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)
  1. Instruct in problem solving skills
  2. Communicate rules, behavioral expectations & consequences using simple language
  3. Redirect or remove patient from source of overstimulation
  1. This encourages patient o perform independently
  2. The patient lacks the ability to assimilate information that may be complicated
  3. Patient learns appropriate social behavior from positive & negative feedback
(3)Goal not met. Patient still has negative interactions with peers & his father.


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