NRS 475



Clinical Assignment Packet for Mental Health Nursing

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Contents:

Clinical Limitations

Medication Knowledge Base

Required Assignments

Clinical Reflective Journal

Therapeutic Communication Definitions

Mental Status Exam

Mental Health Nursing Assessment

Medication Preparation Log (MPL)

Interaction Process Recording (IPR) Instructions

IPR Cover Sheet, Analysis and Evaluation

Nursing Care Plan Forms

**Please note that additional care plan information/forms are available as a separate document on the LRC website.

Limitations to Clinical Practice

During this clinical rotation, students may, with preceptors’ consent and supervision, assume responsibility for all the nursing activities within the preceptors’ roles. The following are exceptions to this rule.

Students may not do the following:

1. Witness any consent forms or advance directive forms.

2. Administer any medications in the mental health setting.

3. Perform any task that requires certification or advanced instruction (i.e., arterial blood gas (ABG) puncture, chemotherapy, removal of central venous catheter, interpretation/monitoring of EKGs).

4. Take physician orders either verbally or by phone.

5. Transcribe physician orders.

6. Initiate invasive monitoring.

7. Regulated epidural analgesia.

8. Remove epidural catheters.

9. Remove surgically inserted drains and/or tubes (e.g. Jackson-Pratt drains, Hemovac drains) without direct supervision by a Registered Nurse.

10. Solely monitor patient during and following conscious sedation.

11. Witness wasting or the sign out controlled medications in Accudose, Pyxis or Meditrol medication delivery systems.

12. Perform end of shift controlled medication count (if applicable).

13. Have controlled medication keys in their possession (if applicable).

14. Verify blood products and/or witness blood administration forms.

15. Perform any invasive procedure on each other in any setting (i.e., injections, catheterization, IV starts).

16. Perform any task during a code situation, except those skills learned in BLS.

17. Interventions that the facility restricts the student from performing.

18. Any skill/procedure that has not been covered in a nursing lab.

19. Any task outside the RN scope of practice as identified by facility.

Any questions regarding specific procedures or responsibilities should be directed to the Denver School of Nursing faculty. Students are expected to maintain standards of care of the facility and function within the scope of their knowledge, skills, and abilities.

Medication Knowledge Base

• Drug required knowledge is mandatory for each medication prescribed for each assigned patient. Students will not be administering medications to patients in this clinical experience.

• If you can memorize and retain information without writing it down, you may do this, but you may not pass medications without this knowledge at hand – use of reference materials at the cart side or at the PYXIS is time prohibitive and must be a rare back-up system.

• Student must be prepared to recite required knowledge base (as outlined below) at med-cart or PYXIS as requested by instructor.

• Using a drug knowledge tool is useful in review for future clinical rotations and for NCLEX review and to prepare for different patients.

• Medication knowledge base MUST include the MINIMAL information as reflected on the following page-Medication Preparation Log (MPL)

• ‘Must know’ could be ‘Take pulse’ for drugs affecting heart rate or rhythm, ‘Take BP’ for drugs affecting BP, ‘Check K+’ before administering potassium supplements, ‘Check BG’ for insulin or other drugs affecting BG, etc.

Required Assignments

ADN:

• 1 Complete Mental Health Nursing Assessment, including the Medication Preparation Log

• 2 Interpersonal Process Recordings (IPR)

• 1 Nursing care plan with at least one nursing diagnosis

• Weekly journaling, per instructor preference

• Students MUST do Reflective Logs in evaluation packets

BSN:

• 2 Complete Mental Health Nursing Assessments, including the Medication Preparation Logs

• 2 Interpersonal Process Recordings (IPR)

• 1 Nursing care plan with at least two nursing diagnoses

• Weekly journaling, per instructor preference

• Students MUST do Reflective Logs in evaluation packets

Clinical Reflective Journal – Optional

Personal Journal:

Students will submit a daily journal to their clinical supervisor on the clinical day designated by the clinical supervisor. A sheet of single paper or a non-spiral notebook may be used.

This is a tool designed for a personal inner journey rather than a reporting of what you have observed or done. It is a journal of your thoughts and feelings about your clinical experiences.

This is confidential between your instructor and you and you may receive feedback. It is hoped that the reflections and insight one develops as a result of the journal will foster personal and professional growth.

Suggestions for beginning journal:

1 – What was the high point of my day? Low point?

2 – Was I in disagreement with anyone? How did I handle it?

3 – What changes did I make in my thinking or behavior?

4 – How could I improve my day?

5 – What has been on my mind today?

6 – What are two choices I made today?

7 – What did I procrastinate on today?

8 – What feelings did I identify today?

9 – Say one positive thing about yourself for today.

10 – What happened to me was…………………..

11 – What this means to me is……………………

12 – For the first time I now understand………..

13 – I still question………………………………..

14 – Other

Journal Goals: Students are expected to submit 2 personal daily goals in their journal. Goals should be evaluated in writing at the conclusion of the day prior to submitting the journal on the following day.

Therapeutic Communication Definitions

Communication: Transaction between sender and receiver

Non-verbal: Physical appearance/dress, body movement & posture, touch, facial expressions, eye movements, vocal cues

Therapeutic Communication Techniques

Silence: give time to collect thoughts, consider other concerns

Accepting: conveys attitude of reception and regard

Giving Recognition: acknowledge and indicate awareness (commend strengths)

Offering Self: making one’s self available on unconditional basis (increases self-worth)

Broad Openings: allows client initiative to introduce topic of concern (client role)

Offer General Leads: offers client the encouragement to continue

Placing the Event in Time or Sequence: clarifies event in time perspective

Making Observations: verbalizing what is observed or perceived (client behavior)

Encouraging Perception Description: ask client to verbalize what perceived-hallucination

Encourage Comparison: ask client to compare similarity and difference-reoccur/change

Restate: repeat main idea of what client said (client can clarify or continue on)

Reflect: questions and feelings referred back to client to recognize/accept own view

Focusing: taking notice of a single idea or word (don’t use if client is anxious)

Exploring: delve further into subject (helpful if client tends to be superficial in communication)

Seek Clarification/Validation: strive to explain the vague or incomprehensible

Present Reality: when client has misperception, nurse indicates perception of situation

Voicing Doubt: expressing uncertainty of reality of client’s perception (delusions)

Verbalizing the Implied: put into words what client has implied or said indirectly

Attempt to Translate Words into Feelings: find clues to feelings expressed indirectly

Formulate Plan of Action: when client has a plan of action for stressful situation, it may prevent anger or anxiety form escalating into unmanageable level

Active Listening: sit facing client, open posture, lean forward, eye contact, relax

Feedback: descriptive of behavior, specific rather than general, directed toward what can be changed, impart information not advice, well-timed (early after behavior)

Non-Therapeutic Communication Techniques (Blocks)

Giving reassurance Rejecting Giving approval/disapproval Agreeing/disagreeing

Giving advice Probing Requesting an Explanation Defending

Using Denial Interpreting Stereotype Comments Belittling Feelings

Indicating Existence of an External Power Introducing an Unrelated Topic

MENTAL STATUS EXAMINATION

The mental status examination is a process wherein a clinician systematically examines an individual’s mental functioning. Each area of function is considered separately.

Appearance: This category covers the physical aspects of the individuals. Include: Physical appearance, height and weight, how person is dressed and groomed, dominant attitude during interview, such as degree of poise or comfort, degree of anxiety, and how anxiety is expressed.

Behavior: How does the person move and the position in which he/she holds body. Note

abnormal tics, movement disorders, and degree of movement.

Speech: Separate speech from content of thought. Note volume, rate of flow of speech

(fast, slow, halting, extremely loud). Include mannerisms, accent, stress or lack of it, hesitations, stuttering. Use descriptive words like garrulous, monotonous, loud or emotional.

Mood/Affect: Affect is the outward show of emotion. Can vary thru depression, elation, anger, and normality, but if the overall sense from the examination is depressed, depressed is the word to describe the mood. Mood is the general pervasive emotional state as reported by client. Range describes if the person shows a full or even expanded range or if the affect is blunted or restricted. Include cultural considerations. Consider appropriateness of affect – is the emotion consistent with the topic being discussed. A client with inappropriate affect may cry when talking about a parking ticket and show little or no emotion when discussing the death of a loved one.

Thought: Thought is divided into process, the way a person thinks, and content. What he/she thinks.

Process: The rate of thoughts, how they flow and are connected. A formal thought disorder comprises processes such as pressured thoughts, (excessively rapid), flight of ideas, thought blocking (speech is halted), disconnected thoughts (loosening of association, derailment), tangentiality, circumstantial thoughts (over inclusive and slow to get to the point), word salad (nonsensical responses), punning (talking in riddles), poverty of speech (limited content).

Content: Includes those things discussed in the interview and the person’s beliefs. May have preoccupying thoughts – ideas of reference, obsessions, ruminations or phobias. The person may have delusions of control, thought insertion, broadcast, or delusions – persecutory, grandiose, religious, reference, somatic, morbid jealousy. For example, a depressed person may have delusions of hopelessness, helplessness or worthlessness.

Perceptions: Covers sensory areas and describes distortions such as illusions, delusions or hallucinations. Describe the nature of the experience in detail. Auditory hallucinations (hearing voices) is more common in schizophrenics, visual disturbances are more common in organic problems. In addition, there are gustatory, olfactory, tactile, somatic, and kinesthetic hallucinations. Depersonalization (the person feels unreal) are described here.

Ask “do you hear voices when no one else is around?” “Do you see things such as ghosts, spirits, or angels?” Ask if the voices are commanding the person to do anything, particularly homicidal or suicidal acts. Hallucinations can be in the form of a running commentary. If the voices command a person to do something, does the person obey the instructions or ignore them. Sometimes hallucinations are not well-formed voices or objects – persons may hear bells ringing, knocking at the door, banging sounds in his ears, or see vague things like halos or colors which are difficult to describe.

Note how persons cope with the hallucinations and whether they are pleasant, unpleasant or terrifying. Comment on the hallucinatory behavior, such as person looking back repeatedly, gesturing or engaged in self-talk. To determine if the person is having delusions, ask do you feel you have some special power or abilities? Does the radio or TV give them special messages? Does the person have thoughts that other people think are strange?

Obsessions and compulsions: Is the person afraid of dirt? Does he wash his hands frequently or wash hands repeatedly.

Phobias: Does the person have any fear, such as animals, heights, snakes, crowds, etc.

Preoccupations: Ask about ideas about the person’s body: He may believe he is changing or has changed, that his elimination functions, sexual functions, or digestive functions work in different or bizarre ways.

Cognition: Look at areas of abstract thought which declines or is absent in a number of conditions such as schizophrenia or dementia, level of general education and intelligence, degree of concentration.

Consciousness: Level of conscious state is assessed, whether it is steady, fluctuating, cloudy, or

clear. Rate: 1=coma 2=stuporous 3=lethargic/evidence of drowsiness 4=alert.

Orientation: Ask if the person knows the time and date, place, person (who he/she is), and the situation the person is in.

Memory: Memory is tested by looking for immediate recall. Give the client 3 unrelated words (yellow, fox, Chicago) and ask him to repeat them. In 5 minutes ask the person to repeat them again. Do not tell the person that you will ask them to repeat them in 5 minutes. (You need to write

them down so you remember.)

Recent recall: What did the person eat two meals ago?

Remote memory: When and where was the person born? Where did he go to

high school?

Confabulation: Filling in memory lapses by guessing or making up events.

Persons may do this if they cannot remember – if this occurs, just note it. You might have to check information with outside sources for verification. You can test for confabulation by asking if the person has seen you before – the person who confabulates may fabricate details of a meeting which did not take place.

Concentration and Attention:

May be impaired for a variety of reasons: cognitive disorder, anxiety, depression,

internal stimuli. Ask the person to subtract 7 from 100 and keep subtracting 7 from the answer (serial 7s). Average time to complete is 90 seconds. Note the person’s response to the task: irritability, frequent hesitation, or questioning. Four or more errors is considered marginal; 7 or more indicates a poor performance. If the person cannot begin the task, start at 50 and subtract 3s. If he is unable to do that, have him count backward from 10. He is not to use paper to complete the task.

Others: Dreams: Are there dreams, how often, how vivid, any repetitive dreams,

nightmares? What is the content of dreams.

Déjà vu: Sensation of having been in situations similar to the present one.

Presence of suicidal/homicidal thoughts. Must inquire about specific plans,

suicide notes, impulse control. If positive, will he contract for safety?

Ask if person has any thoughts of wanting to hurt anyone, wishing someone was dead? If yes, ask about specific plans.

Intellectual Functioning:

General knowledge: Who is the President, name 5 last presidents.

What is happening in the world? (war, economy). Name 5 major

US cities. If you go to McDonalds and buy 2 hamburgers for 70 cents

each and pay $2, how much change will you get back? Or, how much

is a quarter, dime, nickel and penny?

Math calculations: Ask basic math problems: 4+6 or 13-8.

Complex: Add 14+17.

Ability to abstract:

Determine similarities

• How are an orange and a pear alike?

Good answer = fruit, Poor answer = round.

• How are a fly and a tree alike?

Good answer = alive, Poor answer = nothing

• How are a train and car alike?

Good answer = modes of transportation, Poor answer = they both have wheels

Proverbs

• Ask “what does it mean to say: Don’t count your chickens before they are hatched? Good answer = Don’t plan on future gains before they happen. Poor answer = chickens are little.

Judgment and Insight:

Evaluate judgment with person’s response to: “What would you do if you were in a crowded theatre and smelled smoke?”

“What would you do if you found an addressed, stamped envelope lying in the street?”

Insight: How does the person perceive his present problem? “How did things come to be this way?

Mental Health Nursing Assessment

Student’s Name: __________________________________ Date: ____________________________

I. Client Assessment

A. Client’s Demographic Data

Client’s initials: _____ Client’s Age: ____ Client location/room: ___________________

Admit date: ________ Gender: ________ Marital Status: _______ Children: ________

Career: ___________________ Last worked: ___________ Education: _____________

Cultural background: ________________________ Primary language: ______________

Spiritual belief/Religion: ___________________________________________________

Legal status: _____________ Privileges: _______________ Precautions: ____________

Living arrangements: ________________________ ADLs: _______________________

Family/community supports: ________________________________________________

Erikson’s developmental stage: ______________________________________________

B. DSM-IV-TR Admitting Diagnoses

Axis I- (Admitting psychiatric disorder(s)): ____________________________________

Axis II- (Personality disorder(s) or DD: _______________________________________

Axis III- (General medical diagnoses): ________________________________________

Axis IV- (Psychosocial/environmental factors): _________________________________

Axis V- (GAF Score):______________________________________________________

C. Psychopathology Leading to Current Admission

(Behavior, thought processes, dysfunction, crisis event, and past history or mental illness or addictions)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

D. Contributing History or Events (i.e., social, cultural, family, etc.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. Discharge Plan

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

II. Mental Status Exam Flow Sheet

A. Identifying Data

Client initials: ____________ Living arrangements: ________________________

Gender: _________________ Religious preference: ________________________

Age: ____________________ Allergies: _________________________________

Race/Culture: _____________ Special diet: _______________________________

Occupation: _______________ Chief complaints: ___________________________

Significant Other: __________ Medical diagnoses: __________________________

B. General Description

1. Appearance

Grooming/dress: _________________ Hair color/texture: ______________

Hygiene: _______________________ Scars/tattoos: __________________

Posture: ________________________ Appears age?: __________________

Height/weight: ___________________ Level of eye contact: ____________

2. Motor activity

Tremors: ________________________ Rigidity: ______________________

Tics/movements: __________________ Gait: _________________________

Mannerisms: _____________________ Echopraxia: ___________________

Restlessness: _____________________ Psychomotor retardation: _________

Aggressiveness: ___________________ Range of motion: _______________

3. Speech patterns

Slow or rapid pattern: _______________ Volume: ______________________

Pressured speech: __________________ Speech impediment: _____________

Intonation: _______________________ Aphasia: ______________________

4. General attitude

Cooperative/uncooperative: ___________ Interest/apathy: _________________

Friendly/hostile/defensive: ____________ Guarded/suspicious: _____________

C. Emotions

1. Mood

Sad: ___________ Depressed: _____________ Despairing: ____________________

Irritable: ________ Anxious: ______________ Elated: _______________________

Euphoric: _______ Fearful: _______________ Guilty: _______________________

Labile: __________

2. Affect

Congruence with mood: ____________________________________________________

Constricted or blunted: _____________________________________________________

Flat: ____________________________________________________________________

Appropriate or inappropriate: ________________________________________________

D. Thought Processes

1. Form of thought

Flight of ideas: __________________________ Associative looseness: ______________

Circumstantiality: ________________________ Tangentiality: ____________________

Neologisms: ____________________________ Concrete thinking: ________________

Clang associations: _______________________ Word salad: _____________________

Perseveration: ___________________________ Able to concentrate: _______________

Echolalia: ______________________________ Mutism: _________________________

Poverty of Speech: _______________________ Attention span: ___________________

2. Content of thought

Delsusions: persecutory: __________ Grandiose: __________ Reference: _________

Control: _____________ Somatic: ____________ Nihilistic: _________

Suicidal/homicidal ideas: ___________________________________________________

Obsessions: _____________________________________________________________

Paranoia/suspiciousness: ___________________________________________________

Magical thinking: _________________________________________________________

Religiosity: ______________________________________________________________

Phobias: ________________________________________________________________

Poverty of content: ________________________________________________________

E. Perceptual Disturbances

Hallucinations: Auditory: __________________ Visual: ____________________

Tactile: ____________________ Olfactory: _________________

Gustatory: __________________

Illusions:

Depersonalization: ________________________________________________________

Derealization: ____________________________________________________________

F. Sensory and Cognitive Ability

Level of alertness/consciousness

Orientation: Memory:

Time: ____________________________ Recent: _____________________________

Place: ____________________________ Remote: ____________________________

Person: ___________________________ Confabulation: _______________________

Circumstances: _____________________ Capacity/abstract thought: ______________

G. Impulse Control

Ability to control impulses related to the following:

Aggression: ________________________ Guilt: ______________________________

Hostility: __________________________ Affection: ___________________________

Fear: ______________________________ Sexual feelings: ______________________

H. Judgment and Insight

Ability to solve problems

Ability to make decisions

Knowledge about self: awareness of limitations, awareness of consequences of actions, awareness of illness

Adaptive/maladaptive use of coping strategies and ego defense mechanisms.

Laboratory Data

Students MAY NOT use the term WNL or chart by exception on this form.

|Write normal value range, exact value for patient, and indicate if this is normal, high, or low. |

|Sodium |White Blood Cells |

|Potassium |Red Blood Cells |

|Chloride |Hemoglobin |

|Glucose |Hematocrit |

|Blood Urea Nitrogen |Total Bilirubin |

|Creatinine |AST |

|Calcium |ALT |

|Magnesium |Alkaline Phosphatase |

|Phosphorous |Lithium/Depakote/Tegretol Level |

|Total Protein |TSH |

|Albumin |UA |

|Pre-Albumin |Drug Toxicology |

|Cortisol Level | |

|What information can you obtain from these lab values? Why is this information important for this specific patient? |

|Pathophysiology: Briefly summarize significant psychiatric/mental health problems, linking to medical co-morbidities as applicable. |

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Medication Preparation Log (MPL)

Student Name: _______________________________________

Clinical Rotation Date: ___________________________

|Patient Identifier: |Diagnosis: |

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|Code Status: | |

| |Relevant Medical/Surgical History: |

|Allergies: | |

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|Drug (Generic/Trade) |Pt. Dose/ Normal Range |Route |Frequency |Classification |Reason pt. receiving RX |

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IPR Analysis

|Student Verbal |Student |Identify communication technique used. (T |Client Verbal |Client Non-Verbal |Analysis of client thoughts, |

|Communication |Non-Verbal |or NT) |Communication |Communication |feelings and responses. |

|(Minimum 15 statements) |Communication |Analysis of student thoughts, feelings and | | |Anxiety level |

| | |responses. | | |Defense mechanisms if present (2). |

| | |Alternative statements (2). | | | |

| | |(i.e. What could I have said?) | | | |

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IPR Evaluation

Evaluation of interaction goals. Were they met? If so, how? If not, why not?

A. Client-centered goal:

B. Student-centered goal:

2. Student’s communication pattern or style:

3. Student’s thoughts and feelings after the interaction:

Scoring Rubric for MH IPR and Care Plan

|Student Name: |Date: |Grade: |

Below are the criteria that will be used to grade this assignment. A minimum grade of 78% for a rating of “pass” is required. Students receiving less that

78% must rewrite the assignment before the end of the clinical rotation. If second submission is scored less than 78%, the student will be referred to the Director of Clinical Placement who will decide whether to uphold the failing grade or to recommend care plan remediation. Paperwork submitted late will be marked down 5% for each day it is late.

|Patient Profile Database Form |10 pts |8 pts |6 pts |4 pts |Total |

| |Above average |Average |Below average |Unacceptable |Score |

|Laboratory Data |All lab data is recorded |All lab data is recorded |Lab data is recorded |No lab data recorded. | |

|Includes current lab results and their significance |All labs are correlated to patient’s |Some labs are correlated to |Lab data not correlated to |< 50% of medication log | |

|for this patient |medical condition |patient’s medical condition |patient’s medical condition |completed appropriately. | |

| |100% of medications are listed with each |75% of medication log completed |50% of medication log completed | | |

|Medication Prep. Log |area of log completed appropriately |appropriately. |appropriately | | |

|Properly completed including reason taking medication,| | | | | |

|side effects and important nursing implications. | | | | | |

|Nursing Care Plan |10 pts |8 pts |6 pts |4 pts |Total |

| |Above average |Average |Below average |Unacceptable |Score |

|Diagnoses |Appropriate for patient’s medical|Appropriate for patient’s medical |Not appropriate for patient’s medical |Diagnosis portion is | |

|Includes 3 of the most appropriate diagnoses for |condition |condition |condition and/or |incomplete. | |

|patient (2 medical; 1 psychosocial). NANDA-approved. |Supported by assessment data |Supported by assessment data |Not supported by assessment data | | |

|Are written in correct format: PES (for actual |NANDA approved |NANDA approved |Not NANDA approved and/or formatted | | |

|diagnosis); PE (for potential or “at risk” |Formatted correctly |Not formatted correctly |correctly | | |

|diagnosis); P (for wellness diagnosis) | | | | | |

|Plan – Goal Statements |100% of goal statements fit the |75% of goal statements fit the nursing|50% of goal statements fit the nursing |< 50% of goal | |

|Includes 2 appropriate statements for each nursing |nursing diagnoses |diagnoses |diagnoses |statements fit the | |

|diagnosis which are patient centered & written in |Patient centered |Patient centered |May not be patient centered and |diagnoses | |

|SMART (specific, measurable, attainable, realistic, &|Written in SMART format |Written in SMART format |May not be written in SMART format | | |

|time-specific) format. | | | | | |

|Implementation – Interventions with Rationale: |3 interventions are listed |3 interventions are listed |< 3 interventions are listed |Interventions section | |

|Includes three (3) interventions that directly relate|Specific |May not be specific |Not congruent with goals |is incomplete. | |

|to each goal, are specific (who, what, when, how |Include a referenced rationale |May not include a referenced rationale |Not specific and/or do not have a | | |

|much, how often) and include a referenced rationale |with page number (s) |with page number (s) |referenced rationale | | |

|with page number (s). | | | | | |

|Evaluation: |Contains data that directly |Contains data that directly reflects |Does not contain data that directly |Evaluation section is | |

|Includes data that directly reflect goal statements. |reflects goal statements |goal statements |reflects goal statements |incomplete. | |

|State if goal has been met, partially met, or not |Describes goal as met, partially |Does not describe goal as met, |May also not describe goal as met, | | |

|met. If goal was not met or partially met, note |met, not met. |partially met, or not met |partially met, or not met | | |

|whether plan of care will be continued or modified |If goal partially met or not met,|May also not include revision or new |May also not include revision or new | | |

|and set new date/time for evaluation. |notes whether POC will be revised|evaluation date/time |evaluation date/time | | |

| |and set new eval. date/time | | | | |

|IPR |10 pts |8 pts |6 pts |4 pts |Total |

| |Above average |Average |Below average |Unacceptable |Score |

|Student analysis: type of therapeutic techniques (T |100% complete analysis of |75% complete analysis of therapeutic |50% complete analysis of |< 50% complete analysis of | |

|or NT), student rational and alternative responses to|therapeutic techniques, rationale|techniques, rationale and alternatives.|therapeutic techniques, rationale |therapeutic techniques, | |

|(N) techniques noted. |and alternatives. | |and alternatives. |rationale and alternatives. | |

|Client analysis: analysis of client’s thoughts, |100% complete analysis of |75% complete analysis of client’s |50% complete analysis of client’s |< 50% complete analysis of | |

|feelings and responses noted. Client’s anxiety level |client’s thoughts, feelings and |thoughts, feelings and responses. |thoughts, feelings and responses. |client’s thoughts, feelings | |

|and defense mechanisms noted. |responses. |Anxiety level noted. |Anxiety level may not be noted. |and responses. | |

| |Anxiety level noted. |Defense mechanisms noted. |Defense mechanisms may not be |Anxiety level not noted. | |

| |Defense mechanisms noted. | |noted. |Defense mechanisms not noted. | |

Section 1 Score ________

Section 2 Score + ________

Section 3 Score + ________

Deduction - ________ (if applicable)

Final Score = ________

|Point Conversion Table: 10 Graded Criteria (100 Maximum Points) |

|100 |100% |Pass |

|95 |95% |Pass |

|90 |90% |Pass |

|85 |85% |Pass |

|80 |80% |Pass |

|78 |78% |Pass |

|77 |77% |Fail |

|75 |75% | Fail |

Nursing Care Plan Form

Student Name: Date:

Patient Identifier: Patient Mental Health/Medical Diagnosis:

|Nursing Diagnosis (use PES/PE |Goals & Outcome |Nursing Interventions |Rationale |Outcome Evaluation & Replanning |

|format):Assessment Data |(Two statements are required for each |(List at least three nursing or |(Provide reason why intervention is |(Was goal met? How would you revise the |

|(Include at least three-five subjective |nursing diagnosis. Must be Patient |collaborative interventions with |indicated/therapeutic; provide |plan of care according the patient’s |

|and/or objective pieces of data that lead|and/or family focused; measurable; |rationale for each goal & outcome.) |references.) |response to current plan ?) |

|to the nursing diagnosis) |time-specific; and reasonable.) | | | |

|1. |Statement #1 |1. |1. |Outcome #1 |

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| |Statement #2 |1. |1. |Outcome #2 |

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Nursing Care Plan Form

Student Name: Date:

Patient Identifier: Patient Mental Health/Medical Diagnosis:

Nursing Diagnosis (use PES/PE format):

|Assessment Data |Goals & Outcome |Nursing Interventions |Rationale |Outcome Evaluation & Replanning |

|(Include at least three-five subjective |(Two statements are required for each |(List at least three nursing or |(Provide reason why intervention is |(Was goal met? How would you revise the |

|and/or objective pieces of data that lead|nursing diagnosis. Must be Patient |collaborative interventions with |indicated/therapeutic; provide |plan of care according the patient’s |

|to the nursing diagnosis) |and/or family focused; measurable; |rationale for each goal & outcome.) |references.) |response to current plan ?) |

| |time-specific; and reasonable.) | | | |

|1. |Statement #1 |1. |1. |Outcome #1 |

| | | | | |

| | |2. |2. | |

|2. | | | | |

| | |3. |3. | |

| | | | | |

|3. | | | | |

| | | | | |

| | | | | |

|4. | | | | |

| | | | | |

| | | | | |

| |Statement #2 |1. |1. |Outcome #2 |

| | | | | |

| | |2. |2. | |

| | | | | |

| | |3. |3. | |

| | | | | |

Nursing Care Plan Form

Student Name: Date:

Patient Identifier: Patient Mental Health/Medical Diagnosis:

Nursing Diagnosis (use PES/PE format):

|Assessment Data |Goals & Outcome |Nursing Interventions |Rationale |Outcome Evaluation & Replanning |

|(Include at least three-five subjective |(Two statements are required for each |(List at least three nursing or |(Provide reason why intervention is |(Was goal met? How would you revise the |

|and/or objective pieces of data that lead|nursing diagnosis. Must be Patient |collaborative interventions with |indicated/therapeutic; provide |plan of care according the patient’s |

|to the nursing diagnosis) |and/or family focused; measurable; |rationale for each goal & outcome.) |references.) |response to current plan ?) |

| |time-specific; and reasonable.) | | | |

|1. |Statement #1 |1. |1. |Outcome #1 |

| | | | | |

| | |2. |2. | |

|2. | | | | |

| | |3. |3. | |

| | | | | |

|3. | | | | |

| | | | | |

| | | | | |

|4. | | | | |

| | | | | |

| | | | | |

| |Statement #2 |1. |1. |Outcome #2 |

| | | | | |

| | |2. |2. | |

| | | | | |

| | |3. |3. | |

| | | | | |

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Score: _____ (Maximum Section Score = 20 points)

Comments:

Score: ______ (Maximum Section Score = 50 points)

Comments:

Score: ______ (Maximum Section Score = 30 points)

Comments:

Instructions: Add section scores together, and deduct for late paperwork, if applicable. This will give you a Final Score. Then, refer to the Point Conversion Table below to identify the student’s percentage points and letter grade. Place the final letter grade in the identified location on page one.

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