Care Plans

Keely-FutureRN · Mar 23, 2006

Thunderwolf had some really great suggestions in the thread "Advice for any new Psych. RN's." I copied and pasted it here from the other thread...

"I would recommend becoming more familiar with the psych terms used in psych assessment...as well as become more acquainted with how to perform a mental status exam. There is literature out there to help you. Go to the book store and buy a nursing psych book which should have most of this to get you started. A good psych drug book would be good if you do not have one.

Mental assessment breakdown/reporting is similarly done as in nonpsych (systems approach).

Affect, Mood, Attention, Concentration, Interaction, Interest, Eye Contact, Energy, Impulse Control, Thought Processes, Perception, Presence of Hallucinations/Distortions/Paranoia/Suicidal or Homicidal thoughts, plan, intent, Appearance, Sleep, Appetite, Problems with meds (side effects)...etc etc. Create your own report cheat sheet to help organize what you need to convey.

Other info which is often relevant is:

Admit status, If a Guardian is involved and who is it, Concerns regarding discharge, Specific monitoring and/or interventions for THAT patient, and Pertinent Labs.

In report, most nurses only want to hear the abnormals, important mental status changes in condition, and response to recent treatment/intervention. Explore this with your peers. It does take a little organization on your part when you initially start. What most nurses do not wish to hear is a report that drones on and on and/or goes off in tangents. Like nonpsych nursing reports, make your psych reporting objective. It will help you stay focused and on track."

I have also seen nursing care plans at barnes and noble and other book stores so check them out. :idea:

Keely

seisen · Mar 24, 2006

Hi Keely,

Thanks for your reply, you have provided me with lots to think about!

Thanks

Steve