PSYCHIATRIC CARE PLAN

Psychiatric Care Plan During each clinical rotation, you will be required to write a care plan. Individual health care plans for patients will help students to care and teach patients about their diagnosis or problem. Care plans help map out how you will care for the patients specific problem. Below is part of a sample two care plans for a psychiatric clinical rotation. Sample 1

PATHOPHYSIOLOGY NURSING DIAGNOSES: List in Priority Schizophrenia is caused by a combination of factors like genetic disposition, biochemical Dysfunction, physiological factors, and psychosocial stress. A diagnosis includes delusions, hallucinations, disorganized speech, disorganized catatonic movement. The patient’s delusional disorder is characterized by one or more nonbizzare delusions that persist for at least a month Disturbed thought perception Suicidal precautions Anxiety

As Evidenced By:

Subjective	Objective
Patient states that he has to be discharged so he can play with the Jaguars for Monday night football. Patient also stated that he ran out of his meds a few weeks ago.	Patient had on all Jaguar gear with nails painted teal & black

NOC:

Distorted Thought Control

Page # In NOC Book:

263

NIC

Delusion Management

Page # In NIC Book:

277

Outcome Indicators (NOC)		Nursing Activities (NIC)	Rationale (from nursing references)			Evaluation and Revision of Plan
5= Consistently demonstrated 4= Often demonstrated 3= Sometimes demonstrated 2= Rarely demonstrated 1= Never demonstrated 1. Report a decrease in delusions by 11/6/07. Currently at (2).		1. Provide medication compliance teaching to patient.	1. Encouraging patient to take meds as directed will prevent future episodes.			(4) Goal met. Patient stated when he gets discharged from hospital he will only tail gate to a game & not play in it. Patient also attended medication compliance therapy & agreed to continue his meds.
Outcome Indicators (NOC)	Nursing Activities (NIC)			Rationale (from nursing references)	Evaluation and Revision of Plan

Sample 2

PHYSICAL ASSESSMENT
GENERAL Active, oriented & dressed appropriately		SKIN Warm, dry, unremarkable for rashes or eccymosis	HEAD/NECK No headaches or neck pain. No ear pain or nasal discharge. Conjunctivae & sclera are bilat clear	THORAX/LUNGS NO cough or SOB NO chest pain	CARDIOVASCULAR RRR with murmur
ABDOMEN/GI/BM Soft & non tender		GENITOURINARY No dysuria or low back pain	MUSCULOSKELETAL No history of arthritis, joint pain or muscle weakness	NEUROLOGICAL Steady gait. No vision problems.
Nursing Diagnosis / Related to	Ineffective coping					Page # in Ackley	273

As Evidenced By:

Subjective	Objective
None	Observed patient instigate arguments with other peers. Patient called father on telephone & threatened to kill him.

NOC:

Coping

Page # In NOC Book:

249

NIC

Behavior management

Page # In NIC Book:

187

Outcome Indicators (NOC)	Nursing Activities (NIC)	Rationale (from nursing references)	Evaluation and Revision of Plan
5= Consistently demonstrated 4= Often demonstrated 3= Sometimes demonstrated 2= Rarely demonstrated 1= Never demonstrated 1. Uses effective coping strategies by 11/12/07. Patient is at present (3)	Instruct in problem solving skills Communicate rules, behavioral expectations & consequences using simple language Redirect or remove patient from source of overstimulation	This encourages patient o perform independently The patient lacks the ability to assimilate information that may be complicated Patient learns appropriate social behavior from positive & negative feedback	(3)Goal not met. Patient still has negative interactions with peers & his father.