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Client Assessment & Nursing Care Plan

Learning Objectives: Nursing Process, critical thinking, analysis of data, communication

Overview

The ability to assess the client in the clinical setting is an essential skill for the psychiatric nurse. The Nursing Assessment/Care Plan assignment is intended to be a comprehensive learning experience that synthesizes essential psychiatric and medical/surgical nursing theory. Your finished product will demonstrate mastery of principles needed for nurses working with mentally ill clients.

You will us the steps of the nursing process: assessment, diagnosis, goals, client centered interventions and ongoing evaluation to gather important information and data to identify the client’s problems and priority needs. You will have numerous opportunities to perform interviews and assessments of clients each week during your 5 week clinical practicum experience.

Instructions:

· You will complete One Nursing Assessment/ Care Plans for one clients during the clinical practicum experience.

· All components of the Nursing Assessment and Care Plan form must be completed and submitted with a completed Medication Worksheet and a Laboratory/Diagnostic Worksheet (copies available in the Clinical Assignments section on BB).

· Based on the information/data collected during the assessment and interview phase, you will use the nursing process to develop a plan of care.

· The plan of care should include a minimum of THREE priority nursing diagnoses. At least TWO should be psychiatric/psychosocial nursing diagnoses.

· Each submission must include the following:

· Client Interview data

· Nursing assessment, subjective, objective data gained from interview

· Client centered goals

· Nursing interventions

· Client teaching

· Discharge planning with consideration of appropriate community resources/referrals.

· Medication Worksheet

· Laboratory & Diagnostic Worksheet

· A list of NANDA approved nursing Diagnoses can be found in your textbook.

· Key nursing interventions for specific psychiatric mental-health disorders are available in each chapter of the textbook.

Key Points:

· Spend some time interacting with your prospective client before you gather data from the chart. Finding a patient who is more willing to interact will make the process easier. You should request permission from the client prior to beginning the interview.

· You must establish rapport and gain trust (orientation phase) with the patient before you can move in to the (working phase) of the nurse-patient relationship.

· Use your verbal and non-verbal therapeutic communication skills learned in class and BLAST to interact with the client.

· You must address the Psychosocial AND physiological needs of each client(s) you work with.

· You should disclose to the client that all information offered will be held in strictest confidence and will only be shared with those involved in the client’s care.

· UNDER NO CIRCUMSTANCES WILL THE STUDENT SHARE INFORMATION REGARDING A CLIENT OUTSIDE OF THE HOSPITAL UNIT.

· No documents containing patient identification data may be removed from the hospital unit. – NO EXCEPTIONS. Any student found violating patient confidentially may be asked to leave the clinical agency and may fail the course.

Format: Assemble your Plan of Care in this order

• Title Page (Your Name, University, Assignment, Date)

• Assessment

• Plan of Care - NANDA Diagnoses (PRIORITIZED), Client teaching, Discharge plan

• Medication Worksheet

• Lab Values / Tests Worksheet

· Reference Sheet with a minimum of three (3) (drug book, lab book, care plan text, and a peer reviewed article relevant to your client ie: if the client is diagnosed with depression, you may want to include an article about current treatment approaches for reducing auditory hallucinations. Please submit a copy of your article with your assignment.

Attachments

· Attach Lab/Diagnostic Findings Worksheet findings for this client using the Laboratory Worksheet (forms can be downloaded from BB - clinical)

· Attach Medication Worksheet for this client using the Laboratory Worksheet (forms can be downloaded from BB - clinical)

· Please include ALL resources (references, textbooks, online resources) to your assignment using APA format. Minimum 3 References

 You are being graded on your own work and effort - PLEASE DO NOT CUT AND PASTE FROM ANY DOCUMENT – CUTTING AND PASTING FROM ANY SOURCE IS CONSIDERED PLAGIARISM AND A GRADE OF UNSATISFACTORY WILL BE ASSIGNED AUTOMATICALLY AND CONSIDERED VIOLATION OF THE ACADEMIC AND INTEGRITY POLICY (PLEASE REVIEW GUIDELINES REGARDING WHAT CONSTITUTES PLAGIARISM AT THE LINK IN THE SYLLABUS)

NURS 3116

CLIENT ASSESSMENT / CARE PLAN

Client Last initial:

Age/Gender:

Date:

Time of Interview:

Location and environment in which interview took place: (therapeutic/non-therapeutic? Did it provide for client privacy? Potential for risk reduced?

Assess the following areas for your patient:

A. Bio/psychosocial:

1. Reason for Admission:

2. Psychiatric/Mental Health History:

3. Medical History:

4. Occupation:

5. Culture:

6. Family History

B. Relevant History – Personal

1. Social patterns/interactional ability (friendships, describe a typical day):

2. Interests and abilities (what good at, what brings pleasure):

3. Addictive habits and amounts:

4. Sexual patterns (active, orientation, difficulties, protection Most students find it more comfortable to include questions about sexual patterns in the review of systems section):

5. Coping strategies (functional and dysfunctional patterns, identify defense mechanisms used):

6. Support system:

7. Resources

8. Need level based on Maslow (document rationale for level):

9. Risk factors (Danger to self, others, impulsiveness, grave disability, flight risk, EPS, seizures, blood and body fluid precautions, special needs, sexually inappropriate behavior):

C. Mental Status Assessment

1. General Behavior:

2. Attitude:

3. Communication:

4. Voice/Pitch/Volume

5. Thought Process/ Attention/ Concentration:

6. Orientation:

7. Memory:

8. Insight regarding illness:

9. Emotional State /Affect

C. Physical Assessment

1. General Appearance of Client: (describe how client is dressed, grooming etc.)

2. Safety risk (falls, self harm, suicide ideation (current) past attempts:

3. Respiratory:

4. Nutrition:

5. Elimination:

6. Hygiene:

7. Temperature:

8. Mobility:

9. Sleep:

10. Dying:

11. Activities of Daily Living:

D. DSM 5 Formulation (from chart):

F. Clinical impressions based on synthesis of all data gathered (include synthesis of labs, medications and symptom management. Include information regarding compliance to unit activities, medication compliance, and relapse prevention):

Plan of Care

(#1) Nursing Diagnosis (PRIORITY) - NANDA

________________________________________________________________

Assessment

Subjective Data: __________________________________________________

________________________________________________________________

Objective Data:

________________________________________________________________

Goal: ___________________________________________________________

Nursing Interventions:

1.______________________________________________________________

2.______________________________________________________________

3. ______________________________________________________________

4.______________________________________________________________

5. ______________________________________________________________

Client Teaching:

________________________________________________________________

Discharge Planning:

________________________________________________________________

_________________________________________________________________

Community Resources: ____________________________________________

(#2) Nursing Diagnosis - NANDA

________________________________________________________________

Assessment

Subjective Data: __________________________________________________

________________________________________________________________

Objective Data:

________________________________________________________________

Goal: ___________________________________________________________

Nursing Interventions:

1.______________________________________________________________

2.______________________________________________________________

3. ______________________________________________________________

4. ______________________________________________________________

5. ______________________________________________________________

Evaluation:

________________________________________________________________

________________________________________________________________

Education/Teaching:

________________________________________________________________

Discharge Planning:

________________________________________________________________

Community Resources: ____________________________________________

(#3) Nursing Diagnosis - NANDA

________________________________________________________________

Assessment

Subjective Data: __________________________________________________

________________________________________________________________

Objective Data:

________________________________________________________________

Goal: ___________________________________________________________

Nursing Interventions:

1.______________________________________________________________

2.______________________________________________________________

3. ______________________________________________________________

4. ______________________________________________________________

5. ______________________________________________________________

Evaluation:

________________________________________________________________

________________________________________________________________

Education/Teaching:

________________________________________________________________

Discharge Planning:

________________________________________________________________

Community Resources: ____________________________________________

Include references for all resources.

Nursing Assessment / Client Interview Grading Rubric

Evaluation Criteria	Satisfactory (2)	Unsatisfactory (0-1)	Comments
Biographical Data Complete Current Diagnosis Medical/psychiatric History DSM5 included
Assessment data gathered from a completed Assessment Tool and/or other appropriate sources (ie: chart, client etc.).
Includes 2 psychiatric/psychosocial nursing diagnoses and 1 physiological diagnosis from NANDA
Nursing Diagnosis # 1 Supported by assessment findings
Interventions
Evaluation criteria/Patient education/Discharge planning/ Risk assessment
Nursing Diagnosis #2 Supported by assessment findings
Interventions
Evaluation criteria/Patient education/Discharge planning / Risk assessment.
Nursing Diagnosis #3 Supported by assessment findings
Interventions and rationale
Evaluation criteria/Patient education/Discharge planning / Risk assessment.
Lab test(s) worksheet completed and attached
Medication Worksheet completed and attached
Readability: Plan of Care is easy to easy to follow and clear.
Understanding: Plan of Care shows a high level of understanding of the entire patient picture
Includes Reference page with minimum 3 references to support nursing diagnosis and plan of care.
Free from grammatical errors, spelling mistakes, APA format.

Students must achieve satisfactory on all components of the Nursing Assessment/ Client Interview (assessment and plan of care). Students will be given one opportunity to submit a draft copy of this assignment and revise any unsatisfactory score

The nursing care plan is graded on a satisfactory/unsatisfactory basis. Your grade will reflect your overall effort and thoroughness in completing this assignment.

Any student receiving an ‘unsatisfactory’ grade may be required to re-submit part or a new assignment based on the discretion of the clinical faculty. A second unsatisfactory grade will