Sample Care Plan Psych

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PSYCHIATRIC NURSING MAJOR PLAN OF CARE ASSIGNMENT
Guidelines:
1.This assignment is much like a Case Study and 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 impaired patients. 2.It is similar to other Major Plans of Care with face sheet, lab sheets, TACTIS, assessment forms, and etc., but will be different in that it will incorporate elements of care plans you have already done, along with content you will develop using Nurse Squared, our new Electronic Medical Record software that you will be using. After having worked with this software over the summer, I think you will find it easier to use, in that it will prompt you to fill in every important section, and it will give you many choices to select when developing your nursing problems and interventions, so you won’t have to come up with them all on your own. You will, however, have to come up with rationales for each intervention and cite them, as you have in the past. A sample care plan will be provided for you to refer to. 3.It must address the needs of one MENTAL HEALTH patient that you select to work with. The patient should be on at least 2 psych meds. (Remember that you must establish rapport, gain trust, and initiate 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). 4.Select a patient that is not working with another student for this assignment. 5.Try to select a patient that is likely to be hospitalized for several more days or weeks. Check with staff to ensure that there are no imminent discharge plans. 6.Spend some time interacting with your prospective patient before you spend a lot of time gather data from the chart. Some students have made the mistake of selecting a patient who they have not talked to and gathered pages of data, only to find that the patient was not willing to interact. Finding a patient who is more willing to interact will make the whole process much easier. 7.Make a confidential note of the patient’s identification numbers for medical records review. 8.You must ACTIVELY INTERACT with the patient frequently over a period of two or more days. You are expected to select your nursing goals/expected outcomes for the patient and attempt to achieve them. (Remember that the patient does not have to be exceptionally welcoming or talkative to do this assignment. 9.Identify appropriate nursing interventions for each of your patient’s NANDA diagnoses. Try to implement as many interventions as possible during your clinical time with the patient. 10.WHAT DIAGNOSES SHOULD YOU LOOK FOR?

Schizophrenia and related psychoses
Schizoaffective disorder
Psychotic Depression; post-partum psychosis
Bipolar disorder, either manic or depressed
Psychosis related to Dementia/Organic Pathology
Psychosis related to Substance Use Disorders
Major depression and substance abuse are acceptable as long as your patient is on at least 2 psych meds (If questions, ask instructor.) Format Of The Plan of Care:
1.Most parts of the assignment are to be typed. (You may highlight and write directly on forms provided and assessment tools). Your instructor is expecting to see college level work that is neatly and comprehensively done. Use black ink only in areas not typed. Handwriting needs to be easily read. Use APA format. 2.Submit the completed paper in a very small (1/2 inch or less) lightweight three-ring binder. (Second copies are not required unless specifically requested by instructor). 3.It is due at the time specified by your clinical instructor. 4.Note: Do not submit partial or incomplete papers.

5.Sequence Of Pages: (Assemble your paper in this order)
Title Page
Face Sheet (Nurse Squared)
Process Recording...
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