College of Nursing
Psychiatric / Mental Health Nursing Care Plan
Gordon’s 11 Functional Health Pattern
Student
Instructor
Patient Initials
Course NURS 214L
Patient DOB
Gender
Legal Status (Vol, 5150,
Date of Admission
Unit
Date
Patient Age
Ethnicity
Allergies
5250, Conservatorship)
Temp (location)
Height:
Pulse (location)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure
(location)
Pain Scale 1-10 (location,
character, onset)
Weight:
Multiaxial Diagnostic System:
Axis I: (Psychiatric Diagnosis)
Axis II: (Personality Disorder / Mental Retardation)
Axis III: (Medical / Physical Problems)
Axis IV: (Psychosocial and Environmental Problems)
Axis V: (Global Assessment of Functioning)
History of Present Psychiatric Illness:
(Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement)
Psychopathology of admitting and/or related psychiatric diagnosis
Biophysical and/or related medical diagnosis
Describe how does this diagnosis relate to your patient
(With APA citations)
Erickson’s Developmental Stage:
Include Rationale
(APA citation)
West Coast University Course Syllabus
Revision Date:
Page 1
February 2011
Gordon’s 11 Functional Health Pattern
Health Perception / Health Management:
Client's perceived pattern of health and wellbeing and how health is managed.
Self-Perception/Self Concept:
Body comfort, body image, feeling state, attitudes
about self, perception of abilities.
Role-Relationship:
Client's pattern of role engagements and
relationships.
Nutritional-Metabolic:
Pattern of food and fluid consumption relative
to metabolic need and pattern; indicators of
local nutrient supply.
Value – Belief:
Patterns of values, beliefs (including spiritual), and
goals that guide client's choices or decisions for
his/her care)
Coping and Stress Tolerance:
General coping pattern and effective of the
pattern in terms of stress tolerance.
Sleep-Rest Pattern:
Patterns of sleep, rest, and relaxation.
Elimination Pattern:
Patterns of excretory function (bowel, bladder, and
skin). Includes client's perception of a normal"
function.
Activity-Exercise:
Patterns of exercise, activity, leisure, and
recreation.
Cognitive-Perceptual:
Sensory-perceptual and cognitive patterns.
Sexuality-Reproductive:
Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive
pattern.
West Coast University Course Syllabus
Revision Date:
Page 2
February 2011
Mental Status Examination:
Appearance:
Speech:
Eye Contact:
Behavior & Motor Activity:
Mood & Affect:
Orientation:
Cognitive Functioning
Thought Process:
Thought Content:
Insight:
Judgment:
Risk Assessment:
Suicide history, Self-Injurious Behavior,
Hypersexual, Elopement, Fall, Homicidal, Nonadherence to treatment
Substance Abuse and other Addictions: (gambling, sex, shopping, smoking)
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Blood Alcohol Level on admission:
C.A.G.E. Questionnaire
Yes / No
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to
steady your nerves or rid of a hangover (eye-opener)?
Other Addictions:
 None Reported
Multidisciplinary Client Outcome and Discharge
Plans:
Placement, outpatient treatment, partial
hospitalization, sober living, board and care,
shelter, long term care facility, 12 step program
Teaching Assessment and Client Education:
Include barriers to learning and preferred
learning styles
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Revision Date:
Page 3
February 2011
Pertinent lab test (normal ranges in
parentheses) & diagnostic reports (with dates)
Rationale for Abnormal Labs
Abnormal Involuntary Movements:
Facial and oral movements, extremity movements,
and trunk movements
Level of Participation in the Program:
(Group attendance and milieu participation)
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
WBC (4,500 – 10,000)
Urine Drug Screen (negative)
Thyroid Panel
West Coast University Course Syllabus
Revision Date:
Page 4
February 2011
College of Nursing
Diagnostic
Label
Gordon’s Functional
Health Pattern
Document based on
your client’s symptoms
Contributing
Factors
Related to
Nursing Diagnosis
(NANDA) (Actual
and/or potential)
Minimum of 2
Include etiology and
sign and symptoms
Also include
Definition of Nursing
Diagnosis
1.
2.
Nursing Outcome
Criteria (NOC)
Measureable
Goal during your
shift
Minimum 2
1.
2.
1.
2.
Implementations
(Independent and
collaborative nursing
intervention include
further assessment,
intervention and
teaching)
Minimum 4
1.
2.
3.
4.
1.
2.
3.
4.
Signs and
Symptoms
As evidenced by
Rationale
(Use APA citations)
1.
2.
3.
4.
1.
2.
3.
4.
West Coast University Course Syllabus
Revision Date:
Evaluation
Goal Met
Goal not Met
(If not met, what revisions
would you make?)
1.
2.
1.
2.
Page 5
February 2011
Medication List
Medications
Generic / Trade
Dose/Route/
Time
(Frequency)
Class/Rationale
for the patient
Range /
Therapeutic
Levels
Mechanism of
action Onset of
action
Common side effects /
food and drug
Interaction
West Coast University Course Syllabus
Revision Date:
Nursing considerations
Page 6
August 2011
Reference:
West Coast University Course Syllabus
Revision Date:
Page 7
August 2011
Psychiatric / Mental Health Nursing Care Plan Rubric
NAME:
CLIENT INITALS:
CRITERIA
COURSE:
DATE:
CLIENT PSYCHIATRIC DISORDER:
Exemplary
4
Client’s Demographics Clearly and accurately
and Psychiatric Legal
describes the client’s
Status
demographics and
psychiatric legal status in
detail.
Client’s Vital Signs
Clearly and accurately
and Allergies
documented the client’s
vital signs and allergies in
full detail.
History of Present
Clearly and accurately
Illness and Multiaxial describes the client’s
Diagnostic System
history of present illness.
The Multiaxial Diagnostic
System clearly and
accurately supports the
identified chief complaint
and presenting
signs/symptoms.
Psychopathology and Clearly and accurately
biophysical pathology identifies psychopathology
of admitting and/or
and biophysical pathology
related psychiatric
related to the identified
and medical diagnosis diagnostic criterion based
on the client’s history and
presenting symptoms.
Proficient
3
Adequately describes the
client demographics and
psychiatric legal status
with adequate detail.
Developing
2
Vaguely describes the
client’s demographics and
psychiatric legal status
with some detail.
Adequately documented
the client’s vital signs and
allergies. Missing few
minor details.
Adequately describes the
client’s history of present
illness. The Multiaxial
Diagnostic System
adequately supports the
identified chief complaint
and presenting
signs/symptoms.
Incomplete
documentation of the
client’s vital signs and
allergies.
Vaguely describes the
client’s history of present
illness. The Multiaxial
Diagnostic System vaguely
supports the identified
chief complaint and
presenting
signs/symptoms.
Adequately identifies
psychopathology and
biophysical pathology
related to the identified
diagnostic criterion based
on the client’s history and
presenting symptoms.
Vaguely identifies
psychopathology and
biophysical pathology
related to the identified
diagnostic criterion based
on the client’s history and
presenting symptoms.
Ineffective
1
Lack description of the
client’s demographics
and psychiatric legal
status that presents no
detail.
Fails to document the
client’s vital signs and
allergies.
Lack description of
client’s history of
present illness. The
Multiaxial Diagnostic
System does not support
the identified chief
complaint and
presenting
signs/symptoms.
Fails to identify
psychopathology and
biophysical pathology
related to the identified
diagnostic criterion
based on the client’s
history and presenting
symptoms.
West Coast University Course Syllabus
Revision Date:
Page 8
August 2011
POINTS
CRITERIA
Erikson’s
Developmental
Stages
Gordon’s 11
Functional Health
Pattern
Mental Status
Examination
Substance Abuse and
other Addictions
Risk Assessment
Multidisciplinary
Client Outcome &
Discharge Planning.
4
Clearly and accurately
identifies client’s
developmental stage with
rationales based on the
client’s developmental
tasks.
Clearly and accurately
utilizes Gordon’s 11
Functional Health Pattern
in assessing and planning
nursing care.
3
Adequately identifies
client’s developmental
stage with rationales
based on the client’s
developmental tasks.
Clearly and accurately
describes all components
of the mental status
examination based on the
client’s presenting
symptoms.
Clearly and accurately
identifies abused
substances and problems
associated with substance
and other addictions.
Clearly and accurately
identifies all risk factors
related to the client’s
history and presenting
symptoms.
Clearly and accurately
describes collaborative
issues and concerns
related multidisciplinary
client outcome and
discharge planning.
Adequately describes
components of the mental
status examination based
on the client’s presenting
symptoms.
Adequately utilizes
Gordon’s 11 Functional
Health Pattern in assessing
and planning nursing care.
2
Vaguely identifies client’s
developmental stage
without adequate
rationale based on the
client’s developmental
tasks.
Vaguely utilizes Gordon’s
11 Functional Health
Pattern in assessing and
planning nursing care.
Requires cues and
reminders.
Vaguely describes
components of the mental
status examination based
on the client’s presenting
symptoms.
Adequately identifies
abused substances and
problems associated with
substance and other
addictions.
Adequately identifies
some risk factors related
to the client’s history and
presenting symptoms.
Vaguely identifies abused
substances and problems
associated with substance
and other addictions.
Adequately describes
collaborative issues and
concerns related
multidisciplinary client
outcome and discharge
planning.
Vaguely describes
collaborative issues and
concerns related
multidisciplinary client
outcome and discharge
planning.
Vaguely identifies risk
factors related to the
client’s history and
presenting symptoms.
1
Fail to identify client’s
developmental stage
and lack rationale based
on the client’s
developmental tasks.
POINTS
Fails to utilize Gordon’s
11 Functional Health
Pattern in assessing and
planning nursing care.
Requires remediation.
X2
Fails to describe any of
components of the
mental status
examination based on
the client’s presenting
symptoms.
Fails to identify abused
substances and
problems associated
with substance and
other addictions.
Fails to identify any of
the risk factors related
to the client’s history
and presenting
symptoms.
Fails to describe
collaborative issues and
concerns related
multidisciplinary
outcome and discharge
planning.
X2
West Coast University Course Syllabus
Revision Date:
Page 9
August 2011
Teaching Assessment
and Client Education
Pertinent Lab Test
& Abnormal
Involuntary
Movement
NANDA Nursing
Diagnosis (prioritized)
Nursing Diagnosis
Definition
Clearly and accurately
identifies areas of
instructional needs,
learning preference and
learning barriers. Provided
clear and concise client
education the will aid in
health promotion, health
maintenance and self-care
activities.
Clearly and accurately
identifies pertinent
laboratory test and
abnormal movements
related to client’s disease
process.
Both nursing diagnoses
are accurate and
prioritized per NANDA
format with clear etiology
and data to support
diagnosis. Nursing
Diagnosis is consistent and
presents correlation from
the assessment data based
on Gordon’s 11 Functional
Health Pattern and Mental
Status Examination. Clear
and accurate nursing
diagnosis definition.
Adequately identifies
areas of instructional
needs, learning preference
and learning barriers.
Provided some and
adequate client education
the will aid in health
promotion, health
maintenance and self-care
activities.
Adequately identifies
pertinent laboratory test
and abnormal movements
related to client’s disease
process.
Vaguely identifies areas of
instructional needs,
learning preference and
learning barriers. Provided
minimal and vague client
education the will aid in
health promotion, health
maintenance and self-care
activities.
Fails to identify areas of
instructional needs,
learning preference and
learning barriers. Did not
provide client education
the will aid in health
promotion, health
maintenance and selfcare activities.
Vaguely identifies
pertinent laboratory test
and abnormal movements
related to client’s disease
process.
Fails to identify
pertinent laboratory test
and abnormal
movements related to
client’s disease process.
Both nursing diagnoses
are adequate and
prioritized per NANDA
format with sufficient
etiology and data to
support diagnosis. Nursing
Diagnosis is adequate and
presents correlation from
assessment data based on
Gordon’s 11 Functional
Health Pattern and Mental
Status Examination.
Adequate nursing
diagnosis definition.
Both nursing diagnosis are
vague and not prioritized
per NANDA format with
vague etiology and unclear
correlation from the
assessment data that may
or may not be classified as
nursing diagnosis based on
Gordon’s 11 Functional
Health Pattern and Mental
Status Examination.
Inaccurate nursing
diagnosis definition.
Both nursing diagnosis
are indefinable per
NANDA format and does
not correlate to support
assessment data and
cannot be classified as
nursing diagnosis based
on Gordon’s 11
Functional Health
Pattern and Mental
Status Examination. Lack
nursing diagnosis
definition.
West Coast University Course Syllabus
Revision Date:
Page 10
August 2011
X2
Nursing Outcome
Criteria
Clearly and accurately
establishes client’s
outcome criteria and can
be achieved with nursing
assistance. The goal clearly
supports the nursing
diagnosis and plan of care.
The goals are easily
measurable and realistic.
Adequately establishes
client’s outcome criteria
and can be achieved with
nursing assistance. The
goal somewhat supports
the nursing diagnosis and
plan of care. The goals are
somewhat measurable
and realistic.
Nursing Intervention
Criteria & Rationale
Clearly and accurately
Identifies independent
nursing interventions
criteria with teaching
supported by scientific
rationale and evidencebased practice.
Interventions are always
individualized, prioritized,
organized, specific and
realistic. Nursing actions
are always aimed at the
client’s goals and directed
at the stated health
deviation based on
Gordon’s 11 Functional
Health Pattern and
Erickson’s stages of
development.
Adequately Identifies
nursing interventions with
adequate teaching.
Scientific rationale is
adequately supported by
evidence-based practice.
Interventions are
adequate, individualized,
organized, specific and
realistic. Interventions can
be implemented
adequately that is focused
on client’s goal and health
deviation based on
Gordon’s 11 Functional
Health Pattern and
Erickson’s stages of
development.
Vaguely establishes
client’s outcome criteria
and may or may not be
achieved with nursing
assistance. The goals are
inconsistent with the
nursing diagnosis and plan
of care. The goals are
vaguely realistic and
measurable.
Vaguely Identifies nursing
interventions with unclear
teaching. Scientific
rationale is vaguely
relevant & not supported
by evidence-based
practice.
Interventions are
inconsistent, non-specific,
disorganized, and not
adequately focused on the
client’s goal. Interventions
are difficult to implement
and has weak relationship
to nursing diagnosis based
on Gordon’s 11 Functional
Health Pattern and
Erickson’s stages of
development.
Fails to establish client’s
outcome criteria that
cannot be met by
nursing assistance. The
goals lack support and
nonspecific from
gathered data, Outcome
criteria are not realistic
and not measureable.
X2
Fails to identify
interventions and
teaching. Lack Scientific
rationale and is not
supported by evidencebased practice.
Interventions are nonspecific, inappropriate,
unrealistic, unmeasurable and do not
relate to nursing
diagnosis. Intervention
does do not focus on
client goals and/or the
stated health deviation
based on Gordon’s 11
Functional Health
Pattern and Erickson’s
stages of development.
X2
West Coast University Course Syllabus
Revision Date:
Page 11
August 2011
Evaluation
Medications
General Organization
Skillfully and
independently identifies
criteria for evaluation.
Evaluates effectiveness of
interventions and
measures goal completion.
Modifies, revises and
recommends alternative
intervention.
Clearly and accurately
identifies all components
of the medication list,
including mechanism of
action, purpose, range,
side effects, interactions,
levels and nursing
considerations relevant to
the client.
Adequately identifies
criteria for evaluation.
Adequately determines
effectiveness of nursing
interventions and
measures goal completion
with appropriate
modification and revisions
to the treatment plan.
Adequately identifies
components of the
medication list. Adequate
description of mechanism
of action, purpose, range,
side effects, interactions,
levels and nursing
considerations relevant to
the client.
Difficulty utilizing criteria
for evaluation. Difficulty
determining effectiveness
of interventions and goal
completion. Evaluation
vaguely supports if goal is
met or not met with
inaccurate revisions to the
treatment plan.
Vaguely identifies
components of the
medication list. Lack
description of mechanism
of action, purpose, range
side effects, interactions,
levels and nursing
considerations relevant to
the client.
Does not support nor
utilize criteria for
evaluation. Does not
determine effectiveness of
interventions and goal
completion. There is a
lack of alternative
interventions to the
treatment plan.
Fails to identify
components of the
medication list. Failed to
include mechanism of
action, purpose, range
side effects, interactions,
levels and nursing
considerations relevant to
the client.
Accurate APA format,
appropriate citations and
references,
No spelling or grammar
errors.
Adequate APA format.
Minimal citations and
references are
appropriate. Few spelling
or grammar errors.
Numerous APA format
errors, Inaccurate citations
and references.
Few spelling and grammar
errors.
Fails to utilize APA format.
No citations or references
included, numerous
spelling and grammar
errors.
X2
X2
TOTAL:
Comments:
_________________________
_________________________
_________________________
Student Signature:
____
Date:
West Coast University Course Syllabus
Revision Date:
Page 12
August 2011
Instructor Signature:
___
Date:
West Coast University Course Syllabus
Revision Date:
Page 13
August 2011