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:

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, normal
1 = minimal
2 = mild
3 = moderate
4 = severe

Patient's awareness of abnormal movements.

0 = no awareness
1 = aware, no distress
2 = aware, mild distress
3 = aware, moderate distress
4 = aware, severe distress

Dental Status

Current problems with teeth and/or dentures.

0 = no
1 = yes

Does patient usually wear dentures?

0 = no
1 = 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_______________________________________________________________________