Client Assessment & Nursing Care Plan
Learning Objectives: Nursing Process, critical thinking, analysis of data, communication
Overview
The ability to assess the client in the clinical setting is an essential skill for the psychiatric nurse.
The Nursing Assessment/Care Plan assignment is intended to be a comprehensive learning experience
that synthesizes essential psychiatric and medical/surgical nursing theory. Your finished product will
demonstrate mastery of principles needed for nurses working with mentally ill clients.
You will us the steps of the nursing process: assessment, diagnosis, goals, client centered
interventions and ongoing evaluation to gather important information and data to identify the
client’s problems and priority needs. You will have numerous opportunities to perform
interviews and assessments of clients each week during your 5 week clinical practicum
experience.
Instructions:
● You will complete TWO Nursing Assessment/ Care Plans for two different clients during the
clinical practicum experience.
● All components of the Nursing Assessment and Care Plan form must be completed and
submitted with a completed Medication Worksheet and a Laboratory/Diagnostic Worksheet
(copies available in the Clinical Assignments section on BB).
● Based on the information/data collected during the assessment and interview phase, you will
use the nursing process to develop a plan of care.
● The plan of care should include a minimum of THREE priority nursing diagnoses. At least
TWO should be psychiatric/psychosocial nursing diagnoses.
● Each submission must include the following:
➢ Client Interview data
➢ Nursing assessment, subjective, objective data gained from interview
➢ Client centered goals
➢ Nursing interventions
➢ Client teaching
➢ Discharge planning with consideration of appropriate community resources/referrals.
➢ Medication Worksheet
➢ Laboratory & Diagnostic Worksheet
● A list of NANDA approved nursing Diagnoses can be found in your textbook.
● Key nursing interventions for specific psychiatric mental-health disorders are available in
each chapter of the textbook.
Key Points:
● Spend some time interacting with your prospective client before you gather data from the
chart. Finding a patient who is more willing to interact will make the process easier. You
should request permission from the client prior to beginning the interview.
, ● You must establish rapport and gain trust (orientation phase) with the patient before you can
move in to the (working phase) of the nurse-patient relationship.
● Use your verbal and non-verbal therapeutic communication skills learned in class and
BLAST to interact with the client.
● You must address the Psychosocial AND physiological needs of each client(s) you work
with.
● You should disclose to the client that all information offered will be held in strictest
confidence and will only be shared with those involved in the client’s care.
● UNDER NO CIRCUMSTANCES WILL THE STUDENT SHARE INFORMATION
REGARDING A CLIENT OUTSIDE OF THE HOSPITAL UNIT.
● No documents containing patient identification data may be removed from the hospital unit. –
NO EXCEPTIONS. Any student found violating patient confidentially may be asked to leave
the clinical agency and may fail the course.
Format: Assemble your Plan of Care in this order
• Title Page (Your Name, University, Assignment, Date)
• Assessment
• Plan of Care - NANDA Diagnoses (PRIORITIZED), Client teaching, Discharge plan
• Medication Worksheet
• Lab Values / Tests Worksheet
● Reference Sheet with a minimum of three (3) (drug book, lab book, care plan text, and a peer
reviewed article relevant to your client ie: if the client is diagnosed with depression, you may
want to include an article about current treatment approaches for reducing auditory
hallucinations. Please submit a copy of your article with your assignment.
Attachments
➢ Attach Lab/Diagnostic Findings Worksheet findings for this client using the Laboratory
Worksheet (forms can be downloaded from BB - clinical)
➢ Attach Medication Worksheet for this client using the Laboratory Worksheet (forms can be
downloaded from BB - clinical)
➢ Please include ALL resources (references, textbooks, online resources) to your assignment using
APA format. Minimum 3 References
You are being graded on your own work and effort - PLEASE DO NOT CUT AND PASTE
FROM ANY DOCUMENT – CUTTING AND PASTING FROM ANY SOURCE IS
CONSIDERED PLAGIARISM AND A GRADE OF UNSATISFACTORY WILL BE
ASSIGNED AUTOMATICALLY AND CONSIDERED VIOLATION OF THE ACADEMIC
AND INTEGRITY POLICY (PLEASE REVIEW GUIDELINES REGARDING WHAT
CONSTITUTES PLAGIARISM AT THE LINK IN THE SYLLABUS)
Learning Objectives: Nursing Process, critical thinking, analysis of data, communication
Overview
The ability to assess the client in the clinical setting is an essential skill for the psychiatric nurse.
The Nursing Assessment/Care Plan assignment is intended to be a comprehensive learning experience
that synthesizes essential psychiatric and medical/surgical nursing theory. Your finished product will
demonstrate mastery of principles needed for nurses working with mentally ill clients.
You will us the steps of the nursing process: assessment, diagnosis, goals, client centered
interventions and ongoing evaluation to gather important information and data to identify the
client’s problems and priority needs. You will have numerous opportunities to perform
interviews and assessments of clients each week during your 5 week clinical practicum
experience.
Instructions:
● You will complete TWO Nursing Assessment/ Care Plans for two different clients during the
clinical practicum experience.
● All components of the Nursing Assessment and Care Plan form must be completed and
submitted with a completed Medication Worksheet and a Laboratory/Diagnostic Worksheet
(copies available in the Clinical Assignments section on BB).
● Based on the information/data collected during the assessment and interview phase, you will
use the nursing process to develop a plan of care.
● The plan of care should include a minimum of THREE priority nursing diagnoses. At least
TWO should be psychiatric/psychosocial nursing diagnoses.
● Each submission must include the following:
➢ Client Interview data
➢ Nursing assessment, subjective, objective data gained from interview
➢ Client centered goals
➢ Nursing interventions
➢ Client teaching
➢ Discharge planning with consideration of appropriate community resources/referrals.
➢ Medication Worksheet
➢ Laboratory & Diagnostic Worksheet
● A list of NANDA approved nursing Diagnoses can be found in your textbook.
● Key nursing interventions for specific psychiatric mental-health disorders are available in
each chapter of the textbook.
Key Points:
● Spend some time interacting with your prospective client before you gather data from the
chart. Finding a patient who is more willing to interact will make the process easier. You
should request permission from the client prior to beginning the interview.
, ● You must establish rapport and gain trust (orientation phase) with the patient before you can
move in to the (working phase) of the nurse-patient relationship.
● Use your verbal and non-verbal therapeutic communication skills learned in class and
BLAST to interact with the client.
● You must address the Psychosocial AND physiological needs of each client(s) you work
with.
● You should disclose to the client that all information offered will be held in strictest
confidence and will only be shared with those involved in the client’s care.
● UNDER NO CIRCUMSTANCES WILL THE STUDENT SHARE INFORMATION
REGARDING A CLIENT OUTSIDE OF THE HOSPITAL UNIT.
● No documents containing patient identification data may be removed from the hospital unit. –
NO EXCEPTIONS. Any student found violating patient confidentially may be asked to leave
the clinical agency and may fail the course.
Format: Assemble your Plan of Care in this order
• Title Page (Your Name, University, Assignment, Date)
• Assessment
• Plan of Care - NANDA Diagnoses (PRIORITIZED), Client teaching, Discharge plan
• Medication Worksheet
• Lab Values / Tests Worksheet
● Reference Sheet with a minimum of three (3) (drug book, lab book, care plan text, and a peer
reviewed article relevant to your client ie: if the client is diagnosed with depression, you may
want to include an article about current treatment approaches for reducing auditory
hallucinations. Please submit a copy of your article with your assignment.
Attachments
➢ Attach Lab/Diagnostic Findings Worksheet findings for this client using the Laboratory
Worksheet (forms can be downloaded from BB - clinical)
➢ Attach Medication Worksheet for this client using the Laboratory Worksheet (forms can be
downloaded from BB - clinical)
➢ Please include ALL resources (references, textbooks, online resources) to your assignment using
APA format. Minimum 3 References
You are being graded on your own work and effort - PLEASE DO NOT CUT AND PASTE
FROM ANY DOCUMENT – CUTTING AND PASTING FROM ANY SOURCE IS
CONSIDERED PLAGIARISM AND A GRADE OF UNSATISFACTORY WILL BE
ASSIGNED AUTOMATICALLY AND CONSIDERED VIOLATION OF THE ACADEMIC
AND INTEGRITY POLICY (PLEASE REVIEW GUIDELINES REGARDING WHAT
CONSTITUTES PLAGIARISM AT THE LINK IN THE SYLLABUS)
