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)
Pulse (location)
Respiration
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 scale)
Pulse Ox (O2 Sat)
Blood Pressure
(location)
Pain Scale 1-10 (location,
character, onset)
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
Describe how does this diagnosis relate to your patient
(With APA citations)
Erickson’s Developmental Stage:
Include Rationale Based on the Client
(APA citation)
West Coast University Course Syllabus
Revision Date:
Page 1
April 2011
College of Nursing
Gordon’s 11 Functional Health Pattern
Health Perception / Health Management:
Client's perceived pattern of health and well
being 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 effectiveness 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
Aprill 2011
College of Nursing
Mental Status Examination:
Substance Abuse and other Addictions:
(cigarettes, gambling, sex, shopping, smoking, internet)
Appearance:
Speech:
Eye Contact:
Behavior & Motor Activity:
Mood & Affect:
Orientation, Attention & Concentration:
Cognitive Functioning & Memory:
Thought Process:
Thought Content:
Insight:
Judgment:
Substance:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Blood Alcohol Level on admission:
C.A.G.E. Questionnaire:
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 get rid of a hangover (eye-opener)?
 None reported
Risk Assessment:
Suicide history, Self-Injurious Behavior, Hypersexual,
Elopement, Fall, Homicidal, Non-adherence to
treatment
Multidisciplinary Client Outcome and Discharge
Plans:
Placement, outpatient treatment, partial
hospitalization, sober living, board and care,
shelter, long term care facility, 12 step program
Pertinent lab test (normal ranges in parentheses) &
diagnostic reports (with dates)
Include Rationale for Abnormal Labs
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
Abnormal Involuntary Movements:
Facial and oral movements, extremity
movements, and trunk movements
Yes / No
Teaching Assessment and Client Education:
Include barriers to learning and preferred
learning style
Level of participation in the program:
(Group attendance and milieu participation)
West Coast University Course Syllabus
Revision Date:
Page 3
Aprill 2011
College of Nursing
Diagnostic
Label
Gordon’s Functional
Health Pattern
Rationale based on
your client’s symptoms
Related to
Nursing Diagnosis
(NANDA) (Actual
and/or potential)
Minimum of 2
Include etiology and
sign and symptoms
Also include
Definition of Nursing
Diagnosis (Cite)
Contributing
Factors
Nursing Outcome
Criteria (NOC)
Measureable
Goal during your
shift
Minimum 2
Signs and
Symptoms
As evidenced by
Implementations
(Independent and
collaborative nursing
intervention include
further assessment,
intervention and
teaching)
Minimum 4
Rationale
(Use APA citations)
West Coast University Course Syllabus
Revision Date:
Evaluation
Goal Met
Goal not Met
(If not met, what revisions
would you make?)
Page 4
Aprill 2011
College of Nursing
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 5
Aprill 2011
College of Nursing
Reference:
West Coast University Course Syllabus
Revision Date:
Page 6
Aprill 2011
College of Nursing
Psychiatric / Mental Health Nursing Care Plan Rubric
CRITERIA
Client’s
Demographics
4
Clearly and accurately
describes the client’s
demographics in detail.
3
Consistently describes
the client demographics
with adequate detail.
History of Present
Illness and
Multiaxial Diagnostic
System
Clearly and accurately
describes the client’s
history of present illness.
In-depth understanding of
chief complaint and
presenting
signs/symptoms supported
by the Multiaxial
Diagnostic System.
Adequately describes the
client’s history of present
illness. Moderate
understanding of chief
complaint and presenting
signs/symptoms
supported by the
Multiaxial Diagnostic
System.
Vague description of
client’s history of
present illness. Marginal
understanding of chief
complaint and
presenting
signs/symptoms vaguely
supported by the
Multiaxial Diagnostic
System.
Clearly and accurately
Adequately identifies
Vaguely identifies past
identifies past psychiatric past psychiatric history
psychiatric history with
history in detail with full
with some detail and
few detail and minimal
explanation of
some explanation of
explanation of
psychopathology for each psychopathology for each psychopathology for
diagnosis with specific
diagnosis related to the
each diagnosis related to
diagnostic criterion related client’s history and
the client’s history and
to the client’s history and present symptoms.
present symptoms.
present symptoms.
Lack description of
client’s history of
present illness. Poor
understanding of chief
complaint and
presenting
signs/symptoms not
supported by the
Multiaxial Diagnostic
System.
Fails to identify past
psychiatric history and
provided inaccurate
explanation of
psychopathology
related to the client’s
history and present
symptoms.
Clearly and accurately
identifies and defines
correct developmental
stage with rationales of
meeting or not meeting
developmental tasks.
Adequately identifies and
defines correct stage with
some rationale of
meeting or not meeting
developmental tasks.
Fail to identify
developmental stage
without definition or
inappropriate rationale
of developmental tasks.
Psychopathology of
admitting and/or
related psychiatric
diagnosis
Erikson’s
Developmental
Stages
2
Vague descriptions of
the client demographics
with some detail.
Vaguely identifies
developmental stage
without adequate
definition or rationale of
meeting or not meeting
developmental tasks.
West Coast University Course Syllabus
Revision Date:
1
Lack description of the
client and presents no
detail.
Page 7
Aprill 2011
POINTS
College of Nursing
CRITERIA
Gordon’s 11
Functional Health
Pattern
Mental Status
Examination
CRITERIA
Substance Abuse and
other Addictions
Risk Assessment
Teaching Assessment
and Client Education
Pertinent Lab Test
& Abnormal
Involuntary
Movement
10
8
5
3
Clearly and accurately
utilizes Gordon’s Functional
Health Pattern in assessing
and planning nursing care.
Adequately utilizes
Gordon’s Functional Health
Pattern in assessing and
planning nursing care for.
Clearly and accurately
describes all components of
the mental status
examination.
Adequately describes some
components of the mental
status examination.
Vaguely utilizes Gordon’s
Functional Health Pattern
in assessing and planning
nursing care. Requires
cues and reminders.
Vaguely describes
components of the mental
status examination.
Fails to utilize Gordon’s
Functional Health Pattern
in assessing and planning
nursing care. Requires
remediation.
Fails to describe any of
components of the
mental status
examination.
4
3
2
1
Clearly and accurately
identify substance related
problems and other
addictions
Clearly and accurately
identify all risk factors such
as suicide, homicide, falls,
hypersexual behavior,
elopement and nonalliance.
Adequately identify
substance related
problems and other
addictions
Adequately identify risk
factors such as suicide,
homicide, falls, hypersexual
behavior, elopement and
nonalliance.
Clearly and accurately
identify teaching needs,
learning barriers and
provided clear and concise
client education.
Clearly and accurately
identifies pertinent
laboratory test and
abnormal movements
related to client’s disease
process.
Adequately identify
teaching needs, learning
barriers and provided some
client education.
Vaguely identifies
substance related
problems and other
addictions
Vaguely identifies risk
factors such as suicide,
homicide, falls,
hypersexual behavior,
elopement and
nonalliance.
Vaguely identifies
teaching needs, learning
barriers and provided
minimum client
education.
Vaguely identifies
pertinent laboratory test
and abnormal movements
related to client’s disease
process.
Fails to identify
substance related
problems and other
addictions
Fails to identify any of
the risk factors such as
suicide, homicide, falls,
hypersexual behavior,
elopement and
nonalliance.
Fails to identify teaching
needs, learning barriers
and provided
inconsistent client
education.
Fails to identify pertinent
laboratory test and
abnormal movements
related to client’s disease
process.
Adequately identifies
pertinent laboratory test
and abnormal movements
related to client’s disease
process.
West Coast University Course Syllabus
Revision Date:
Page 8
Aprill 2011
POINTS
POINTS
College of Nursing
Multidisciplinary Client
Outcome & Discharge
Planning.
Clearly and accurately
describes collaborative
issues and concerns related
multidisciplinary client
outcome and discharge
planning.
CRITERIA
10
8
5
3
Both nursing diagnoses are
accurate and prioritized per
NANDA format with clear
etiology and sufficient data
to support diagnosis.
Nursing Diagnosis is
consistent and presents
correlation from assessment
data that can be classified as
nursing diagnosis based on
Gordon’s Functional Health
Pattern and Mental Status
Examination. Clear and
accurate nursing diagnosis
definition.
Both nursing diagnoses are
adequate per NANDA
format with sufficient
etiology and data to
support diagnosis. Nursing
Diagnosis is adequate and
presents correlation from
assessment data that can
be classified as nursing
diagnosis based on
Gordon’s Functional Health
Pattern and Mental Status
Examination. Adequate
nursing diagnosis
definition.
Both nursing diagnosis are
vague 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 Functional
Health Pattern and Mental
Status Examination.
Incorrect 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 Functional
Health Pattern and
Mental Status
Examination. Lack
nursing diagnosis
definition.
NANDA Nursing
Diagnosis (prioritized)
Nursing Diagnosis
Definition
CRITERIA
Nursing Outcome
Criteria
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.
Fails to describe
collaborative issues and
concerns related
multidisciplinary
outcome and discharge
planning.
5
3
2
1
Nursing outcome criteria are
clear and accurate which
establishes client goals and
can be achieved with
nursing assistance that
clearly matches the nursing
diagnosis, are easily
measurable and have a time
frame. Data supports if goals
are met or not met with
appropriate revisions.
Nursing outcome criteria
are adequate which
identifies clients goals and
usually match nursing
diagnosis, can be met with
nursing assistance,
measurable and have a
time frame. Data
somewhat supports if goals
are met or not met with
appropriate revisions.
Nursing Outcome criteria
are vague, presents some
support from gathered
data, which cannot be met
with nursing assistance.
Some outcome criteria are
not realistic and some are
not measureable. Data
vaguely supports if goal is
met or not met with
inaccurate revisions.
Nursing outcome criteria
are unsupported and
nonspecific from
gathered data, which
cannot be met by nursing
assistance. Outcome
criteria are not realistic
and not measureable.
Data does not support if
goals are met or not met
with inaccurate revisions.
West Coast University Course Syllabus
Revision Date:
Page 9
Aprill 2011
POINTS
College of Nursing
CRITERIA
Nursing Intervention
Criteria & Rationale
CRITERIA
Evaluation
10
8
5
3
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
Functional Health Pattern
and Erickson’s stages of
development.
Adequately Identifies
independent nursing
interventions with
teaching; somewhat
supported by scientific
rationale and 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, which is based
on Gordon’s Functional
Health Pattern and
Erickson’s stages of
development.
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
client goal. Interventions
are difficult to implement
and has weak relationship
to nursing diagnosis,
based on Gordon’s
Functional Health Pattern
and Erickson’s stages of
development.
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
Functional Health Pattern
and Erickson’s stages of
development.
5
3
2
1
Skillfully and independently
identifies criteria for
evaluation. Evaluates
effectiveness of
interventions and measures
goal completion. Modifies,
recommends alternative
intervention.
Demonstrates adequate
information in identifying
and using criteria for
evaluation. Determines
effectiveness of
interventions and
measures goal completion.
Difficulty utilizing criteria
for evaluation. Difficulty
determining effectiveness
of interventions and goal
completion.
Does not support nor
utilize criteria for
evaluation. Does not
determine effectiveness
of interventions and goal
completion.
West Coast University Course Syllabus
Revision Date:
Page 10
Aprill 2011
POINTS
College of Nursing
CRITERIA
Medications
CRITERIA
General Organization
10
8
5
3
Lists clearly and accurately
all medications with
relevant side effects and
nursing considerations
specific to client and
purpose for client receiving
the medications.
Lists all medications and
adequately include
relevant side effects and
nursing considerations
specific to client and
purpose for client receiving
the medications.
Lists most of the
medications with relevant
side effects and nursing
considerations specific to
client and purpose for
client receiving the
medications.
Incomplete list of
medications and does
not include relevant side
effects and nursing
considerations specific to
client.
4
Accurate APA format,
appropriate citations and
references,
No spelling or grammar
errors
3
2
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
1
POINTS
POINTS
No APA formatting,
No citations or
references included,
numerous spelling and
grammar errors
TOTAL:
COMMENTS:
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STUDENT SIGNATURE:
____
DATE:
INSTRUCTOR SIGNATURE:
___
DATE:
West Coast University Course Syllabus
Revision Date:
Page 11
Aprill 2011