Fill out a mental health treatment plan template

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Fill out a  mental health treatment plan template

Fill out a mental health treatment plan template
Chamberlain University Mental Health Treatment Care Plan STUDENT’S NAME: _____ __________DATE:___ ______ Admission Data (20 pts) Date of admission: (02/09/23) How long has the client been here? 15 Days. Last Vital Signs: T: 47.7 F HR: 58bpm RR: 18/min BP: 98/64 mmHg PAIN: 2/10 In this section describe what you SHOULD assess for- and then what you were able to see with your client. You will not get an opportunity to assess every body system in this clinical- but based on what you know about the client- what would you want to look for. General Survey – Observed: The patient had an Athletic body build, good hygiene, his appearance was appropriate for age, his mood was happy, and he was active. HEENT – Observed: The patient’s hair was well distributed, no signs of dysphasia, no deafness, no blurred vision, or discharge from the eye. His skin color is appropriate for ethnicity. I would assess for legions on the head, and neck. Also, for a deviated septum and patency of each nostril. Neurological – Observed: The patient showed no muscle weakness. I would have assessed for the effectiveness of the remaining cranial and facial nerves. Cardiovascular (including peripheral vascular) – Observed: The patient showed no signs of chest pain, and exercise tolerated. I would have assessed Respiratory – Observed: The patient had no cough and did not show signs of shortness of breath. Steady rate and rhythm of expiration. I would have assessed for chest symmetry during respiration and listen to lungs sounds. Gastrointestinal – Observed: The patient had no signs of nausea, and no apparent abdominal pain. I would have assessed for abdomen symmetry, masses, and muscle separation on the abdomens. Genitourinary – Observed: The patient showed no signs of urgency or frequency. Musculoskeletal – Observed: The patient had mild left knee pain, he showed no signs of stiffness or spasms. I would have assessed for C.V.A. tenderness. Pain, tenderness, and ROM at any other joints besides the left knee. Integumentary – The patient had no rashes or hives. I would have assessed head to toe any lesions, cuts, or bruises. Pertinent laboratory values- GFR, BUN, albumin, Creatinine for kidney function due to the potential of damage from substance and alcohol abuse, Full liver function (bilirubin, ALT, AST, APS, and protein) to asses for liver damage due to alcohol and substance abuse. Urinalysis DSM V DIAGNOSIS: F10.20 Alcohol use disorder. F12.20 Cannabis dependence. F15.20 Other stimulant dependence. F13.20 Sedative, hypnotic, or anxiolytic. F17.200 Nicotine dependence. F11.10 Opioid use disorder. F32.1 Major depressive disorder. F90.0 Attention deficit disorder hyperactivity. M25.562 Pain in left knee. F43.12 Post-traumatic stress disorder. Client’s understanding of Dx Do they know what their DSM V diagnosis is? The client is understanding of his current situation and acknowledges most of his DSM V diagnosis. ______________________________________________________________________________ Client’s perceived reason for admission: Drug and Alcohol abuse Chief Complaint: “My dad brought me here” Reason for admission: Substance Abuse Cultural Assessment: N/A Spiritual Assessment: N/A Home Assessment: Patients mother kicked him out and his father brought him here. Discharge Plan: If none on the chart ask pt & document their response. Who is involved in discharge planning? Counselor, case worker, and family. What is the role of Case Management in this setting? Plan the patients care plan. Are there any Complementary Medicine Practices that would benefit? The patient was educated in group therapy about deep breathing techniques and was interested. I think giving the patient resources regarding breathing techniques would be an acceptable compliment to current treatment. What would be the optimal plan for this client if the client had unlimited resources and time? After talking with the patient, I think he would benefit from correct medication, goal-oriented therapy, family involved therapy, and resources for education with idea about future careers. REFLECTION (20 pts) Using the “What” “So What” “Now What” Critical Reflective Model- Describe your learning today. Describe your reaction to this clinical experience. Include thoughts & feelings; demonstrate self awareness. What?​ (What happened, objectively). Without judgment or interpretation, describe in detail the facts and event(s) of this experience. Today, I observed and assisted the nurses within the adolescent unit. The schedule for the day entailed group meetings, exercise, game room activities, and art. The group meeting contained a group leader and all the adolescents within the unit. They pulled individuals for one-on-one counseling throughout the meeting. Exercise and activity was done in groups. So What?​ ​ (What did you learn? What difference did the event make?) Discuss feelings, ideas, and analysis of this experience. The adolescent unit experience was tough emotionally. During group meetings you would here the stories of neglect or abuse that these adolescents have experienced. It answers a lot of the questions on why they have an adolescent unit. I learned that a lot of the diagnosis stem from traumatic events within the lives of the adolescents. This experience made a difference on being more sympathetic to situation regarding alcohol/drug abuse. It is more of a cry for help rather than a self-control issue. Now What?​ ​(How will you think or act in the future as a result of this experience?) As a result of this experience, I would try to get the root cause of why the abuse if occurring. There are layers to the reason behind the abuse. Also, adolescents are not quick to open up about the truth 100% right away. I would act with more patience with a client in this situation in the future. Describe the Milieu of the unit and did you feel it helped or hindered the clients. The milieu of this group is accepting, open, and nonjudgmental. They all encourage each other during group and are respectable to one another. There are certain clicks that like to share past stories and curse at each other in a jokingly way. I think this environment built among the adolescents made it encouraging for others to share with each other and at group. No one adolescent was shy during any of the activities we participated in. Describe any groups you attended? Do you feel they helped or hindered the clients? What did you find effective and what would you do differently? The group meetings took place within the adolescent unit and was hosted by the group leader that typically leads. They went over a power point that encourage sharing. A couple of the slide required the participation of the entire group, but one was shy, so everyone shared. The group meeting seemed to have the adolescents open up and becoming more comfortable with one another. This comfortability brought out the tough topics from the adolescents. I don’t think any changes are necessary because they have the kids talking and opening up. __________________________________________________________________________Describe the role of each Provider on the unit and what did you learn from them or about their role? RN: Medication administration, chart daily, and carry out orders directed by the practitioner/physician. Tech: Takes vitals and assist the nurse with any daily tasks that can be delegated. Doctor or NP: Assess clients upon entering the center, diagnose, order medication, and refer clients. Social worker or Case Manager: Provides resources and works with the patient and family. Group Leaders: Lead group therapy and provide daily counsel. CARE PLAN (20pts) Chart professionally EXACTLY as you would in the client’s record: Priority Problem: Substance Abuse Situation: The patient is a 17-year-old male that originally got kicked out of his mother’s home for repeated drug use. He then moved in with his dad and got brought here after lying to his father about having drugs in the house. Background (history): The patient has a history of alcohol, marijuana, nicotine, and opioid abuse. The patient got influenced by others to consume drugs and alcohol originally, which led to the mother removing the patient from the home. The drug and alcohol use continued at the fathers how which led to his admission to the recovery center. Assessment (what do you see): The patient is well groomed, with appropriate weight and height for age and gender. His behavior is pleasant and cooperative. The patient’s mood is euthymic with no suicidal ideation. There is no loosening of associations or flight of ideas. Nursing Diagnosis (from Ackley): Ineffective coping related to inadequate opportunity to prepare for stressor as evidence by alteration in sleep pattern, inability to deal with situation, and risk-taking behavior. Short Term Goal (by end of shift) Must be SMART: The short-term goal would be to use behavior to decrease stress by verbalizing his stress level out of 10 by 1500 on 2/24/23. Three interventions would be (1) use verbal and nonverbal therapeutic communication. (2) Educate the patient on effective coping strategies. (3) Observe contributing factors of ineffective coping by the patient. Long Term Goal (3 months) Must be SMART: The long-term goal for my patient would be remain free of destructive behavior toward self by having 0 incidents of consuming alcohol or drugs. The three interventions would be (1) Encourage the use of social services, (2) Provide mental and physical activities within the clients ability, (3) Collaborate with the client to identify the source of the stressors. Mental Status Assessment (20 pts) (Use you MSE handout to address each area- Use medical terminology as you would in the medical record- This should paint a picture of what the client looks like) * Appearance: The patient is of athletic build, with appropriate weight and height for age. He is appropriately groomed, dressed, and with good hygiene. The client has good posture. * Behavior: Pleasant and cooperative * Speech: Normal rate and volume * Mood: Euthymic Potential for suicide thought: No suicide Ideation Plan: N/A Means to carry out the plan: N/A Intent to carry out the plan: N/A * Affect: Appropriate * Thought process: Logical and goal directed. No loosening of associations or flight of ideas. Concrete thinking. * Thought content: No homicidal ideations. No suicidal ideations. No delusions. Attention and concentration: Intact * Orientation: Alert to person, place, and time. AOx4 Memory: Intact (recent and remote) Judgment: Good, ability to solve problems and make decisions. * Insight: Good, Knowledge about self. Adaptive use of coping strategies. Comparison with admission mental status exam (Is the client the same, better, worse than admission- find the admission MSE on your chart or description in MD and Nursing notes): The patient MSE performed today (2/24/23) is unremarkable in comparison to the initial screening MSE (2/09/23) except for two focal findings; The patient demonstrated improved mood from irritable to euthymic. The patient demonstrated mild distractibility consisted with diagnosis of ADHD. This is a change from the initial finding of an intact attention and concentration. Client’s Current Medications (20 Pts) Name 3 medications that would require an AIMS assessment: 1. Perphenazine (Trilafon) 2. Risperidone (Risperdal) 3. Haloperidol (Haldol) Define: Extrapyramidal effects: Symptoms of antipsychotic medications that are described as uncontrolled movement. Tardive Dyskinesia: The symptoms of extrapyramidal effects such as uncontrolled muscle contraction and tremors. What is Benadryl used for in this population? Why is it important? OTC Benadryl is used as a fast-acting anti-anxiety medication. It is important because of the rapid onset effect it has for psych patients with anxiety. How and why are Vitamins and Minerals used in the mental health client? Vitamins and minerals are taken by patients with substance abuse disorders because of the improper intake due to diet, hepatic, renal function, and reduced psychological function. Make as many of these cards as your client has meds. Drug #1 Generic name Trazodone Trade name Trazodone D. Dose 50mg Route PO Frequency 1 Tab Daily Classification Antidepressant Serotonin reuptake inhibitor Rationale: To treat depression Indication: Depression relief Side effects: Drowsiness, Hypotension Educate patient, encourage good sleep schedule/PRN melatonin, and monitor close for serious AR. Nursing implications: Drowsy or Dizzy Allergy Rash, trouble swallowing, SOB, and swelling in the throat. Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Patient understands why he is taking this drug. “Antidepressant” Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) Nursing action would be to fall precaution due to the drowsiness and take BP in case of hypotension. Drug #2 Generic name Lisdexamfetamine dimesylate Trade name Vyvanse Dose 60mg Route PO Frequency 1 Tab Daily Classification CNS stimulant Amphetamines Controlled Sub: II Rationale: To treat ADHD Indication: Relief of attention deficit Side effects: Dizziness, tachycardia Educate patient and monitor close for serious AR. Nursing implications: Drowsy or Dizzy Allergy (rare) Rash, swelling, and dizziness Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Patient understands why he is taking this drug. “Chills me out” Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) Nursing action would be to fall precaution due to the dizziness, and take HR in response to tachycardia. Drug #3 Generic name Buspirone Trade name Buspar Dose 15mg Route PO Frequency 1 Tab Daily Classification Anxiolytics Anti-anxiety Rationale: To treat anxiety Indication: Anxiety relief Side effects: Dizziness, tachycardia, and chest pain. Educate patient, regularly take vitals, and monitor close for serious AR. Nursing implications: Dizzy Allergy Rash, trouble swallowing, SOB, and swelling in the throat. Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Patient understands why he is taking this drug. “Helps me not get nervous” Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) Nursing action would be to fall precaution due to the dizziness and to asses pain level due to chest pain. Drug #4 Generic name Bupropion Trade name Wellbutrin Dose 150mg Route PO Frequency 2 Tab Daily Classification Antidepressant Serotonin reuptake inhibitor Rationale: To treat depression Indication: Depression relief Side effects: Insomnia, hypotension. Educate patient, encourage good sleep schedule/PRN melatonin, and monitor close for serious AR. Nursing implications: Drowsy Allergy Anaphylaxis Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Patient understands why he is taking this drug. “For depression” Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) Nursing action would be to fall precaution due to the drowsiness and take BP in case of hypotension. Drug #5 Generic name Acetaminophen Trade name Tylenol (PRN) Dose 500mg Route PO Frequency 1 Tab every 6 Hrs Classification Analgesics Rationale: Pain Indication: Mild pain relief Side effects: Nausea, rash, clay colored stool. Educate patient, regularly take vitals, and monitor close for serious AR. Nursing implications: Blood in the stool Allergy Trouble swallowing, SOB, and swelling in the throat and mouth. Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Patient understands why he is taking this drug. “Helps me with any pain” Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) Nursing action would be to assess stool looking for blood. Look at ALT and AST lab looking for damage to the liver. Drug #6 Generic name Lactulose Trade name Constulose Dose 10mL Route PO Frequency 1x Daily Classification Laxatives Rationale: To treat constipation Indication: Abdominal pain relief Side effects: Abdominal cramps, constipation. Educate patient, and monitor close for serious AR. Nursing implications: Depending on length of use, monitor for serious AR. Allergy Rash, trouble swallowing, SOB, and swelling in the throat. Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Patient understands why he is taking this drug. “Help with going to the bathroom.” Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) Nursing action would be to monitor electrolytes depending on length of administration due to the loss of fluid through consist bowel movement or diarrhea. AIMS Assessment To be conducted on patients receiving antipsychotic medications From http://www.dr-bob.org/tips/aims.html Examination Procedure Either before or after completing the examination procedure, observe the patient at rest The chair to be used in this examination should be a hard, firm one without arms. Ask the patient whether there is anything in his or her mouth (such as gum or candy) and, if so, to remove it. Ask about the *current* condition of the patient’s teeth. Ask if he or she wears dentures. Ask whether teeth or dentures bother the patient *now*. Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If yes, ask the patient to describe them and to indicate to what extent they *currently* bother the patient or interfere with activities. Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at the entire body for movements while the patient is in this position.) Ask the patient to sit with hands hanging unsupported — if male, between his legs, if female and wearing a dress, hanging over her knees. (Observe hands and other body areas). Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.) Do this twice. Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement.) Do this twice. Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first with right hand, then with left hand. (Observe facial and leg movements.) (Is this movement activated?) Flex and extend the patient’s left and right arms, one at a time. Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips included.) Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth.) (Is this movement activated?) Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.) Do this twice (Is this movement activated?) For the movement ratings (the first three categories below), rate the highest severity observed. 0 = none, 1 = minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. One point is subtracted if movements are seen only on activation, Facial and Oral Movements Muscles of facial expression,e.g., movements of forehead, eyebrows, periorbital area, cheeks. Include frowning, blinking, grimacing. 0 Lips and periorbital area,e.g., puckering, pouting, smacking. 0 Jaw,e.g., biting, clenching, chewing, mouth opening, lateral movement. 0 Tongue,Rate only increase in movement both in and out of mouth, not inability to sustain movement. 0 Extremity Movements Upper (arms, wrists, hands, fingers).Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements). 0 Lower (legs, knees, ankles, toes),e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot. 0 Trunk Movements Neck, shoulders, hips,e.g., rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements. 0 Global Judgments Severity of abnormal movements. 0 based on the highest single score on the above items. Incapacitation due to abnormal movements. 0 = none, normal Patient’s awareness of abnormal movements. 0 = no awareness Dental Status Current problems with teeth and/or dentures. 0 = no Does patient usually wear dentures? 0 = no Total score: 0 Patient’s condition: N/A Implications for nursing: To assess the patient on an antipsychotic for extrapyramidal effects Have you communicated significant information to the nurse in charge in a timely manner? N/A To your clinical instructor? N/A Mental Health Clinical Portfolio Grading Criteria: Mental Health CARE PLAN Student: __________________________________________________ Date: _____________ Criteria Meet Expectations Points earned Admission Data 20 20 Physical assessment findings Labs HPI Cultural and spiritual assessment Discharge plan Reflection using What, So What, Now What Model– reflects on self-awareness as documented clinical experience based on the following concepts 20 20 Thoughts and feelings about the experience Documented reflection and evaluation of what might have been learned by the experience Care Plan – Demonstrates understanding of patient-nurse interaction as evident per ADPIE charting of the following concepts 20 20 Nursing diagnosis based on priority problem Identifying the problem Assessment of patient behavior Intervention Plan of action Evaluation as response to intervention Mental Status Exam (MSE)- Demonstrates understanding of the following concepts as evident per documentation: 20 20 Mood Affect Thought Process and content Appearance Behavior Judgment Insight Orientation Memory Medication regimen – Demonstrates understanding of medication regimen as evidence of thorough medication documentation of patients psychiatric medications relative to: AIMS if applicable 20 20 Generic and trade name of medication Classification of medication Dose, route, and frequency Rationale of medication Side effects Nursing implications for the medication Patients; perspective of medication, knowledge Nurses action (teaching, noted drug-drug interaction) Total 100 100 Each PSYCHIATRIC CARE PLAN is worth 9% of your course grade. Comments: Students______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Faculty: Your care card shows a good understanding of all the components that answers to a wholistic patient care.
Fill out a mental health treatment plan template
Chamberlain University NR326 Mental Health Treatment Plan Template STUDENT’S NAME: ______________________________DATE: __________________ Admission Data (20 pts) Date of Admission: ______ How long has the client been here? __________ Last Vital Signs: T: HR: RR: BP: /___PAIN: /10 In this section describe what you SHOULD assess for- and then what you were able to see with your client. You will not get an opportunity to assess every body system in this clinical- but based on what you know about the client- what would you want to look for. General Survey-Overall body build and appearance, mood or character, activity level, hygiene HEENT Neurological Cardiovascular (including peripheral vascular) Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Pertinent laboratory values- what labs would you WANT to have and why? DSM V DIAGNOSIS: Client’s understanding of Dx: Do they know what their DSM V diagnosis is? _____________________________________________________________________________ ______________________________________________________________________________ Client’s perceived reason for admission: Chief_Complaint: __________________________________________________ Reason for Admission:________________________________________________________ Cultural Assessment:__________________________________________________________ Spiritual Assessment:____________________________________________________________ Home Assessment:_____________________________________________________________ Discharge Plan: If none on the chart ask pt & document their response. Who is involved in discharge planning? What is the role of Case Management in this setting? Are there any Complementary Medicine Practices that would benefit? What would be the optimal plan for this client if the client had unlimited resources and time? REFLECTION (20 pts) Using the “What” “So What” “Now What” Critical Reflective Model- Describe your learning today. Describe your reaction to this clinical experience. Include thoughts & feelings; demonstrate self awareness. What?​ (What happened, objectively). Without judgment or interpretation, describe in details the facts and event(s) of this experience. So What?​ ​ (What did you learn? What difference did the event make?) Discuss feelings, ideas, and analysis of this experience. Now What?​ ​(How will you think or act in the future as a result of this experience?) Describe the Milieu of the unit and did you feel it helped or hindered the clients. Describe any groups you attended? Do you feel they helped or hindered the clients? What did you find effective and what would you do differently? __________________________________________________________________________Describe the role of each Provider on the unit and what did you learn from them or about their role? RN:________________________________________________________________ Tech:_______________________________________________________________ Doctor or NP:_________________________________________________________ Social worker or Case Manager:___________________________________________ Group Leaders:________________________________________________________ Other:________________________________________________________________ CARE PLAN (20pts) Chart professionally EXACTLY as you would in the client’s record: Priority Problem:_______________________________________________________________ Situation:_____________________________________________________________________________ _____________________________________________________________________________ Background (History): Assessment (What do you see): Nursing Diagnosis ( from Ackley): _____________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Short Term Goal (by end of shift) Must be SMART _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Interventions (3 to meet this goal) Must be applicable to this client Long Term Goal (3 months) Must be SMART Interventions (3 to meet this goal) Must be applicable to this client ______________________________________________________________________________ Evaluation How will you know if these goals are met? What will you see? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Mental Status Assessment (20 pts) (Use youR MSE handout to address each area- Use medical terminology as you would in the medical record- This should paint a picture of what the client looks like) * Appearance: _________________________________________________________________ * Behavior: ____________________________________________________________________ ______________________________________________________________________________ * Speech: _____________________________________________________________________ * Mood _______________________________________________________________________ *Potential for suicide: Thought: ______________________________________________ ________________________________________________________________________ *Plan: ___________________________________________________________________ ________________________________________________________________________ *Means to carry out the plan: _________________________________________________ ________________________________________________________________________ *Intent to carry out the plan: _________________________________________________ ________________________________________________________________________ *Affect _______________________________________________________________________ *Thought process: ______________________________________________________________ ______________________________________________________________________________ *Thought content: ______________________________________________________________ ______________________________________________________________________________ *Attention and concentration: _____________________________________________________ *Orientation: __________________________________________________________________ *Memory: _____________________________________________________________________ ______________________________________________________________________________ *Judgment: ____________________________________________________________________ ______________________________________________________________________________ *Insight: _______________________________________________________________________ Comparison with admission mental status exam (Is the client the same, better, worse than admission- find the admission MSE on your chart or description in MD and Nursing notes): _____________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Client’s Current Medications (20 Pts) Name 3 medications that would require an AIMS assessment: 1. 2. 3. Define: Extrapyramidal effects: Tardive Dyskinesia: What is Benadryl used for in this population? Why is it important? How and why are Vitamins and Minerals used in the mental health client? Make as many of these cards as your client has meds. Drug #1 Generic name Trade name Dose Route Frequency Classification Rationale Indication (What should this med do for this client) Side effects (What can you do for these side effects. Nursing implications (what should you look for- ex- client may be drowsy or dizzy) What would an allergy to this med look like? Patient’s perspective of drug (name of med, reason to take, side effects, lab needed) Nursing action needed (ex Fall Precautions, take BP, draw what lab etc) AIMS Assessment To be conducted on patients receiving antipsychotic medications From http://www.dr-bob.org/tips/aims.html Examination Procedure Either before or after completing the examination procedure, observe the patient at rest The chair to be used in this examination should be a hard, firm one without arms. Ask the patient whether there is anything in his or her mouth (such as gum or candy) and, if so, to remove it. Ask about the *current* condition of the patient’s teeth. Ask if he or she wears dentures. Ask whether teeth or dentures bother the patient *now*. Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If yes, ask the patient to describe them and to indicate to what extent they *currently* bother the patient or interfere with activities. Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at the entire body for movements while the patient is in this position.) Ask the patient to sit with hands hanging unsupported — if male, between his legs, if female and wearing a dress, hanging over her knees. (Observe hands and other body areas). Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.) Do this twice. Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement.) Do this twice. Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first with right hand, then with left hand. (Observe facial and leg movements.) (Is this movement activated?) Flex and extend the patient’s left and right arms, one at a time. Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips included.) Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth.) (Is this movement activated?) Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.) Do this twice (Is this movement activated?) For the movement ratings (the first three categories below), rate the highest severity observed. 0 = none, 1 = minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. One point is subtracted if movements are seen only on activation, Facial and Oral Movements Muscles of facial expression,e.g., movements of forehead, eyebrows, periorbital area, cheeks. Include frowning, blinking, grimacing. 0 1 2 3 4 Lips and periorbital area,e.g., puckering, pouting, smacking. 0 1 2 3 4 Jaw,e.g., biting, clenching, chewing, mouth opening, lateral movement. 0 1 2 3 4 Tongue,Rate only increase in movement both in and out of mouth, not inability to sustain movement. 0 1 2 3 4 Extremity Movements Upper (arms, wrists, hands, fingers).Include movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine). Do not include tremor (repetitive, regular, rhythmic movements). 1 2 3 4 Lower (legs, knees, ankles, toes),e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot. 0 1 2 3 4 Trunk Movements Neck, shoulders, hips,e.g., rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements. 0 1 2 3 4 Global Judgments Severity of abnormal movements. 0 1 2 3 4 based on the highest single score on the above items. Incapacitation due to abnormal movements. 0 = none, normal1 = minimal2 = mild3 = moderate4 = severe Patient’s awareness of abnormal movements. 0 = no awareness1 = aware, no distress2 = aware, mild distress3 = aware, moderate distress4 = aware, severe distress Dental Status Current problems with teeth and/or dentures. 0 = no1 = yes Does patient usually wear dentures? 0 = no1 = yes Total score:_____________ Patient’s condition: Improving _______ About the same __________ Deteriorating _______ Implications for nursing: ________________________________________________________ Have you communicated significant information to the nurse in charge in a timely manner? _______________________ To your clinical instructor? ______________________________ Mental Health Clinical Portfolio Grading Criteria: Mental Health Treatment PLAN Student: __________________________________________________ Date: _____________ Criteria Meet Expectations Points earned Admission Data 20 Physical assessment findings Labs HPI Cultural and spiritual assessment Discharge plan Reflection using What, So What, Now What Model– reflects on self-awareness as documented clinical experience based on the following concepts 20 Thoughts and feelings about the experience Documented reflection and evaluation of what might have been learned by the experience Care Plan – Demonstrates understanding of patient-nurse interaction as evident per ADPIE charting of the following concepts 20 Nursing diagnosis based on priority problem Identifying the problem Assessment of patient behavior Intervention Plan of action Evaluation as response to intervention Mental Status Exam (MSE)- Demonstrates understanding of the following concepts as evident per documentation: 20 Mood Affect Thought Process and content Appearance Behavior Judgment Insight Orientation Memory Medication regimen – Demonstrates understanding of medication regimen as evidence of thorough medication documentation of patients psychiatric medications relative to: AIMS if applicable 20 Generic and trade name of medication Classification of medication Dose, route, and frequency Rationale of medication Side effects Nursing implications for the medication Patients; perspective of medication, knowledge Nurses action (teaching, noted drug-drug interaction) Total 100 Each PSYCHIATRIC CARE PLAN is worth 9% of your course grade. Comments: Students______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Faculty_______________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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