental words like that was good, bad or great.14. Don’t spend time discussing a client’s diagnosis.15. Do not give advice.16. If the client talks about things he would not do, ask what he would do or did.17. Do not defend the staff or hospital.18. Do not share personal information about yourself, students, or staff. Divert the questions by

saying “This is your time to talk about you.”19. If your client is crying or emotional at the end of a session, stay with them. Ask if they are

feeling OK and do they have someone to talk to. Don’t just leave them.20. Always report what client told you to staff before leaving the unit.

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IPR Cover Sheet

The purpose of the IPR is to provide you an analysis and critique of your communication knowledge and skill. It also provides an opportunity to synthesize principles and concepts of the therapeutic relationship. Use a 10-minute segment of your interaction and complete the following.

Student’s name: _____________________________________________Date: ______________________________Client: M or F Age: _____________DSM-IV-TR Diagnoses: ______________________________________ Ethnicity: _________________

Prologue: Describe where and when the interaction took place (environmental setting, emotional climate of the milieu/setting, any significant client related data prior to the interaction and presence of others in the area). DO NOT name the agency or unit. What was the presenting behavior of the client?

Phase of the relationship: (circle one) Orientation Working Termination

Student thoughts and feelings prior to interaction:

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IPR Analysis

Student VerbalCommunication (Minimum 15 statements)

Student Non-Verbal Communication

a. Identify communication technique used. (T or NT)

b. Analysis of student thoughts, feelings and responses.

c. Alternative statements (2).(i.e. What could I have said?)

Client Verbal Communication

Client Non-Verbal Communication

a. Analysis of client thoughts, feelings and responses.

b. Anxiety levelc. Defense mechanisms if

present (2).

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IPR Analysis

Student VerbalCommunication (Minimum 15 statements)

Student Non-Verbal Communication

a. Identify communication technique used. (T or NT)

b. Analysis of student thoughts, feelings and responses.

c. Alternative statements (2).(i.e. What could I have said?)

Client Verbal Communication

Client Non-Verbal Communication

a. Analysis of client thoughts, feelings and responses.

b. Anxiety levelc. Defense mechanisms if

present (2).

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24 of 31IPR Evaluation

Evaluation of interaction goals. Were they met? If so, how? If not, why not?

A. Client-centered goal:

B. Student-centered goal:

2. Student’s communication pattern or style:

3. Student’s thoughts and feelings after the interaction:

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Scoring Rubric for MH IPR and Care Plan

Student Name: Date: Grade:

Below are the criteria that will be used to grade this assignment. A minimum grade of 78% for a rating of “pass” is required. Students receiving less that 78% must rewrite the assignment before the end of the clinical rotation. If second submission is scored less than 78%, the student will be referred to the Director of Clinical Placement who will decide whether to uphold the failing grade or to recommend care plan remediation. Paperwork submitted late will be marked down 5% for each day it is late.

1. Patient Profile Database Form 10 ptsAbove average

8 ptsAverage

6 ptsBelow average

4 ptsUnacceptable

TotalScore

Assessment Portion of ProfileIncludes subjective, objective, and historical data as well as medical history

PathophysiologyBriefly summarizes significant psychiatric/ mental health problems, linking to medical co-morbidities as applicable.

100% of sections of profile completed utilizing subjective, objective, and historical data.

Pathophysiology of primary disease is accurate

Symptoms and/or co-morbidities are correlated

Includes dynamic interactions of medications & treatment to disease process


Symptoms and/or co-morbidities are correlated

75% of profile completed utilizing subjective, objective and historical data.


Symptoms and/or co-morbidities not correlated

50% of profile completed utilizing subjective, objective and historical data.

< 50% of profile completed.

Student does not display under-standing of basic pathophysiology

Laboratory DataIncludes current lab results and their significance for this patient

Medication Prep. LogProperly completed including reason taking medication, side effects and important nursing implications.

All lab data is recorded All labs are correlated to

patient’s medical condition100% of medications are

listed with each area of log completed appropriately

All lab data is recorded Some labs are

correlated to patient’s medical condition

75% of medication log completed appropriately.

Lab data is recordedLab data not correlated

to patient’s medical condition

50% of medication log completed appropriately

No lab data recorded.

< 50% of medication log completed appropriately.

2. Nursing Care Plan 10 pts 8 pts 6 pts 4 pts Total

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Score: _____ (Maximum Section Score = 20 points)

Comments:

27 of 31Above average Average Below average Unacceptable Score

AssessmentIncludes subjective, objective and historical data that support actual or risk for nursing diagnosis.

All pertinent data related to nursing diagnosis included

All pertinent data related to nursing diagnosis

Data unrelated to nursing diagnosis included

Pertinent data related to nursing diagnosis not included

Data unrelated to nursing diagnosis included

Assessment section is incomplete.

DiagnosesIncludes 3 of the most appropriate diagnoses for patient (2 medical; 1 psychosocial). NANDA-approved. Are written in correct format: PES (for actual diagnosis); PE (for potential or “at risk” diagnosis); P (for wellness diagnosis)

Appropriate for patient’s medical condition

Supported by assessment data

NANDA approved Formatted correctly

Appropriate for patient’s medical condition

Supported by assessment data

NANDA approvedNot formatted correctly

Not appropriate for patient’s medical condition and/or

Not supported by assessment data

Not NANDA approved and/or formatted correctly

Diagnosis portion is incomplete.

Plan – Goal StatementsIncludes 2 appropriate statements for each nursing diagnosis which are patient centered & written in SMART (specific, measurable, attainable, realistic, & time-specific) format.

100% of goal statements fit the nursing diagnoses

Patient centeredWritten in SMART

format


Patient centeredWritten in SMART format


May not be patient centered and

May not be written in SMART format

< 50% of goal statements fit the diagnoses

Implementation – Interventions with Rationale: Includes three (3) interventions that directly relate to each goal, are specific (who, what, when, how much, how often) and include a referenced rationale with page number (s).

3 interventions are listed

Specific Include a referenced

rationale with page number (s)

3 interventions are listedMay not be specific May not include a

referenced rationale with page number (s)

< 3 interventions are listed Not congruent with goalsNot specific and/or do not

have a referenced rationale

Interventions section is incomplete.

Evaluation: Includes data that directly reflect goal statements. State if goal has been met, partially met, or not met. If goal was not met or partially met, note whether plan of care will be continued or modified and set new date/time for evaluation.

Contains data that directly reflects goal statements

Describes goal as met, partially met, not met.

If goal partially met or not met, notes whether POC will be revised and set new eval. date/time

Contains data that directly reflects goal statements

Does not describe goal as met, partially met, or not met

May also not include revision or new evaluation date/time

Does not contain data that directly reflects goal statements

May also not describe goal as met, partially met, or not met

May also not include revision or new evaluation date/time

Evaluation section is incomplete.

3. IPR 10 ptsAbove average

8 ptsAverage

6 ptsBelow average

4 ptsUnacceptable

TotalScore

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Score: ______ (Maximum Section Score = 50 points)

Comments:

28 of 31All verbal and non-verbal communication during the interaction noted (student and client).

Utilized an equal number of open- and close-ended questions 100% of the time.

Zero use of “why” and “how” questions.

Non-verbal communication techniques noted


Minimal use of “why” and “how” questions.

Non-verbal communication techniques noted


Frequent use of “why” and “how” questions and/or

Non-verbal communication techniques not noted

Utilized an equal number of open- and close-ended questions < 50% of the time.

Frequent use of “why” and “how” questions

Non-verbal communication techniques not noted

Student analysis: type of therapeutic techniques (T or NT), student rational and alternative responses to (N) techniques noted.

100% complete analysis of therapeutic techniques, rationale and alternatives.



< 50% complete analysis of therapeutic techniques, rationale and alternatives.

Client analysis: analysis of client’s thoughts, feelings and responses noted. Client’s anxiety level and defense mechanisms noted.

100% complete analysis of client’s thoughts, feelings and responses.

Anxiety level noted.Defense mechanisms

noted.


Anxiety level noted.Defense mechanisms noted.


Anxiety level may not be noted.

Defense mechanisms may not be noted.

< 50% complete analysis of client’s thoughts, feelings and responses.

Anxiety level not noted.

Defense mechanisms not noted.

Section 1 Score ________ Section 2 Score + ________ Section 3 Score + ________Deduction - ________ (if applicable)Final Score = ________

Revised 03.27.14

Score: ______ (Maximum Section Score = 30 points)

Comments:

Instructions: Add section scores together, and deduct for late paperwork, if applicable. This will give you a Final Score. Then, refer to the Point Conversion Table below to identify the student’s percentage points and letter grade. Place the final letter grade in the identified location on page one.

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Point Conversion Table: 10 Graded Criteria (100 Maximum Points)100 100% Pass95 95% Pass90 90% Pass85 85% Pass80 80% Pass78 78% Pass77 77% Fail75 75% Fail

Nursing Care Plan Form

Revised 03.27.14

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Student Name: Date:

Patient Identifier: Patient Mental Health/Medical Diagnosis:

Nursing Diagnosis (use PES/PE

format):Assessment Data(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

Goals & Outcome(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.)

Nursing Interventions(List at least three nursing or collaborative interventions with rationale for each goal & outcome.)

Rationale(Provide reason why intervention is indicated/therapeutic; provide references.)

Outcome Evaluation & Replanning

(Was goal met? How would you revise the plan of care according the patient’s response to current plan ?)

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2.

3.

4.

Statement #1

Statement #2

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2.

3.

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3.

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2.

3.

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2.

3.

Outcome #1

Outcome #2

Revised 03.27.14

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Nursing Care Plan Form Student Name: Date:


Nursing Diagnosis (use PES/PE format):

Assessment Data(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)






1.

2.

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4.

Statement #1

Statement #2

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Outcome #1

Outcome #2

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Nursing Care Plan Form Student Name: Date:


Nursing Diagnosis (use PES/PE format):

Assessment Data(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)






1.

2.

3.

4.

Statement #1

Statement #2

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2.

3.

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3.

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2.

3.

Outcome #1

Outcome #2

NRS 475 - mydsn.net€¦ · Web view1 Nursing care plan with at least two nursing diagnoses....

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