Mental Health Care Plan (Updated)
Course: NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902.

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Week: 6 Dates of Care:05/20/23

Patient Initials

F A Sex

M Age

95 Room

804 Admitting Date
05/19/23 Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Fatigue and general weakness and experiencing pain in the lower back. The patient was brought by his son because he was too weak to get out of bed.

Attending physician/Treatment team:

Ayman M Jabr

Consults:
Present Diagnosis: (Why patient is currently in the hospital)

Acute Pyelonephritis

ER Management: (if applicable)

Allergies:

No allergies
Code Status:
Full code Isolation: (type and reason)
Admission Height:

5’6 inches Admission Weight:

62kg (136 Ib 11 oz) Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)
Patient speak Spanish only and

Past Medical History: (pertinent & how managed)

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day)

Time 05/20/23 0735
T 99.2 F(37.3C)
P 85
R 18
B/P 132/78

Time 05/21/23 0755
T 98.6
P 75
R 18
B/P

GI:

Diet:
Swallow precautions:
Tube feedings:
NG / G tube:
Blood Glucose: (time & date)
Last bowel movement: (time & date)
Pertinent Labs/Test:
Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:
02 Saturation:
Suction:
Resp Rx’s:
Trach:
Chest Tubes:
Pertinent Labs/Test:
Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:
Alert & Orientated:
Follows commands:
Speech Comprehensible:
Pertinent Labs/Test:
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
Cardiovascular:

Telemetry:
Pacemaker/IAD:
DVT Prevention:
Daily Weights:
Pertinent Labs/Test:
Assessments/Interventions:
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
Musculoskeletal:

Activity:
Traction:
Casts/Slings:
Pertinent Labs/Test:
Assessments/Interventions:
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):
CBI:
Dialysis:
A/V access:
Pertinent Labs/Test:
Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:
Pertinent Labs/Test:
Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score:
Assessments/Interventions:
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural:

Assessments/Interventions:
(immediate post procedure care)

Safety:

Call light:
Bed Rails:
Bed alarms:
Fall risk:
Assistive Devices:
Sitter use:
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA:
Hospice:

Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient
WBC 11.5 4.0-11.k/mm
RBC 3.55 3.6-5.04
HGB 11.5
HCT
MCV 90.3
MCH 29.3
MCHC 32.5
Platelets 260
RDW 15.9
MPV 8.3

PT
INR
APTT

Glucose 90
BUN 24
Creatinine 1.0
Sodium 3.5
Potassium 3.8
Cloride 1.08
Calcium 7.7
T Protein 6.1
Albumin 3.4
SGOT
SGPT
Alk Phos 98
Magnesium 1.6
Amylase
Lipase

CPK
LDH 34
Cholestrol 105

CK
CK-MB
Troponin I
Myoglobin
LDI

Urinalysis
Color
Character
Spec. Grav.
pH
Protein
Glucose
Acetone
Bilirubin
Blood
Nitr
Urobili
RBC
WBC
Epithelium

Urine Culture

Chest X-ray

MRI

CT Scan

Others test:

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)
Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article.

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority Nursing Diagnosis Related to As Evidence By Rationale (reason for priority)
1 Acute Pain
Inflammation and infection of the urinary tact Report of pain/ burning discomfort when urinating The patient experienced severe pain during urination.
2 Hyperthermia
Inflammation process secondary to pyelonephritis
Increasing body temperature above the normal range The patient always has fever symptoms
3
Impaired Urinary elimination
Kidney infection and inflammation

Urinary retention
The patient experienced frequency and hesitancy urine
4

5

Medications Classification Dose Route
Freq Purpose/Mechanism of Action Significant Side Effects / Adverse Reactions Nursing Implications

Lipitor

Atorvastatin

40mg

oral

daily
Inhibits HMG -COA retake enzyme which reduces cholesterol synthesis high dose lead to plaque regression Feeling sick (nausea), Headaches, diarrhea, runny nose, sore throat, constipation

Rocephin

Ceftriaxone

1g

oral

daily
Inhibits cell wall biosynthesis by Black tarry stool. Chest pain, shortness of breath. Sore throat, Swollen glands, and weakness

Plavix

Clopidogrel

75mg

oral

daily
Headaches, dizziness Nausea, Diarrhea, constipation, nosebleeds

Vasotec

Enalapril

10mg

oral

Daily Blurred vision itching or mild rash, diarrhea, Headaches

Tylenol

Heparin

Acetaminophen

650mg

650mg

oral

6 hours
Red, peeling or blistering skin, rash , hives, itching, and difficulty breathing

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) Patient Goal(s)
Statement of purpose for the patient to achieve Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
(Must have at least two short term outcomes and two long term outcomes)
Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale. Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis) Patient Goal(s)
Statement of purpose for the patient to achieve Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
(Must have at least two short term outcomes and two long term outcomes)
Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale. Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

2/9/23, 2:46 PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 1/9
Mental Health Care Plan (Updated)
Course: NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902
Part I Criteria
Level 4
6 points
Level 3
4 points
Level 2
2 points
Level 1
0 points
Criterion Score
Demographics
and Brief
History
Demonstrates a / 6
mastery level of
understanding in
completion of
section & all of the
following areas:
– Diagnosis
extracted from
DSM-V manual.
– Provides relevant
data regarding past
medical history
(pertinent & how
managed).
– Significant events
during current
hospitalization with
times & dates.
– All sections
completed.
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– Diagnosis
extracted from
DSM-V manual.
– Provides relevant
data regarding past
medical history
(pertinent & how
managed).
– Significant events
during current
hospitalization with
times & dates.
– All sections
completed.
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– Diagnosis
extracted from
DSM-V manual.
– Provides relevant
data regarding past
medical history
(pertinent & how
managed).
– Significant events
during current
hospitalization with
times & dates.
– All sections
completed.
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– Diagnosis
extracted from
DSM-V manual.
– Provides relevant
data regarding past
medical history
(pertinent & how
managed).
– Significant events
during current
hospitalization with
times & dates.
– All sections
completed.
2/9/23, 2:46 PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 2/9
Part I Criteria
Level 4
6 points
Level 3
4 points
Level 2
2 points
Level 1
0 points
Criterion Score
Physical
Assessments
and
Interventions
/ 6
Psychosocial
Assessment
/ 6
Demonstrates a
mastery level of
understanding in
completion of
section & all of the
following areas:
– Vital Signs, 2 sets.
– General
appearance & ADLs.
– Review of systems,
each area
documented fully.
– Lab values.
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– Vital Signs, 2 sets.
– General
appearance & ADLs.
– Review of systems,
each area
documented fully.
– Lab values.
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– Vital Signs, 2 sets.
– General
appearance & ADLs.
– Review of systems,
each area
documented fully.
– Lab values.
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– Vital Signs, 2 sets.
– General
appearance & ADLs.
– Review of systems,
each area
documented fully.
– Lab values.
Demonstrates a
mastery level of
understanding in
completion of
section & all of the
following areas:
– General
information
(1
st section).
– Stages of
development.
– Support system.
– Stressors/stress
management
practices.
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– General
information
(1
st section).
– Stages of
development.
– Support system.
– Stressors/stress
management
practices.
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– General
information
(1
st section).
– Stages of
development.
– Support system.
– Stressors/stress
management
practices.
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– General
information
(1
st section).
– Stages of
development.
– Support system.
– Stressors/stress
management
practices.
2/9/23, 2:46 PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 3/9
Part I Criteria
Level 4
6 points
Level 3
4 points
Level 2
2 points
Level 1
0 points
Criterion Score
Pathophysical
Discussion
Demonstrates a / 6
mastery level of
understanding in
completion of
section & all of the
following areas:
– Discussion of the
current disease
process.
– Discussion of the
etiology of the
patient’s illness.
– Complications that
may occur with
treatment & the
patient’s overall
prognosis.
– Summary of article
written using APA
format.
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– Discussion of the
current disease
process.
– Discussion of the
etiology of the
patient’s illness.
– Complications that
may occur with
treatment & the
patient’s overall
prognosis.
– Summary of article
written using APA
format.
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– Discussion of the
current disease
process.
– Discussion of the
etiology of the
patient’s illness.
– Complications that
may occur with
treatment & the
patient’s overall
prognosis.
– Summary of article
written using APA
format.
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– Discussion of the
current disease
process.
– Discussion of the
etiology of the
patient’s illness.
– Complications that
may occur with
treatment & the
patient’s overall
prognosis.
– Summary of article
written using APA
format.
2/9/23, 2:46 PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 4/9
Part I Criteria
Level 4
6 points
Level 3
4 points
Level 2
2 points
Level 1
0 points
Criterion Score
Medications
Demonstrates a / 6
mastery level of
understanding in
completion of
section & all of the
following areas:
– Medications
– Classification
– Dose
– Route
– Frequency

Purpose/Mechanis
m of Action
– Side Effects
– Nursing
Implications
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– Medications
– Classification
– Dose
– Route
– Frequency

Purpose/Mechanis
m of Action
– Side Effects
– Nursing
Implications
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– Medications
– Classification
– Dose
– Route
– Frequency

Purpose/Mechanis
m of Action
– Side Effects
– Nursing
Implications
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– Medications
– Classification
– Dose
– Route
– Frequency

Purpose/Mechanis
m of Action
– Side Effects
– Nursing
Implications
Part II Criteria
Level 3
3 points
Level 2
2 points
Level 1
1 point
Level 0
0 points
Criterion Score
2/9/23, 2:46 PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761 5/9
Part II Criteria
Level 3
3 points
Level 2
2 points
Level 1
1 point
Level 0
0 points
Criterion Score
Nursing
Diagnosis
/ 3
Table 1
Assessment
/ 3
Demonstrates a
mastery level of
understanding in
completion of
section & all of the
following areas:
– List of nursing
diagnoses.
– Related to . . .
– As Evidenced by . .
.
– Rationale (reason
for priority).
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– List of nursing
diagnoses.
– Related to . . .
– As Evidenced by . .
.
– Rationale (reason
for priority).
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– List of nursing
diagnoses.
– Related to . . .
– As Evidenced by . .
.
– Rationale (reason
for priority).
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– List of nursing
diagnoses.
– Related to . . .
– As Evidenced by . .
.
– Rationale (reason
for priority).
Demonstrates a
mastery level of
understanding in
completion of
section & all of the
following areas:
– Signs &
Symptoms:
a. 2 objective.
b. 2 subjective.
Demonstrates a
satisfactory level of
understanding in
completion of
section &/or is
deficient in 1 of the
following areas:
– Signs &
Symptoms:
a. 2 objective.
b. 2 subjective.
Demonstrates a
basic level of
understanding in
completion of
section &/or is
deficient in 2 of the
following areas:
– Signs &
Symptoms:
a. 2 objective.
b. 2 subjective.
Does not
demonstrate
understanding in
completion of
section &/or is
deficient in 3 or
more of the
following areas:
– Signs &
Symptoms:
a. 2 objective.
b. 2 subjective.
2/9/23, 2:46 PM Week 6: MH Care Plan – NUR4020-01:Nursing Care of Mental Health Patients (2023 Spring Term 1)-15902 – Resurrection University
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=44247&grpid=0&isprv=0&bp=0&ou=19761
52 points minimum
Level 3
47 points minimum
Level 2
42 points minimum
Level 1
37 points minimum

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