N 310  CLINICAL PACKET

Fall  2012

GRADED CLINICAL ASSIGNMENTS
	All paperwork is to be turned in to your clinical instructor.
	Due dates are at the discretion of the clinical instructor.
	Handouts will be given for MMSE

	JOURNAL DUE WEEKLY to CLINICAL INSTRUCTOR         50 points
		(5 points per wk. for 10 wks)										
	MENTAL STATUS EXAM (2)
		Mini Mental Status Exam (MMSE)				20 points
		Large Mental Status Exam (LMSE				50 points
		(Each on a different age group, summary for each)

	FAMILY GENOGRAM ( 3 generations),				30 points
	Include: m/f, ages, jobs, deceased relatives, sibling order, physical illness,     
	mental health, relationship’s, and occupations, turn in a practice first														CARE PLAN (1)							50 points
		4 NANDA Ns. Dx.
		1 short term and 1 long term goal for each Dx.
		3 interventions for each goal
		   Cite references APA format	

	PROCESS RECORDING (1 pass/fail & 1 graded)		75 points
		Therapeutic with at least 15 dyadic interactions

	Milieu Project
		Milieu Assessment						10 points
		Milieu Presentation 						30 points
		Milieu Paper							50 points

	CLINICAL PERFORMANCE EVALUATION 	                      100 points

**All assignments must have a cover page (there are 2 different ones) and medication sheets (minimum of 4 medication sheets if your client has no meds).  The exception is the Milieu Project.
	
465 points possible-Your clinical grade is 20% of the total grade for the course.

Cover Sheet 
(Short Form-use for everything except care plan and process recording)

Student Name_____________________________		Date___________

IDENTIFYING DATA

Pt. Initials _____

Date of Admission_____	How many previous admissions for psych?_____

Date of interview______

Gender____       Age _____   Race/Ethnicity_________________________

Marital Status: ___________  If married previously, how many times? _______

Religious preference____________________

Education________________________________________________________

Occupation:______________________________________________________

Diagnosis: Axis I__________________________________________________

	      Axis II__________________________________________________

                   Axis III_________________________________________________

                   Axis IV_________________________________________________

                   Axis V__________________________________________________

Chief Complaint: (quotations)

Allergies: (include type of reaction) Current Medications: (include all, including herbals and vitamins).  Note dose, frequency, if patient follows prescribed times/amounts), purpose of medication, and drug classification.

Summary-Be detailed. Tell what was happening prior, during and after you administered the exam.  Tell whether these events influenced the exam.  Did the meds influence the exam in a positive/negative way.  What did you learn?

HANDOUT FOR MINI MENTAL STATUS WILL BE GIVEN TO YOU

N310 Medication Worksheet
Attach to all assignments
                                		Address ALL the medications,  
                                         	including OTC/herbals
Use as Many sheets as needed per medications ordered.
Medication Name (generic name, brand trade, drug classification) ___________________________________________________________________
Reason/reasons why the med. Is prescribed for this client._____________________
Dosage/Route:  Pt. _____________________Recommended Dosage____________
½ life ______________________	Recommended Client Age_______________
Pertinent assessments to make before and after giving this med._________________________________________________________________
Parameters to consider__________________________________________________
Any reason to hold this med.______________________________________________
Pertinent labs and interventions for the med.________________________________
Changes recommended in dosage for physiologic reasons (renal/hepatic, etc.) ______
_____________________________________________________________________
Desired action “how” it works______________________________________________
Common Adverse Affects ________________________________________________________________________________________________________________________________________________
INTERVENTIONS FOR EACH ADVERESE EFFECTS
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Expected therapeutic effects for this client______________________________________
Evaluate the effects experienced by this client? _________________________________
Side effects______________________________________________________________
NURSING INTERVENTIONS FOR EACH SIDE EFFECT
________________________________________________________________________________________________________________________________________________________________________________________________________________________

Possible drug/drug interactions _______________________________________________________________________

Possible drug/food interactions _______________________________________________________________________
Possible drug/environment interactions _______________________________________

Pertinent info to document__________________________________________________

LOG BOOK/JOURNAL ASSIGNMENT

You will need to turn in a journal to your clinical instructor for their review each week.  The expectation is that you reflect on your clinical experiences for the previous week.  After writing out what happened and how it affected you, identify the thoughts and feelings in each entry.  An easy way to do this is to underline the thoughts with one color and the feelings with another.  Then utilizing (RET) describe your or your clients
“A” (event/situation) X “B” (Irrational belief) X “C” (Feelings/thoughts) = rational change
DO NOT USE CLIENTS NAMES, ONLY INITIALS.

Purpose 1.  To give the clinical instructors a better idea of your progress.
              2.  To help you identify the differences in a thought and a feeling so you may
                   help the client to do the same.

GENOGRAM (2)
You can down load a form for a genogram on the internet. Otherwise draw out (CLEARLY) and utilize a key for male/female, diseases etc. List (initials only) all grandparents, parents, siblings, children and step or common law family members, (3 generations are required).  List all medical and psychiatric problems (don’t forget to list substance or sexual abuse suspected or known for all those in the genogram).  If a client has been married, divorced, separated or is with a significant other note this as well (relationship issues).  Include legal, occupation, profession, schooling or other significant social information.  Include approximate ages for all people listed and if deceased list the cause and age.  
Then present and summarize your findings.  What diseases/or mental illness run in families?  What are the individual’s risk factors for the disease/or mental illness?  How did performing the genogram affect your interaction with the client?  What did you learn? What would you do differently next time? How do think a genogram can be helpful to the client for the nurse/client relationship? How could you use the genogram to help this client understand their mental health, lifestyle changes needed, and patterns of behavior?
Don’t forget your medication sheets and cover sheet.

MINI MENTAL STATUS EXAM (MMSE or FOLSTEIN)
This form will be given to you in clinical. Medication and full summary is required.
Summary must discuss events prior, during, and after the exam.  Discuss each question and patient’s response. Give an interpretation of the score.  Describe how you think the patient’s diagnosis and meds may have influenced their score.  

LARGE MENTAL STATUS EXAM
Content of Examination

I.  Appearance, Behavior, Attitude

General Appearance
a.	Appearance in relation to age__________________________________
b.	Attractiveness_______________________________________________
c.	Clothing, appropriateness for age, etc.___________________________
d.	Hygiene_____________________________________________________
e.	Odor_______________________________________________________
f.	Overall physical health______________________________________________________

          Motor Status
a.	Gait_____________________________________________________
b.	Handshake_______________________________________________
c.	Any abnormal movements_______________________________________________
d.	Movements, coordination___________________________________
e.	Movements, pace and  energy_______________________________
f.	Posture__________________________________________________
g.	Activity__________________________________________________
h.	Facial expression__________________________________________

         Behavior_______________________________________________________

II. Characteristics of speech
a.	Amount of speech_________________________________________
b.	Clarity of speech__________________________________________
c.	Liveliness of speech________________________________________
d.	Pressure of speech_________________________________________
e.	Rate of speech____________________________________________
f.	Rhythm of speech_________________________________________
g.	Volume of speech_________________________________________
h.	Repetition________________________________________________
i.	Coherent/Incoherent_______________________________________
j.	Logical association/disordered_______________________________
        
       Speech Patterns
a.	Blocking_________________________________________________
b.	Circumstantiality__________________________________________
c.	Perseveration_____________________________________________
d.	Flight of Ideas____________________________________________
e.	Mutism_________________________________________________

III. Emotional State: Affective Reactions

Mood and Affect
a. Attitude toward nurse______________________________________
b. Affect, appropriateness_____________________________________
c. Affect, range______________________________________________
d. Affect, stability____________________________________________
e. Specific feelings and moods__________________________________
       f. Emotional trends, Depth/Intensity/Persistence____________________________________
Shallowness, flattening or blunting of affect_______________________________________________________
Dissociation or     Disharmony_________________________________________________
Emotional Reactions
      a. constant__________________________________________________
      b. fluctuating________________________________________________
      c. Ease of Readiness of occurrence to stimuli _____________________
d. Degree of Intensity_________________________________________________
e. Playacting_________________________________________________
f. Emotional Deterioration_____________________________________________

IV.  Content of Thought, Special Preoccupations and Experiences

Thought
a.	Clarity of thought_________________________________________________
b.	Content of thought________________________________________________
c.	Flow of thought___________________________________________________
d.	Logical_____________________________________________________
e.	Coherent____________________________________________________
f.	Relevant____________________________________________________
g.	Patterns__________________________________________________--

Ideation
a.	Self-Destructive/suicidal___________________________________________
b. Suspicious/paranoid__________________________________________
                  c. Homicidal___________________________________________________

 Delusional 
a.	Reference or persecution__________________________________________________
b.	Nihilistic____________________________________________________
c.	Grandeur___________________________________________________
d.	Somatic_____________________________________________________
         
         Hallucinations
a.  Auditory____________________________________________________
b. Visual_______________________________________________________
c.  Olfactory____________________________________________________
d.  Gustatory___________________________________________________
e.  Tactile______________________________________________________

Obsessions________________________________________________________
Compulsions______________________________________________________
Phobias___________________________________________________________
Fantasies/Daydreams_______________________________________________
Main preoccupation or content of thought___________________________________________________________

       V.  Orientation and Awareness
	
	a. Level of Consciousness responds to: (verbal, touch, noxious, unresponsive) _____________________________________________________
	b. Orientation
	Person_____________________________________________________
	Place______________________________________________________
	Time_______________________________________________________
	Situation____________________________________________________

        VI. Memory
	
	a. Recall of Remote Past Experiences______________________________
	b. Recall of Recent Past Experiences______________________________
	c. Recall of Immediate Impressions_______________________________
	D. General Grasp Recall_________________________________________
Family and Significant Others
a.	Position in the family_________________________________________
b.	Others in the family__________________________________________
c.	Living arrangement__________________________________________
d.	Role/s in family______________________________________________
e.	Significant others____________________________________________
f.	Other support services________________________________________
g.	Interactional ability_________________________________________

VII. General Intellectual Evaluation

	a.General Information________________________________________
	b. Calculations______________________________________________
	c. Reasoning and Judgment___________________________________
	d. Capacity for Abstract Thinking_______________________________
	e. Social Judgment___________________________________________

Addictive/Coping habits – how much, how often, how long (in general and for the last year)
Tobacco__________________________________________________
Alcohol___________________________________________________
Food_____________________________________________________
Exercise__________________________________________________
Street drugs_______________________________________________
Medications (OTC and prescribed – used for coping) _____________
__________________________________________________________
Intelligence
a.	Performance in relation to education________________________
b.	Attention and concentration_______________________________

Knowledge about Illness (state specifics) ________________________
     ___________________________________________________________
         
         VIII. Insight

	a. Understands and realizes significance of symptoms_________________
	b. Does the patient consider her/himself to be ill? ____________________
	c. Possible explanation of symptoms (who helped to formulate) _
           ____________________________________________________________
Suggestions for treatment_________________________________________
         
         IX. Development and coping

Developmental Stage (Erickson) _____________________________________
Coping devices and defense mechanisms_____________________________
a.	Effectiveness
b.	Usefulness
c.	Appropriateness
d.	Assets, resources, strengths & Interests__________________________
____________________________________________________________

Interpretation/Impression with nursing diagnoses and goals. (Write this out). 
4 Dx., 1 short term and 1 long term goal for each Dx., 3 NURSING interventions for each stg and ltg.

X. Written Summary: Be specific.  Describe all behavior fully and articulately.  Your clinical instructor should be able to identify your client (without the need of initials) based on your accurate description.  Do NOT use: within normal limits, yes/no, appropriate or other vague terms.  Medication sheets and complete summary, as you would present to Dr. on the unit (this is a b/f, 27 y/o, presenting with ______, with a past history of______, diagnosis is _____, the following meds have been given in outpt. without success.  Categories assessed are: describe each category from appearance on

Nursing 310 									PAGE 1 0F 2

Client Information Cover Sheet to be used for Care Plan and Process Recording – Use for Care Plan and Process Recordings – Attach as a face sheet when turning in for grading.

Pt. Initials_____		Age_______	Gender ______		
Other demographic data

DSM –IV Diagnoses
Axis I: 
Axis II:
Axis III:
Axis IV:
Axis V:

NANDA diagnoses:

Mental status exam findings (be sure to be VERY descriptive) 
	Appearance
	Behavior
	Attitude
	Speech
	Mood
	Affect
Main Thought Content
		Ideations
		Delusions
		Illusions
		Obsessions
		Compulsions
		Phobias
	Orientation
Memory
	Remote
	Recent
	Immediate
Reasoning
	Judgment
	Calculations
	Intelligence
Insight
	Coping Mechanisms (what are they and are they + or -)

Allergies:
										PAGE 2 OF 2

Medications (Attach Medication Grid):

Factors that lead to treatment:

Significant psychiatric history:

Family history:

Strengths:

Support system:

Discharge Plans (YOURS FOR THE CLIENT)

NURSING 310

PROCESS RECORDING FORM

STUDENT’S NAME
DATE AND TIME OF MEETING
CLIENT’S INITIALS________ GENDER ________ AGE ______

Verbatim statement by the student in one box. Then verbatim statement of the client in the next box.  Include all non-verbal (posture, gestures, facial expression, vocal tone and inflections-for both client and student	Analysis of the client’s behavior.
What is the relationship of the client’s behavior to DX?  What coping behavior is present (+ and/or -)? Defense mechanisms? Did medication affect the interaction?  Was verbal (V) and non-verbal (NV) congruent (C) or (NC)?  What was the client communicating with their V or NV communication?	Critique of the interaction:
What specific therapeutic techniques were used (ex. Clarification, summarizing, restatement, etc)? What specific alternative comm... Technique was needed?
Therapeutic (T) or non-therapeutic (NT)? Open (O) or closed (C) question?  Your feelings-describe (one word)	Process of the interaction.
Phases of the nurse/client interaction and characteristics of this phase that are evident.	

				

				

				

				

				

				

				

				

				

				

				

For Process recording only: Answer each question individually.

Goals for Interaction.
What were the relevant circumstances to this meeting? (For example, was the 	meeting spontaneous or did you have an appointment to talk?)  
What were your seating arrangements?
What is the relationship of the client’s behavior to their diagnosis?
What coping strategies (or lack of) are evident (+ or -)?
What defense mechanisms are evident?
In what ways are the client’s medications influencing (+/-) their behavior in 	
The interaction?
What was the client communicating by their verbal and non-verbal? 
communication?
Was the verbal and non-verbal congruent?
What specific communication techniques did you use?
Did you use a variety of techniques? If not why not?
What techniques did you use the most? Why?
Do you feel you were therapeutic during the conversation? Why, why not?
How did you feel during the interaction? 
Did your feelings affect the interaction?  In what way?
What were you thoughts during the interaction and how do you think they 
affected the interaction?
What would you do/say differently next time?
What specifically do you need to work on?
Were your goals for the interaction met?
What goals would you have if you were to meet with the client again?
Generally summarize.

N310 
NURSING CARE PLAN FORM
STUDENTS NAME____________________________________
CLIENT INITIALS_____________________________________

Demographic and Nursing Dx. (4)
Use complete NANDA Dx.
Prioritize the 4 Dx.	Goals (Must be measurable and specific to your client):
1 Short term
1Long term
3 Interventions for each goal (6 totals for each Ns. Dx.
Cite references APA format	Rationale.
Cite your references APA format.	Evaluation.
Suggested teaching for client &/or fm.
Follow up for Discharge.
Resources for client for discharge.	
1.
				
2.
				
3.
				
4.

Nursing N 310
MILIEU PROJECT

Clinical area assessment tool for Milieu Project

Agency: _____________________________ Unit ________________________________

Date of Assessment __________

Student: ____________________________________

Milieu Assessment:

Physical Layout:

Lighting, color, décor

Pace activity level:

Emotional atmosphere:

Factors that are contributing to the emotional atmosphere:

Typical clients who use this service:

Age: (average and range)

Gender:

Cultures:

Socioeconomic status					Education level:

Reading ability:					Communication ability:

Reasons for using this agency/service?

What could a nurse do to improve the milieu today on this unit?  (use extra pages if necessary)

What needs are being focused on by the staff? (physical, vocational, social, spiritual, emotional, etc.)

Lakeview College of Nursing
N 310 Psychiatric/Mental Health Nursing
Louann Lord, RN, MS, CADC – Danville Course Coordinator
217-493-4377
llord@lakeviewcol.edu

This form is to verify that the student has attended the group listed below for the time specified as required for the course.  If you have any questions, please feel free to call the above number.

Date____________________________________		
Student Name__________________________

Agency or Group Name___________________________________________________________________

Number of hours________________________

________________________________________________________________________
Signature and date(s) of leader or other responsible person (note: for 12 step groups, initials are acceptable)