2003 - Fundamentals of Psychiatric Treatment Planning - Kennedy
Content
FUNDAMENTALS OF
PSYCHIATRIC TREATMENT
PLANNING
Second Edition
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FUNDAMENTALS OF
PSYCHIATRIC TREATMENT
PLANNING
Second Edition
James A. Kennedy, MD
Associate Professor of Psychiatry
University of Massachusetts Medical School
Worcester, Massachusetts
Director
Demonstration Unit
Westborough State Hospital
Westborough, Massachusetts
President
KennedyMD Consulting
Shrewsbury, Massachusetts
Washington, DC
London, England
Copyright
Copyright © 2003 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED.
Users of the manual are free to make unlimited photocopies of the following: Blank forms for the Master
Treatment Plan and Treatment Plan Review, Step-by-Step Instructions for using the blank forms, Sample Master
Treatment Plan, Quick Reference to Problem Categorization by the Kennedy Axis V, and the AIMS Plus EPS
(Abnormal Involuntary Movement Scale Plus EPS). Permission must be obtained from American Psychiatric
Publishing, Inc., to copy other parts of this manual. Use of the Kennedy Axis V and the Kennedy NOSIE (Kennedy
Nurses’ Observation Scale for Inpatient Evaluation) questionnaires requires a licensing agreement. Royalties may be
waived when these questionnaires are used for piloting or research purposes. Visit www.kennedymd.com for details
on licensing agreements.
Cautionary Note
Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual
authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association.
The author has worked to ensure that all information in this manual is accurate at the time of publication
and consistent with general psychiatric and medical standards and that information concerning drug dosages,
schedules, and routes of administration is accurate at the time of publication and consistent with standards set by
the U.S. Food and Drug Administration and the general medical community. As medical research and practice
continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a
specific therapeutic response not included in this manual. For these reasons and because human and mechanical
errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care
or the care of a family member.
This manual is not presented as a standard of care. The clinical examples are just that: examples. They are not
intended to prescribe care for patients. This manual is intended to help treatment teams take a more systematic
approach to treatment planning. Each treatment team must use its own clinical judgment to decide how to use this
manual and its clinical examples. Even within this manual, the examples vary in the standard of care that they set
(i.e., some of the examples represent clearly higher standards than other examples).
The varying nature of the examples in this manual represents to some degree the wide range of treatments
available, as well as varying clinical standards for many clinical problems. Also, there are often different
interpretations of the standards set forth by various accrediting bodies. Finally, treatment teams have a limited
amount of time to complete treatment plans. Many examples are intended to represent plans taken from actual
team meetings; those examples certainly reflect to some degree that limited time.
Users should slowly replace the examples in this manual with examples developed by their own treatment
team members. These examples should better reflect the standards and treatment style expected from their own
treatment teams.
Computerized Treatment Planning
The current standard for computerized treatment planning is to generate the plan using a word processor; however,
this standard is rapidly changing. Visit www.kennedymd.com for updates on computerized treatment planning and
to download electronic copies of blank treatment planning forms.
Also available by Dr. Kennedy: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning
(Washington, DC, American Psychiatric Publishing, 2003)
Manufactured in the United States of America on acid-free paper.
07 06 05 04 03
5 4 3 2 1
Second Edition
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209
www.appi.org
Library of Congress Cataloging-in-Publication Data
Kennedy, James A., 1946–
Fundamentals of psychiatric treatment planning / James A. Kennedy.—2nd ed.
p. ; cm.
Includes bibliographical references.
ISBN 1-58562-061-0 (alk. paper)
1. Mental illness—Treatment. 2. Psychiatric records. 3. Diagnostic and statistical
manual of mental disorders. I. Title.
[DNLM: 1. Mental Disorders—therapy. 2. Patient Care Planning. WM 400 K35f 2003]
RC480.5 K445 2003
616.89′1—dc21
2002027688
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
Preface .......................................................................................................................................... vii
Acknowledgments ....................................................................................................................... viii
Identifying Patient Data.............................................................................................................. viii
Introduction.......................................................................................................................... Intro–1
Master Treatment Plan (Sample)..........................................................................................MTP–1
Psychological Impairment ......................................................................................................... 1–1
Social Skills ................................................................................................................................. 2–1
Violence ...................................................................................................................................... 3–1
ADL–Occupational Skills ............................................................................................................. 4–1
Substance Abuse......................................................................................................................... 5–1
Medical Impairment .................................................................................................................. 6–1
Ancillary Impairment .................................................................................................................. 7–1
Blank Forms ............................................................................................................................. BF–1
Questionnaires............................................................................................................................Q–1
Appendix..................................................................................................................................... A–1
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Fundamentals of Psychiatric Treatment Planning
vii
Preface
This manual forms the cornerstone for the Kennedy Approach to Psychiatric Treatment Planning. This
approach is based on the Kennedy Axis V questionnaire, which organizes psychiatric problems into
seven categories or problem areas:
•
•
•
•
•
•
•
Psychological Impairment
Social Skills
Violence
Activities of Daily Living (ADL)–Occupational Skills
Substance Abuse
Medical Impairment
Ancillary Impairment
This approach allows use of the Kennedy Axis V to capture baseline problems and baseline level of
functioning for each of these problem areas. These baseline findings can then flow directly into the
Master Treatment Plan and Nursing Care Plan via the Problem List and the problem descriptions. This
approach can then continue through Treatment Plan Reviews and Nursing Care Plan Reviews, progress
notes, and measurements of outcome.
This manual includes blank Master Treatment Plan forms, blank Treatment Plan Review forms,
sample Master Treatment Plans, and numerous sample Individual Problem Plans. In addition to this
manual and the Kennedy Axis V questionnaire, support for the Kennedy approach is available in
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric
Publishing 2003) and online.
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning is both a training manual
and a reference for the Kennedy Axis V questionnaire. It maximizes your ability to use the Kennedy Axis
V to capture, track, and profile your clinical impressions. Numerous clinical vignettes demonstrate the use
of the Kennedy Axis V.
Mastering the Kennedy Axis V also shows how the Kennedy Axis V can condense your psychiatric
outcome measures into a single clinical instrument, including using the Global Assessment of
Functioning (GAF) Equivalent to replace the GAF Scale and using the Kennedy Axis V’s subscales to
replace or act as a screening tool for other instruments that focus on specific problem area(s).
Online Support
Visit www.kennedymd.com for support and updates to the Kennedy approach to psychiatric treatment
planning and outcome measurement, including additional sample plans, training and credentialing
opportunities, updates of blank forms, and other information.
viii
Fundamentals of Psychiatric Treatment Planning
Acknowledgments
I express my gratitude to the contributors to the first edition of this manual. Their help was essential to
its success. Many aspects of the first edition continue to be vital to treatment planning, therefore, they
have been included in this edition.
Since the first edition, many clinicians have helped with numerous suggestions and clinical
examples related to treatment planning, many of which have been integrated into this second edition.
Especially useful have been recommendations relating to the integration of the Nursing Care Plan into
the Master Treatment Plan. Clinicians from a wide range of facilities, as well as visitors to
www.kennedymd.com, have provided suggestions and help.
At Worcester State Hospital, Worcester, Massachusetts, I owe thanks to many current and past
nursing and psychiatric staff who were helpful with the integration of the Nursing Care Plan into the
Master Treatment Plan. Also, staff in the Mental and Behavioral Health Services at Our Lady of the Lake
Hospital, Baton Rouge, Louisiana, were very supportive, including Frank Silva, MD, medical director,
and Cami Ledford, BSN, RNC, clinical instructor.
I express my appreciation to Rose Mary Carroll-Johnson, MN, RN, editor, Nursing Diagnosis: The
International Journal of Nursing Language and Classification. She provided vital help with the integration
of nursing diagnoses into the Master Treatment Plan.
My thanks to Gretchen H. Horner, RNC, former administrative director, Memorial Hospital,
Johnstown, Pennsylvania, and Kathy Andolina, RN, MSN, CS, at The Center for Case Management, Inc.,
South Natick, Massachusetts, for their support of the concept of using an outcome measure to help
structure and track clinical care.
Special thanks to Chris Beaudoin, CNS, for her support during my visits to work with staff on
treatment planning at Greater Bridgeport Community Mental Health Center, Bridgeport, Connecticut;
Steve Sorkin, PhD, for his support during my work with staff on treatment planning at the Northern
Virginia Mental Health Institute, Falls Church, Virginia; and Dorothy Erney, RRA, Quality Coordinator,
Binghamton Psychiatric Center, Binghamton, New York. I also express my thanks to staff from the
Hudson River Psychiatric Center, Poughkeepsie, New York, and the New Hampshire Hospital, Concord,
New Hampshire.
I appreciate Joseph Black, MD, Chief Psychiatrist, Competency Program, North Texas State
Hospital–Vernon, Vernon, Texas, for his years of support for my systematic approach to psychiatric
treatment planning, including the use of the Kennedy Axis V questionnaire. The appendix includes a
sample Master Treatment Plan provided by Dr. Black, which is organized around the Kennedy Axis V
subscales.
Finally, without the structure provided by the Kennedy Axis V questionnaire, this manual would
not be possible; therefore, I refer you to the “Acknowledgments” section in the companion manual,
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric
Publishing 2003).
Identifying Patient Data
The patient and client names and associated responsible staff and treatment facilities used in this book
are fictitious. They are intended to aid in identifying individual Master Treatment Plans, Treatment
Plan Reviews, and Individual Problem Plans being discussed among staff using this manual. Even
though patient names are fictitious, the plans are based on many years of clinical experience writing
psychiatric treatment plans and gathering case material from colleagues and conferences.
Even though the plans and reviews are not based on actual cases, they are usually composites of
actual cases; therefore, the plans should resemble plans that would be generated during actual team
meetings. Identifying data has been changed or eliminated. Any resemblance to or association with real
individuals is purely coincidental.
INTRODUCTION
Intro–1
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Introduction
Intro–3
INTRODUCTION
CONTENTS
History and Development of the Manual .......................................................................................... Intro–5
Overview ................................................................................................................................................... Intro–5
Moving From Diagnosis to Level of Functioning ...................................................................................... Intro–5
Kennedy Axis V ......................................................................................................................................... Intro–5
Abbreviations ............................................................................................................................................ Intro–6
Online Support.......................................................................................................................................... Intro–7
Rationale for Categorization of Problems by the Kennedy Axis V .................................................... Intro–8
Overview ................................................................................................................................................... Intro–8
No Perfect Fit............................................................................................................................................. Intro–9
Quick Reference to Problem Categorization by the Kennedy Axis V ........................................................ Intro–9
Quick Reference to Problem Categorization by the Kennedy Axis V .............................................. Intro–10
General Instructions for Treatment Planning.................................................................................. Intro–11
Overview ................................................................................................................................................. Intro–11
Is It Necessary to Use This System and the Forms in This Manual? ........................................................ Intro–11
Standards for Treatment Planning and Use of the Manual by Accreditors.............................................. Intro–12
Treatment Planning Depends on the Total Clinical Picture.................................................................... Intro–13
Treatment Plan Reviews .......................................................................................................................... Intro–13
Integration of the Nursing Care Plan Into the Master Treatment Plan ................................................... Intro–14
Significant Problems Should Not Be Omitted From the Problem List ..................................................... Intro–14
Tracking the Flow of Treatment .............................................................................................................. Intro–15
Date Problem Established Versus Date of Onset...................................................................................... Intro–15
Long-Term Goals and Short-Term Goals Versus Goals and Objectives ................................................... Intro–15
Treatment Goals Versus Treatment Modalities ....................................................................................... Intro–16
Treatment Modalities That Have Effects Across Problem Areas............................................................... Intro–17
Steps for Building Goals and Treatment Modalities ................................................................................ Intro–18
Individual Problem Plan for Each Active Problem .................................................................................. Intro–19
Avoiding Excessive Documentation ........................................................................................................ Intro–20
Inclusion of Milieu Staff in Treatment Planning..................................................................................... Intro–23
Master Treatment Plan Forms (Step-by-Step Instructions)............................................................. Intro–24
Problem List/Cover Sheet ........................................................................................................................ Intro–24
Strengths/Discharge Plan/Diagnosis Page ............................................................................................... Intro–30
Individual Problem Plan.......................................................................................................................... Intro–31
Signature Page ......................................................................................................................................... Intro–34
Treatment Plan Review Form .................................................................................................................. Intro–34
Notes
Introduction
Intro–5
History and Development of the Manual
Overview
First, I would like to say that I am a clinician and much of my clinical experience comes from my work
over many years primarily at Worcester State Hospital in Worcester, Massachusetts. My expertise in
treatment planning comes from developing treatment plans as a member, and often as the leader, of a
treatment team. I also act as a consultant to help other clinicians improve their treatment plans. Since
the first edition of this manual was published in 1992, it has been the standard for treatment planning
throughout the country. Before its publication, I saw numerous treatment planning systems fail because
of their inability to manage the complexity of treatment planning. This was especially true when it
came time to review and modify the plan. The first edition has helped guide clinicians and
administrators toward a much more rational and systematic approach to treatment planning. This
second edition will further efforts toward improving the quality of treatment plans and will improve
the efficiency of writing treatment plans.
As with the first edition, the second edition is built around the structure of the Kennedy Axis V
(formerly the Axis V Subscales). Outcome measurement is a vital part of the treatment planning process.
Therefore, Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (Kennedy
2003), which introduces the latest version of the Kennedy Axis V, is released in conjunction with this
second edition of Fundamentals of Psychiatric Treatment Planning.
Moving From Diagnosis to Level of Functioning
Because of the increasing importance of treatment planning and continuing difficulties with this
process, I began attempting to develop a system that would allow our treatment teams to more
effectively plan, document, evaluate, and revise treatment. The first step in that process involved
moving from diagnosis to psychiatric symptoms and level of functioning as the basic system of
categorization used for treatment planning.
Most psychiatric treatment and nursing care planning manuals address treatment planning from
the perspective of the diagnosis. However, for many years, treatment planning has been mostly based
on a problem-oriented record. A major difficulty in organizing treatment planning around the diagnosis
is the fact that symptoms and behaviors are by no means unique to a diagnosis or even a group of
diagnoses. Also, level of functioning, not diagnosis, often determines treatment needs, including the
need for hospitalization. Therefore, this manual is based on categories of the symptoms and behaviors
that make up Problem Lists.
Kennedy Axis V
To develop this systematic approach to treatment planning, I selected Axis V from the Diagnostic and
Statistical Manual of Mental Disorders. Axis V, which measures psychiatric symptoms and level of
functioning, seemed ideal because of its focus on adaptive, problematic behaviors and outcome. In the
next step, drawing from Axis V and similar scales, I developed the Kennedy Axis V (see the
“Questionnaires” section of this manual for a copy of the Kennedy Axis V).
The Kennedy Axis V divides the symptoms and behaviors from Axis V into four problem areas:
Psychological Impairment, Social Skills, Violence, and ADL–Occupational Skills. To complete the
problem categorization, I added Substance Abuse, Medical Impairment, and Ancillary Impairment. This
categorization forms the basic structure of the manual. The categories are elaborated in the next section,
“Rationale for Categorization of Problems by the Kennedy Axis V.” In addition, the Kennedy Axis V can
be used to measure outcome of treatment in each of the subscale areas.
Intro–6
Fundamentals of Psychiatric Treatment Planning
Abbreviations
The following abbreviations are often associated with the treatment planning system presented in this
book:
AA
Alcoholics Anonymous
ADL
Activities of Daily Living–Occupational Skills
AEB
As evidenced by
AIMS Plus
EPS
AIMS Plus Extrapyramidal Side Effects
AIMS
Abnormal Involuntary Movement Scale
ANC
Ancillary Impairment
ASA
Aspirin (acetylsalicylic acid)
AWA
Away without authorization
bid
Twice a day
BP
Blood pressure
BPRS
Brief Psychiatric Rating Scale
BUN
Blood urea nitrogen
COPD
Chronic obstructive pulmonary disease
COTE
Comprehensive Occupational Therapy
Evaluation
CT scan
Computer-aided tomography scan
DBT
Dialectical behavioral therapy
DL
Dangerousness Level
ECG
Electrocardiogram
ECT
Electroconvulsive therapy
EEG
Electroencephalogram
EPS
Extrapyramidal side effects
FBS
Fasting blood sugar
GAF Eq
GAF Equivalent
GAF Scale
Global Assessment of Functioning Scale
HS
Hour of sleep
Hx
History
Hz
Hertz (cycles per second)
IPP
Individual Problem Plan
K Axis
Kennedy Axis V
LTG
Long-Term Goal
MED
Medical Impairment
meds
Medications
MHA
Mental health assistant
MHW
Mental health worker
Introduction
MRI
Magnetic resonance imaging
MTP
Master Treatment Plan
NCP
Nursing Care Plan
Nsg.
Nursing
po
By mouth, orally
prn
As needed
PSY
Psychological Impairment
pt.; pts.; pt.’s
Patient, patients, patient’s
q
Every
R/O
Rule out
SAb
Substance Abuse
SNF
Skilled nursing facility
SOC
Social Skills
SSDI
Social Security Disability Income
SSRI
Selective serotonin reuptake inhibitor
STD
Sexually transmitted disease
STG
Short-Term Goal
Sx
Symptoms
TLE
Temporal lobe epilepsy
TPR
Treatment Plan Review
Tx
Treatment
VIO
Violence
WBC
White blood cell count
WNL
Within normal limits
Intro–7
Online Support
Visit www.kennedymd.com for support and updates of the Kennedy Approach to Psychiatric Treatment
Planning and outcome measurement using the Kennedy Axis V questionnaire. Additional sample plans,
training opportunities, updates of blank forms, and other materials are also available at the website. You
can contact the author at the website and you are encouraged to make comments or ask questions
about psychiatric treatment planning.
Intro–8
Fundamentals of Psychiatric Treatment Planning
Rationale for Categorization of Problems by the
Kennedy Axis V
Overview
The purpose of this categorization system is to simplify problem identification and planning by
grouping problems using the Kennedy Axis V. The wide range of psychiatric symptoms and behaviors
are divided into the four broad categories of the Kennedy Axis V:
1.
2.
3.
4.
Psychological Impairment
Social Skills
Violence
ADL–Occupational Skills
To complete the system, the following three categories were added:
5. Substance Abuse
6. Medical Impairment
7. Ancillary Impairment
The use of the Kennedy Axis V Categorization System for problem identification and treatment
planning has several advantages:
•
•
•
•
•
These categories are not new theoretical areas. The areas are well known to clinicians and they
make a lot of clinical, intuitive sense. The areas are consistent with much of the training
received by clinicians. Because of the universal nature of the categories, they can be easily used
across disciplines. Minimal training is required to understand the categories.
By going step by step through these seven categories, practitioners can take a systematic
approach to identifying the problems. When one has proceeded through these seven
categories, one is very unlikely to have overlooked significant clinical areas.
Many symptoms and behaviors cluster together in syndromes that can be found within each of
the seven areas. Therefore, treatment can be directed at the syndrome within a problem area,
rather than at several individual problems. For example, use “depressive symptoms” rather
than “sadness,” “loss of appetite,” “insomnia,” and “lethargy.”
Training can be directed toward the individual categories as well as toward the categories as an
interactive system.
Finally, the Kennedy Axis V can be used to measure baseline functioning and the outcome of
treatment.
The Kennedy Axis V Categorization System allows the clinician to set a reasonable balance
between being too broad when defining problems and being too specific. Problem Lists that are broken
up into a lot of individual, discrete problems often lead to treatment plans and progress notes that are
choppy and disconnected. Defining a problem somewhat broadly allows clinicians to more easily
integrate what is happening in a clinically meaningful way. Progress notes tracking treatment and its
outcome are often more coherent and useful when directed at syndromes consisting of discrete
problems. However, the use of very discrete problems can tighten up one’s thinking and planning.
There are certainly advantages to directing treatment toward individual, discrete problems as opposed
to very broad groups of problems. Again, the Kennedy Axis V Categorization System allows clinicians to
set a reasonable balance between discrete versus broad problem names based on one’s clinical
judgment.
The system discourages collapsing problems from separate subscale areas into a single problem,
even though there may be a clear relationship between the problems. For example, “depressive
symptoms” and “suicidal ideation” should not be collapsed into a single problem, nor should “cocaine
Introduction
Intro–9
abuse” and “assaultiveness” be collapsed into a single problem, even if there is a clear relationship
between the problems.
If a problem area consists of a single, specific symptom or behavior, a broad problem name should
not be used. For example, “psychotic symptoms” should not be used if the patient’s only symptom of
psychosis is paranoia.
No Perfect Fit
Any classification system that attempts to divide human behaviors into their component parts will
quickly run into areas in which the components do not fit cleanly into one problem area or “box.” In
such systems, ambiguity and disagreement about where particular symptoms and behaviors should be
placed is unavoidable. Despite the drawbacks and difficulties of classifying human behavior, use of the
Kennedy Axis V Categorization System serves to organize the complexity of clinical features that
patients present.
As indicated earlier, if a syndrome does not fit into one problem area, the syndrome should be
broken down so its components can fit into the appropriate problem areas. For example, “suicidal
ideation“ should be removed from “depressive symptoms” and placed under the subscale area of
Violence. “Lack of motivation” should be removed from the problem of “poor job skills” and placed
under the subscale of Psychological Impairment. Further, “lack of motivation” may be placed under the
problem name of “depressive symptoms” or “psychotic symptoms.”
Quick Reference to Problem Categorization by the Kennedy Axis V
The next page in this manual, “Quick Reference to Problem Categorization by the Kennedy Axis V,” can
be copied and used as a reference guide to problem names. Additional listings of problem names and
descriptions classified by the Kennedy Axis V can be found at the beginning of each chapter on the
individual subscale areas of the Kennedy Axis V.
Intro–10
Fundamentals of Psychiatric Treatment Planning
Quick Reference to Problem Categorization
*
by the Kennedy Axis V
This classification system serves to simplify problem identification and treatment planning by
categorizing problems using the Kennedy Axis V subscales. The wide range of psychiatric and medical
symptoms, syndromes, and issues are divided into the following seven problem areas. Listed below are
some examples of problems from each of the seven areas.
1.
Psychological Impairment
Psychotic symptoms
Poor motivation
Mood disturbance
Personality disturbance
Poor focal attention
Eating disturbance
2.
Social Skills
Limited interpersonal skills
Poor communication skills
Lack of awareness of social norms
Sexually inappropriate behavior
3.
Violence
Threatening and assaultive
Suicidal
Homicidal
Sexually violent
Arsonist
4.
ADL–Occupational Skills
Poor job skills
Lack of skills to care for self
Poor workmanship
Lack of basic survival skills
Poor personal hygiene skills
5.
Substance Abuse
Alcohol abuse
Cocaine abuse
Polysubstance abuse
Nicotine addiction
6.
Medical Impairment
Hypertension
Allergy to penicillin
Diabetes
Family planning concerns
Tardive dyskinesia
Dental problems
7.
Ancillary Impairment
Homelessness
Financial problems
Abusive spouse (domestic violence)
Legal problems
Incarceration
Need for guardianship
Permission granted by American Psychiatric Publishing, Inc., and James A. Kennedy, MD, to copy this page.
Introduction
Intro–11
General Instructions for Treatment Planning
Overview
These instructions are intended to address a few of the key issues often raised when doing treatment
planning, including nursing care planning. This manual is based to a great degree on treatment
planning for long-term-care patients. However, the principles and methods can be generalized to any
psychiatric treatment setting or population. This manual is based on the assumption that the Master
Treatment Plan (MTP) can form the working center of the patient’s record (see Figures 1 and 2). It can
guide staff through complicated, interdisciplinary treatment processes.
Certainly it is hoped that the manual will be used as a reference and teaching guide outside the
treatment team; however, its main function is to assist team members during the actual planning
process. To this end, I attempted to make the manual thorough, but brief. Further, the organization of
the manual is intended to allow rapid access to needed material during the actual treatment team
meeting. Quick access to information is critical during the limited time for a team meeting. Therefore,
tabbed divider pages and separate numbering for each section facilitate access to information.
Comprehensive lists of problems, goals, and treatment modalities characterize the manual. To a
great degree, the complexity of human symptoms and behaviors, as well as the limitless range of goals
and the numerous treatment approaches, drove the length of these lists. A close look at the lists reveals
many entries that should apply to patients whose MTPs you are currently writing.
Finally, it is suggested that you explore using the Kennedy Approach to Psychiatric Treatment
Planning across inpatient and outpatient care providers. A standard MTP approach across treatment
providers can be very helpful to ensure continuity of care.
Database Assessments
Psychological
Tests
Master Treatment Plan
Consults
&
Laboratory Tests
Nursing Care Plan
Progress Notes
&
Legal
Treatment Plan Reviews
Physician’s
Orders
Figure 1. Treatment plans do not stand alone. The treatment plan, including the Nursing Care Plan, is the engine that
drives the treatment process; however, it must work in conjunction with the rest of the patient’s record. Only when the
treatment plan is working effectively with the other sections of the patient’s record will it be acceptable to the accreditors
as well as to the clinicians who use the plan.
Is It Necessary to Use This System and the Forms in This Manual?
What if you do not want to change to this system or use the forms included in this manual? Because
almost all accreditors require treatment plans with behaviorally oriented problem definitions,
measurable treatment goals, and treatment modalities, this manual will be useful even when the
Intro–12
Fundamentals of Psychiatric Treatment Planning
clinicians are not using the systematic approach and forms in this manual. The audience to which this
manual is addressed includes staff at psychiatric hospitals, halfway houses, and community mental
health centers and students in academic programs—that is, anyone working where treatment planning
or nursing care planning is practiced or taught.
Problem List
Problem
Description
Goals and Target
Dates
Master Treatment Plan
Strengths
&
Treatment
Modalities
Nursing Care Plan
Diagnosis
&
Discharge
Planning
Treatment Plan Reviews
Signatures
Status and Status Changes
Figure 2. The parts of the treatment plan, including the Nursing Care Plan, must work together as a unit. The goals and
treatment modalities should reflect the problem description. The treatment modalities should consist of treatments that
will help attain the goals. The signatures should reflect real contributions to the interdisciplinary plan. The plan should be
able to easily and accurately reflect any changes or additions in the goals, treatment modalities, target dates, and so
forth. Without these capabilities, it will not be an effective tool for clinicians.
Standards for Treatment Planning and Use of the Manual by Accreditors
The treatment planning system presented in this manual is increasingly becoming the standard for
psychiatric treatment planning. This is evidenced as accreditors and consultants use this manual as a
standard for comparison when checking psychiatric treatment plans. Also, the manual is well known to
many reviewers and consultants who use it when making decisions and recommendations concerning
psychiatric treatment planning. For example, an accreditor could compare a patient’s plan on “suicidal
ideation” with an Individual Problem Plan (IPP) on suicidal ideation in the Violence subscale section of
this manual. In the same section, the accreditor could compare the plan against lists of goals and
treatment modalities that address the suicidal patient, as well as suggestions on what would be expected
in the problem description of a patient with suicidal ideation.
Use of this manual makes it much easier for an accreditor to discuss how treatment planning
deviates from what he or she sees as acceptable. In addition, by using this manual, the mental health
facility can more intelligently respond to any criticism by the accreditor and more easily implement
corrective actions within the facility. The accreditors may also modify this manual so that it
approximates the standard of care expected in a specific type of facility.
Increasingly, there are accepted standards of treatment for various psychiatric symptoms and
behaviors. This manual will continue to be a part of the process of developing such standards in
treatment planning. As a part of those standards, it is hoped that increasingly there will be support for
the integration of formal outcome measures into the treatment planning process. The Kennedy Axis V
questionnaire is presented as ideal for meeting such a standard.
Introduction
Intro–13
Treatment Planning Depends on the Total Clinical Picture
Treatment planning cannot be conducted in a vacuum (see Figure 1). It touches on and interacts with
all aspects of the clinical process. Of special importance is the interaction between the treatment plan
and the discipline assessments and progress notes. The need for thorough assessments and good
progress notes cannot be overstated. Without accurate, complete clinical evaluations by the various
disciplines, rational treatment planning and reviewing are impossible. Once the assessments are
completed, a consistency must be established between the assessments and the MTP. This consistency
must then continue between the plan and progress notes. Accreditors often cite inconsistencies between
the treatment plan and the assessments or progress notes as deficiencies.
Treatment Plan Reviews
Once the MTP has been completed, subsequent changes in the plan must be documented. This is done
through formal Treatment Plan Reviews during a treatment team meeting and through less formal
documentation, such as using progress notes to document changes. The day-to-day changes in the
patient’s status and progress toward goals are generally captured in the progress notes. These changes
are then summarized in subsequent Treatment Plan Reviews.
Accreditors, such as the Joint Commission on Accreditation of Healthcare Organizations and CMS
(Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration
[HCFA]), generally require formal treatment plan reviews in the following situations:
•
•
•
•
When the patient is admitted, transferred, or discharged
When a major change occurs in the patient’s clinical condition
When the patient has successfully completed any treatment goals
When the patient fails to reach treatment goals despite reasonable clinical care
These formal Treatment Plan Reviews are generally used to review, summarize, and update changes.
These formal reviews are also used to ensure that changes in treatment are added or have been added to
the MTP itself.
Scheduling team meetings to immediately review changes is often impossible. The inability to hold
a treatment team meeting each time a review is needed or a change is made in the treatment plan is
often dealt with in one of two ways:
1. A team member who wants a change in the treatment plan discusses the change with available,
relevant team members. The patient should also be included in this process to the degree that
is clinically appropriate. If it is decided that the plan should be changed, the team member
enters the change on the MTP and dates and initials the change. The team member enters
details of the change and the rationale for the change in the progress notes. At the next
treatment team review, the change is discussed with the entire treatment team.
2. The same as #1, except no entry is made on the treatment plan until the next Treatment Plan
Review meeting. As in #1, a team member enters details of the change and the rationale for the
change in the progress notes.
When a change in the plan occurs, it is unacceptable not to make an entry in one of the following: the
Master Treatment Plan, the Treatment Plan Review, or the Progress Notes.
Finally, the clinical team may be so conservative in its definition of “major changes” or
“reasonable clinical care” that few, if any, formal Treatment Plan Reviews occur. Therefore, to ensure
that treatment reviews occur at least with some minimal frequency, it is recommended to use a
combination of reviews according to the four clinical requirements mentioned earlier, as well as
scheduled periodic reviews. For example, for a very stable patient, Treatment Plan Reviews might be
scheduled for every 3 months. If a review were done before 3 months, then the next review would be
rescheduled for 3 months following the last completed review. This schedule would ensure that a
review is done at least every 3 months, as well as when clinically indicated by the clinical criteria.
Intro–14
Fundamentals of Psychiatric Treatment Planning
The minimal frequency for formal Treatment Plan Reviews should be based on the usual rate of
change in the patients’ clinical treatment/status within a particular facility or unit within the facility.
For many facilities, it seems reasonable to have a scheduled review every month for the first 6 months
to 1 year and every 2 to 4 months thereafter. One may also want to make allowances for patients
readmitted after only a short time out of the hospital.
Integration of the Nursing Care Plan Into the Master Treatment Plan
There is tremendous overlap between the MTP and the Nursing Care Plan (NCP). The description of the
problems (nursing diagnoses), including response to previous treatments, should be identical. The
nursing interventions on the NCP and the MTP should be essentially identical; therefore, simply
consolidating them into the MTP can eliminate the redundancy. All members of the team should be
working toward the same long-term goals and short-term goals (objectives), even though specific team
members may be more focused on particular goals. Therefore, it is recommended that nursing staff
integrate the NCP into the MTP rather than have separate plans.
Because the nursing interventions (nursing treatment modalities) often form the main component
that differentiates the MTP from the NCP, it is suggested that the nursing interventions (treatment
modalities) in the MTP be labeled as the “Nursing Care Plan.”
Another equally important reason for integrating the NCP into the MTP is to encourage nursing
staff to be more actively involved with the development and implementation of the MTP. It is not
unusual for nursing staff members to complete their NCP and feel they have met their obligations to
the treatment planning process. They may then move forward with implementing their plan with
minimal investment in the MTP—that is, they feel little ownership of the MTP because they already
have their own plan.
Nursing staff may even see the NCP as a means of separating themselves from the problems,
difficulties, and even at times the chaos that can be associated with poorly developed MTPs. With their
own plan, nursing staff members may not have to worry about the difficulties of becoming an
integrated member of the team process. They have their separate, defined role as outlined in their NCP.
If there are problems with the MTP, those problems can be seen as problems for other team members.
Because they have their own plan, nursing staff members may have little vested interest in the MTP.
Finally, it is suggested that the inclusion of the NCP in the MTP be the “standard of care.”
Throughout this manual, it is assumed that the NCP has been integrated into the MTP. Often in this
manual, you will see that the NCP has been clearly indicated as part of the MTP; however, even when
not clearly indicated, it should be understood that the NCP has been integrated into the MTP.
Significant Problems Should Not Be Omitted From the Problem List
If the Problem List is complete, clinicians will not be surprised by significant clinical issues or problems
lost or buried in the patient’s chart. Generally the Problem List is the only place in the chart where
there is a comprehensive, condensed, and updated outline of all significant clinical issues. This list is a
key part of any clinical chart. The Problem List is one of the first places clinicians should go when
attempting to get a quick overview of the patient’s clinical situation.
To help ensure that significant problems are not overlooked, when determining the Problem List
you should work your way systematically through each problem area, starting with Problem Area 1
Psychological Impairment and ending with Problem Area 7 Ancillary Impairment.
The Problem List should contain all significant clinical problems. In addition to the obvious
problems, the Problem List should contain items such as history of assaultive behavior, history of
suicidal attempt, allergy to penicillin, single kidney, and so on. These problems should not be listed if
they are felt to be of no clinical significance (e.g., if the suicidal attempt was an isolated incident that
occurred years ago and is of no future clinical relevance to the case). Problems should not be listed if
they are already incorporated into an active problem. Allergies do not need to be included on the
Problem List if there is already a system in place to prominently display allergies in the patient’s record.
Also, in addition to problems, the list should contain other clinical factors that require treatment
or clinical resources, such as pregnancy, criminal charges, Tarasoff warning, placement, health
Introduction
Intro–15
maintenance, and so on. This is the treatment plan, not the problem plan; therefore, important areas
involving treatment should not be omitted from the treatment plan simply because they are not seen as
a “problem.”
Tracking the Flow of Treatment
A very important feature of the treatment planning system in this manual is the innovative ability of
the IPP forms to illustrate the flow of treatment. The clinical process is a fluid process; therefore, the
treatment planning system and forms must be able to reflect the progressive changes that occur in the
clinical process. This system is able to capture the changes in treatment when the patient progresses to
the point that new treatments are clinically useful. It can also capture any changes in treatment when
the desired results are not obtained. The details on the use of the IPP forms to track the flow of
treatment are presented in the “Master Treatment Plan Forms (Step-by-Step Instructions)” section
presented later in this chapter.
Date Problem Established Versus Date of Onset
There is often confusion over the difference between the “date established” for the problem and the
“date of onset” of the problem. The date established serves the purpose of marking how far back into
the chart one should search to review the documentation on a problem. Without a date established, the
entire chart might have to be searched to find all the information on a problem. In a long-term-care
facility, this could mean unnecessary searching through years of records.
The date of onset of the problem means exactly what it says. The date of onset is often at or near
the date the problem was established. However, these two dates can often be very different. There are
often major problems in psychiatry determining the date of onset of a problem. The onset of many
psychiatric problems is insidious. It is not unusual for the onset to span a period of years. Attempting to
establish an exact date for onset of a problem often leads to long, nonproductive arguments within the
treatment team. The date of onset of the problem is certainly important and, if known, can be included
in the description of the problem. Figure 3 shows a few examples.
1.1 Depressive Symptoms
Problem Description: Over the last several months, there has been a progressive return of patient’s
depression. About 2 weeks ago, there was a marked worsening in association with several arguments
with his wife …
3.1 Suicidal Attempt
Problem Description: Patient’s first suicidal attempt was at age 13; however, about 8 years passed
before his next attempt just before his current hospitalization …
6.1 Laceration of Left Forearm
Problem Description: The laceration on the patient’s left forearm occurred on 01/01/03 as a result of
his suicidal attempt with a razor …
Figure 3.
Examples of the date of onset.
In these examples, except for “laceration of left forearm,” various arguments could be put forth as
to which date to include as the date of onset. These arguments can be very time consuming. Including
this information in the problem description allows the clinicians the opportunity to explain the
progression of the development of a problem and often eliminates the arguments and confusion.
Long-Term Goals and Short-Term Goals Versus Goals and Objectives
In this system, long-term goals and short-term goals are used to track outcome of treatment. In other
treatment planning systems, especially NCPs, the terms “goals” and “objectives” are substituted for
“long-term goals” and “short-term goals.”
Intro–16
Fundamentals of Psychiatric Treatment Planning
Use of either pair of outcome measures is acceptable; however, the use of long-term goals and
short-term goals has several advantages.
• The phrases “long-term goals” and “short-term goals” are unambiguous. Little or no training is
needed to have at least some working understanding as to the meaning of these phrases.
However, the term “objective” has a wide range of commonly used meanings. Due to its wide
range of definitions, the introduction of “objective” can be confusing to the writer and anyone
who reads the plan. This confusion leads to the need for additional training, which can be timeconsuming and expensive.
• The concepts of long-term goals and short-term goals fit very well along a continuum. However,
goals and objectives do not intuitively fall along a continuum. The terms imply much more of a
qualitative difference than should exist between them.
• Separate categories of possible long- and short-term goals are not necessary. Depending on the
clinical situation, a long-term goal can be a short-term goal and vice versa. For example,
“patient will be free of assaultive behavior for a 1-week period” can be a long-term goal in an
acute setting if freedom from assaultive behavior for 1 week is determined to indicate that the
problem is no longer active or is adequately treated so that the patient can be discharged from
the acute setting. The same goal may be a short-term goal in a chronically assaultive patient if it
is determined that being assault-free for 1 week simply indicates improvement; however, a
much longer assault-free period is felt necessary to indicate that the problem is no longer active
or that adequate improvement has occurred for discharge.
As a rule of thumb, long-term goals are essentially the same as goals, and short-term goals are
essentially the same as objectives. Of course, all outcome measures, regardless of how they are named,
need to comply with rules that ensure they are observable and measurable. See “Master Treatment Plan
Forms (Step-by-Step Instructions)” later in this chapter for further information on long- and short-term
goals and target dates.
Treatment Goals Versus Treatment Modalities
Several issues are frequently raised concerning treatment goals and treatment modalities
(interventions):
Differentiating Goals and Treatment Modalities
The difference between goals and treatment modalities seems very simple: goals equal “ends” and
modalities equal the “means” by which the goals are attained. However, the picture clouds when goals
are further defined as “targeted, measurable” changes that occur in the patient. Completing a test or
procedure can be seen as a goal or an end point; however, such tests or procedures cannot be seen as
“targeted, measurable” changes in the patient.
When deciding whether to define an item as a goal rather than a treatment modality, one may
also want to consider that goals have target dates. If the item is defined as a goal, target dates can be
easily assigned and a mechanism is in place to track whether the test or procedure has been completed.
For certain items, especially tests and evaluations, these target dates can be very useful.
A rule of thumb that many clinicians find helpful to distinguish goals from modalities is the fact
that most goals can be stated as “Patient will …,” whereas most treatment modalities can be stated as
“Staff will …” However, this manual does not make an inflexible distinction between goals and
modalities. One is, therefore, encouraged to use his or her clinical judgment as to whether particular
items should be defined as goals or modalities.
Establishing the Importance of Treatment Modalities
Treatment modalities are generally real, actual occurrences. Even well thought out goals can often turn
out to be the clinician’s “wish list.” This is especially true for the long-term-care patient. For this reason,
it is often argued that more emphasis should be placed on treatment modalities. Another reason for the
emphasis on modalities is that staff members frequently go to treatment plans to get an update on
Introduction
Intro–17
treatments for various problems. Though certainly important, goals have never seemed to gain the
clinical usefulness to the staff that treatment modalities have.
Further, if the goals are reached, but the treatment modalities are unclear, it may appear as if one
accidentally stumbled into attaining the goals. Finally, it is much easier to defend inaccurate goals and
inaccurate target dates than to defend inaccuracies in the treatment modalities. Predicting the future is
difficult; however, failing to accurately represent what is happening in the present, such as treatment
modalities, can leave one open to criticism.
Working Backward From Treatment Modalities to Goals
In filling out treatment planning forms, one major argument concerning the sequence is often raised.
That argument relates to whether one should enter the treatment modalities before the goals. Logically,
it seems to make a lot of sense to start with the goals; however, clinically, it is sometimes much more
useful to start with the treatment modalities. It is not unusual for the availability of resources to drive
treatment to a greater degree than the goals do. This is especially true for the long-term patient who has
exhausted many of his or her resources, including family supports. The availability of specific
treatments, including the expertise needed for those treatments, can markedly affect the development
of realistic goals and realistic target dates. Therefore, once treatment modalities have been determined,
the modalities can be surprisingly helpful when attempting to write realistic treatment goals.
Treatment Modalities That Have Effects Across Problem Areas
Psychotropic medications often have effects in several problems areas; however, in some areas, the
effects are brought about primarily by improvements made by the medications in other areas.
Therefore, it is recommended that medications be listed only within the one or two problem areas in
which they are expected to have their primary effects.
For example, even though antipsychotics and antidepressants can have significant direct and
indirect effects in Problem Area 2 (Social Skills), Problem Area 4 (ADL–Occupational Skills), Problem
Area 5 (Substance Abuse), and Problem Area 7 (Ancillary Impairment), the improvements are often due
to the secondary effects of improvements in energy, motivation, focal attention, paranoia, and
hostility. These medications are often given primarily as a treatment for Problem Area 1 (Psychological
Impairment) and Problem Area 3 (Violence), even though they have clear, important roles in other
problem areas. Therefore, it is recommended that antipsychotics and antidepressants be listed under
Problem Area 1 and Problem Area 3, if Problem Areas 1 and 3 are the primary problem areas being
targeted by these medications.
This pervasive effect is also true for many nonmedication treatments. Treatment should be listed
only in the one or two primary problem areas to which it is being targeted. For example, a substance
abuse group may have significant effects on the patient’s depressive symptoms and social skills; however,
its primary target is substance abuse. Therefore, generally the substance abuse group would only be listed
on an IPP under Problem Area 5 (Substance Abuse). Other groups and treatments would probably be used
to treat the patient’s depressive symptoms and problems with social skills. These other groups and
treatments would then be listed as the treatments for the depressive symptoms and social skills problems,
rather than the substance abuse group.
Intro–18
Fundamentals of Psychiatric Treatment Planning
Steps for Building Goals and Treatment Modalities
In this section, simple steps are presented as a “rule-of-thumb” for writing goals and treatment
modalities. These steps will guide you through writing basic goals and treatment modalities and help
ensure that important components of goals and treatment modalities are not overlooked. When you
have decided on the components, you do not have to follow the same sequence when actually entering
them; however, the sequence often flows easily into the goal or treatment modality.
Use four steps to write goals (Figure 4):
1. “Pt. will ______ [plus active verb]”: Document that the patient is the one expected to accomplish
the goal. This goal includes an active verb, which indicates the patient’s action to accomplish
the goal.
2. Behavior expected [observable and measurable]: Present and write the target behavior in observable
and measurable terms. The more effective one is in writing the goal in observable and
measurable terms, the more likely it will be that it is clear when the goal has been attained.
3. Target frequency: Enter the expected frequency for the expected behavior when the goal has
been attained.
4. Time period: Enter the expected length of time it should take the patient to attain the goal.
Four Steps for Building Goals
1. Patient will ...
[plus active verb]
2. Behavior expected
[observable/measurable]
Pt. will make …
3. Target frequency
4. Time period
at least one nondelusional, relevant
comment in community meeting …
twice a week …
for 1 month.
Pt. will discuss …
the importance of taking his meds as
prescribed …
for 15 minutes twice weekly …
for 1 month.
Pt. will cooperate …
with at least one treatment team
member in the treatment planning
process …
once daily …
for 1 week.
Pt. will maintain …
relevance and focus on topics
beyond the first two sentences of a
conversation …
three times a week …
for 1 month.
Pt.’s motivation will
improve such that she
will have …
her personal dorm area in acceptable
order …
at least 3 out of 5 weekdays …
for 1 month.
Pt. will cooperate with
discharge plans so that
he is accepted …
into a halfway house program.
[not needed]
[not needed]
[not needed]
[not needed]
Pt.’s score on the
from the current score of 40 to 60.
Kennedy Axis V
subscale Social Skills will
improve …
Figure 4.
Examples of goals generated using the four steps.
Introduction
Intro–19
Also use four steps to write treatment modalities (interventions):
1. “Staff will ________ [plus active verb]”: Document that the staff will be providing the treatment.
This step includes an active verb that indicates the action that the staff will take to provide the
treatment.
2. Time period: Enter the length of time that the staff will use to provide the treatment.
3. Frequency: Enter the frequency with which the staff will provide the treatment.
4. Modality: Enter the treatment. At this point, you may also want to enter a reason for
recommending this particular treatment modality.
Figure 5 illustrates examples of treatment modalities generated using these four steps.
Four Steps for Building Treatment Modalities
1. Staff will ...
[plus active verb]
2. Time period
3. Frequency
4. Modality
Nurse will meet with pt. for at least 15 minutes … once weekly …
…
to educate pt. about her illness and the
importance of taking her meds.
Psychologist will lead
pt. …
1 hour …
once weekly …
in anger management group to help him
understand how his violent behavior acts as
a barrier to his discharge.
Nursing staff will assess
pt. …
[time necessary]
when she returns
from passes …
for any evidence of intoxication and will
report significant findings to the
psychiatrist.
Rehab staff will
schedule pt. …
for 1 hour …
twice weekly …
for AA meetings to learn more about alcohol
abuse risk factors and how to avoid them.
Psychiatrist will rate
pt. …
[time necessary]
once every
6 months …
on the Kennedy Axis V to help track pt.’s
level of assaultiveness.
Nurse will begin …
[as soon as clinically
reasonable]
[as often as clinically to assess pt.’s level of understanding of
reasonable]
antidepressant medication and his readiness
to learn before educating him.
Psychiatrist will meet
with pt. ...
for at least 35 minutes … once weekly …
to assess pt.’s level of psychosis and to
prescribe medications such as Zyprexa
(olanzapine).
Nursing staff will
encourage pt. …
[as needed]
to attend program activities and provide
escort, if needed.
Figure 5.
[on an ongoing
basis]
Examples of treatment modalities generated using the four steps.
Individual Problem Plan for Each Active Problem
It is recommended that one have a separate IPP sheet for each active problem on the Problem List.
There are several reasons why this is important to a good, comprehensive treatment planning system:
Ease of Documentation of Treatment Progress and
Rapid Access to Current Status of Treatment
An individual sheet for each active problem allows changes for each problem to be entered easily. The
clinical process is a fluid process; the treatment planning system needs to be able to reflect the flow of
Intro–20
Fundamentals of Psychiatric Treatment Planning
that clinical process. A benefit of including the IPP forms in this manual is their ability to reflect these
shifts in the clinical process. As a result, IPPs can allow a clinician to quickly determine the current
status of treatment for particular problems. The clinician can also quickly review the progress of the
treatment that has led to the current IPPs. It is not necessary to move back and forth between the
original MTP, Treatment Plan Reviews, and progress notes to determine the general progress and
current standing of the treatment.
Sharing of IPPs
IPPs are critical to the sharing and exchange of ideas on treatments for individual problems. If a good
plan is developed for a particular problem, then the IPP for that problem can be removed from the MTP
and copied and distributed as a guide for members of other treatment teams. Also, as indicated earlier,
IPPs could be written by experts in various areas and made available to users of the manual. These new
IPPs and shared plans can be added to the manual for quick reference.
Training
Training can be done for problem areas using IPPs. For example, IPPs on suicide and suicidal ideation
could form the basis for training related to treatment planning for the suicidal patient. IPPs on
symptoms and behaviors of the psychotic patient could be used for training related to treatment
planning for the psychotic patient.
No Increase in Documentation
Finally, there should be no significant increase in the amount of documentation. The information
required by the accreditors is the same regardless of whether the documentation is collapsed into one
central document or organized in a different manner. There may be more pages in a plan that requires a
page for each active problem; however, because both systems contain the same required information,
there should be no difference in the amount of documentation needed. This can create a problem
because there is a tendency by clinicians to want to completely fill any blank areas based on the size of
the blank area rather than the amount of information needed. Staff members need to be trained to
write briefly and concisely, regardless of the size of the blank areas.
Avoiding Excessive Documentation
Staff members want to provide clinically good treatment planning while avoiding excessive
documentation and use of valuable team time. Determining the necessary level of documentation is
often a difficult clinical decision. The following guidelines suggest where cuts can and cannot be made
as well as the costs and benefits of these decisions.
Situations in Which Cuts Are Not Recommended
An IPP is requested for each active problem. Also, taking a thorough, systematic approach to listing the
problems can lead to an increase in the number of problems identified. However, when a thorough
treatment planning process leads to a dozen separate sheets of paper, the patient obviously has multiple
impairments. In such cases, a good, comprehensive treatment plan can be very helpful and can save
time. These plans act as effective, clinical blueprints for integrating and working with a complex group
of goals and treatments.
It is not unusual for clinicians to exclude even active problems from the treatment plan. This is
unacceptable. A practitioner should not discover after reading the treatment plan that important
symptoms and behaviors (or even medical problems) have been excluded. These “surprises” can have
dangerous consequences.
Treatment planning without cutting corners or making major compromises can be timeconsuming and expensive. These high costs are up front and obvious. The savings gained by making
major compromises in treatment planning are often clearly evident, and the hidden costs may be
almost totally obscured. This illusion has led to an almost knee-jerk reaction to opt for major cuts and
compromises when developing the MTP; however, without the solid foundation of a good MTP,
subsequent treatment planning and reviews can be disorganized and confusing.
Introduction
Intro–21
A major contributor to this knee-jerk reaction is the fact that many clinicians falsely believe that
treatment planning has no clinical value. These are often responsible clinicians who think treatment
planning is necessary for satisfying accreditors but for little else. This attitude is fueled by years of
frustration with the poor results of even genuine attempts to generate good, useful treatment plans.
One of the primary purposes of this manual is to assist clinicians in their attempts to quickly generate
clinically effective treatment plans. If successful, it will help to reduce some of the frustration, anger,
and cost of treatment planning, while helping to improve the quality of care.
Situations in Which Cuts Are Recommended
There are certainly many ways to achieve direct compromises and cost-cutting measures. There are
situations in which such cuts and compromises can lead to better staff acceptance and more appropriate
treatment plans.
• Anticipated length of hospitalization. Certainly there may be less need for a comprehensive
treatment plan in an acute setting in which the average stay of the patient is only 8 to 10 days.
Many treatment decisions may be fresh in the minds of the clinicians; therefore, there may be
less of a need to refer to a comprehensive treatment plan. This is especially true if the treatment
team relies almost exclusively on other parts of the record for clinical information and
documentation of the clinical progress, for example, the progress notes.
The opposite is often true of the long-term-care patient. In the long-term-care patient,
treatment may be no more complicated than treatment for the acute-care patient; however, the
treatment is often much more unconventional and individualized. These patients have
generally failed to respond to the initial, somewhat standardized treatment strategies. As plans
get increasingly individualized, comprehensive treatment plans become increasingly important
to keep the team informed and working together. Also, as the length of hospitalization
increases, treatment planning decisions will no longer be fresh in the minds of the clinicians;
therefore, a comprehensive treatment plan can be helpful to remind staff of their roles with a
particular patient.
Problems in the long-term-care setting that are often deferred in the acute-care setting also
have to be addressed. For example, deficits in work skills may not be addressed at all in an
acute-care setting. However, these same deficits in work skills may be the primary focus of
treatment in a long-term-care facility.
• Degree to which the rest of the record effectively reflects treatment and its progress. If the
treatment planning information is well organized and easily accessed in the rest of the record,
the team may be less dependent on having a very comprehensive treatment plan. However, if
information about the team’s treatment plan and its outcome is buried in the record and
difficult to locate, then a comprehensive treatment plan can be extremely helpful with keeping
the team focused on their common goals and the methods to achieve those goals.
• Clinical style of the treatment team. Clinical styles vary greatly in the development and use
of MTPs. Some clinical styles may work better with an abbreviated, short plan. This manual and
its forms do not limit the use of the system to clinicians with a particular style. Therefore, if the
clinician wants to do a short, quick MTP, the system will allow for it. If the clinician wishes to
write a comprehensive plan, the system will continue to satisfy the needs of the clinician. The
system also allows clinicians and the quality assurance department a lot of flexibility to impose
their clinical judgments and standards onto what should be included in the treatment plan.
• Time constraints for a hurried treatment team. Obviously, if the team is not provided with
adequate time to prepare a reasonable treatment plan, the plan may lack many critical elements
or the plans may be extremely “canned” as clinicians take desperate steps to meet various
deadlines. It has been my experience that it is not unusual for clinicians to be expected to write
comprehensive treatment plans without the minimal time and staff needed to write reasonable
plans. I have seen this lead to anger and frustration among the staff.
Intro–22
Fundamentals of Psychiatric Treatment Planning
Clinically Appropriate Cuts
Finally, the following discussion covers several clinically appropriate ways to limit the size of a
treatment plan and to decrease the amount of team time needed to complete a plan.
• Limit the number of active problems that will require an IPP. This limit can result in a
clinically effective plan as short as three or four pages. Two methods can be used to achieve this
goal:
1. Collapse related problems under one name (e.g., delusions, hallucinations, and bizarre
behavior can be treated under the problem “psychotic symptoms”). The problem
description would contain an explanation of the symptoms and behaviors being addressed
by the problem “psychotic symptoms.” In this way, individual symptoms and behaviors are
retained in the plan without the plan being overwhelmed by the number of problems. The
system allows for collapsing of problems within the same subscale area; however, one
should not collapse problems from different subscale areas. For example, one should not
collapse the problem of suicidal attempts from the subscale area of Violence into depressive
symptoms because depressive symptoms should be under the subscale Psychological
Impairment.
2. Defer the treatment of active problems, if they do not require acute attention (“Deferred”
should be written in the problem status column of the Problem List). This can be especially
useful in acute-care settings.
• Delegate parts of the treatment plan to individual team members. Once these individuals
have completed drafts of their sections, the team should meet to finalize the plan. The full team
should meet to quickly put together a Problem List and Strength List by systematically going
through the seven problem areas and then assign the active IPPs to specific team members.
Generally speaking, IPPs from Problem Area 1 (Psychological Impairment) and Problem
Area 3 (Violence) might go to the psychiatrist or psychologist. IPPs from Problem Area 2 (Social
Skills) and Problem Area 4 (ADL–Occupational Skills) might go to the team member from
rehabilitation or to nursing. IPPs for Problem Area 5 (Substance Abuse) might go to the
individual or discipline that is most involved in substance abuse treatment. IPPs for Problem
Area 6 (Medical Impairment) may go to the psychiatrist, nurse, or the primary care physician.
IPPs for Problem Area 7 (Ancillary Impairment) often address placement or financial issues and
often go to the social worker. Legal problems under Problem Area 7 may go to the psychiatrist,
psychologist, or social worker.
The assigned clinicians then enter the problem description and goals. They enter only the
treatment modalities for treatment that they will provide. They do not write any treatment
modalities for other disciplines. When the team meets to finalize the plan, the clinicians
responsible for implementing the remaining treatment modalities can then enter those
modalities. At that time, the nurse(s) could also complete the NCP section of the treatment
modalities.
• Be brief and to the point with the problem description, treatment goals, and treatment
modalities. As mentioned earlier, there is a tendency by clinicians to fill blank areas based on
the size of the area rather than the amount of information needed. Staff members need to be
trained to write briefly and concisely, regardless of the space available.
• Don’t reinvent the wheel. When you write IPPs on active problems in your patient’s MTP,
refer to this manual or go online at www.kennedymd.com for sample IPPs. This resource is
especially helpful if there is a sample IPP similar to the IPP that you are about to enter into your
patient’s MTP. If an earlier MTP is available on your patient, it is likely to be similar to the new
MTP that the team is going to write. I recommend that the earlier plan be photocopied. The
team can often quickly update the copy and then type the edited copy onto the MTP forms to
create the new plan. If an electronic version of an earlier plan is available, the editing could be
Introduction
Intro–23
done directly on the electronic version and then stored, printed, or both. I also recommend that
IPPs created within your facility be categorized by the Kennedy Axis V and placed in a binder
for later reference. As more IPPs are added, this binder can be an invaluable resource for writing
future plans.
Inclusion of Milieu Staff in Treatment Planning
Even though the milieu staff members often form the backbone of treatment, they are frequently excluded from the treatment planning process. This exclusion will certainly alienate them from this
process. If the milieu staff members disagree with a plan, the plan is often doomed from the beginning.
Therefore, a critical part of an effective plan is the working relationship between the treatment team
and the milieu staff. In developing this working relationship, it is vital to include the milieu staff as
much as possible in relevant parts of the treatment planning process.
Intro–24
Fundamentals of Psychiatric Treatment Planning
Master Treatment Plan Forms
(Step-by-Step Instructions)
These instructions are intended to walk the reader through the process of completing the MTP and the
Treatment Plan Review forms. The instructions follow the sequence of the forms. In the next section is
a sample of a completed MTP with five Treatment Plan Reviews. It may be helpful to follow that sample
plan and its reviews when going through these instructions.
I.
Problem List/Cover Sheet
A.
Date of Admission
Enter the date of the current admission.
B.
Patient Identification Data
In the upper right corner, place the patient’s name, hospital ID number, ward (area), and the
current date.
C.
Problem Number
Enter the number of the problem. A suggested numbering system is a categorization in which
all problems are placed into one of seven categories (based on the Kennedy Axis V subscales).
This is the numbering system used in this manual:
1.
2.
3.
4.
5.
6.
7.
Psychological Impairment
Social Skills
Violence
ADL–Occupational skills
Substance Abuse
Medical Impairment
Ancillary Impairment
The following sample Problem List is based on this system:
1.1
3.1
3.2
6.0
6.1
6.2
6.3
7.0
Depressive Symptoms
Suicidal Ideation
Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
Placement
In the above numbering system the period (.) separates the problem area from the designation of a specific, individual problem within that problem area. The problem numbers
should be entered in numerical order when developing the Problem List. As additional
problems are added, they would be added in the next available row at the bottom of the list
and assigned the next available number within that problem area.
In the Problem List example, if all the problems were active, seven IPPs would have to be
completed. However, in two subscale areas, there is more than a single problem number:
3.1
3.2
6.0
6.1
Suicidal Ideation
Homicidal Ideation
Health Maintenance
Diabetes
Introduction
Intro–25
6.2 Hypertension
6.3 Kidney Failure
Whenever clinically reasonable, problems within a subscale area should be covered under a
single problem number. This can reduce the complexity of the MTP by decreasing the
number of IPPs that have to be tracked separately. Therefore, if it is clinically reasonable to
collapse the above problems into a single number within their respective subscale areas, the
list may appear as follows:
1.1
3.1
6.0
6.0a
6.0b
6.0c
Depressive Symptoms
Suicidal and Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
Even if all the problems listed were active, only three IPPs would need to be completed for
this list. Because the hypertension and kidney failure may be secondary to diabetes, the list
could also be collapsed as follows:
1.1
3.1
6.0
6.1
6.1a
6.1b
Depressive Symptoms
Suicidal and Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
In this example, four IPPs would be needed. Problems 6.1a and 6.1b would be collapsed into
problem 6.1 Diabetes. The “.0” position, as illustrated in the example, is reserved for a special
problem within a problem area. No other problem would be assigned the “.0” position, even
if it were not used on a particular plan. Currently two such problem names are often
associated with the “.0” position:
6.0 Health Maintenance
7.0 Placement
It is common for a 6.0 to be entered into the Problem List of every patient being treated at a
particular facility and given an active status, even when a patient has no significant medical
problems. This listing allows for tracking of routine health issues, as well as relatively minor
health problems. Serious health problems should generally be given a separate problem
number, for example, a serious case of diabetes could be assigned 6.1 Diabetes, rather than
being collapsed under 6.0. A case of diabetes that is stable and well controlled by diet and an
oral hypoglycemic medication may be easily tracked under 6.0 Health Maintenance.
The problem number should follow revisions of the problem name, if it continues to be
essentially the same problem. For example, in the original MTP “psychotic symptoms” may
have been identified; however, later the patient was determined to have bipolar symptoms.
This would lead to the following changes in the Problem List:
Problem
Number
1.1
1.1
Problem Name
Psychotic Symptoms
Bipolar Symptoms
Discharge
Barrier
Date Estab. &
Status
Yes
01/15/03
02/15/03
Active
Revised to 1.1
Yes
01/15/03
Active
Date Changed
& New Status
Intro–26
Fundamentals of Psychiatric Treatment Planning
In a similar example, “hostile and threatening” may be revised to “assaultive:”
Problem
Number
Problem Name
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
02/15/03
Revised to 3.1
3.1
Hostile and Threatening
Yes
01/15/03
Active
3.1
Assaultive
Yes
01/15/03
Active
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
02/15/03
Revised to 6.1
Another example:
Problem
Number
Problem Name
6.1
Hypothyroidism
No
01/15/03
Active
6.1
Hypothyroidism Secondary to Lithium
No
01/15/03
Active
At the time of a rewrite of the MTP (often annually), it may be reasonable to redo the
problem numbers to allow the most prominent problem in a problem area to be moved to
the numerical top of the problem area. For example, at the time of the rewrite on 01/15/04,
the old Problem List for the Violence area would appear as follows:
Problem
Number
Problem Name
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
3.1
Hx of Suicidal Attempt
No
01/15/03
Noted
01/15/04
Revised to 3.2
3.2
Assaultive Behavior
Yes
02/15/03
Active
01/15/04
Revised to 3.1
In the new MTP on 01/15/04, “assaultive behavior” can be moved to the numerical top:
Problem
Number
Problem Name
Discharge
Barrier
Date Estab. &
Status
3.1
Assaultive Behavior
Yes
02/15/03
Active
3.2
Hx of Suicidal Attempt
No
01/15/03
Noted
Date Changed
& New Status
Similarly, if information was gathered concerning the patient’s suicide attempt and on
04/15/03 it was determined to have been fabricated by family to get needed treatment for
their mentally ill family member, then on 04/15/03, “Hx of suicidal attempt” could be
canceled:
Introduction
Problem
Number
Problem Name
Intro–27
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
04/15/03
Canceled
3.1
Hx of Suicidal Attempt
No
01/15/03
Noted
3.2
Assaultive Behavior
Yes
02/15/03
Active
In the annual rewrite of the MTP on 01/15/04, “assaultive behavior” can be moved to the
numerical top and “Hx of suicidal attempt,” which was canceled, would not appear on the
Problem List:
Problem
Number
3.1
D.
Problem Name
Assaultive Behavior
Discharge
Barrier
Date Estab. &
Status
Yes
02/15/03
Active
Date Changed
& New Status
Problem Name
Write the name of the problem in this column. The name should be brief, generally no
longer than three words. The name is intended to be a quick, concise way of identifying the
problem. For example, use “suicidal ideation” rather than “suicidal ideation because of recent
job loss.” Document descriptive and interpretive statements related to the problem, such as
“because of recent job loss,” in the problem description section on the IPP sheets.
As indicated earlier, to help ensure that significant problems are not overlooked, when
determining the Problem List work your way systematically through each problem area,
starting with Problem Area 1 (Psychological Impairment) and ending with Problem Area 7
(Ancillary Impairment).
The Problem List should contain all significant clinical problems. In addition to the
obvious problems, the Problem List should contain items such as history of assaultive
behavior, history of suicidal attempt, allergy to penicillin, single kidney, and so on. These
problems should not be listed if they are thought to be of no clinical significance (e.g., if the
suicidal attempt was an isolated incident that occurred years ago and is of no future clinical
relevance to the case). Problems should not be listed if they are already incorporated into an
active problem. Allergies do not need to be included on the Problem List if there is already a
system in place to prominently display allergies in the patient’s record.
Also, in addition to problems, the Problem List should contain other clinical factors that
require treatment or clinical resources, such as pregnancy, criminal charges, Tarasoff warning,
placement, health maintenance, and so on. This is the treatment plan, not the problem plan;
therefore, important areas involving treatment should not be omitted from the MTP simply
because they are not seen as a “problem.”
If the Problem List is complete, clinicians will not be surprised by significant clinical
issues or problems lost or buried in the patient’s chart. Generally, the Problem List is the only
place in the chart where there is a comprehensive, condensed, and updated outline of all
significant clinical issues. This is a key part of any clinical chart and is one of the first places
clinicians should go when attempting to get an overview of the patient’s clinical situation.
Intro–28
E.
Fundamentals of Psychiatric Treatment Planning
Discharge Barrier
Enter “Yes” or “No” as appropriate:
Yes—This problem is a significant barrier to discharge.
No—This problem is not a significant barrier to discharge.
There is no column to indicate a status change in the discharge barrier. When the
problem is no longer active, it is assumed to no longer be a discharge barrier. If needed, one
can revise the problem on the Problem List to the same problem number and enter the
revised problem on the next available row on the Problem List. You can then indicate that
the problem is no longer a discharge barrier or indicate that it is now a discharge barrier.
Finally, it is important to note that if a problem is not a barrier to discharge, funding
sources may mandate that any treatment of that problem be deferred.
F.
Date Established and Status
The date established should be the date that the problem was entered into the treatment
plan. This date will frequently not correspond to the date that the problem started. The date
the problem actually started may be documented on the IPP sheet under problem description.
The status of the problem can be any of the following: Active, Inactive, Inactive With Tx,
Deferred, or Noted. Section H contains a brief explanation of each status.
G.
Date Changed and New Status
This column is intended to allow anyone reviewing the Problem List to quickly determine the
current status of all problems. The treatment team should indicate the date that the status
changed and the new status. The date that the team changed the status should be entered
here. The actual date that the change in the problem occurred should be documented in the
progress notes, the Treatment Plan Review, or both.
The status changes include all of the statuses listed for the previous column (Active,
Inactive, Inactive With Tx, Deferred, and Noted) plus Resolved, Revised, and Canceled. The
next section briefly explains each status.
H.
Brief Explanation of Each Status
1. Active Problem: A problem that would require active assessment, treatment, or both. An IPP
sheet is required, and progress notes should be written on active problems.
2. Inactive Problem: A problem that is inactive and requires no treatment; however, it should
be noted because it is likely that it may become active or it could have some significant
impact on treatment. Some examples include history of homicidal attempt, history of
suicidal attempts, allergy to penicillin, only one functioning kidney, abnormal ECG. No
IPP is required.
3. Inactive With Tx: A problem that is inactive; however, continued treatment is required to
prevent the recurrence of the problem. An example includes assaultiveness under control
with lithium and present when lithium is withdrawn. Therefore, continued treatment
would be indicated for this inactive problem. An active problem should not be changed to
“Inactive With Tx” until you are fairly certain that the change in status is real and not just
a fairly temporary state. The IPP for the active problem would continue to be used;
however, all goals, including long-term goals, would have been Attained or Canceled. Any
changes in treatment would be documented in the same way that changes were documented for the active state for the problem, including writing progress notes to document
the continued treatment and with hope, continued control of symptoms.
Introduction
Intro–29
4. Noted Problem: Similar to an inactive problem; however, it is even less likely to become
active or to require treatment. Noted problems fit along the following continuum:
Active or Inactive With Tx
Å
Inactive
Å
Noted
Å
Resolved
For example, a fractured arm will be an “Active” problem while it is in the cast
healing and being followed up. After a few weeks, when the arm is taken out of the cast
and appears to have healed and no follow-up is recommended, the problem may be
changed to “Inactive.” After a few months, if there is a rewrite of the MTP, the problem
may be “Noted” on a treatment plan. After about 6 months or longer, if the arm continues
to appear to have healed well and the patient does not appear to be at risk for another
fracture, the problem may be listed as “Resolved.” If “Resolved,” it would be taken off the
Problem List at the next rewrite of the MTP.
Of course, no IPP is needed for a “Noted” problem.
5. Resolved Problem: This status is used when a problem has reached a state whereby it is felt
to be of little or no clinical significance. For example, as indicated in the last example, a
well-healed fracture of an arm that in no way predisposes the patient to future fractures
would be considered “Resolved.” No IPP is required once a problem has resolved and as
indicated above, it would be removed from the Problem List at the next rewrite of the
MTP.
6. Revised Problem: This status is used when a change is made in the problem name, number,
or in rare cases the discharge barrier. This revision is intended to clear up any confusion or
misunderstanding in the present problem name or number. Revisions in the problem
name include better wording for clarity, changes in the name to reflect changes in the
nature of the problem itself, and so on. For example, “allergy to Risperdal” could be
revised to “severe EPS on Risperdal,” if it were determined that rather than an allergy, the
patient had severe EPS when on Risperdal.
If the problem is revised for inclusion with one or more other problems, the resultant
problem could be assigned a number already held by one of the problems or it could be
assigned a new number. Problems losing their numbers would be “Revised” to the chosen
number.
If there were a change in the status of the revised problem, the need for an IPP would
depend on the final status assigned to the problem. For example, if the Revised status was
an Active status, an IPP would be required. If the problem were revised to an Inactive
status, no IPP would be needed.
7. Deferred Problem: An active problem whose assessment, treatment, or both have been
postponed until a later time or another place. For example, treatment of a learning
disability may be deferred in an acutely psychotic or acutely suicidal individual. A deferred
problem could also be an active problem that for various reasons would probably never be
treated or require further assessment. In addition, a deferred problem could be a problem
that is being actively treated; however, a decision to stop treatment is made for various
reasons and any further treatment is deferred until a later time or another place.
As indicated earlier, it is important to note that if a problem is not a barrier to
discharge, funding sources may mandate that any treatment of the problem be deferred.
No IPP is required on deferred problems; however, a partial IPP can be completed at
the discretion of the treatment team. On such a partial IPP, one would enter the
description of the problem. “Deferred problem” and the reason for deferral could then be
written in the area for the long-term goal. Later, if the problem changes to an Active status, a line could be drawn through “Deferred problem” and the rest of the form could
then be updated and completed.
Intro–30
Fundamentals of Psychiatric Treatment Planning
8. Canceled Problem: This status should be used to cancel out a problem that may have been
incorrectly identified as a problem for the patient. For example, “suicidal ideation” would
be canceled if it were determined that the patient is not and has never been suicidal or
self-abusive. Of course, no IPP would be needed for a canceled problem.
II.
Strengths/Discharge Plan/Diagnosis Page
A.
Patient’s Strengths
Enter either a list of the patient’s strengths or a narrative statement listing and integrating the
patient’s strengths. These strengths should be related to treatment and discharge. As with the
Problem List, to help ensure that significant strengths are not overlooked, it is suggested that
you work systematically through each strength area as defined by the Kennedy Axis V subscale
problem areas as shown in Table 1.
Table 1.
Kennedy Axis V Categorization System for problems and strengths
PROBLEMS
STRENGTHS
1. Psychological Impairment
1. Psychological Strengths
2. Social Skills (Deficits)
2. Social Skills (Assets)
3. Violence
3. Nonviolence
4. ADL–Occupational Skills (Deficits)
4. ADL–Occupational Skills (Assets)
5. Substance Abuse
5. Sobriety
6. Medical Impairment
6. Medical Strengths
7. Ancillary Impairment
7. Ancillary Strengths
As with the problems, once you have gone through the strengths areas it is unlikely that
significant strengths will be overlooked.
B.
Discharge Criteria/Planning
Discharge criteria are often equated with the long-term goals of the problems that are
discharge barriers; therefore, you may want to work backward from the long-term goals to the
discharge criteria.
Prediction of placement should be realistic (i.e., based on the patient’s strengths and
weaknesses and the availability of resources in the community). Enter here the realistic
placement plans, rather than the idealistic ones. Also enter concerns about the lack of
availability of appropriate community resources. If needed, complete an IPP on placement.
Such a problem plan helps the social workers to document in the progress notes their efforts
to place the patient. This also makes it easier to locate information in the progress notes
concerning placement that has been written by social work staff, as well as non–social work
staff.
Enter the target discharge date here. It is rare for the target discharge date to be beyond
1 year; however, if realistic, it is acceptable to indicate a discharge date of 2 or 3 years or even
“indefinite.” Be sure to document one’s clinical reasons for such an extensive length of stay.
Introduction
C.
Intro–31
Psychiatric Diagnosis
Enter the patient’s DSM-IV-TR diagnosis at the time of the MTP. The Kennedy Axis V should
be used for both Axis IV and Axis V (Kennedy 2003). Figure 6 shows an example of a
psychiatric diagnosis.
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
Major Depression, Recurrent, Severe Without Psychotic Features
AXIS II:
Obsessive-Compulsive Personality Disorder
AXIS III:
Insulin-Dependent Diabetes Mellitus
AXIS IV:
Ancillary Impairment = 45 (Divorce)
AXIS V:
PSY = 40 + SOC = 65 + VIO = 40 + ADL = 75 = 220/4 = 55
Figure 6.
Psychiatric diagnosis.
III. Individual Problem Plan
A.
Problem Number and Name
Enter the number and name of the problem directly from the Problem List.
B.
Nursing Diagnosis
As a part of the integration of the NCP into the MTP, enter the nursing diagnosis below the
†
problem name. To assist with this task, nursing diagnoses have been categorized by the
Kennedy Axis V (see Appendix).
C.
Patient Identification Data
In the upper right corner, place the patient’s name, hospital ID number, ward (area), and
current date. Enter the date the IPP was completed. For most problems, this date will be the
same as the date for the MTP. However, following the completion of the MTP, new problems
may be entered. The date entered on each new IPP should reflect the date that IPP was
completed and placed in the chart.
D.
Problem Description
Enter a brief description of the problem. The following six components are often seen in
problem descriptions:
1.
2.
3.
4.
†
Onset of symptoms and chronicity
Precipitants (e.g., noncompliance with treatment, command hallucinations, substance
abuse, losses, stress, poor frustration tolerance, poor coping mechanisms, peer pressure,
lifestyle)
Characteristics, frequency, intensity, and variance of symptoms
Response to previous and current treatments and expected response to any proposed
treatments
Nursing Diagnoses: Definitions and Classifications 2001–2002. Philadelphia, PA, North American Nursing Diagnosis
Association, 2001.
Intro–32
Fundamentals of Psychiatric Treatment Planning
5.
6.
Presence of need for psychotropic medication guardianship, guardianship of person
and/or estate, or any other related legal issues
Current level of symptoms, activity level, including frequency of attendance at
therapeutic activities
These components should relate to goals, treatment modalities, and target dates.
E.
Long-Term Goal(s) (Discharge Criteria)
Indicate reasonable expectations of what the patient is thought to be capable of achieving
1) at discharge or 2) within 1 year for patients expected to remain in treatment for 1 year or
longer.
Goals must be obtainable, measurable outcomes. The measures of outcome should
address 1) frequency, 2) duration, or 3) change in condition or status. The outcome measures
should allow the clinician to ascertain, at any time, whether the goal has been obtained.
Standardized questionnaires should be considered as an ongoing part of the measurement of
outcome.
Often there is only one long-term goal for each problem. The Kennedy Axis V score is
suggested for consideration as a second long-term goal. For example, long-term goals for
psychotic symptoms could be as follows:
1.
2.
Pt.’s psychotic symptoms will decrease such that she can participate in full-time program
activities for 1 month without serious disruption by psychotic process.
Pt.’s Kennedy Axis V for Psychological Impairment will improve from a score of 30 to
50.
At a minimum, the long-term goal(s) should reflect the intention of preventing further
deterioration in the patient’s mental or physical condition. One exception would be a
problem that is part of a progressive disease process. In such a disease, there may be no
treatment that will fully stop the progressive nature of the illness (e.g., the cognitive
deterioration associated with Alzheimer’s disease). The goals for these progressive problems
should reflect realistic attempts to minimize the deterioration.
No active problem should be without a long-term goal.
F.
Target Date
Indicate the anticipated date when the long-term goal(s) or the short-term goal(s) will be
achieved. Attempt to make these dates realistic. The treatment team should take into account
the various expected delays and difficulties. The date should not reflect an “ideal” date or a
“best-case scenario.” Generally the treatment team should set up long-term goals that are
thought to be achievable before discharge or within 1 year for patients who are expected to
remain in the hospital for 1 year or longer. The target date for the short-term goals may vary
widely depending on many clinical factors. Generally, the date should not be longer than
6 months for short-term goals.
If a target date has to be extended, draw a line through the target date and place the new
target date below the old target date. Initial the change and document the reason for the
change in the progress notes, the Treatment Plan Review, or both.
“Ongoing” as a target date for an attained goal can be useful. Ongoing reflects that the
goal has been attained; however, the team does not want to eliminate the goal from the plan
because it helps to convey that the patient has achieved a specific level of functioning. An
additional goal would not have to be added to the plan to replace this attained goal if the
team is satisfied that the level of functioning achieved is adequate for discharge. The team
would work on at least maintaining the patient at the level of the “ongoing” goal. For
example, if an assaultive patient has attained a goal of being assault free for 6 months and
this is adequate for discharge, the team may want to simply indicate “ongoing” as the target
date. At the time of the MTP rewrite, the “ongoing” goal could be moved forward or
Introduction
Intro–33
incorporated into the problem description to document the current level of functioning for
the problem.
Ongoing can also be useful for problems that are “Inactive With Tx” because use of the
term allows the level of functioning necessary for the patient to have achieved the “Inactive
With Tx” status to be clearly documented, as well as the level of functioning needed to
maintain the status of “Inactive With Tx.”
G.
Date/Status
Indicate status change and date of that change in this column. The status changes include
Attained, Canceled, and Revised (see Section J). Draw a line through the long-term goal when
its status has changed. If this is the only long-term goal and the problem is not Inactive,
Inactive With Tx, Deferred, or Resolved, then another long-term goal or a revised long-term
goal should be added.
H.
Short-Term Goal(s) (Objective[s])
A short-term goal is an expected or desired change in a current patient behavior, condition,
or situation. As with the long-term goal, it should be stated in observable, measurable terms.
The following system can be helpful in identifying short-term goals: First, establish
where the patient is currently with respect to the problem and where the patient is expected
to ultimately be as defined by the long-term goal. Then describe the next step that would
have to occur if the patient were to make progress toward the long-term goal. This next step
can often be used as a short-term goal. This next step must be converted into observable,
measurable behaviors or symptoms that could signify to the team that the improvement has
occurred.
Additionally, it may be useful to focus first on the treatment modalities before determining the short-term goals. Once some of the treatment modalities have been laid out, the
short-term goals may become obvious.
Two or three short-term goals should be used for a problem. If it is not used as one of
the long-term goals and if it is appropriate, a Kennedy Axis V score might be used as a shortterm goal. Each short-term goal should have its own target date.
I.
Treatment Modalities (Interventions)
Treatment modalities, also known as “interventions,” are specific services, treatments,
therapies, or other active interventions that the patient will receive or participate in or a staff
action taken on the patient’s behalf.
Treatment modalities may be Completed, Canceled, or Revised (see Section J). Draw a
line through any treatment modality that has been Completed, Canceled, or Revised.
Include the name and discipline of staff members who will either directly provide or
supervise a treatment, therapy, or staff action. If someone is responsible for supervising or
overseeing others in implementing the treatment modality, use an arrow to indicate the
person(s) being supervised. For example,
Linda Larkin, RN Å Ward Staff
This arrow indicates that Linda Larkin, RN, will be responsible for supervising the ward
staff with the particular treatment modality. This documentation indicates the responsible
person(s) and the person(s) actually providing the treatment. Both are certainly important.
If helpful, place the identifying number of associated short-term goals after each
treatment modality to indicate which short-term goals are being addressed by each treatment
modality. However, because it is often obvious which goals are associated with which
treatment modality and because of the limited time to complete treatment plans, this
numbering is discouraged.
Intro–34
J.
Fundamentals of Psychiatric Treatment Planning
Status
The goals may be Attained, Canceled, or Revised, depending on the patient’s response to
treatment and additional information obtained. A treatment modality can be Completed,
Canceled, or Revised. Draw a line through a goal or treatment that has been Attained,
Completed, Canceled, or Revised:
1.
2.
3.
K.
Attained goal or completed treatment: This status indicates that the goal or treatment has
been reached or completed. Enter a date and status change and draw a line through the
goal or treatment. If appropriate, enter another goal or treatment, along with a target
date for each new goal.
Revised goal or treatment: This status indicates that a change has been made in the goal or
treatment. Enter a date and status change and draw a line through the goal or treatment
to be revised. In the appropriate column, enter the revised goal or treatment. If a goal is
being revised, enter a target date in the column next to the new goal.
Canceled goal or treatment: This status indicates that a goal or treatment has been
canceled. At this time, enter the appropriate date and status change and draw a line
through the goal or treatment that is being canceled.
Date Treatment for the Problem Ended and Final Status
Indicate the date that the treatment ended for the overall problem (not the end of treatment
for a specific goal) by drawing a line across the front of the IPP. Around the middle of the
line, enter the date and change in problem status that led to the discontinuation of treatment
for the problem. Possible changes in status include Resolved, Revised, Inactive, Canceled, or
Deferred. This change in status would also be indicated on the MTP’s Problem List.
IV. Signature Page
V.
A.
Patient Participation in Treatment Planning
Indicate the level of participation by the patient in the development of the MTP. Areas are
available for patient and staff comments. If the patient refuses to sign the plan, the team
should indicate the reason for the patient’s refusal, if known, in “Staff Members’ Comments.”
B.
Treatment Team Members
The signatures entered here should document the treatment team members who were involved in developing and completing the MTP. Everyone involved in the planning should
sign; however, the accreditors require only the signatures of the physician, nurse, and social
worker.
Treatment Plan Review Form
A.
Patient Identification Data
In the upper right corner, place the patient’s name, hospital ID number, ward (area), and
current date.
B.
Psychiatric Diagnosis (DSM-IV-TR)
Enter the patient’s DSM-IV-TR diagnosis as of the time of the Treatment Plan Review. If the
diagnosis has changed, enter any changes here. On the Strengths/Discharge Plan/Diagnosis
page of the MTP, enter the date of the Treatment Plan Review, which documents the changes
and the reason for the change. It is also recommended that you enter the changes directly
onto the diagnosis section of the Strengths/Discharge Plan/Diagnosis page and date and
initial the changes. This documentation will allow you to go directly to the MTP for the
current diagnosis without having to go to the Treatment Plan Reviews. If more information is
needed about the change in diagnosis, you could then go to the appropriate Treatment Plan
Review. If there are no changes in the Problem List, simply indicate “no change” in this area.
Introduction
Intro–35
C.
Changes in the Problem List
Enter any changes in the Problem List in this section. These changes should also be entered
onto the MTP’s Problem List. If there are no changes, simply indicate “No Change” in this
area.
D.
Evaluation of Progress and Plan’s Effectiveness in
Achieving Goals for Active Problems
Enter the summary of the progress for each active problem made by the patient since the last
MTP or the last Treatment Plan Review. If there are no changes, indicate the reasons for the
lack of progress, rather than simply indicating “no change” in this area.
E.
Changes in Treatment Plan Goals or Modalities
Enter changes in the MTP directly onto the MTP, then date and initial the entry. Enter the
summary of those changes, including goals that have been attained or added or modalities
that have been completed or added. If there are no changes, simply indicate “no change” in
this area.
F.
Reasons for Continued Hospitalization
Enter the summary of the reasons for continued hospitalization, especially issues related to
violence and other forms of dangerousness. The Kennedy Axis V’s “Dangerousness Level”
may be helpful with documenting the reasons for continued hospitalization. Also use this
section to address any obstacles to securing an appropriate community placement when the
patient is clinically ready for discharge.
G.
Discharge Planning Update
Enter the update to discharge planning, including progress toward overcoming various
obstacles to discharge. If there are no changes, indicate the current status of discharge
planning.
H.
Continuation/Comments Section
This area provides additional space if adequate space is not available in the previous sections.
Patient or staff comments can also be entered here.
I.
Level of Care
This section can be useful for Medicare and Medicaid billing purposes by indicating the
following:
Active Treatment [ ]
Extended [ ]
Awaiting SNF [ ]
Refer to the Centers for Medicare and Medicaid Services (formerly HCFA) for details and help
with Medicare and Medicaid billing (SNF, skilled nursing facility).
J.
Treatment Team Members
The signatures entered here should document the treatment members who were involved in
developing and completing the Treatment Plan Review. For clinical purposes, all participants
involved in the Treatment Plan Review must sign it; however, the accreditors require as a
minimum the signatures of the physician, nurse, and social worker.
The patient should also be asked to read and sign the Treatment Plan Review to indicate
that he or she participated in the review and is aware of its content. The patient’s signature
on the review does not indicate that he or she agrees with the review. If the patient does not
agree with the review, the patient should be encouraged to enter his or her concerns in the
“Continuation/Comments” section.
Notes
MASTER TREATMENT PLAN
(Sample)
MTP–1
This page intentionally left blank
Master Treatment Plan (Sample)
MTP–3
MASTER TREATMENT PLAN
(Sample)
CONTENTS
Kennedy Axis V: Scoring Sheet ...........................................................................................................MTP–4
The sample Master Treatment Plan is based on a Kennedy Axis V rating of a fictitious patient, Derek
Rossi. The Kennedy Axis V organizes information that can then flow into Master Treatment Plans.
Master Treatment Plan (Sample) ........................................................................................................MTP–5
This sample Master Treatment Plan will help demonstrate the treatment planning system used in this
book, including how the Kennedy Axis V can help organize information that is often critical to good
treatment planning.
Treatment Plan Reviews (Samples) ...................................................................................................MTP–17
These sample Treatment Plan Reviews demonstrate how the Treatment Plan Reviews act with the
Master Treatment Plan to capture the flow of treatment. The sample Treatment Plan Reviews will
take one through about half of the patient’s hospitalization.
MTP–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V: Scoring Sheet
Name: Derek Rossi
© 1986–2003
#: 12345
Age:
26
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
ÄÄ FUNCTIONAL
DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Primarily (check one):
Not Impaired___
Antisocially Impaired___
Other Impairment X
Both___
Derek’s current depression is characterized by feelings of hopelessness and worthlessness. He is anxious, lethargic, socially
isolated, and frequently up most of the night. His depression is also associated with self-deprecating and command
hallucinations.
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
Derek’s attempts to be pleasant and engaging are usually awkward. He has a couple of friends; however, he does see them often.
He often gets into conflicts due to inappropriate social behavior.
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 X 40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Primarily (check one):
Nonviolent___
Violent to Self X
Violent to Others___
Violent to Self and Others___
Derek has a long history of suicidal attempts, gestures, and manipulations. He has made serious attempts to hurt himself in
response to command hallucinations, including taking overdoses of meds and attempting to hang himself. Since he stopped
drinking 2 years ago, he has not acted on any suicidal impulses. Currently he continues to have command hallucinations and
suicidal ideation; however, he reports that he would not actually attempt to harm himself.
4. ADL–Occupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Derek is a high school graduate with average intelligence. He has some mild difficulty following instructions on his job as an
office assistant. He has a driver’s license and has no more than mild difficulty maintaining his own apartment. Overall he has
fairly good independent living skills.
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Primarily (check one):
Nonabuser___
Alcohol Abuser X
Drug Abuser___
Both___
Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and self-medicating his
depression. He had some very serious problems with alcohol that led to serious attempts to hurt himself when intoxicated,
including taking overdoses of meds and attempting to hang himself. Generally, since he stopped drinking 2 years ago, he has had
much better control of these impulses. He goes to AA on a weekly basis and is committed to continued sobriety. Derek smokes
one pack of cigarettes a day.
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 X 60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Derek is in fairly good physical health, even though he has mild reflux esophagitis secondary to a hiatal hernia. This disorder is
fairly well controlled with a prescription med to reduce stomach secretions; however, currently he drinks 8 to 12 carbonated
beverages every day and eats other foods that exacerbate his heartburn.
7. Ancillary Impairment (optional)
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Derek has his own apartment that his family maintains if he is unable to pay the rent. He has some mild difficulties paying his
credit card bills. He is not in trouble with the law.
GAF Equivalent:
#1
40
+ #2
60
+ #3
45
+ #4
70
Dangerousness Level (indicate only the most dangerous rating):
Signature:
Victor Dyson, MD
=
215
/
4
=
55
45
Date:
01/05/03
Master Treatment Plan (Sample)
MTP–5
Name: Rossi, Derek
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Problem List
ID #: 12345
Lakeview Hospital
Name of Facility
Area: West Unit
Date of Admission: 01/15/03
Problem
Number
Problem Name
Date: 01/15/03
Discharge
Barrier*
Date Estab. &
Status**
1.1
Depressive and Psychotic Symptoms
Yes
01/15/03
Active
2.1
Impaired Social Skills
No
01/15/03
Deferred
3.1
Suicidal Ideation
Yes
01/15/03
Active
5.1
Alcohol Abuse
No
01/15/03
Inactive With Tx
6.0
Health Maintenance
No
01/15/03
Active
6.0a
Reflux Esophagitis
No
01/15/03
Active
Date Changed
& New Status***
02/12/03
Inactive With Tx
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
MTP–6
Fundamentals of Psychiatric Treatment Planning
Name: Rossi, Derek
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Strengths/Discharge Plan/Diagnosis
Area: West Unit
Date: 01/15/03
Patient’s Strengths (related to treatment and discharge):
•
•
•
•
•
•
•
•
•
•
•
Interests: watching TV, especially sports
Motivated for treatment
Good verbal skills
No history of assaultive behavior
Fairly good independent living skills
High school graduate with average intelligence; holds job as an office assistant
Alcohol-free for 2 years and is motivated to continue sobriety
Fairly good physical health
Supportive family
Apartment in the community
Good working relationship with community case manager
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
Derek Rossi will be free of any suicidal ideation or any command hallucinations to harm himself for 4 weeks. Derek
will be able to participate in a full schedule of program activities for 2 weeks. Plans will be in effect for Derek to
return to his job in the community immediately following discharge. Derek will complete three overnight passes
back to his apartment without any return of suicidal ideation. Derek will continue to participate in community AA
meetings after discharge.
Discharge Coordinated By: Brenda St. Martin, MSW
Anticipated Discharge Date: 04/15/03
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
Depressive disorder with psychotic features; history of alcohol abuse
AXIS II:
No diagnosis
AXIS III:
Reflux esophagitis and hiatal hernia
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
40
SOC =
GAF Equivalent =
70
60
55
VIO =
45
ADL =
70
SAb =
70
Dangerousness Level =
MED =
65
45
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /__
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Depressive and Psychotic Symptoms
MTP–7
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Disturbed Thought Processes
Date: 01/15/03
Problem Description:
Derek has a long history of depressive symptoms that began during his senior year of high school following a
breakup with a girlfriend. His current depression appears to be associated with his stopping his meds and his
perception that he was not doing a good job at work. However, his employer reports being satisfied with Derek’s
performance. Pt. reports being a loner with lots of feelings of hopelessness and worthlessness. He is anxious,
lethargic, and frequently up most of the night. His depression is also associated with self-deprecating and
command hallucinations. The hallucinations generally occur only during periods of decompensation and disappear
when he is doing fairly well. Derek’s compliance with aftercare is poor, despite his having a reasonable
understanding of his meds. Last week, he started taking his meds as prescribed. Social isolation is felt to be a
significant contributor to his depressive symptoms and associated noncompliance with his meds. In the past, Derek
has responded well to a combination of Risperdal and Effexor. His hospitalizations usually last about 2 to 3 months
before he has recompensated to the point that he is ready for discharge.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Derek will complete at least three overnight passes into the
community, including returning part-time to his job in the
community.
04/15/03
2.
Pt. will comply with a full schedule of program activities,
including social activities, for 2 weeks.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Derek will accept prescribed meds and lab work for 2 weeks.
Date/Status*
Target Date
Date/Status*
01/29/03
01/29/03
Attained
2.
Derek will be free of auditory hallucinations for 2 weeks.
02/29/03
3.
Derek will engage in 5-minute conversations twice daily with
staff in which he makes at least two positive self-statements for
2 weeks.
02/29/03
4.
Derek will be free of feelings of hopelessness and worthlessness
for 2 weeks.
02/29/03
5.
Derek’s anxiety, lethargy, and social isolation will improve such
that he will complete one scheduled program activity at least 4
of 5 weekdays for 2 weeks.
02/29/03
6.
Derek will be able to consistently and realistically report the fact
that he is an asset at his job in the community for 2 weeks.
03/15/03
7.
Derek’s score on the Kennedy NOSIE score will improve from
his current score of –11 to at least +4.
03/15/03
02/12/03
Attained
02/05/03
Attained
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–8
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any
changes in Derek’s psychotic and depressive symptoms in order to monitor Derek’s
response to being restarted on a combinations of antipsychotic meds such as
Risperdal and an antidepressant such as Effexor. Labs will be ordered as needed.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with Derek twice weekly for 30 minutes to discuss his
depression and psychotic symptoms and the effect on his discharge. She will evaluate
Derek’s readiness for discharge and discuss discharge options with Derek. She will also
help Derek work on a list of activities to help structure his life.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive
therapy sessions to direct Derek back to reality and to help improve Derek’s ability to
identify stressors, including dispelling stressors that are not real, and helping improve
his ability to better cope with those stressors that are real.
Joseph LeBlanc, PhD
Rehab:
1.
Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to
review his daily treatment schedule and refer him to appropriate groups to improve
his contact with reality and self-esteem, increase his social interactions, and develop
structure in his daily routine. His groups will include stress management group and
socialization group (see weekly Rehab Schedule for details).
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will redirect and refocus Derek to reality issues. When derogatory
hallucinations are present, nsg. staff will express an understanding of Derek’s distress,
give reassurance, suggest interventions, and if indicated, offer prn meds to help
relieve his distress. Nsg. staff will provide support and praise for reality-based
statements.
2.
Nsg. staff will encourage Derek to attend morning meeting, other on-ward activities,
and rehab groups; staff will provide escort, if needed.
3.
Building on Derek’s understanding of the need to take his meds, nsg. staff will
explore with Derek his difficulty continuing his meds in the community and help pt.
develop a plan for him to work with his community case manager to correct this
problem.
4.
Nsg. staff will rate the Kennedy NOSIE once per week to help track Derek’s response
to treatment.
5.
Nsg. staff will encourage appropriate interactions with his peers.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Suicidal Ideation
MTP–9
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Risk for Self-Directed Violence
Date: 01/15/03
Problem Description:
Derek has a long history of suicidal attempts, gestures, and manipulations beginning at age 17 when he was a
senior in high school. When decompensated, he has command hallucinations to hurt himself. In the past, when
intoxicated, he has made serious attempts to hurt himself in response to command hallucinations, including taking
overdoses of meds and attempting to hang himself. Since he stopped drinking 2 years ago, Derek has not attempted
to hurt himself and overall has had much better control of these impulses. Immediately before this hospitalization,
Derek was having command hallucinations to harm himself, including commands to jump from the fourth floor at
work. He was concerned that he was losing control of these impulses. Currently he continues to have command
hallucinations and suicidal ideation; however, he reports that he would not actually attempt to harm himself.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Derek will be free of any suicidal ideation or command
hallucinations to harm himself for 4 weeks.
04/15/03
2.
Derek’s K Axis score on Violence will improve from his current
score of 45 to a score of 60.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
2.
3.
4.
Derek will be able to consistently identify at least three coping
mechanisms to help direct him away from self-destructive
impulses for 1 week.
Derek will be able to identify feelings of worthlessness,
hopelessness, and frustration as they occur, AEB his coming to
staff for support rather than attempting to hurt himself for
2 weeks.
Derek will be free of any command hallucination to harm
himself for 2 weeks.
Derek will be free of any suicidal ideation for 2 weeks.
02/19/03
5. Derek will be able to go safely on three independent day passes into the community during
1 week.
VD
Date/Status*
Target Date
Date/Status*
02/29/03
02/05/03
Attained
02/29/03
02/29/03
02/19/03
Attained
02/29/03
03/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–10
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any
changes in Derek’s suicidal impulses, including command hallucinations to hurt
himself. This will allow the psychiatrist to assess the need for special precautions.
This meeting will also allow the psychiatrist to prescribe treatment with antipsychotic
meds such as Risperdal and an antidepressant such as Effexor (as outlined under
Problem 1.1).
Victor Dyson, MD
Social Work:
1.
Social worker will meet with Derek twice weekly for 30 minutes to discuss his suicidal
impulses and the effect on his discharge. Social worker will evaluate Derek’s readiness
for discharge, discuss discharge options with Derek, and help him to locate
community supports that will help him to remain free of suicidal ideation following
his discharge.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive
therapy sessions to help Derek develop strategies to more effectively cope with
stressors rather than becoming suicidal.
2.
Psychologist will lead the suicide prevention group once weekly for 45 minutes to
help pt. reduce feelings of hopelessness and worthlessness and more effectively deal
with stress.
Joseph LeBlanc, PhD
Rehab:
1.
Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to
review his daily treatment schedule and refer him to appropriate groups to decrease
his self-destructive impulses and frustration tolerance, including stress management
group and anger management group (see weekly Rehab Schedule for details).
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will immediately redirect and refocus Derek away from self-destructive
impulses and discuss appropriate alternative means of coping.
2.
Nsg. staff will question Derek at least once each shift to determine whether he is
having impulses to hurt himself.
3.
When command hallucinations are directing him to harm himself, nsg. staff will give
reassurance, suggest interventions, and if indicated, offer prn meds to help relieve his
impulses to harm himself.
4.
If there are any concerns about Derek attempting to hurt himself, at a minimum, nsg.
staff will have him verbally contract for safety each time he goes off the ward. For
safety reasons, pt. may be restricted to the ward and placed on special precautions
until the psychiatrist can evaluate him.
5.
Nsg. staff will provide support and praise when Derek is demonstrating appropriate
coping skills to maintain safe behaviors.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.1 Alcohol Abuse
MTP–11
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Ineffective Coping
Date: 01/15/03
Problem Description:
Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and selfmedicating his depression. He had some very serious problems with alcohol that led to serious attempts to hurt
himself when intoxicated, including taking overdoses of meds and attempting to hang himself. Generally, since he
stopped drinking 2 years ago he has had much better control of these impulses. He goes to AA on a weekly basis
and is committed to continued sobriety. Derek smokes one pack of cigarettes a day; however, he has no interest in
quitting smoking.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Derek will continue to be free of alcohol for at least 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Derek will continue to demonstrate his commitment to
maintain sobriety by going to AA meetings once a week for at
least 1 month.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–12
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek weekly and as needed to monitor for any evidence
of intoxication and any changes in intensity of impulses to abuse alcohol. If needed,
psychiatrist will order Breathalyzer to ensure that pt. has not been abusing alcohol.
Victor Dyson, MD
Rehab:
1.
Derek will attend AA meetings once weekly to help support his continued sobriety.
Derek will start the AA meetings in the hospital; however, when it is safe for him to
go into the community, rehab staff will take him to AA meetings in the community.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will monitor Derek for any evidence of intoxication and report any
significant findings to the psychiatrist.
2.
Nsg. staff will do a Breathalyzer test if substance abuse is suspected.
3.
Nsg. staff will be alert to a return of any impulses to abuse alcohol and, if present, will
assist him to deal with these in an appropriate, sober manner.
4.
Nsg. staff will give encouragement and verbal praise for Derek’s involvement in
non-drug-related social activities.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.0 Health Maintenance
MTP–13
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Derek’s physical exam revealed no significant abnormality. Derek’s medical history reveals that he has mild
heartburn due to reflux esophagitis, which is fairly well controlled with Zantac (ranitidine) 150 mg po bid.
However, currently he drinks 8 to 12 carbonated beverages every day and eats other foods that exacerbate his
heartburn.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Derek will maintain an optimal level of health while
hospitalized, AEB his compliance with all prescribed meds, lab
work, and treatments for his medical problems.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Derek will eat a diet that will help promote control of his reflux
esophagitis, AEB no heartburn for 2 weeks.
Target Date
Date/Status*
02/29/03
Ongoing
Target Date
Date/Status*
02/29/03
Attained
02/12/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.0
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
MD will treat Derek’s reflux esophagitis with Zantac (ranitidine) and monitor him as
needed for any burning in his stomach. MD will request a dietary consult to assess
Derek’s diet and make needed recommendations.
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor Derek daily and follow up on any signs and symptoms of
illness.
2.
Nsg. staff will work with Derek and the dietician on developing a dietary plan to help
control Derek’s heartburn.
3.
Nsg. staff will administer all prescribed meds and treatments as ordered, including
dietary recommendations, and will document Derek’s compliance.
4.
Nsg. staff will assess and document pt.’s level of understanding of prescribed
treatments, including diet, and will provide necessary teaching at Derek’s level of
understanding.
5.
Nsg. staff will prompt Derek to comply with treatments, diet, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany Derek to
procedures. Staff will offer praise for compliance and document compliance.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
MTP–15
Name: Rossi, Derek
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Signature Page
Lakeview Hospital
Name of Facility
Area: West Unit
Date: 01/15/03
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
X
X
X
Derek Rossi
01/15/03
(Patient’s or guardian’s signature and date)
(If guardian, relation to patient)
Patient’s Comments (optional):
Staff Members’ Comments (optional):
Derek appears to have a reasonably good understanding of his Master Treatment Plan. He is motivated to work
with the team on his problems, especially on getting rid of the voices. At discharge, Derek hopes to return to his
own apartment; however, he does not believe that his employer wants him back because pt. feels that his
performance at work was inadequate.
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/15/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/15/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/15/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/15/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
01/15/03
Print Name:
Albert Sanchez, Rehab
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.”
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
Notes
Master Treatment Plan (Sample)
MTP–17
Treatment Plan Reviews
(Samples)
The following sample Treatment Plan Reviews (TPRs) demonstrate how the TPRs act with the Master
Treatment Plan (MTP) to capture the flow of treatment. The sample TPRs take the reader through about
half of the patient’s (Derek Rossi’s) hospitalization.
MTP–18
Fundamentals of Psychiatric Treatment Planning
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 01/22/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to take his meds. Yesterday he started going to some program activities. However,
he continues to have lots of feelings of hopelessness and low self-esteem.
Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself;
however, they may be decreasing somewhat. Derek continues to feel that he has control of the impulses to hurt
himself.
Problem 6.0. Nsg. staff and the dietitian are working with Derek on getting him to cooperate with moving toward a
bland diet to help control his heartburn.
4. Changes in Treatment Plan Goals and/or Modalities:
Continue to titrate pt.’s Risperdal and Effexor upward.
5. Reasons for Continued Hospitalization:
Due to continued suicidal ideation, pt. is unsafe to be discharged.
6. Discharge Planning Update:
When ready, Derek is to be discharged back to his apartment with support from Case Management.
7. Level of Care: Active Treatment [ X ] Extended [ ]
Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/22/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/22/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/22/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/22/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
01/22/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
01/22/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
Master Treatment Plan (Sample)
MTP–19
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 01/29/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to cooperate with treatment, including taking his meds and going to at least one
program every day. However, he continues to have lots of feelings of hopelessness and low self-esteem.
Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself.
Recently Derek has been having problems with feeling that he is losing control of the impulses to hurt himself;
however, he has not made any plans to hurt himself.
Problem 6.0. Derek’s heartburn appears to be responding to a bland diet, including cutting back on carbonated
beverages.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 1.1 Short-Term Goal attained. Continue to titrate patient’s Risperdal and Effexor upward. Special one-onone close observation may be needed, if Derek’s suicidal impulses worsen.
5. Reasons for Continued Hospitalization:
Due to worsening suicidal impulses, patient is unsafe to be discharged.
6. Discharge Planning Update:
When ready, Derek will be discharged back to his apartment with support from Case Management.
7. Level of Care: Active Treatment [ X ] Extended [ ]
Awaiting SNF [ ]
8. Treatment Team Members (All participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/29/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/29/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/29/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/29/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
01/29/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
01/29/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP–20
Fundamentals of Psychiatric Treatment Planning
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/05/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to cooperate with treatment and has completed 1 week of at least 4 days/week of
program activities. He is having much fewer feelings of hopelessness and low self-esteem. The hallucinations are
decreasing.
Problem 3.1. Derek has done better for the last few days; however, he continues to have some suicidal ideation. For
the last couple of days, the command hallucinations have stopped, and for the last week, pt. has been able to
identify ways to help direct himself from self-destructive impulses.
Problem 6.0. Derek’s heartburn appears to be responding to a bland diet, including cutting back on carbonated
beverages. He denies having any heartburn for about 1 week.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 3.1 Short-Term Goal 1 was attained. Increase Risperdal to 8 mg/day and continue current dose of Effexor
150 mg/day.
5. Reasons for Continued Hospitalization:
Pt. continues to be a risk for a suicidal attempt; therefore, patient is unsafe to be discharged.
6. Discharge Planning Update:
When ready, Derek will be discharged back to his apartment with support from case management.
7. Level of Care: Active Treatment [ X ] Extended [ ]
Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/05/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/05/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/05/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
02/05/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
02/05/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
02/05/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
Master Treatment Plan (Sample)
MTP–21
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/12/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
Problem 6.0a was changed from Active to Inactive With Treatment.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek’s spirits are improving and he is no longer having feelings of hopelessness and low self-esteem.
Next week, he is expected to participate in a full schedule of program activities. For the last couple of days, all
hallucinations stopped completely.
Problem 3.1. Derek reports that he in now free of both suicidal ideation and command hallucinations.
Problem 6.0. Derek’s heartburn appears to have responded very well to a bland diet, including cutting back on
carbonated beverages. He denies having any heartburn for about 2 weeks.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 1.1 Short-Term Goals 3 and 5 were attained. Problem 6.0a Short-Term Goal 1 was attained. Problem 6.0
Long-Term Goal 1 was changed to ongoing. Continue current meds, including Risperdal 8 mg/day and Effexor 150
mg/day.
5. Reasons for Continued Hospitalization:
Suicidal impulses appear to be just getting under control; however, without further progress, Derek is very likely to
quickly relapse. Staff is continuing to work with him on ways to help prevent a return of suicidal impulses.
6. Discharge Planning Update:
When ready, Derek will be discharged back to his apartment with support from case management.
7. Level of Care: Active Treatment [ X ] Extended [ ] Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/12/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/12/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/12/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
02/12/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
02/12/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
02/12/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP–22
Fundamentals of Psychiatric Treatment Planning
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/19/03
1. Changes in Psychiatric Diagnosis (DSM-IV):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek’s spirits continue to be good and he continues to be free of feelings of hopelessness and low
self-esteem. For the last few days, he has participated in a full schedule of program activities. No hallucinations
since 02/10/03.
Problem 3.1. Derek reports that for the last week he has been free of suicidal ideation and impulses to hurt himself.
The command hallucinations to hurt himself stopped more than 2 weeks ago.
Problem 6.0. Derek continues to be free of any heartburn or any other medical complaints.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 3.1 Short-Term Goal 3 was attained and Short-Term Goal 5 was added.
5. Reasons for Continued Hospitalization:
Suicidal impulses continue to be under control; however, without further progress, Derek continues to be at risk to
relapse shortly after discharge. Staff is continuing to work with him on ways to help prevent a return of depression,
psychosis, and suicidal impulses.
6. Discharge Planning Update:
Pt.’s case manager will be contacted to discuss Derek’s returning part-time to his job in the community and to
begin plans for him to go for an overnight to his apartment.
7. Level of Care: Active Treatment [ ] Extended [ X ] Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/19/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/19/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/19/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
02/19/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
02/19/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
02/19/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
PSYCHOLOGICAL IMPAIRMENT
(Problem Area 1)
1–1
This page intentionally left blank
Psychological Impairment (Problem Area 1)
1–3
PSYCHOLOGICAL IMPAIRMENT
(Problem Area 1)
CONTENTS
Kennedy Axis V for Psychological Impairment......................................................................................... 1–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Psychological Impairment and can be helpful in composing a short
description of each problem.
Problem Names and Descriptions ............................................................................................................ 1–5
Examples of problem names and descriptions that may relate to Psychological Impairment are listed here.
These examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 1–7
Examples of strengths that may be related to treatment and discharge in the area of Psychological
Strengths are listed here.
Goals ......................................................................................................................................................... 1–7
Examples of treatment goals that may relate to problems in the area of Psychological Impairment are
listed here.
Treatment Modalities ............................................................................................................................. 1–10
Examples of treatment modalities that may relate to problems in the area of Psychological Impairment
are listed here.
Individual Problem Plans (Frequent Entries).......................................................................................... 1–16
Two Individual Problem Plans that contain examples of information frequently entered into Individual
Problem Plans for Psychological Impairment are included here.
Sample Individual Problem Plans ........................................................................................................... 1–21
A wide range of Individual Problem Plans relating to Psychological Impairment are included here.
1–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Psychological Impairment
100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems
never seem to lead to any significant anxiety or depression. No symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all
areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday
problems or concerns.
80 If symptoms are present, they are transient and expected reaction to psychosocial
stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild
preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The
stress is too much”); not considered to have mental problems by those who know him/her.
70 Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the
household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally
functioning fairly well; however, those who know him/her well might express some concerns about his/her mental
state.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently
preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others;
to those who know him/her well it is clear that he/she has mental problems.
50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe
phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety
attacks, moderately guarded, mild but definite manic syndrome).
40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is
at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however,
probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or
mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative
symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have
mental problems.
30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to
hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is
occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications;
inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job,
home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost
totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe
sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.
20 Thinking and communication are generally grossly impaired; manic excitement or catatonia;
largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal
personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe
food off shirt; smears feces for bizarre, delusional reasons).
10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely
incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or
minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a
few seconds; chronic, self-induced vomiting has led to a very life-threatening situation.
NR Not rated
Psychological Impairment (Problem Area 1)
Problem Names and Descriptions
I.
II.
Mood Disturbance Problems (depressive symptoms, manic symptoms,
anxious symptoms)
A.
Sadness
1.
Low self-esteem
2.
Extremely fragile and brittle self-esteem
3.
Depression with persecutory delusions
4.
Difficulty accepting significant loss
5.
Preoccupation with perceived rejection
B.
Anxiety and tension
1.
Hyperactivity
2.
Agitation and restlessness
3.
Chronic tension
4.
Apprehensiveness about changes in routine or environment
5.
Work-related anxiety
C.
Lethargy and lack of motivation
1.
Loss of interest in surroundings
2.
Loss of interest in hobbies or usual activities
3.
Slow moving and sluggish
4.
Marked lethargy
5.
Fatigue
6.
Lack of motivation for ADLs
7.
Lack of motivation for care of personal hygiene
8.
Indifference to personal appearance
D.
Other
1.
Insomnia
2.
Disturbance in eating habits
3.
Poor attention span
4.
Rumination or racing thoughts
5.
Mood swings
6.
Manic episodes, elation, grandiosity
Thought Disorder Problems (psychotic symptoms)
A.
Primary psychotic symptoms
1.
Delusions
2.
Fixed paranoid delusions
3.
Auditory or visual hallucinations or both
4.
Marked distraction by hallucinations and delusions
5.
Disorganized, confused cognition caused by psychotic process
6.
Psychotically impaired judgment and insight
7.
Inappropriate affect
8.
Periods of psychotic decompensation
9.
Work or social adjustment difficulty secondary to paranoia
B.
Withdrawal and apathy
1.
Is withdrawn, reclusive
2.
Has minimal interpersonal interactions
3.
Is noncommunicative
4.
Will not initiate social interactions
5.
Has no hobbies or normal interests
1–5
1–6
Fundamentals of Psychiatric Treatment Planning
6.
7.
Wants to be left alone
Has limited motivation to improve and leave the hospital
C.
Bizarre behaviors
1.
Bizarre behavior such as lying on the floor or exhibiting constant rocking, head banging, and
stereotypical movements
2.
Bizarre, inappropriate dress
3.
Bizarre compulsive eating or drinking habits (e.g., occasionally drinking from the toilet, eating
feces)
4.
Bizarre episodes of screaming and yelling
D.
Other
1.
Poor attention span
2.
Agitation and restlessness
III. Miscellaneous Psychological Impairment Problems
A.
Personality disturbances
1.
Obsessive-compulsive behaviors
2.
Ritualistic, compulsive mannerisms
3.
Overemphasis on cleanliness and neatness
4.
Psychosomatic symptoms and conversion reactions
5.
Stealing and other antisocial behaviors toward property
6.
Dependent personality style
7.
Overly dependent on others for decision making and support
8.
Resistant to independent functioning
9.
Passive-aggressive manipulation
B.
Eating disturbances
1.
Anorexia (inadequate food or fluid intake or both)
2.
Obesity
3.
Bulimia (gorging and vomiting)
4.
Polydipsia (drinking fluids to dangerous excess)
5.
Pica (persistent and compulsive craving to eat nonfood items such as dirt, clay, coffee grounds, or
cigarettes)
C.
Other
1.
Noncompliance with treatment
2.
Escape risk
3.
Nocturnal enuresis secondary to psychological factors
4.
Gender identity confusion
5.
Manipulative behavior
6.
Nonviolent attention seeking
Psychological Impairment (Problem Area 1)
1–7
Strengths (Brief List)
I.
Psychological Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Has no thought disorder
Has insight into problems
Copes well with stress
Has good self-esteem
Has satisfactory sense of social and family belonging
Is motivated to work on realistic treatment goals and returning to the community
Is interested in relating to others in a therapeutic relationship
Has had good response to past treatments
Is treatment and medication compliant
Is able to appropriately advocate for self
Is motivated for leisure or recreational activities
Participates in leisure interests
1.
Sports
2.
Exercise
3.
Reading
4.
Socializing, developing friendships, developing relationships
5.
Watching TV, movies
6.
Listening to radio, music, concerts
7.
Shopping trips
8.
Computers, Internet, computer games
M.
Other
Goals
I.
Expected Improvements in Symptoms
A.
Thought disorder
1.
Pt. will make at least one nondelusional, relevant comment in community meeting twice a week
for 1 month.
2.
Pt. will be able to engage in one 2-minute conversation during the 7-to-3 shift with no evidence of
delusional content three times weekly for 1 month.
3.
Pt. will complete a two-step task successfully without performance being impeded by ritualistic
behavior or delusional speech twice weekly for 1 month.
4.
Pt. will gain insight into delusions and hallucinations so that he or she will suspect that they are a
part of the illness for 1 month.
B.
Mood disturbance
1.
Pt. will consistently verbalize a sense of self-worth and express realistic hopes for his or her future
for 1 week.
2.
Pt. will be able to participate in a program activity without extreme mood swings at least four
times a week for 1 month.
3.
Pt. will be free of depressive or manic symptoms for 1 week.
C.
Focal attention
1.
Pt. will maintain relevance and focus on topics beyond the first two sentences of a conversation
consistently for 1 week.
2.
Pt.’s focal attention will improve to the point that pt. will be able to maintain involvement in one
day-program activity each weekday for 1 month.
3.
Pt.’s focus will improve such that he or she will consistently carry out three-step tasks with only a
single prompt for 1 week.
1–8
II.
Fundamentals of Psychiatric Treatment Planning
D.
Apathy and motivation
1.
Pt.’s motivation will increase to the point that he or she will get out of bed at least 3 days a week
with a single prompt for 1 month.
2.
Pt.’s motivation will increase to the point that the pt. will have his or her personal ward dorm area
in acceptable order at least 3 out of 5 weekdays for 1 month.
3.
Pt. will shave and dress self 4 out of 7 days a week for 1 month.
4.
Pt.’s apathy will diminish such that he or she will use independent privileges once daily for
1 week.
5.
Pt.’s motivation will improve such that he or she will attend two art therapy classes a week for
1 month.
E.
Social withdrawal
1.
Pt. will initiate at least a one one-word greeting daily for 1 month.
2.
Pt. will initiate and sustain a 5-minute conversation once each shift for 1 week.
3.
Pt. will spontaneously initiate a request to go on “buddy” privileges with one of the other pts.
F.
Other
1.
Psychosomatic complaints will be reduced such that these complaints will interfere with assigned
program no more than once per week for 1 month.
2.
Pt. will attempt to escape no more than once per month during a 3-month period.
3.
Pt. will be able to go on supervised privileges with staff once a day for 1 week without attempting
to escape.
4.
Pt. will decrease his or her excessive fluid intake, such that his or her blood Na level remains WNL
for 3 months.
5.
Pt.’s anorexia will improve, AEB gaining 2 pounds per month for 2 months.
6.
Pt. will cooperate with staff requests to toilet self for 1 week.
7.
Pt.’s incidences of nocturnal enuresis will decrease to fewer than three times per week for
1 month.
Reporting of Symptoms
A.
B.
C.
D.
E.
Pt. will verbalize any return of hallucinations for 1 week.
Pt. will verbalize any return of hallucinations for 1 week AEB pt. not being noted to be
responding to hallucinations without having notified staff of the return of
hallucinations.
When tormented by hallucinations, pt. will learn to approach staff and try
interventions for reducing the hallucinations.
In psychotherapy, pt. will express feelings of sadness and loss, if present, once weekly
for 1 month.
Pt. will not feign or exaggerate symptoms for 1 week.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
D.
E.
F.
G.
Pt. will consistently remain in the group activity area with minimal redirection for at
least ½ hour per weekday for 1 month.
Pt. will attend two program activities per week for 1 month.
Pt. will attend art therapy twice a week for 1 month to help improve self-esteem.
Pt. will participate in a full-time load of day-program activities for 1 month.
Pt. will start a supportive job in the hospital gift shop.
Pt. will start a job in the community.
Pt. will attend assigned programs (with medical clearance), despite psychosomatic
complaints, at least once per weekday for 1 month.
Psychological Impairment (Problem Area 1)
1–9
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the importance of taking meds as prescribed once a week for 1 month.
2.
Pt. will spontaneously state the benefits of taking antipsychotic meds twice during 1 month.
3.
Pt. will take antipsychotic meds as prescribed for 1 month.
4.
Pt. will comply with blood and other laboratory work for 3 months.
5.
Pt. will understand the possible benefits of Clozaril AEB cooperating with the necessary workup
for a trial on Clozaril.
B.
Program activities
1.
Pt. will state the benefits of attending program twice weekly for 2 weeks.
2.
Pt.’s level of compliance will improve such that he or she will attend art therapy class twice a week
for 1 month.
C.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process for
1 week.
2.
Pt. will be willing to participate in the evaluation process AEB meeting with the psychologist
weekly for 1 hour.
3.
Pt. will demonstrate cooperation with all aspects of the treatment plan, including meds and blood
work, for 1 month.
4.
Pt. will be free of unrealistic, grandiose discharge plans for 1 month.
D.
Consequences of actions
1.
Pt. will demonstrate a realistic orientation toward his or her progress such that the pt. understands
and explains the connections between the following:
a. Rational, trusting behavior; program attendance; medication compliance; and the ability to be
discharged from the hospital
b. Bizarre, paranoid thinking; inconsistent program attendance; medication noncompliance; and
recurring setbacks, including the need for continued care at the hospital
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate so that psychological tests can be completed.
2.
Pt. will cooperate so that rehabilitation assessment for an appropriate day-program referral can be
completed.
B.
Evaluations to R/O various diagnoses
1.
Pt. will cooperate so that he or she can complete evaluation to R/O psychotic process.
2.
Pt. will complete evaluation to R/O borderline personality disorder.
3.
Pt. will cooperate with psychological testing to R/O organic etiology for psychosis.
4.
Pt. will overcome fears to complete evaluation to R/O cardiac disease.
C.
Laboratory tests
1.
Pt.’s medication compliance will improve so that the medication blood level is in the therapeutic
range for 3 months.
2.
Pt. will control his or her drinking of excessive fluids AEB maintaining a proper electrolyte balance
for 3 months.
1–10
Fundamentals of Psychiatric Treatment Planning
VI. Standardized Outcome Measures
A.
Kennedy Axis V (K Axis)
1.
Pt.’s K Axis score on Psychological Impairment will improve from a current score of 30 to 40.
B.
Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)
1.
Pt.’s K NOSIE score on Manifest Psychosis will improve from a current score of –20 to –12.
2.
Pt.’s K NOSIE score on Social Interest will improve from a current score of +12 to +20.
3.
Pt.’s K NOSIE score on Motor Retardation will improve from a current score of –16 to –10.
C.
Mini-Mental State Exam
1.
Pt.’s score on the Mini-Mental State Exam will improve from a current score of 12 to 18.
D.
Brief Psychiatric Rating Scale (BPRS)
1.
Pt.’s score on the BPRS will improve from a score of 62 to 40.
E.
Beck Depression Inventory
1.
Pt.’s score on the Beck Depression Inventory will improve from a score of 35 to 18.
Treatment Modalities
I.
Verbal Treatment Modalities (emphasis on verbal interactions)
A.
Support and reassurance
1.
Staff will provide one-to-one supportive problem-solving therapy for 1 hour once weekly.
2.
Staff will provide one-to-one relationship to increase trust in staff, to build a trusting relationship,
and to reduce paranoia.
3.
Staff will provide one-to-one contact to provide pt. with needed support and reassurance that
people care for him or her for 1 hour once weekly.
4.
Staff will reassure and reality test with pt. about his or her delusions that the pt.’s thoughts can
kill.
5.
Staff will express understanding of pt.’s distress and suggest interventions when tormenting
hallucinations are present.
B.
Cognitive refocusing (redirecting focus toward reality and realistic self-appraisal)
1.
Staff will treat drops in pt.’s self-esteem by helping pt. focus on his or her assets and
accomplishments (e.g., program attendance, hobbies, relatives who care for the pt., memories of
happy experiences).
2.
Staff will help pt. recognize and express self-worth (e.g., compliment pt. when appearance
improves to bolster self-esteem; engage pt. in activities in which he or she can succeed).
3.
Staff will intervene to refocus, redirect, and orient to reality whenever pt. is confused and disorganized.
4.
Staff will redirect pt. away from behavior based on delusional thinking toward adaptive
requirements of the moment.
5.
Staff will maximize structured activities to minimize regressive episodes by helping the pt. to stay
focused away from psychotic processes, including delusions and hallucinations. This can be done
by maximizing the pt.’s involvement in structured day program, including open workshop,
patient wage program, leisure interest group, and community meeting.
6.
Staff will engage the pt. in two sessions weekly of 30 to 45 minutes in woodworking, using one-toone with pt. to maintain maximum focus.
7.
Staff will focus pt. away from plans based on pt.’s psychotic thinking to plans based on realistic,
achievable goals (e.g., passes with family, shopping trips, and discharge to a halfway house).
8.
Staff will use a substitute stimulation (e.g., listening to radio headset) to help pt. focus away from
tormenting hallucinations.
Psychological Impairment (Problem Area 1)
C.
II.
1–11
Psychotherapy
1.
Staff will meet with pt. for one-to-one, insight-oriented psychotherapy once a week to help work
through psychological conflicts that result in high levels of anxiety.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help the pt. more
effectively cope with day-to-day problems.
3.
Social worker will provide weekly one-to-one dialectic behavior therapy (DBT) counseling for pt.
and lead weekly DBT skills practice group to help reduce pt.’s depressive symptoms.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Staff will give pt. positive feedback and encouragement for coherent, reality-based
communications.
2.
Staff will praise pt. for reality-based speech.
3.
Staff will provide positive verbal reinforcement for independent action when around the ward or
when in program (to reduce apathy and lack of motivation).
4.
Staff will provide constant encouragement to help relieve pt.’s lack of motivation to wash face,
comb hair, wipe nose, and so on.
5.
Staff will give positive reinforcement for any spontaneous activity other than going to bed.
6.
Staff will give positive verbal reinforcement for each step toward greater involvement in ward activities.
7.
Staff will encourage pt. to be involved in the treatment-planning process.
8.
Staff will give pt. reinforcement for accumulating points for specific compliant acts (e.g., making
bed, dressing appropriately, going to program). When pt. receives 10 points, he or she will be
given an identified reinforcer. (See attached behavioral plan for details.)
9.
Staff will give pt. money, clothes, and gym activities to richly reinforce independent, self-initiated
behaviors such as getting dressed, making bed, and going to program.
B.
Negative reinforcement (including discouragement, restriction, and withholding of reinforcement)
1.
Staff will restrict pt. to supervised privileges for 24 hours if he or she fails to go to morning
program activities.
2.
Pt.’s independent privileges will be held for 1 week following his or her return from escape.
During the 1-week period, pt. will be assessed for the safety of restarting independent privileges.
3.
Pt. will lose smoking privileges for 24 hours when he or she steals from other pts.
C.
Extinction
1.
All staff will ignore bizarre and delusional speech, thus helping to extinguish this psychotic
behavior.
2.
Staff will acknowledge psychosomatic complaints but will encourage pt. to attend assigned
program.
3.
Staff will disregard delusional speech.
D.
Shaping and modeling
1.
Staff will provide primary and secondary positive reinforcers for incremental increases in focal
attention.
2.
To improve focal attention, pt.’s contact will involve pt. at least twice daily in 15-minute sessions,
such as tossing and catching a ball, playing pool, and so on.
3.
Nsg. staff will assign pt. on-ward activities with gradually increasing focal requirements as pt.’s
focal attention improves.
4.
Rehab staff will refer pt. to day programming for involvement in tasks that require gradually
increasing amounts of time attending to the task.
5.
Staff will promote pt.’s independence by gradually increasing his or her decision-making
responsibilities.
1–12
Fundamentals of Psychiatric Treatment Planning
E.
Channeling of energies
1.
Staff will channel pt.’s high level of anxiety into structured day-program activities, including
exercise group.
F.
Task simplification (reducing confusion and frustration by simplifying tasks and providing
consistency and assistance)
1.
Nsg. staff will use the same person as consistently as possible for redirection.
2.
All staff will be as consistent as possible in redirecting pt. away from inappropriate, bizarre
behavior.
3.
To reduce level of dependency, contact will help pt. write down all basic answers and procedures
to questions and routines that confuse him or her. When appropriate, contact will direct pt. to
these written lists.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family/couple treatment modalities
1.
Family will engage in therapy to help improve the pt.’s feelings of inadequacy.
2.
Social worker will provide pt. with family therapy once a month for 1 hour to help pt. and his or
her family to cope better with pt.’s delusions.
3.
Psychologist will work with pt. and his or her significant other for 1 hour each week on
recognizing and coping with pt.’s manic episodes.
B.
Religious treatment modalities
1.
Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling for support and hope
in relation to depression once weekly for 1 hour.
2.
Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling to help pt. get a
religious perspective on his or her delusions of demonic possession.
3.
Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling to help pt.
objectively examine his or her guilt and to give appropriate assurance of forgiveness, as needed.
4.
Religious services will be provided to enhance pt.’s self-esteem and feelings of meaning and
community twice weekly for 1 hour.
C.
Other modalities
1.
DBT
a.
Social worker trained in DBT will meet with pt. for therapy and training on means of
managing his or her impulsive behaviors for 1 hour twice a week.
b.
Because of failure to respond to treatment, the team will refer pt. to the DBT ward for
treatment of his or her problems with borderline personality disorder.
2.
Group therapy
a.
Group therapy to facilitate discussion of problems and to learn means of more appropriately
coping with those problems will be undertaken once weekly for 1 hour.
3.
Psychodrama
a.
Role playing will be used to help reduce pt.’s anxiety about talking about his or her illness
once weekly for 1 hour.
4.
Behavioral plan
a.
Psychologist will oversee behavioral plan to change specific behaviors (see attached
behavioral plan).
5.
Desensitization
a.
Psychologist will develop a plan to help desensitize the pt. to his or her fear of driving.
b.
Rehab staff will provide activities that pt. can successfully complete to help relieve pt.’s fear
of failure.
c.
Recreational therapist will work with pt. in bowling group to reduce anxiety associated with
participating in groups.
Psychological Impairment (Problem Area 1)
1–13
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will redirect pt. from triggering events or overstimulating areas to reduce level of
hallucinations.
2.
Sound-absorbing material will be added to pt.’s dorm area to help reduce noise.
B.
Protective procedures (including special observations)
1.
Staff will keep pt. away from street drugs and alcohol to prevent further neuropsychological
damage and associated bizarre behavior. At the same time, pt. will be treated for substance abuse
(as outlined under Problem 5.1 Polysubstance Abuse) in the hopes that pt. will abstain from
substance abuse once pt. has the opportunity to use drugs again.
2.
Nsg. staff will use escape precautions when pt. is on the ward.
3.
Staff will closely monitor pt. whenever pt. is off the ward to minimize escapes.
4.
Staff will install a locating device in pt.’s car to locate pt. when he or she takes off in the car
during a manic episode.
C.
Other milieu treatment modalities
1.
Staff will use increased lighting and brighter colors in the pt.’s day area.
2.
Staff will move pt. to a semiprivate room, and pt. will be allowed to bring in items to give the
room a “home” look and feel.
Medical Treatment Modalities
A.
Medication
1.
Psychiatrist will prescribe antipsychotic meds to reduce intensity of persecutory beliefs.
2.
Nsg. staff will give pt. prn meds to relieve pt. from acute episodes of tormenting hallucinations.
B.
Other medical treatment modalities
1.
Electroconvulsive therapy (ECT)
a.
Intractable depressive symptoms will be treated at St. John’s Hospital with a series of ECT
followed by maintenance ECT.
2.
Light therapy
a.
Pt.’s seasonal depressive symptoms will be treated using light therapy for 1 hour daily.
3.
Psychosurgery
a.
Pt.’s severe unremitting depression will be treated using psychosurgery.
b.
Severe, incapacitating obsessive-compulsive symptoms will be treated at a general hospital
by psychosurgery.
4.
Miscellaneous
a.
Restrict fluids to 350 cc following dinner to prevent nocturnal enuresis.
b.
Nsg. staff will toilet pt. every 2 A.M. to help reduce nocturnal enuresis.
c.
Staff will provide wheelchair to increase pt.’s independence around the ward.
VI. Patient and Family Education
A.
Mental illness
1.
Staff will discuss ways to cope with mental illness with pt. for 1 hour once weekly.
2.
Staff will teach pt. and the family ways to recognize the signs of manic decompensation.
3.
Staff will discuss the nature of pt.’s mental illness and its prognosis with the pt. and family.
B.
Medication
1.
Psychiatrist will discuss the risks and benefits of meds with pt. once weekly for ½ hour.
2.
Nsg. staff will point out concrete benefits of taking meds (e.g., “There is a decrease in the
hallucinations,” “You are more focused on tasks,” “You are less paranoid”).
3.
Pt.’s psychiatrist will discuss with pt.’s family the reasons pt. needs to take meds.
1–14
Fundamentals of Psychiatric Treatment Planning
C.
Benefits and consequences of behaviors
1.
Staff will discuss connections between daily appropriate behavior (such as being out of bed,
attending program) and realistic progress toward pt.’s goals, including passes, shopping trips, and
discharge planning.
2.
Psychiatrist will discuss with pt. alternative means of gaining freedom (demonstrating ability to
appropriately use pt.’s independent privileges within the hospital and off the grounds) rather than
escaping.
3.
Staff will discuss for ½ hour once a week the benefits of neatness and good personal hygiene to
improve pt.’s motivation to attend to daily personal hygiene.
4.
The social worker will discuss with pt.’s family members the benefits of their visits, their support,
and their money for pt.’s shopping trips.
D.
Miscellaneous
1.
Staff will involve pt.’s family in a psychoeducational program to improve their ability to cope with
pt.’s psychotic symptoms.
2.
Psychologist will meet to educate pt.’s parents about the effect that lack of monitoring and lack of
discipline has on the pt. for 1 hour once a month.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Psychological testing for personality assessments
2.
Psychological testing to assist in the diagnostic evaluation
3.
An inventory of reinforcements, including activities, money, relationships with significant others,
and so forth
4.
Psychological testing to determine pt.’s ability to engage in treatment
5.
Neuropsychological testing
B.
Psychiatric evaluations
1.
Psychiatric diagnostic evaluation
2.
Psychiatric medication evaluation
3.
Neuropsychiatric evaluation
4.
AIMS or AIMS Plus EPS exam, as needed
C.
Medical/laboratory tests and evaluations
1.
Urology consult to determine if there is an organic basis for pt.’s bed-wetting
2.
Blood levels to help determine medication compliance
3.
Blood levels to determine whether the psychotropic medication is in the therapeutic range
4.
EEG to R/O temporal lobe epilepsy
5.
CT scan/MRI to R/O organic etiology
6.
Incontinence chart to follow enuresis
D.
Other evaluations and assessments
1.
Rehab staff will assess pt.’s areas of interests and motivation to assign structured activities
congruent with pt.’s interests.
2.
Social worker will interview family members to assess their ability to communicate with each
other and to identify areas of significant conflict.
3.
Social worker will complete the Residential Care Scale for level of care needed at discharge.
4.
Conduct weekly one-to-one meetings with pt. and monthly meetings with family to determine
pt.’s ability to tolerate increased involvement with family.
5.
Conduct vocational assessment to develop a step-by-step plan to reengage pt. in vocational
activities.
6.
Psychologist will meet with pt. once a week for ½ hour to attempt to understand pt.’s stealing
behavior.
7.
Nsg. staff will monitor pt. for evidence that pt. is planning an escape.
8.
Conduct religious assessment to determine consistency of potentially delusional thinking with
pt.’s religious community.
Psychological Impairment (Problem Area 1)
9.
1–15
Conduct religious assessment to evaluate validity of pt.’s guilt feelings from a religious
perspective.
VIII. Legal Treatment Modalities
A.
Court commitment
1.
Psychiatrist will seek court commitment under Sections 7 and 8 for a period of up to 6 months
because pt. is unable to safely function in the community due to her poor insight and judgment.
2.
Psychiatrist will initiate petition for mandatory outpatient commitment and treatment under
Section 23c.
B.
Court approval for forcing meds
1.
Team will seek court approval for the use of antipsychotic meds for treatment of pt.’s disabling
psychosis.
IX. Miscellaneous Treatment Modalities
A.
Treatment of related problems (optional and can be included with the treatment
modalities or in the problem description)
1.
Treat pt.’s problem with suicidal ideation as indicated under Problem 3.1 (Suicidal Ideation).
2.
Treat pt.’s problem with assaultiveness as indicated under Problem 3.1 (Violence Secondary to
Paranoia).
3.
Treat pt.’s problem with substance abuse as indicated under Problem 5.1 (Polysubstance Abuse).
1–16
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plans (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Psychotic Symptoms
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
•
•
•
•
2.
3.
4.
Onset of symptoms and chronicity
Precipitants (e.g., noncompliance with treatment, substance abuse, stress)
Characteristics, frequency, intensity, and variance of symptoms
Response to previous and current treatments and expected response to any proposed treatments
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
Make sure that the above relate to goals and treatment modalities.
If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it
into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment.
Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem
Area 3, Violence.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
1.
Pt. will participate in _______________________ group(s) at least ___
out of ___ days a week for ___ month(s).
2.
Pt. will be involved in at least ___ hours per day of either
treatment programs or vocational programs for a ___-week/month
period without significant interference from psychotic symptoms.
3.
Pt. will be free of overt psychosis AEB not acting on delusions or
hallucinations for ___ week(s)/month(s).
4.
Pt. will accept prescribed meds and lab work for a ___-week/month
period.
5.
Pt. will engage in reality-based, ___-minute conversations with
staff without evidencing delusional ideas at least ___ time(s) per
week for ___ month(s).
6.
Pt. will cooperate with a least one treatment team member in the
treatment planning process.
7.
Pt. will be able to explain the nature of his or her illness and its
treatment in a fairly rational, fairly accurate manner.
8.
Pt. will tolerate ___ overnight visits to a community residence
without significant interference from psychotic symptoms.
9.
Pt.’s score on the Kennedy Axis V Psychological Impairment will
improve from the current score of ___ to ___.
Target Date
Date/Status*
10. Pt.’s score on the Kennedy NOSIE’s Manifest Psychosis and Social
Interest will improve from the current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
1–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ____ minutes at least ______ time(s) weekly/monthly to
monitor any changes in psychosis to prescribe treatment with antipsychotic meds,
______________, and _____________ for EPS. Lab (blood levels, WBCs). AIMS q 6 months.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
discuss the effect of pt.’s psychosis on discharge, to evaluate pt.’s readiness for
discharge, and to discuss discharge options with pt.
Brenda St. Martin, MSW
Psychology (or Social Work):
1.
Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
times weekly/monthly in supportive, problem-solving, cognitive therapy to direct pt.
back to reality or help pt. function, even if psychotic symptoms persist.
2.
Psychologist (social worker) will rate the Kennedy Axis V quarterly/annually.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise the daily treatment schedule. Staff will refer pt. to
appropriate groups working to improve contact with reality, self-image, motivation,
and focal attention and to develop structure in pt.’s daily routine.
2.
Staff will work with pt. in _____________________ group program for ___ hour(s) a
day/week to help improve pt.’s (contact with reality, self-image, motivation, focal
attention, ____________________).
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will provide decreased stimulation, verbal redirection, and refocusing to
reality issues. If tormenting hallucinations or paranoid thoughts are present, nsg. staff
will express understanding of pt.’s distress, give reassurance, suggest interventions and,
if indicated, offer prn meds to help relieve pt.’s distress.
2.
Nsg. staff will encourage attendance at morning meeting (staff will encourage role
modeling of appropriate behavior), other on-ward activities, and rehab groups. Staff
will provide escort if needed. Nsg. staff will document frequency of attendance.
3.
Nsg. staff will offer support and praise for appropriate, reality-based interactions.
4.
Nsg. staff will begin to assess pt.’s level of understanding of antipsychotic meds and his
or her readiness to learn before educating pt.
5.
Nsg. staff will meet with pt. for ___ minutes at least ___ time(s) a week/month to
educate pt. about his or her illness and the importance of taking his or her meds. This
process will be simple, clear, concrete, and according to pt.’s ability to understand.
Nsg. staff will request feedback from pt. to validate pt.’s level of comprehension.
6.
Nsg. staff will rate the Kennedy NOSIE once weekly/monthly/quarterly.
7.
Nsg. staff will prompt pt. to perform ADLs and will document compliance.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.2 Depressive Symptoms
Name: Smith, Jane
ID #:
Area:
Nursing Diagnosis: Chronic Low Self-Esteem; Hopelessness;
Powerlessness
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
•
•
•
•
2.
3.
4.
Onset of symptoms and chronicity
Precipitants (e.g., noncompliance with treatment, substance abuse, stress)
Characteristics, frequency, intensity, and variance of symptoms
Response to previous and current treatments and expected response to any proposed treatments,
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
Make sure that the above relate to goals and treatment modalities.
If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it
into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment.
Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem
Area 3, Violence.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
1.
Pt. will be able to engage in a _____-minute conversation without
any evidence of helplessness or hopelessness.
2.
Pt. will be able to discuss options for the future beyond feelings
of helplessness and hopelessness for a _____-day/week period.
3.
Pt. will be able to report improvement in his or her depressive
symptoms consistently for a ___-day/week period.
4.
Pt.’s motivation will improve to the point that pt. will get out of
bed and have his or her dorm area in acceptable order at least ___
weekdays per week for a ___-week/month/period.
5.
Pt.’s energy and motivation will improve so that he or she will
be involved in a least ___ hours per day ___ days per week of
either treatment programs or vocational programs for a
___-week/month period.
6.
Pt.’s depressive symptoms will improve to the extent that he or
she will be able to successfully function during ___ overnight
visit(s) to community residence or home.
7.
Pt.’s score on the Beck Depression Inventory will improve from
the current score of ___ to ___.
8.
Pt.’s score on the Kennedy Axis V Psychological Impairment will
improve from the current score of ___ to ___.
9.
Pt.’s score on the Kennedy NOSIE’s Social Interest and/or Motor
Retardation will improve from the current score of ___ to ___.
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.2
1–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to
monitor any changes in depression to prescribe treatment with antidepressant meds,
such as _______________________ . Labs as ordered, including antidepressant levels.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
discuss pt.’s depression’s affect on discharge, to evaluate pt.’s readiness for discharge,
and to discuss discharge options with pt.
Brenda St. Martin, MSW
Psychology (or Social Work):
1.
Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
time(s) weekly/monthly in supportive, problem-solving cognitive therapy to improve
pt.’s mood and/or help pt. function, even if depressive symptoms persist.
2.
During these meetings, drops in pt.’s self-esteem will be treated by helping pt. focus on
his or her assets and accomplishments (e.g., career accomplishments, relatives who
care for pt., hobbies, memories of happy experiences).
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.s’ daily treatment schedule. Staff will refer pt.
to appropriate groups working to improve his or her contact with reality, self-image,
motivation, and sense of helplessness or hopelessness (see weekly schedule).
2.
Staff will work with pt. in _____________________ group program for ___ hour(s) a
day/week to help improve pt.’s ______________ (self-esteem, self-image, motivation, and
sense of helplessness or hopelessness).
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive
aspects of his or her life. Nsg. staff will help pt. learn ways to resolve or cope with
negative aspects of his or her life.
2.
Nsg. staff will begin to assess pt.’s level of understanding of antidepressant meds and
his or her readiness to learn before educating pt.
3.
Nsg. staff will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
educate pt. about his or her illness and the fact that pt.’s meds can help to reduce his
or her sadness and sense of hopelessness or helplessness. Nsg. staff will request
feedback from pt. to validate pt.’s level of comprehension.
4.
Nsg. staff will begin to assess pt.’s level of understanding of antipsychotic meds and his
or her readiness to learn prior to educating pt.
5.
Nsg. staff will offer support and praise for realistic, positive interactions or statements
about self or about pt.’s future.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Psychological Impairment (Problem Area 1)
1–21
Sample Individual Problem Plans
CONTENTS
Depressive Symptoms............................................................................................................................. 1–22
Manic-Depressive Symptoms ................................................................................................................. 1–24
Depressive and Psychotic Symptoms ..................................................................................................... 1–26
Psychotic Symptoms............................................................................................................................... 1–28
Residual Psychosis................................................................................................................................... 1–30
Apathy and Lack of Motivation .............................................................................................................. 1–32
Poor Focal Attention............................................................................................................................... 1–34
Noncompliance With Treatment............................................................................................................ 1–36
Resists Independent Functioning ........................................................................................................... 1–38
Escape Risk.............................................................................................................................................. 1–40
Stealing ................................................................................................................................................... 1–42
Psychosomatic Complaints ..................................................................................................................... 1–44
Work-Related Anxiety............................................................................................................................. 1–46
AIDS-Related Distress ............................................................................................................................. 1–48
1–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Depressive Symptoms
Name: Williams, Alice
ID #:
Area:
Nursing Diagnosis: Hopelessness
Date: 01/15/03
Problem Description:
Pt. presents with consistent attitude of hopelessness and helplessness about situation. She has no plans for future
and views her immediate situation as totally beyond her control. Behavior has adolescent quality in that negative
behaviors are used as retaliatory measures against others and to keep others at a distance. Pt. will be able to discuss
options for future.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Patient will be able to discuss options for future beyond feelings
of helplessness and hopelessness.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will be able to engage in a 5-minute conversation without any
evidence of helplessness or hopelessness.
04/15/03
2.
Pt. will cooperate with at least one treatment member in the
treatment planning process.
04/15/03
3.
Pt. score on the Beck Depression Inventory will improve from the
current 30 to 18.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
1–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for at least ½ hour once weekly to monitor any changes
in depression to prescribe treatment with antidepressants, such as Zoloft (sertraline).
Order labs, including antidepressant levels.
Victor Dyson, MD
Psychology:
1.
Psychologist will perform psychological testing to assess depressive cognition.
2.
Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive,
problem-solving therapy to improve pt.’s mood and help her function even if
depressive symptoms persist.
Joseph LeBlanc, Psychologist
Social Work:
1.
Social worker will meet with pt. for ½ hour once weekly to evaluate pt.’s readiness for
discharge.
2.
Social worker will consistently offer pt. the opportunity for treatment planning
involvement.
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will meet with pt. as needed to review and revise her daily treatment
schedule and will refer her to appropriate groups working to improve her self-image,
motivation, and sense of helplessness and hopelessness (see weekly schedule).
Jane Hoover, Rehab
Nursing Care Plan:
1.
Staff will verbally reward pt. for cooperative acts on ward and toward other pts.
2.
Staff will discuss with pt. the fact that the meds reduce her sense of hopelessness and
helplessness.
3.
Nsg. staff will offer support and praise for positive interactions, positive statements
about herself, or positive statements about her future.
Ronald Donahue, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.2 Manic-Depressive Symptoms
Name: Chabot, Joe
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
For the last several years, pt. has been having increasing problems with mood swings, which occur every few
months. During the depressive phase, pt. experiences motor retardation and low self-esteem and becomes
withdrawn. During the manic episodes, pt. experiences euphoric mood, marked insomnia, hyperactivity,
intrusiveness, marked irritability, and assaultiveness. Pt. often feels that the moods are related to external events,
and he is reluctant to take his lithium on a regular basis. When pt. takes his lithium as prescribed, there is a marked
reduction in the severity of his mood swings. Tremors appear to be the only significant side effect of the lithium.
Treatment of irritability as outlined under Problem 3.1 Assaultive, Irritable Behavior.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt.’s manic-depressive symptoms will be controlled to the point
that he can be discharged back to an independent living situation
in the community.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt.’s mood will stabilize such that he gets at least 6 hours of sleep
each night for 1 month.
03/15/03
2.
Pt. will be able to express an understanding of his illness,
including his own “first signs” of manic and depressive trends
and the need to take his meds.
03/15/03
3.
Pt.’s mood will stabilize such that he maintains a normal level of
activity (i.e., reasonably socially outgoing and involved in
recreational activities for 1 month).
04/15/03
4.
Pt. will be free of any significant side effects from the lithium for
1 month.
03/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.2
1–25
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for at least 1 hour and 35 minutes monthly to monitor
any changes in manic-depressive symptoms and to prescribe treatment with mood
stabilizer (such as lithium or Depakote) and beta-blockers (such as Inderal) to help
relieve tremors secondary to the lithium therapy.
2.
Psychiatrist will conduct periodic lab tests to monitor lithium levels and to detect
possible adverse effects of lithium on the thyroid gland, kidney, and the like.
Victor Dyson, MD
Nursing Care Plan:
1.
Nsg. staff will lead medication group once weekly to help pt. understand the nature of
his cyclic mood disturbance, to help him monitor signs of changing mood, and to help
him recognize the benefits of medication for relieving his symptoms.
2.
Nsg. staff will encourage attendance at morning meeting and program activities. Nsg.
staff will document frequency of attendance.
Ronald Donahue, RN
Rehab:
1.
Staff will engage pt. in meaningful activities to redirect excessive energy when pt. is
manic and to minimize withdrawal and drifting when pt. is depressed.
Albert Sanchez, Rehab
Social Work:
1.
Social worker will hold a family meeting once weekly to address pt.’s brothers’
concerns about pt. illness, to educate them regarding his cyclic mood disturbance, and
to support them in coping with his behavior.
Brenda St. Martin, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–26
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.3 Depressive and Psychotic Symptoms
Name: Murphy, John
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
Pt. has a long history of depressive and psychotic symptoms, including persecutory delusions, constant auditory
hallucinations, disorganized thinking, marked sadness, and marked apathy. Exacerbation of depressive and
psychotic symptoms often occurs in association with stress, noncompliance with his meds, or both. Currently pt. is
actively psychotic and very unmotivated. He rejects most interpersonal contact, including that of family members.
Pt. often appears depressed and at times self-reports feelings of depression. The depression is reflected in his lack of
motivation to attend to personal hygiene and his appearance, as well as a generalized appearance of sadness.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will improve to the extent that he can participate in two offward groups per day for 1 month.
01/15/04
2.
Pt.’s Kennedy Axis V score on Psychological Impairment will
improve from current 30 to 40.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. apathy and poor motivation will diminish such that he is out
of bed for at least 2 hours per shift for 2 weeks.
04/15/03
2.
Pt. will use unsupervised privileges at least ½ hour per shift for
2 weeks without significant interference from his psychotic
symptoms.
04/15/03
3.
Pt. will participate in rehabilitation groups three times a week for
2 weeks.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.3
1–27
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ½ hour once a week to monitor pt. for any changes
in his depressive and psychotic symptoms. Antipsychotic and antidepressant meds as
prescribed. Labs as needed and AIMS Plus EPS exam q 6 months.
Virginia Coleman, MD
Social Work:
1.
Social worker will hold weekly meetings with pt. for 45 minutes (family to be included
monthly) to assess and address individual and family issues.
2.
Social worker will hold weekly meetings with pt. to assess readiness for discharge and
to determine obstacles to his discharge.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will hold weekly reality testing for ½ hour to determine obstacles to
improved level of functioning.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Nsg. staff will provide positive feedback to pt. for spontaneous attendance to his
appearance.
2.
Nsg. staff will engage pt. in one-to-one contact two to three times per day to encourage
interpersonal contact in on- and off-ward supervised activities.
3.
Nsg. staff will provide support and praise for appropriate, reality-based interactions.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–28
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.4 Psychotic Symptoms
Name: Kaplan, Carolyn
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
For more than 10 years, pt. has been almost constantly experiencing auditory hallucinations, persecutory
delusions, and bizarre behavior. Because of interference from her thought disorder, she currently is unable to
engage in meaningful conversation for more than 30 seconds. Pt. is becoming increasingly apathetic and does not
participate in any structured activities. Numerous treatment interventions have failed to bring about significant
improvement in her psychosis. These treatments have included trials of several different antipsychotics. Pt. has
recently been approved for a trial on clozapine. Pt. has a borderline abnormal ECG and tardive dyskinesia.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will improve to the extent that she can function on an
unlocked ward successfully for 3 months.
01/15/04
2.
Pt.’s Kennedy Axis V subscale score on Psychological Impairment
will improve from current 20 to 40.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt.’s thought disorder will improve to the extent that she is able
to participate in supervised groups for 1 hour, twice weekly for
1 month.
04/15/03
2.
Pt.’s hallucinations and disorganized thinking will diminish to
the extent that she is able to engage in a focused conversation for
5 minutes twice a week for 1 month.
04/15/03
3.
Pt. will participate in rehabilitation groups three times a week for
1 month.
04/15/03
4.
Pt.’s score on the BPRS will improve from current 61 to less than
40.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.4
1–29
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. to monitor any changes in pt.’s psychotic symptoms to
prescribe antipsychotic meds, such as clozapine.
2.
BPRS will be completed q 3 months. Kennedy Axis V to be completed q 6 months.
3.
Psychiatrist will order weekly WBC for first 6 months of treatment with clozapine,
then WBC twice a month.
4.
AIMS Plus EPS evaluation will be repeated as needed.
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor pt.’s pulse, BP, and temp weekly for the first month of clozapine
treatment, then monitor her as needed.
2.
Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a
conversation.
3.
Nsg. staff will provide one-to-one contact to encourage pt. to participate in program
activities two to three times per day.
4.
Nsg. staff will provide positive feedback to pt. for spontaneous participation in any
structured activity.
5.
Nsg. staff will monitor pt.’s weight monthly for possible excessive weight gain
secondary to clozapine.
Marilyn Davis, RN Å Nsg. Staff
Rehab:
1.
Rehab staff will meet one-to-one with pt. to refer pt. to appropriate groups to increase
her motivation and develop structure in her daily routine.
2.
Rehab staff will work with pt. to develop and update her weekly program schedule (see
attached weekly schedule).
Thomas Parker, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–30
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.5 Residual Psychosis
Name: Newman, Anne
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
Pt. thinking is often disorganized and she is easily overwhelmed by external stimuli. Pt. demonstrates moderate to
marked lethargy and frequently spends much of the day in bed. Pt. has a history of active psychosis; however,
currently she isn’t delusional and she does not appear to be hallucinating. Pt.’s insight and judgment are
moderately impaired. Care has to be taken when planning activities for pt. because she often, at a superficial level,
appears able to function higher than her actual skills will allow. Recently pt. has been able to function well several
days a week in a community day program.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will participate in full-time community day program 5 days a
week for 3 months.
01/15/04
2.
Pt.’s Kennedy Axis V score on Psychological Impairment will be
maintained at level 50 or better.
Ongoing
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will participate in full-time community day program 3 days
per week for 1 month.
04/15/03
2.
On days when not in community program, pt. will attend 2
hours of a ward- or hospital-based program per day for 1 month.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.5
1–31
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ½ hour once a month to monitor pt. for any return
of delusions or hallucinations and adjust pt.’s antipsychotic meds accordingly. Lab
work as needed and AIMS Plus EPS q 6 months.
Victor Dyson, MD
Social Work:
1.
Social worker will conduct weekly one-to-one meeting with pt. for 1 hour to discuss
methods of coping with and tolerating group interactions in daily ward and program
routine.
2.
Social worker will conduct weekly one-to-one meeting with pt. to evaluate pt.’s
readiness for discharge.
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will encourage pt. to participate in hospital and community programs.
2.
Rehab staff will make ongoing assessments of pt.’s actual abilities through observation
of her ability to perform specific ward and program tasks.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will encourage pt. to attend morning meeting and rehab groups.
2.
Nsg. staff will provide positive feedback to pt. for staying out of bed during the day for
periods of 2 hours or more.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–32
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.6 Apathy and Lack of Motivation
Name: King, Robert
ID #:
Area:
Nursing Diagnosis: Activity Intolerance
Date: 01/15/03
Problem Description:
Pt. has a lifelong history of noninvolvement in productive activities. He spends the bulk of the day lying in bed,
preoccupied with internal thoughts. Hospital staff has consistently been unsuccessful during previous hospitalizations in getting pt. involved in on- or off-ward activities. Recently pt. has expressed some interest in earning
money for extra cigarettes. Pt. has been tried on a number of antipsychotic meds, including typical and atypical
meds. Pt. has not had a trial on Clozaril.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will participate in 3 of 10 regularly scheduled program
activities.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will participate in 1 of 10 regularly scheduled program
activities.
03/15/03
2.
Pt. will participate in one structured work activity of 15 minutes
per day, such as washing windows on the ward.
03/15/03
3.
Kennedy NOSIE score in area of Motor Retardation will improve
from current score of –16 to –10.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.6
1–33
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ½ hour once a week to prescribe antipsychotics, such
as Clozaril, to help relieve the negative symptoms of pt.’s psychotic process. Lab as
needed, such as weekly WBC and periodic Clozaril blood levels.
Virginia Coleman, MD
Rehab:
1.
Rehab staff will arrange for pt. to participate in the Patient Wage Program.
2.
Rehab staff will schedule pt. for activities that he can complete successfully and that
lead to increased self-esteem and motivation to continue with the activities (see pt.’s
weekly schedule).
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will provide encouragement for pt. to participate in structured work
activities, such as washing windows or cleaning the dayroom.
2.
Nsg. staff will provide support and praise for pt.’s involvement in any program
activity.
Linda Larkin, RN Å Nsg. Staff
Social Work:
1.
When pt. is able to consistently participate in program activities, social worker will
begin meeting with pt. for ½ hour once weekly to evaluate his readiness for discharge
and to discuss discharge options.
Brenda St. Martin, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–34
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.7 Poor Focal Attention
Name: Brown, William
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
Pt. has a very short attention span; however, with frequent staff redirection, he is able to complete assigned
program tasks. This has been a long-standing problem for pt.; however, he does appear to respond to staff
member’s attention and verbal praise.
Implementation of treatment of Problem 1.1 Psychotic Symptoms to help relieve the contribution of pt.’s
psychotic symptoms to pt.’s poor focal attention.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt.’s focal attention will improve as measured by his ability to
maintain involvement in program 5 days a week with minimal
prompts.
01/15/04
2.
Score on the Kennedy Axis V Psychological Impairment will
improve from a current 40 to 60.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt.’s focal ability will improve such that he will be able to
maintain involvement in program 3 days per week.
07/15/03
2.
Pt. will be able to consistently maintain focus on topic beyond
the first two sentences of a conversation for 2 weeks.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.7
1–35
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Staff will increase focal attention through the use of graded activities designed to meet
his needs and interests.
2.
Staff will give verbal reinforcement for incremental increases in focal attention during
tasks.
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a
conversation.
2.
When nsg. staff members observe pt. wandering off task or off verbal focus, they will
immediately redirect pt. back to task, with immediate reinforcement for returning to
task, even though it requires guided redirection.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–36
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.8 Noncompliance With Treatment
Name: Krause, Cheryl
ID #:
Area:
Nursing Diagnosis: Noncompliance
Date: 01/15/03
Problem Description:
Pt. has a long history of noncompliance with her meds, despite being under a court order to take her psychotropic
meds. When she stops her meds, she gradually decompensates over a few weeks to a few months. Once
decompensated, she is very slow to recompensate after being restarted on her meds. There are concerns that after a
period of decompensation she never fully recovers back to her baseline. Currently she continues to be very resistant
to taking her meds. Pt. also refuses blood work and often refuses to go to program.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will demonstrate cooperation with all aspects of the treatment
plan, including meds and blood work for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will comply with blood work for 3 months.
04/15/03
2.
Pt. will attend assigned programs at least three times weekly for
3 months.
07/15/03
3.
Pt. will accept meds as prescribed for 3 months.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.8
1–37
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will maintain permission for forced treatments, including antipsychotic
meds, as outlined under Problem 7.1 Court Guardianship Plan.
Virginia Coleman, MD
Psychology:
1.
Psychologist will inventory reinforcing events, activities, and objects specific to this pt.
2.
Pt. will receive second-level reinforcement by accumulating one point for each
compliant action (e.g., allowing blood to be drawn or attending assigned group). When
pt. accumulates five points, she will receive a previously identified reinforcer (see
attached behavioral plan).
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Staff will discuss with pt. the importance of blood work and meds.
2.
Staff will give verbal reinforcement for all aspects of treatment compliance, such as
taking meds, complying with blood work, and going to program.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–38
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.9 Resists Independent Functioning
Name: Smith, Mary
ID #:
Area:
Nursing Diagnosis: Ineffective Role Performance
Date: 01/15/03
Problem Description:
Since adolescence, pt. has had difficulty functioning independently of her family or institutions. She is terrified of
growing up and separating from caregivers. However, she denies these fears and expresses a desire to leave the
hospital to live on her own. To avoid independence, she gets herself restricted by breaking the rules, assaulting
others, dressing inappropriately, making somatic complaints that have no physical basis, going AWA (away
without authorization), and refusing to go to programs or social activities that she has identified as interesting. Pt.’s
family often does things that increase pt.’s dependence, such as interrupting treatment despite their agreement to
schedule visits when she is not involved in program activities.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will demonstrate progress toward independent functioning
AEB at least ½ day involvement in off-ward program activities of
her choice 5 days per week for 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will be up, dressed appropriately, and have completed all
personal hygiene with no more than two verbal cues in time for
cafeteria at least 3 days per week for 1 month.
04/15/03
2.
Pt. will complete two ½-day sessions of off-ward programs per
week for 1 month.
07/15/03
3.
Pt.’s family will support pt. treatment plan.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.9
1–39
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will give pt. immediate verbal reinforcement for any significant independent
functioning, such as getting out of bed without cues, going to program with no more
than one cue, and independently preparing to go to program without any cues (see
attached behavioral plan).
2.
Nsg. staff will remind pt. to get ready for program activities with minimal verbal cues
(e.g., she will be reminded to get ready for her DBT group only once, 15 minutes before
the group).
Marilyn Davis, RN Å Nsg. Staff
Psychology:
1.
Psychologist will use DBT techniques to work with pt. one-to-one and in the DBT
group for 1 hour twice a week.
2.
Psychologist will inventory reinforcing events, activities, and objects specific to the pt.
and make modifications in the DBT plan as indicated by the results of the inventory.
Joseph LeBlanc, Psychologist
Social Work:
1.
Family education meetings will be held once weekly for ½ hour to engage parents in
pt. treatment, to help them identify and modify behaviors they contribute that slow
pt.’s improvement, and to teach them to identify and reward small improvements in
pt.’s independent functioning.
2.
Social worker will meet with pt. ½ hour once weekly to help pt. see the advantages of
living in the community and how her acting-out behaviors sabotage her transition into
the community.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–40
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.10 Escape Risk
Name: Jeneski, Raymond
ID #:
Area:
Nursing Diagnosis: Ineffective Coping
Date: 01/15/03
Problem Description:
Pt. has an extensive history of escaping from the hospital while on independent privileges. While on such
unauthorized passes, pt. has abused alcohol and attempted to break into houses. His escaping appears to be related
to his impulsivity and disorganized thinking. Pt. may put himself and others in dangerous situations while on
escape because of his poor judgment, especially when intoxicated.
Implementation of treatment of Problems 1.1 Psychotic Symptoms and 5.1 Alcohol Abuse to help lower pt.’s
escape risk.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will not attempt to escape for 6 months or more from
independent privileges and day passes.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will attend off-ward programs and supervised privileges
without attempting to escape for at least 1 month.
04/15/03
2.
Pt. will be able to go on independent privileges for ½ hour three
times daily for at least 1 month without attempting to escape.
04/15/03
3.
Pt. will be able to verbalize an understanding of the relationship
between his continued escaping and the increasing difficulty of
placing him in the community consistently for 1 month.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.10
1–41
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Pt.’s supervised privileges will be held for at least 1 week following his return from
escape. During this week, he will be assessed as to whether he is safe to restart
supervised privileges.
Virginia Coleman, MD
Social Work:
1.
Social worker will meet with pt. for 45 minutes once weekly to help pt. understand
how escaping from his treatment leads to increased loss of freedom and increased
difficulty with placing him in the community.
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will closely monitor pt.’s whereabouts while he is off-ward in scheduled
groups.
Thomas Parker, Rehab Å Rehab Staff
Psychology:
1.
Staff will provide one-to-one to assistance pt. to develop appropriate alternative means
of gaining freedom and independence.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Nsg. staff will monitor pt. for evidence that he is planning an escape (e.g., hoarding
money, wearing a coat while going to in-hospital activities).
2.
If suspicious behavior is noted, nsg. staff will discuss it with pt. to assess his rationale
for the behavior. If suspicions continue, staff will be very conscientious about
monitoring pt. and will notify psychiatrist of concerns.
3.
Prior to pt.’s going on privileges, nsg. staff will caution him against attempting to
escape. Upon his return from successful privileges, nsg. staff will praise pt. for his not
having attempted to escape.
4.
Nsg. staff will provide verbal praise and reinforcement for comments and behaviors
that suggest that he is working on alternatives to gain freedom, rather than escaping.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–42
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.11 Stealing
Name: Miller, Nancy
ID #:
Area:
Nursing Diagnosis: Ineffective Coping
Date: 01/15/03
Problem Description:
Pt. steals a wide variety of items, most frequently cosmetics. While on pass in the community, she has been
arrested twice during the last year. No charges were filed. Pt. could easily buy the items that she steals. Because of
her psychotic process, it is very difficult to understand why she steals; however, there does appear to be a
compulsive quality to her stealing. Her stealing makes it very difficult to give her unsupervised passes. Her family is
very interested in having pt. return home to live with them; however, her stealing makes it very difficult to allow
her to go unsupervised in the community. Rewarding her for not stealing with weekly trips to visit her family has
decreased the frequency of the stealing. Generally pt. does not steal when at home. Prozac has been helpful with
reducing pt.’s compulsion to steal.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will refrain from stealing and thus demonstrate behavioral
control such that she earns a pass home 3 weeks per month for
6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will refrain from stealing and thus demonstrate behavioral
control such that she earns a day pass for 2 weeks per month for
3 months.
04/15/03
2.
Pt. will be able to verbalize an understanding of why she steals.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.11
1–43
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
On each day there is an absence of conclusive evidence that she has stolen, staff will
take pt. to the canteen for a snack.
2.
In association with taking pt. on an earned trip to the canteen, staff will verbally
reinforce her appropriate (nonstealing) behavior. For example, saying, with smiling
approval, “You did such a good job controlling your impulse to steal that I want to
take you to the canteen.”
3.
Pt. will be rewarded with a day pass to home once weekly, if she is able to control her
urge to steal on the ward or in the community during the preceding week. This control
will be measured by the absence of conclusive evidence that she has stolen during the
last week.
Marilyn Davis, RN Å Nsg. Staff
Social Work:
1.
Social worker will arrange the schedule for passes with pt. family.
2.
Social worker will meet with pt.’s family for 1 hour once a month for supporting,
problem-solving family therapy.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will meet with pt. once a week for ½ hour to attempt to understand her
stealing and to develop strategies that will help decrease her stealing.
Joseph LeBlanc, Psychologist
Psychiatry:
1.
Psychiatrist will meet with pt. in treatment team for 1 hour once a month to monitor
any changes in pt.’s stealing and to prescribe treatments with SSRIs, such as Prozac
(fluoxetine).
Virginia Coleman, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–44
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.12 Psychosomatic Complaints
Name: Stone, David
ID #:
Area:
Nursing Diagnosis: Impaired Health-Seeking Behaviors
Date: 01/15/03
Problem Description:
Pt. has a long history of somatic complaints that are related to attention seeking and avoidance of involvement in
activities. Complaints include problems with stomach, bowel, broken bones, and headaches. Only rarely is there a
physical basis for the complaint.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Somatic complaints will be reduced such that these complaints
interfere with assigned program no more than 1 day per week.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Somatic complaints will reduce such that they interfere with
program attendance a maximum of 3 days per week.
Target Date
Date/Status*
01/15/04
Target Date
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.12
1–45
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will assess medical aspects of all somatic complaints and treat or arrange
for treatment of actual physical problems. Psychiatrist will give staff feedback
concerning the medical safety of pt.’s participation in various activities.
Victor Dyson, MD
Nursing Care Plan:
1.
Following medical assessment of complaints and reasonable assurance that pt. is not at
risk, nsg. staff will provide strong support and encouragement to patient for
functioning in program despite complaints.
2.
Nsg. staff will discuss health issues with pt. and teach healthy lifestyle changes for
½ hour once weekly.
3.
Nsg. staff will provide support and praise for any reductions in pt.’s seeking medical
attention for his psychosomatic complaints; for example, staff will praise pt. for being
able to go for a day without any significant attention obtained through the use of
psychosomatic complaints.
Linda Larkin, RN Å Nsg. Staff
Psychology:
1.
Psychologist will discuss stress reduction training with pt. and initiate if appropriate.
Susan Green, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–46
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.13 Work-Related Anxiety
Name: Pierce, Kenneth
ID #:
Area:
Nursing Diagnosis: Anxiety
Date: 01/15/03
Problem Description:
Two years ago, pt. developed temporal lobe epilepsy (TLE) syndrome. With treatment, he still has an episode about
once a month that is characterized by confused, disorganized thinking. The episodes are preceded by a “weird”
feeling and last only a few minutes. Since the development of TLE, pt. has not been involved in any productive
activity. Pt. states that his confidence is low and he is afraid of having an episode of TLE in front of customers in a
work setting. Pt. had been a very successful computer programmer before the onset of TLE, and the TLE should not
have significantly impaired his work performance.
Implementation of the medical treatment of Problem 6.1 Temporal Lobe Epilepsy.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will work 10 to 20 hours per week as a computer programmer
for a 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will be able to participate in scheduled exercise groups for
1 month.
03/15/03
2.
Pt. will able to participate in the sports and fitness club three
times weekly for 1 month.
04/15/03
3.
Pt. will be able to work in the hospital computer work program
5 hours per week for 1 month.
07/15/03
4.
Pt. will begin taking small programming jobs in the community
for 5 to 10 hours a week for 1 month.
10/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.13
1–47
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in exercise group three times weekly for 20 minutes to engage pt. in
a structured social activity to reduce anxiety in group activities.
2.
Pt. will participate in sports and fitness club three times weekly for 2 hours to engage
pt. in a structured social activity that will help reduce anxiety in group activities.
Albert Sanchez, RT
3.
Pt. will participate in vocational counseling for 1 hour once weekly to develop stepwise plan of engagement in vocational activities.
Thomas Parker, OT
4.
Pt. will participate in hospital industries program 5 hours weekly to assess and renew
his confidence in his work skills and to develop means of coping with the episodes of
TLE.
5.
Pt. will participate in vocational group for 1 hour once weekly to explore and
encourage vocational adjustment activities and to develop a means to cope with
occasional episodes of TLE while on the job.
Jane Hoover, OT
Psychology/Rehab:
1.
Pt. will participate in behavioral treatment to reduce anxiety correlated with the
initiation of structured activities (see Behavioral Plan).
Thomas Parker, OT, and Susan Green, Psychologist
Psychiatry:
1.
Pt. will take anxiolytics as prescribed for job-related anxiety and panic.
Victor Dyson, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–48
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.14 AIDS-Related Distress
Name: Diamond, Dennis
ID #:
Area:
Nursing Diagnosis: Disturbed Personal Identity
Date: 01/15/03
Problem Description:
Pt. is a 23-year-old gay male. He is HIV+ by history and appears to have a good understanding of being HIV+. He
presents with an adjustment disorder, which is apparently secondary to the stress of being labeled as an AIDS
patient. Despite no physical evidence of illness or any evidence of danger of transmitting the disease to others, he
has lost his job and his health insurance. He feels shunned by many of the people in his community. He is having
increasing financial difficulties and often wonders whether life is worth living; however, pt. is not believed to be
suicidal.
Implement treatment of medical aspects of being HIV+ and AIDS precautions as outlined under Problem 6.1 HIV+
(including an appointment with an infectious disease specialist).
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
The painful psychological and psychosocial impact of HIV
diagnosis will be minimized AEB pt. regaining a sense that his life
has meaning and that he is able to again enjoy living consistently
for a 2-month period.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will have fewer and milder psychological symptoms
(depression, anxiety, panic, and isolation) of AIDS-related distress
consistently for a 1-month period.
Target Date
Date/Status*
07/15/03
Target Date
Date/Status*
04/15/03
2.
Pt. will use legal and social supports consistently for a 1-month
period.
04/15/03
3.
Pt. will regain access to ongoing, optimal medical care
consistently for 1 month.
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.14
1–49
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will begin individual psychotherapy (being sure to include a discussion of
the limits of confidentiality) and pt. education with a plan to address the distress pt. is
feeling. This would include exploring pt.’s individual understanding of the meaning of
the infection, ostracism, and discrimination. Psychiatrist will reassure pt. that he is not
“losing his mind” and that this is a psychological reaction at present, not AIDS
dementia complex. Psychiatrist will explore possible solutions and sources of relief of
the pt.’s distress. Psychiatrist will caution pt. to be selective about informing others of
his infection, given the current social climate. However, psychiatrist will encourage pt.
to give appropriate warning at the appropriate time to anyone he could infect, such as
a potential sexual partner. Also, psychiatrist will address and monitor pt.’s feelings of
hopelessness and thoughts that life is not worth living. Consider antidepressant meds
and family therapy (including lover).
Victor Dyson, MD
Social Work:
1.
Social worker will discuss and introduce the pt. to the notion of group psychotherapy
and community support groups. These can lessen sense of being the “only one.” The
theme of the group is that some choices have been taken away by the nature of the
illness but that other choices remain and should be used and appreciated.
2.
Social worker will help pt. see how other gay men cope and ideally will stick with pt.
when healthy and when hospitalized.
Roger Sing, MSW, and Robert Weaver, Community Case Manager
3.
Social worker will explain to pt. that job and insurance discrimination is illegal and
refer pt. to community advocacy groups (both gay and HIV). Advise pt. that asserting
his rights can be psychologically therapeutic.
Roger Sing, MSW
Nursing Care Plan:
1.
Nsg. staff will conduct ongoing assessment of pt.’s sexual practices with regard to
encouraging safe ways to have physical intimacy. Staff will provide extensive teaching
of safer sex practices, as well as reassurance that the need for intimacy increases when
people are faced with the HIV diagnosis.
2.
Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive
aspects of his life. Staff will support him in learning ways to cope with being HIV+.
Marilyn Davis, RN
Psychology:
1.
Psychologist will perform baseline neuropsychological testing.
Joseph LeBlanc, Psychologist
Rehab:
1.
Psychologist will perform detailed functional history.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
SOCIAL SKILLS
(Problem Area 2)
2–1
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Social Skills (Problem Area 2)
2–3
SOCIAL SKILLS
(Problem Area 2)
CONTENTS
Kennedy Axis V for Social Skills ................................................................................................................ 2–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Social Skills and can be helpful in composing a short description of each
problem.
Problem Names and Descriptions ............................................................................................................ 2–5
Examples of problem names and descriptions that may relate to Social Skills are listed here. These
examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 2–5
Examples of strengths that may be related to treatment and discharge in the area of Social Skills are
listed here.
Goals ......................................................................................................................................................... 2–6
Examples of treatment goals that may relate to problems in the area of Social Skills are listed here.
Treatment Modalities ............................................................................................................................... 2–8
Examples of treatment modalities that may relate to problems in the area of Social Skills are listed here.
Sample Individual Problem Plans ........................................................................................................... 2–13
A wide range of Individual Problem Plans relating to Social Skills are included here.
2–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Social Skills
100
Superior social skills, sought out by others because of his/her outstanding social/communication skills,
has many friends and no difficulty making new friends. No symptoms.
90 Good social skills, no difficulty being pleasant and engaging, good communication skills, socially
effective.
80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to
infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.
70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show
sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally
functioning fairly well, has some meaningful interpersonal relationships.
60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other
inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate
difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with
others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of
problems with social skills; communications are understandable but vague.
50 Serious impairment in social skills; has no friends because of clearly impaired social skills;
however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers
or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great
difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear
difficulty; frequently intrusive; inappropriate, nonsexual touching.
40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing
situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately
engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the
behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from
school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others;
great difficulty recognizing that his/her sexual advances are not welcome.
30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how
to share with others, and/or how to show sympathy toward others; conversations with others are grossly
inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual
touching, and the like.
20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short
phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as
smearing of feces or making sexual advances toward young children; however, may have some understanding that
such behavior is inappropriate.
10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent
awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others);
extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of
approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social
situations).
NR Not rated
Social Skills (Problem Area 2)
2–5
Problem Names and Descriptions
I.
II.
Poor Social Skills Problems
A.
Nonsexual
1.
Limited interpersonal skills
2.
Extremely impoverished social skills secondary to social isolation
3.
Socially inappropriate behavior due to lack of awareness of social norms
4.
Lack of consideration for others due to poor interpersonal skills
5.
Demanding, intrusive behavior
6.
Teasing, pestering, or agitation of peers due to poor social skills
7.
Poor communication skills
B.
Sexual
1.
Overly affectionate
2.
Inappropriate seductive dress and sexual actions with little or no understanding that these actions
are inappropriate
3.
Frequent, inappropriate masturbation without an understanding of the social and legal
consequences of such behavior
4.
Inappropriate sexual advances without awareness that the behavior is inappropriate
5.
Inappropriate hugging or inappropriate touching of other without an understanding of the
inappropriate nature of these acts
Other
A.
No examples given
Strengths (Brief List)
I.
Social Skills Strengths
A.
B.
C.
D.
E.
F.
Has fairly good social skills
Is able to be polite and pleasant
Is able to make and maintain friendships
Is able to communicate fairly well
Has good sense of humor
Other
2–6
Fundamentals of Psychiatric Treatment Planning
Goals
I.
II.
Expected Improvements in Skills and Symptoms
A.
Demonstration of socially appropriate behavior
1.
Pt. will initiate at least one socially appropriate interaction during each social activities group for
1 month.
2.
Pt. will make one clear, socially appropriate statement to a peer once a day for 1 week.
3.
Pt. will display appropriate social behavior for at least 30 minutes of each social skills group for
3 months.
4.
Pt. will make at least one comment that acknowledges the feelings or needs of the other person
once each waking shift in interactions with staff for 1 month.
5.
Pt. will develop an inventory of alternative, socially appropriate behaviors.
6.
Pt. will be able to consistently express an understanding of what is needed to assess prospective
relationships for 2 weeks.
7.
Pt. will consistently express an understanding of the effect on others of not attending to personal
hygiene for 1 month.
B.
Extinction of socially inappropriate behavior
1.
Pt. will not grab drinks or cigarettes from others for 2 out of 5 weekdays for 1 month.
2.
Pt.’s inappropriate attention-seeking behavior will decrease such that pt. requires no more than
two staff interactions for limit-setting during each social activities group for 1 month.
3.
Pt. will decrease inappropriate touching of others to less than one time per each 7-to-3 shift for
1 month.
4.
Pt. will not expose genitals to others for 6 months.
5.
Pt. will not make sexually provocative statements for 1 week.
6.
Pt. will be free of screaming episodes for at least 1 day per week for 1 month.
7.
Pt. will be able to consistently recognize inappropriate sexual impulses for 1 month.
8.
Pt.’s inappropriate teasing of others will decrease to one incident or less per week for 1 month.
Reporting of Symptoms
A.
Pt. will consistently discuss any problems that he or she is having in social interactions
for 1 month.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
D.
Pt. will participate in on-ward group activities for 5 minutes a day for 1 month.
Pt. will attend morning ward meeting twice per week for 1 month.
Pt. will attend one off-ward group activity per week for 1 month.
Pt. will engage in one independent off-ward social activity with a peer at least once a
week for 3 months.
IV. Understanding of and Compliance With Treatment Plans
A.
Medication and laboratory work
1.
Pt. will consistently acknowledge the importance of taking his or her meds for 1 month.
2.
Pt. will spontaneously express an understanding of the need to take psychotropic meds at least
once a week for 1 month.
B.
Program activities
1.
Pt. will consistently express the benefits of attending program activities focused on improving
social skills for 3 months.
2.
Pt.’s level of compliance will improve such that he or she will attend the group social activities
twice a week for 4 weeks.
Social Skills (Problem Area 2)
V.
2–7
C.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will be willing to participate in the evaluation process.
3.
Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and
blood work, for 2 weeks.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate a realistic orientation toward his or her progress such that pt. understands
and explains the connections between—
a.
Appropriate social interactions with others and positive responses and acceptance from
others, and
b.
Inappropriate social interactions and negative responses and avoidance by others.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it
can be completed.
2.
Pt. will cooperate so that an assessment can be made as to whether cultural factors significantly
interfere with the demonstration of pt.’s social skills.
B.
Evaluations to R/O various diagnoses
1.
Pt. will cooperate with testing to R/O mental retardation.
C.
Laboratory tests
1.
No examples given.
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V subscale score on Social Skills will improve from a current score of 30 to 40.
B.
Comprehensive Occupational Therapy Evaluation (COTE)
1.
Pt.’s COTE Rehabilitation score in the area of Interpersonal Behavior will improve from a current
score of ___ to ___.
VII. Miscellaneous
A.
No examples given
2–8
Fundamentals of Psychiatric Treatment Planning
Treatment Modalities
I.
II.
Verbal Treatment Modalities (emphasis on verbal interactions)
A.
Support and reassurance
1.
Staff will provide pt. with regular one-to-one support and reassurance, even when pt. is doing well
in the development of new social skills.
B.
Cognitive refocusing (redirection of focus toward reality and realistic self-appraisal)
1.
Staff will conduct one-to-one weekly meeting with pt. to discuss and assess pt.’s interpersonal
relationships with the opposite sex and to discuss appropriate alternatives to inappropriate
behavior.
2.
Staff will focus pt. away from plans based on psychotic thinking to realistic, achievable
relationship goals.
C.
Psychotherapy
1.
Staff will conduct weekly one-to-one interview to encourage and help increase social involvement
as a means of improving pt.’s social skills.
2.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand
how his or her behavior impacts others and how to modify behavior to more effectively meet pt.’s
needs.
3.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand
and cope with conflicts in pt.’s relationships.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Staff will praise pt. for improvements in social skills.
2.
Staff will give positive verbal feedback to pt. for appropriate social interactions, such as asking for
things wanted, rather than grabbing them.
3.
Staff will reinforce alternative, appropriate attention-seeking behaviors, such as pt. playing guitar.
4.
Nsg. staff will praise pt. when pt. makes appropriate statements and requests to peers.
5.
Nsg. staff will give pt. one extra cigarette, token, or quarter as a reward for appropriate social
interactions during community meeting.
6.
Staff will positively reinforce pt. with trips to the canteen for attending social skills group.
7.
Nsg. staff will give encouragement and praise when patient knows the daily schedule.
B.
Negative reinforcement (including discouragement, restriction, and
withholding of reinforcement)
1.
Staff will discourage inappropriate touching.
2.
Nsg. staff will confront pt. when he or she neglects personal hygiene to the point that pt. drives
others away with body odor, bad breath, or both.
3.
Staff will give pt. frequent reminders as to the offensiveness to others of unattended drooling and
nasal drainage.
4.
Staff will withhold privileges unless pt. is relatively free of sexually inappropriate behavior.
5.
Staff will limit pt. to supervised privileges for 24 hours when pt. fails to attend social skills group.
C.
Extinction
1.
All staff will ignore inappropriate social behavior, thus helping to extinguish it.
2.
Nsg. staff will interact with pt. as little as possible during screaming incidences in the hope of
extinguishing this behavior.
3.
Staff will ignore incoherent communications in an attempt to get pt. to try to communicate more
clearly.
Social Skills (Problem Area 2)
2–9
D.
Shaping and modeling
1.
Staff will use daily modeling of appropriate social behavior, such as addressing others by their first
name, maintaining eye contact, asking for things, and the like.
2.
Staff will consistently request pt. to articulate his or her speech more distinctly and more slowly.
3.
Nsg. staff will encourage pt. to restate incoherent communications in understandable terms.
4.
Staff will consistently reinforce incremental improvements in pt.’s ability to communicate.
5.
Rehab staff will assign social activities with gradually increasing levels of skill requirement as pt.’s
social skills improve.
6.
Staff will use group therapy to help pt. learn to model the behavior of others by observing
appropriate behaviors in relationships, such as dating or leisure activities group.
7.
Staff will assign a higher functioning pt. as a “buddy” for pt. to model during off-grounds outings.
8.
Pt.’s case manager will take pt. off the grounds once a week to model appropriate social behavior
in various off-grounds activities, such as eating in a restaurant or shopping in a store.
E.
Channeling of energies
1.
Staff will help pt. sublimate his or her sexual energies into more appropriate social activities.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
All staff will be as consistent as possible in redirecting pt. away from the inappropriate social
behavior.
2.
Nsg. staff will redirect pt. to go to his or her ward contact for all questions concerning appropriate
sexual behavior.
3.
Rehab staff will reduce the level of frustration and disorganization by breaking simple social
interactions into small, concrete, realistic steps.
4.
Staff will redirect pt. away from social interactions and relationships that are grossly unrealistic or
overly complicated for the pt.
5.
Nsg. staff will engage pt. during ward activities in relevant, appropriate conversations that will
help the pt. to understand how to communicate in a socially appropriate manner during various
activities.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will encourage family involvement in helping pt. to develop more effective social skills.
2.
Social worker will engage family members in psychoeducational counseling to help them model
appropriate social behaviors.
B.
Religious treatment modalities
1.
Staff will arrange small-group, supportive, religious outings to improve pt.’s ability to interact with
others and broaden his or her interests.
2.
Spiritual counselor will encourage members from pt.’s congregation to take pt. to services so that
pt. can interact with other members in a social environment.
C.
Other modalities
1.
Group therapy
a.
Staff will hold group therapy once weekly to facilitate discussions of problems with forming
relationships.
b.
Group leader will regularly attempt to engage pt. in topics being discussed.
2.
Psychodrama
a.
Psychologist will provide role playing to assist pt. in understanding and dealing with
complicated social interactions.
3.
Rehabilitation
a.
Rehab counselor will lead social skills building group for 1 hour once a week to help pt.
learn more appropriate social interactions.
2–10
Fundamentals of Psychiatric Treatment Planning
4.
Practicing social skills
a.
Staff will encourage pt. to practice social skills in various social settings, including
community meetings, dances, and leisure group activities.
b.
Staff will encourage pt. to participate in task-oriented groups that will allow pt. to socially
interact with peers.
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will redirect pt. to a quiet environment to allow pt. to practice appropriate social interaction
with fewer distractions.
2.
Staff will remove pt. from overwhelming social situations and place pt. in supportive,
nonthreatening social situations until his or her skills improve to allow pt. to interact in these
more demanding situations.
B.
Protective procedures (including special observations)
1.
Staff will provide a safe, secure environment so that the pt. is not victimized.
2.
Nsg. staff will observe pt. for signs that he or she is engaging in social activities that place him or
her at risk.
C.
Other milieu treatment modalities
1.
No examples given.
Medical Treatment Modalities
A.
Medication
1.
Meds will be taken as prescribed.
B.
Other medical treatment modalities
1.
Staff will provide a wheelchair to improve pt.’s social skills by allowing better access to social
outings.
VI. Patient and Family Education
A.
Social skills deficits
1.
Social worker will discuss with pt. and the family the effect of pt.’s inappropriate social
interactions on others and how pt.’s family can assist pt. to be more socially appropriate when
visiting at home.
B.
Medication
1.
Staff will discuss with the pt. the risks and benefits of meds.
2.
Staff will conduct one-to-one discussion for ½ hour once weekly about the need to take meds as
prescribed.
3.
Staff will show the concrete benefits of taking meds (e.g., “You seem more relaxed in social
situations,” “You act more appropriately toward others,” “You have more friends”).
C.
Benefits and consequences of behaviors
1.
Staff will discuss connections between improvements in pt.’s social skills and getting positive
responses from others, having friends, and going out on dates.
2.
Nsg. staff will provide recognition of pt.’s comment(s) and will praise to help the pt. understand
the consequences of his or her actions when pt. makes at least one socially appropriate comment
in the community meeting.
3.
Staff will demonstrate to pt. the benefits of being able to appropriately request something from
someone.
4.
Staff will work with pt. to help pt. to have a clearer understanding of the negative effects alcohol
has on pt.’s social skills.
5.
At least once weekly, staff will discuss the benefits of neatness and generally good personal
hygiene when trying to develop a relationship with someone.
Social Skills (Problem Area 2)
D.
2–11
Miscellaneous patient and family education
1.
Nsg. staff will provide one-to-one education to help pt. recognize inappropriate social behaviors
and to develop alternative behaviors.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Pt. will complete psychological testing for personality assessments.
2.
Pt. will complete psychological testing to determine pt.’s ability to engage in social interactions.
B.
Psychiatric evaluations
1.
Pt. will receive psychotropic medication evaluation to help determine whether psychotropic meds
will enhance his or her ability to participate in social skills training.
C.
Medical tests and evaluations
1.
See section on Psychological Impairment for examples of medical tests and evaluations for
psychological impairment that may apply to social skills.
D.
Other evaluations and assessments
1.
Pt. will complete speech evaluation at the Communication and Language Disorders Clinic at the
local university.
2.
Staff will refer pt. to rehab for standardized testing of social skills.
3.
Nsg. staff will make on-ward observations of pt.’s social interactions to assess pt.’s level of social
skills.
4.
Rehab staff will assess pt.’s areas of greatest interests and motivation to begin social activities
congruent with pt.’s interests.
VIII. Legal Treatment Modalities
A.
No examples given
IX. Miscellaneous Treatment Modalities
A.
Treatment of related problems (This is optional and can be included with the treatment modalities
or in the problem description.)
1.
Staff will treat pt.’s bizarre behavior as indicated under Problem 1.1 Psychotic Symptoms.
2.
Staff will treat pt.’s social withdrawal as indicated under Problem 1.1 Psychotic Symptoms.
3.
Staff will treat pt.’s sexually assaultive behavior as indicated under Problem 3.1 Sexually Assaultive
Behavior.
Notes
Social Skills (Problem Area 2)
2–13
Sample Individual Problem Plans
CONTENTS
Impoverished Social Skills....................................................................................................................... 2–14
Impaired Social Skills (Deferred) ............................................................................................................ 2–16
Sexually Inappropriate Behavior ............................................................................................................ 2–18
2–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.1 Impoverished Social Skills
Name: Snow, Karen
ID #:
Area:
Nursing Diagnosis: Impaired Social Interaction
Date: 01/15/03
Problem Description:
Pt. has a 15-year history of mental illness. Skills acquired before the onset of her illness have decreased
dramatically. Most of her interactions are with family members, and her skills demonstrated with her family are
often very awkward and ineffective. Her verbal responses are passive and monosyllabic. She generally avoids others
and has no close friends because of her impaired social skills. Pt. has only a minimal awareness of social norms;
however, she doesn’t act grossly inappropriately toward others, such as by initiating inappropriate sexual touching.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to follow the rules of a task group environment
(e.g., ask for things she needs about four out of five times
instead of taking things from others) for 3 months.
01/15/04
2.
Pt.’s Kennedy Axis V subscale score on Social Skills will improve
from a current score of 40 to 50.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
2.
3.
Pt. will ask for materials that she needs about 50% of the time
for 1 month.
Pt. will ask for things that she needs about four out of five times
for 1 month.
Pt. will be able to consistently interact with her peers in social
skills group without the interactions leading to very awkward
situations for 1 month.
Target Date
Date/Status*
Date/Status*
07/15/03
10/15/03
10/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Social Skills (Problem Area 2)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.1
2–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Staff will provide psychoeducational counseling of family with focus on helping the
family to model effective social interaction skills.
Brenda St. Martin, MSW
Rehab:
1.
Staff will focus on feedback of basic social skills, cooperative behavior, approximation
to the group, discrimination, and demand for minimal interaction with group leader
(e.g., asking for materials and instructions).
2.
Rehab programs will allow pt. to observe and practice social skills, including leisure
awareness, leisure exploration, recreational groups, and the like (see Program
Schedule).
3.
Staff will redirect her through modeling for more functional alternatives when pt.’s
social behaviors are ineffective.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Staff will interact with pt. one-to-one for at least 5 minutes for a minimum of three
times per shift to model effective social behaviors (e.g., addressing pt. by her first
name, maintaining eye contact, asking for things needed).
2.
Staff will provide pt. with daily encouragement and praise for keeping track of her
daily schedule of activities.
3.
Staff will provide support and praise for appropriate social interactions on the ward.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
2–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.2 Impoverished Social Skills (Deferred)
Name: Cosby, Laura
ID #:
Area:
Nursing Diagnosis: Impaired Social Interaction
Date: 01/15/03
Problem Description:
Pt. has markedly impaired social skills that prevent her from having any friends or peer relationships. Her skills are
not so impaired that she displays grossly inappropriate social acts. As indicated under Problem 1.1 Psychotic
Symptoms, pt. is withdrawn and has great difficulty trusting others.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
Date/Status*
Target Date
Date/Status*
Deferred: Due to the high level of psychotic symptoms, pt. is
currently not using the social skills she already possesses.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Social Skills (Problem Area 2)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.2
2–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
Social Work:
Psychology:
Rehab:
Nursing Care Plan:
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
2–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.3 Sexually Inappropriate Behavior
Name: Royal, Rebecca
ID #:
Area:
Nursing Diagnosis: Impaired Social Interaction
Date: 01/15/03
Problem Description:
Pt. is generally pleasant and engaging; however, she will often attempt to inappropriately kiss others. About once a
month, she will attempt to touch others in private areas. She does not appear to be aware of the inappropriateness
of her behaviors. She appears to be looking for love, affection, and acceptance. Her inappropriate advances
generally turn people off instead of meeting her needs for a caring, affectionate relationship. However, because of
her desperateness for affection, strangers could easily take advantage of her.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to develop a caring, appropriate relationship
with at least one person and maintain that relationship for at
least 3 months.
01/15/04
2.
Pt. will not inappropriately touch others on their private areas
for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will be free of inappropriate kissing and hugging for 1 week.
04/15/03
2.
Pt. will touch others on their private areas no more that once
during 3 months.
07/15/03
3.
Pt. will be able to appropriately participate in a social activity
for 1 hour three times a week for 1 month.
04/15/03
4.
Pt. will be able to recognize inappropriate sexual impulses and
avoid acting on them for 1 month.
05/15/03
5.
Pt. will develop an inventory of at least three alternative
behaviors to use when inappropriate impulses are recognized.
06/15/03
6.
Pt. will be able to identify criteria for evaluating prospective
relationships.
07/15/03
7.
Pt. will consistently demonstrate appropriate behavior related to
initiating prospective relationships for 2 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Social Skills (Problem Area 2)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.3
2–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in relationships group for 1 hour once weekly to review and learn
appropriate social interactions, especially with someone with whom she may develop
a relationship.
2.
Pt. will have one-to-one daily modeling of appropriate interactions with others,
including appropriate expressions of affection.
3.
Pt. will participate in leisure activity group for 1 hour three times weekly to help her
develop interests and skills in activities that would allow her to appropriately interact
with others at a social, affectionate, friendship level, such as going for a walk, meal,
or movie with a friend or playing board games or a physical sport with a friend.
Albert Sanchez, Rehab Å Program Staff
Nursing Care Plan:
1.
Pt. will participate in women’s group for 1 hour once weekly to explore the issues of
relationships and the skills related to these issues.
2.
Staff will provide stern one-to-one redirection when pt. inappropriately touches
others on private areas.
3.
Staff will redirect pt. with a minimum of attention to avoid reinforcing inappropriate
sexual behaviors that do not involve sexual touching.
4.
Staff will encourage and praise pt. for appropriate expression of affection.
5.
Staff will provide one-to-one skill teaching regarding the recognition of inappropriate
sexual impulses and development of alternative behaviors for 1 hour once weekly.
Linda Larkin, RN & Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
VIOLENCE
(Problem Area 3)
3–1
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Violence (Problem Area 3)
3–3
VIOLENCE
(Problem Area 3)
CONTENTS
Kennedy Axis V for Violence..................................................................................................................... 3–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Violence and can be helpful in composing a short description of each
problem.
Problem Names and Descriptions ............................................................................................................ 3–5
Examples of problem names and descriptions that may relate to Violence are listed here. These examples
can be used to develop the Problem List and to help compose a short description of each problem.
Strengths .................................................................................................................................................. 3–6
Examples of strengths that may be related to treatment and discharge in the area of Nonviolence are
listed here.
Goals ......................................................................................................................................................... 3–6
Examples of treatment goals that may relate to problems in the area of Violence are listed here.
Treatment Modalities ............................................................................................................................... 3–9
Examples of treatment modalities that may relate to problems in the area of Violence are listed here.
Individual Problem Plans (Frequent Entries).......................................................................................... 3–14
Two examples of information that is frequently entered into Individual Problem Plans relating to
Violence are listed here.
Sample Individual Problem Plans ........................................................................................................... 3–19
A wide range of Individual Problem Plans relating to Violence are included here.
3–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Violence
100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to
any inappropriate anger, frustration, or conflicts. No symptoms.
90 No significant evidence of violence to self or others; generally satisfied with life, no more than
everyday problems or conflicts (e.g., an occasional argument with family members).
80 No more than slight problems with anger and irritability; if symptoms are present, they are transient
and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild
anger after family argument); no suicidal ideation.
70 Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior;
thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning;
severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant
problems with violence or self-harm.
60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due
to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be
present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with
violence.
50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally
threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits
someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such
as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or
others; however, some precautions including close observation may be indicated.
40 Major problems with anger and irritability; some real danger of hurting self or others; violent
outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual;
occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single
suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others;
set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or
two minor fires.
30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met;
suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation;
actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close
observation or restraints may be necessary to prevent serious harm to self or others.
20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone;
attempted to very violently harm or violently rape someone within the last month; constant suicidal
preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal
attempts without clear expectation of death within the last month; close observation to prevent harm to self or
others may be required 1 or 2 days a week.
10 Persistent danger of severely hurting self or others; attempted to kill someone within the last
month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last
month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of
death; little or no control of impulses to hurt self or others; expressing loss of control of command
hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for
prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within
the last 2 years.
NR Not rated
Violence (Problem Area 3)
3–5
Problem Names and Descriptions
Note: This problem area relates to acts where one appears to be intentionally putting self or others at risk. Not all
dangerousness and risk factors are included here. Additional examples of dangerousness can be found in all of the
other problem areas.
I.
Assaultive and Threatening Behavior
A.
II.
Assaultive behavior (general)
1.
Assaultive, hostile, or combative behavior
2.
Assaultiveness associated with alcohol
3.
Periodic assaults against a particular person
4.
Retaliatory assaultiveness
5.
Agitated and explosive behavior
6.
Hostile, assaultive mood swings
7.
Episodes of bizarre behavior associated with violence
8.
Violent attention-seeking behavior
9.
Assaultiveness due to command hallucinations
10.
Teasing, pestering, or agitation of peers
11.
Disruptive behavior
12.
Unpredictable displays of hostility
13.
Overt hostility to any delay in immediate gratification
14.
Attempted murder or murder
B.
Threatening, irritable, and oppositional behavior
1.
Argumentative and threatening behavior
2.
Low frustration tolerance
3.
Oppositional attitude
4.
Anger and yelling in response to hallucinations
5.
Hostility in response to excessive stimulation (noise)
6.
Aggressive acts to get coffee or cigarettes
7.
Explosive outbursts (motivated by obvious secondary gains)
8.
Explosive outbursts (not motivated by obvious secondary gains)
C.
Sexually assaultive behavior
1.
Rape
2.
Sexual assault
3.
Overly or dangerously sexually aggressive
4.
Sexually disordered (e.g., sexual predator)
D.
Other violent acts or threats
1.
Stalking
2.
Kidnapping
3.
Potentially violent antisocial acts such as arson or armed robbery
Suicidal Ideation or Attempts
A.
Suicide (general)
1.
Suicidal ideation or attempts
2.
Self-abuse in response to hallucinations
3.
Self-abuse (due to obvious secondary gain)
4.
Noncontingent self-abuse
5.
Self-mutilation
III. Other
1.
No examples given
3–6
Fundamentals of Psychiatric Treatment Planning
Strengths (Brief List)
I.
Nonviolent Strengths
A.
B.
C.
D.
E.
F.
G.
No significant problems with being assaultive
No significant problems with being suicidal or self-abusive
Strong ethical and moral values against violent behavior
Strong ethical and moral values against suicidal and self-abusive behavior
Motivation to work on problems with violent behavior
Good response to past treatments for self-abusive behavior
Other
Goals
I.
Expected Improvements in Symptoms
A.
Assaultiveness
1.
General
a.
Pt. will be able to converse with staff for 1 minute once per shift without threatening or
attempting to assault staff.
b.
Pt.’s threatening behavior will decrease to no more than once per week for 1 month.
c.
Pt.’s frequency of explosive episodes (e.g., throwing chairs, ripping curtains) will be reduced
to no more than one time per week for 1 month.
d.
Pt. will be able to control his or her behavior such that other pts.’ complaints of his or her
aggression toward them will diminish to a maximum of one per week.
e.
Pt.’s assaultive behavior will decrease such that no incidences of assault occur for 2 months.
f.
Pt. will be able to demonstrate control of hostility by being able to apologize to anyone he or
she threatens.
g.
Pt. will maintain current status of no evidence of threatening or assaultive behavior.
h.
Pt. will be able to consistently express an understanding of the connection between his or
her paranoia and hostility and his or her assaultive behaviors for 1 month.
2.
Anger and frustration associated with having to perform
a.
Pt. will be able to tolerate the frustration of cooperating with the ward routine with a
maximum of one disruptive episode per waking shift for 1 week.
b.
Pt. will able to consistently complete two-step tasks without his or her performance being
impeded by angry, hostile behavior for 1 week.
c.
Pt.’s hostility will decrease to the point that pt. will be able to participate in one dayprogram activity each day for 2 weeks.
d.
Pt.’s irritability will decrease to the point that he or she can participate in community
meetings on a daily basis for 1 week.
3.
Tolerance of delays in gratification
a.
Pt.’s frequency of verbal outbursts when needs are not met will decrease to once per week or
less for 1 month.
b.
Pt. will be able to consistently tolerate delay of promised gratification for 2 hours without
irritable, demanding, intrusive behavior for 1 month.
c.
Pt. will be able to tolerate corrective feedback without becoming threatening once daily for
3 of 5 weekdays during the 7-to-3 shifts for 1 month.
4.
Alternative coping behaviors
a.
For 2 weeks, pt. will verbalize feelings of anger and frustration at least once per shift rather
than acting out on them.
b.
For 1 week, when feeling out of control pt. will demonstrate at least one alternative coping
skill per shift rather than losing control.
Violence (Problem Area 3)
B.
5.
Sexually assaultive behavior
a.
Pt. will be free of any inappropriate sexual touching for 6 months.
b.
Pt. will not show any inappropriate hostility toward the opposite sex for 6 months.
c.
Pt. will not have any interactions with children for 1 year.
d. Pt. will cooperate with taking meds to reduce his or her hostile, sexual impulses AEB a
reduction in pt.’s urge to masturbate from pt.’s current frequency of twice a day to no more
than twice a week for 3 months.
6.
Miscellaneous
a.
Pt. will be prevented from acting on aggressive, homicidal impulses directed at his or her
parent for 6 months.
Suicidal and self-abusive behavior
1.
General
a.
Pt.’s head slapping will decrease to once per week.
b.
Pt. will display no more than one incident of self-abuse or suicidal gesture per month for
3 months.
c.
Episodes of self-abuse or suicidal gesture will decrease to less than one every 3 months for
6 months.
d.
Pt. will be free of suicidal ideation for 3 months.
e.
Pt. will maintain his or her current status of showing no evidence of suicidal ideation or acts
of self-abuse.
f.
Pt. will be able to express an understanding of the connection between his or her feelings of
hopelessness and helplessness and pt.’s suicidal impulses.
2.
II.
3–7
Attention seeking and manipulative acts
a.
Pt. will not use threats of suicide to receive extra cigarettes or to avoid program attendance
for 1 week.
b.
Pt. will learn more appropriate methods of getting needed attention (such as verbalizing
feelings or asking for attention) other than cutting herself.
Reporting of Symptoms
A.
Suicidal and homicidal ideation and impulses
1.
Upon inquiry, pt. will accurately express either the presence or absence of homicidal threats
toward pt.’s parent.
2.
Upon inquiry, pt. will attempt to accurately express the degree of suicidal impulse.
3.
Pt. will make a verbal or written contract not to hurt self when he or she is suicidal.
4.
Pt. will spontaneously verbalize any thoughts of hurting self or others for 1 month.
5.
Pt. will consistently reveal to staff commands by voices to hurt self or others for 1 month.
6.
Pt. will consistently reveal to staff suicidal plans before attempting to act on them for 1 month.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
D.
E.
F.
G.
Pt. will remain in the group activity area with minimal redirection for 15 minutes per
day for 1 week.
Pt. will attend two program activities per week for 1 month.
Pt. will attend full-day programs 3 days a week for 1 month.
Pt. will start a Corps Services job.
Pt. will start a job in the community.
Pt. will participate in the anger management group once a week for 1 month.
Pt. will attend the self-abuse prevention group once weekly for 4 weeks.
IV. Understanding of and Compliance With Treatment Plans
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking his or her meds as prescribed twice weekly for 1 month.
2.
Pt. will be able to explain the reasons for taking his or her meds as prescribed.
3.
Pt. will take his or her antipsychotic or antidepressant meds as prescribed for 1 month.
4.
Pt. will comply with blood work for 3 months.
3–8
Fundamentals of Psychiatric Treatment Planning
B.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and
blood work, for 4 weeks.
3.
Pt. will express a willingness to participate in the evaluation process.
C.
Program activities
1.
Pt. will verbalize the reasons for attending program.
2.
Pt.’s level of compliance will improve such that pt. will attend art therapy class twice a week for
1 month.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate an understanding of his or her progress by being able to explain that—
a.
Having control of suicidal and homicidal ideation leads to privileges, passes, and ultimately
discharge; and
b.
Losing control of suicidal and homicidal ideation leads to restrictions and continued care at
the hospital.
2.
3.
4.
5.
6.
V.
Pt.’s statements will reflect a clear understanding of how others feel threatened and intimidated by
pt.’s aggressive, erotic attachments.
Pt. will express an understanding as to the association between pt.’s use of drugs and alcohol and
violent behavior.
Pt. will express an understanding as to the connection between pt.’s paranoia and his or her
violent behavior.
Pt. will express an understanding of the connection between possessing a gun and the pt. not
being allowed to live in the community.
Pt. will agree not to purchase a gun, despite his or her failure to understand that owning a gun
would pose a serious danger to pt. and others.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will allow needed psychological tests to be completed.
2.
Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it
can be completed.
3.
Pt. will cooperate with psychological assessment to determine whether low self-esteem leads to an
expectation of failure to which pt. reacts with hostility and suicidal ideation.
4.
Pt. will cooperate with the assessment to determine whether pt.’s irritability reflects his or her
attempts to avoid communicating with anyone.
B.
Evaluations to R/O various diagnoses
1.
Pt. will allow the completion of an evaluation to R/O temporal lobe epilepsy.
2.
Pt. will allow the completion of an evaluation to R/O borderline personality disorder.
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V subscale score on Violence will improve from a current score of 40 to 60.
B.
Kennedy Nurses’ Observation Scale for Inpatient Evaluation
1.
Pt.’s K NOSIE score on Irritability will improve from a current score of –24 to –10.
2.
Pt.’s K NOSIE score on Social Competency will improve from a current score of +10 to +26.
VII. Miscellaneous
A.
No examples given
Violence (Problem Area 3)
3–9
Treatment Modalities
I. Verbal Treatment Modalities (emphasis on verbal interactions)
II.
A.
Support and reassurance
1.
To help pt. cope with delayed gratification (e.g., delay in privileges, coffee) and to reduce
frustration, staff will reassure pt. that gratification will occur.
2.
When pt. is agitated, nsg. staff will give pt. support and reassurance by expressing acceptance of
his or her emotional distress. Nsg. staff will avoid arguments with pt. over the justification of his
or her distress.
3.
Even when pt. is doing well, staff will provide pt. with regular one-to-one support and reassurance
at least once each shift (this should help reduce pt.’s inappropriate attention-seeking behaviors,
such as suicidal gestures).
B.
Cognitive refocusing (redirecting focus toward nonassaultive, nonsuicidal areas)
1.
Staff will reduce level of frustration by redirecting pt. toward alternative responses rather than
feelings of anger and frustration.
2.
Staff will ask pt. to apologize to anyone pt. threatens.
C.
Psychotherapy
1.
Staff will provide pt. with one-to-one insight-oriented psychotherapy once a week to help reduce
psychological conflicts that result in periods of uncontrollable anger and hostility.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help pt. better cope with
life’s day-to-day frustrations and thus lessen pt.’s anger.
3.
Social worker will provide one-to-one DBT counseling for pt. and lead DBT skills practice group to
help reduce pt.’s level of self-abusive behavior.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Nsg. staff members will verbally reinforce pt. for informing them of his or her suicidal feelings and
then suggest interventions
2.
Ward staff will provide positive feedback to pt. for appropriate control of pt.’s hostile impulses.
3.
Staff will praise pt. for completion of 1 hour of program without any evidence of anger or
hostility.
4.
Staff will positively reinforce pt. with canteen and cafeteria privileges for nonassaultive behaviors.
B.
Negative reinforcement (including discouragement, restriction, and
withholding of reinforcement)
1.
Staff will restrict pt. to supervised privileges for 1 week if pt. is self-abusive, such as by breaking a
window with his or her fist.
2.
To closer evaluate pt., staff will restrict pt. to the ward for 1 week following assaultive behaviors.
3.
Staff will restrict pt. to the ward for at least 1 week for reassessment if pt. is found bringing
weapons to the ward.
4.
Staff will restrict pt. from independent use of the phone for 1 week if pt. continues to call 911 for
frivolous reasons.
5.
After full review, staff will use aversive therapy to stop head banging (see court-approved plan).
C.
Extinction
1.
Following a suicidal gesture, staff will carry out all necessary medical procedures with minimal
dialogue and conversation with pt.
D.
Shaping and modeling
1.
Staff will provide primary and secondary positive reinforcers for incremental decreases in level of
hostility.
3–10
Fundamentals of Psychiatric Treatment Planning
E.
Channeling energies
1.
Pt. will participate in weekly group therapy to facilitate expression of anger in a more appropriate
manner.
2.
Pt. will talk with staff or go for a short walk with staff to reduce the level of frustration.
3.
Staff will increase structured periods to appropriately channel potentially aggressive behavior into
various activities; for example, maximize pt.’s involvement in structured day program, including
open workshop, patient wage program, leisure interest group, and community meeting.
4.
Staff will encourage pt. to verbalize his or her agitation rather than become oppositional or
unreasonable.
5.
Staff will divert pt. into acceptable channels to reduce chronic hypersexual arousal and associated
sexual assaults.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
Staff will break tasks down into small, concrete, realistic steps to reduce the level of frustration and
disorganization.
2.
Staff will break down the steps of dressing into small, understandable, reachable goals to reduce
pt.’s anger over failure.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will provide family therapy to explore conflicts within pt.’s family.
2.
Staff will provide family counseling to help pt.’s family learn means to cope with pt.’s hostile,
threatening episodes.
3.
Priest/rabbi/reverend will provide religious counseling to help pt. survive the loss of a child.
B.
Religious treatment modalities
1.
Spiritual advisor will counsel pt. concerning his or her reported voices from God demanding pt. to
kill others.
2.
Spiritual/religious advisor will counsel pt. concerning suicidal ideation.
C.
Other modalities
1.
Group therapy
a.
Pt. will participate in group therapy for 1 hour once weekly to facilitate discussions of
suicidal impulses.
b.
Pt. will participate in relapse prevention group to help pt. understand the importance of his
or her meds and of continuing DBT treatments.
2.
Psychodrama
a.
Pt. will participate in role playing to allow pt. to see alternative ways of responding to
frustrations and disappointments in life.
3.
Confrontations and pressures
a.
Staff will avoid pressuring pt. when pt. indicates that he or she wishes to be left alone
because pressuring pt. often simply leads to increased agitation and assaultiveness.
b.
Staff will avoid giving pt. ultimatums because ultimatums often lead to pt. striking out in
anger at a perceived authority figure.
4.
Empowerment
a.
Staff will empower pt. with the opportunity to make choices as to which activities to pursue
to reduce his or her anger and frustration of feeling unimportant and helpless.
IV. Milieu Treatment Modalities
A.
Stimulus reduction
1.
Staff will redirect pt. to a quiet environment if the pt. is agitated or expresses threats.
2.
Staff will redirect pt. to a quiet room when necessary to decrease stimulation and agitation.
Violence (Problem Area 3)
3.
4.
5.
B.
C.
V.
3–11
When pt. makes threats, staff will redirect him or her to the quiet room for 15 minutes or until pt.
is no longer threatening.
Staff will redirect pt. from triggering events or overstimulating areas.
Staff will remove pt. from overwhelming situations to reduce his or her level of frustration.
Protective procedures (including special observations)
1.
Staff will provide a safe, secure environment with special monitoring as necessary.
2.
Staff will continue to monitor the pt. for evidence of suicidal impulses. Pt. will be placed on
special precautions as necessary (strict suicidal precautions, suicidal precautions, or close
observation).
3.
If there appears to be a return of suicidal impulses, staff will ask pt. whether these are active
impulses or just isolated ideas, whether pt. has a plan, is future oriented on other matters, and the
like.
4.
If there appears to be a return of suicidal impulses, staff will ask pt. to provide a written or verbal
contract not to harm self.
5.
Nsg. staff will observe pt. for signs that pt. is becoming assaultive, such as agitation and internal
torment.
6.
Staff will consider transfer to the observation room for closer monitoring of sexual assaultiveness
and/or self-destructive behavior.
7.
Staff will refer pt. for screening for the Intensive Treatment Unit if pt.’s assaultive behavior
significantly worsens.
8.
When pt. becomes agitated, staff will place mitts on his or her hands to prevent self-abuse.
9.
Staff will employ escape precautions.
10.
If pt. brings weapons to the ward, staff will search pt. upon return to the ward for at least
1 month, in conjunction with continued counseling on the dangers of bringing weapons into the
hospital.
Other milieu treatment modalities
1.
No examples given.
Medical Treatment Modalities
A.
Medication
1.
Staff will prescribe antipsychotic meds to reduce the intensity of pt.’s anger and irritability.
2.
Psychiatrist will prescribe mood stabilizers, such Depakote, to help control pt.’s explosive
episodes.
3.
Prn meds, such as a combination of Haldol and Ativan, will be used to relieve acute explosive
episodes.
4.
Psychiatrist will prescribe an SSRI, such as Zoloft, or hormonal therapy, such as Depo-Provera, to
reduce pt.’s libido and associated hostile, sexual impulses.
B.
Other medical treatment modalities
1.
ECT
a.
Staff will give the pt. a course of ECT to help relieve intractable suicidal ideation.
VI. Patient and Family Education
A.
Mental illness
1.
Psychologist will discuss the association between the pt.’s paranoia and his or her assaultiveness.
2.
Social worker will discuss with the pt. and family the association between pt.’s feelings of
hopelessness and suicidal impulses.
B.
Medication
1.
Psychiatrist will discuss with pt. the risks and benefits of meds.
2.
Nsg. staff will meet one-to-one to educate pt. about the fact that the meds decrease pt.’s level of
anger and irritability.
3–12
Fundamentals of Psychiatric Treatment Planning
3.
Staff will show concrete benefits of taking meds (such as, “You are less angry and irritable,” “Your
suicidal impulses are decreased,” “You spend less time in restraints,” “People are less fearful of
you”).
C.
Benefits and consequences of behaviors
1.
Staff will discuss with pt. the fact that pt.’s paranoid, threatening behavior is running off all his or
her friends.
2.
Staff will discuss with pt. the fact that the effect of his or her threats is simply to cause others to
avoid pt. and that the threats do not result in getting what the pt. wants from other people.
3.
Psychologist will discuss with pt. the association between paranoia, drugs, alcohol, and violence.
4.
Social worker will discuss with the pt. and family the effect on pt.’s family of his or her
dependent, attention-seeking behaviors, including suicidal gestures.
5.
Staff will discuss connections between control of hostile, threatening behavior and realistic
progress toward pt.’s goals, including passes, shopping trips, and discharge planning.
6.
Nsg. staff will verbally outline for pt., three times per shift, the steps necessary to obtain
gratification (e.g., act civilly in community meeting and be in reasonable control of his or her
hostility before receiving coffee, privileges, and such) to help pt. understand the consequences of
his or her actions.
7.
Staff will work with pt. to help him or her have a clearer understanding of the effects alcohol has
on hostile, threatening behavior.
D.
Miscellaneous patient and family education
1.
No examples given.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Staff will conduct psychological tests to assess the potential lethality of pt.’s hostile impulses.
2.
Staff will conduct psychological tests to evaluate impulse control.
3.
Staff will conduct neuropsychological tests for evidence of organicity as the cause of pt.’s explosive
episodes.
4.
Staff will conduct neuropsychiatric tests for evidence of organicity as the cause of pt.’s assaultive
behavior.
B.
Psychiatric evaluations
1.
Psychopharmacology staff will consult for recommendations of meds that may reduce pt.’s
explosive behavior.
2.
Staff will conduct a psychiatric assessment of pt.’s violent behavior.
C.
Medical/laboratory tests and evaluations
1.
Staff will conduct an EEG to R/O TLE as the etiology of pt.’s explosive episodes.
2.
Staff will conduct a urine toxicology screen to R/O substance abuse as the etiology of pt.’s
explosive episodes.
3.
Staff will test pt.’s blood levels to help determine medication compliance.
4.
Staff will test pt.’s blood levels to determine whether the psychotropic meds are in the therapeutic
range.
D.
Monitoring for suicidal and homicidal ideation
1.
Staff will have one-to-one contact with pt. to assess suicidality.
2.
Nsg. staff will make on-ward observations to assess pt.’s level of irritability and potential for
assaultiveness.
3.
Staff will observe pt. for evidence of agitation and hostility and, if present, monitor pt. from a
distance to ensure reasonable safety to others.
4.
Psychologist will attempt to determine the nature of pt.’s frustration that leads to acts of selfabuse.
5.
Staff will conduct extended one-to-one evaluations to develop a working hypothesis as to the
source of the interactional hostility.
Violence (Problem Area 3)
E.
3–13
Other evaluations and assessments
1.
Rehab staff will assess pt.’s areas of greatest interests and motivation to begin structured activities
congruent with pt.’s interests.
VIII. Legal Treatment Modalities
A.
Court commitment
1.
Staff will seek court commitment for 6 months because of the dangers to self and others due to
mental illness.
B.
Guardianship
1.
Staff will seek court approval of the forced use of antipsychotics to control pt.’s assaultive
behavior.
C.
Other legal treatment modalities
1.
Psychiatrist will seek court approval for use of psychosurgery to control pt.’s unremitting
assaultive behavior.
IX. Miscellaneous Treatment Modalities
A.
Implementation of other treatment plans (This step is optional; instead, this information may
be included in the problem description.)
1.
Staff will implement treatment of Problem 1.1 Psychotic Symptoms to reduce the level of Bill’s
paranoia.
2.
Staff will implement treatment of Problem 1.1 Depressive Symptoms to relieve the depression that
is driving Angela’s suicidal impulses.
3–14
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plans (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Threatening and Assaultive
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Risk for Violence: Other-Directed Grieving;
Hopelessness; Powerlessness
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
Onset of symptoms and chronicity
•
•
•
•
•
•
Characteristics, frequency, intensity, and variance of threats and assaults
Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor
frustration tolerance)
Response to previous and current treatments and expected response to any proposed treatments
Current level of threats and assaults
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any psychotic or depressive symptoms that may be driving pt.’s hostility
should be addressed in Problem Area 1 Psychological Impairment.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
Target Date
Date/Status*
1. Pt. will be free of assaults for a ___-week/-month period.
2. Pt. will be free of vicious assaults for a ___-week/month period.
3. Pt. will be free of threatening behavior at least ___ days a week for
___ month(s).
4. Pt. will not act in response to any paranoid delusions or
command hallucinations for a ___-week/month period.
5. Pt. will be free of command hallucinations telling him or her to
assault others for a ___-week/month period.
6. Pt. will not fail to accept redirection by staff when demonstrating
hostile or threatening behavior for a ____-week/month period.
7. Pt. will watch video(s) or read pamphlet(s) on anger management
entitled ______________________________________________.
8. Pt. will not allow the provocation or intrusiveness of other pts. to
escalate him or her to threatening or assaultive behavior for a
___-week/month period.
9. Pt. will be able to identify feelings of anger and frustration as
they occur, AEB pt. coming to staff for support rather than
threatening or assaulting for a ___-week/month period.
10. Pt.’s score on the Kennedy Axis V for Violence will improve from
the current score of ___ to ___.
11. Pt.’s score on the Kennedy NOSIE Irritability will improve from
the current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
3–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to
monitor any changes in intensity of agitation and out-of-control behavior. This will
allow the psychiatrist to assess the need for special precautions and level of privileges
and to prescribe treatment with antipsychotic meds such as __________________,
beta-blockers such as ____________________, anticonvulsants such as ____________,
lithium, or other meds such as __________________. Lab will be as ordered, including
blood levels.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. for ___ minutes at least ___ times weekly/monthly to
help pt. understand how his or her violent behavior acts as a barrier to discharge.
Brenda St. Martin, MSW
Psychology (or Social Work):
1. Psychologist (or social worker) will meet one-to-one with pt. for ___ minutes at least
___ time(s) monthly in supportive, problem-solving, cognitive therapy to reduce or
redirect pt.’s anger, impulsivity, and frustration.
2. Psychologist (or social worker) will lead group (e.g., anger management group) weekly
to help pt. recognize anger and learn methods for reducing and or more appropriately
expressing anger.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ times
weekly/monthly to review and revise his or her daily treatment schedule, will refer pt.
to appropriate groups, and will work to improve his or her frustration tolerance.
2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about
risk factors and how to avoid them. See weekly schedule for programs.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to pt.’s expressions of anger and frustration and will assist pt. in
dealing with these in an appropriate, nonthreatening manner.
2. Nsg. staff will immediately redirect pt. from hostile, angry, or threatening behavior and
will discuss appropriate alternatives to cope with anger and frustration.
3. Nsg. staff will question pt. directly at least ___ time(s) each shift/day/week to determine
whether pt. has any impulses to threaten or assault others.
4. If there are concerns about the pt.’s safe behavior, nsg. staff will have pt. verbally
contract for safety each time pt. goes off the ward. If needed, nsg. staff will escort pt. to
off-ward groups, programs, and other activities. If it is felt that pt. will threaten or
assault someone, nsg. staff may restrict pt. to the ward and place him or her on Special
Precautions until the psychiatrist can evaluate him or her.
5. Nsg. staff will meet with pt. for ___ minutes at least ___ weekly/monthly to educate pt.
about the consequences of violent behavior and about alternative methods to cope
with anger and frustration.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.2 Suicidal and Self-Abusive
Name: Smith, Jane
ID #:
Area:
Nursing Diagnosis: Risk for Violence: Self-Directed
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
•
•
•
Onset of symptoms and chronicity
Precipitants (e.g., depression, losses, substance abuse, command hallucinations)
Characteristics, frequency, intensity, and variance of suicidal threats, attempts, self-abusive behavior
Response to previous and current treatments and expected response to any proposed treatments
Current level of suicidal threats, attempts, self-abusive behavior
Barriers to treatment, such as hopelessness about outcome of treatment, poor self-esteem, poor motivation,
lethargy
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any psychotic or depressive symptoms that may be driving pt.’s hostility,
should be addressed in Problem Area 1 Psychological Impairment.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
Target Date
Date/Status*
1. Pt. will be free of suicidal attempts for a ___-week/month period.
2. Pt. will be free of suicidal ideation for a ___-week/month period.
3. Pt. will be free of suicidal ideation and self-abusive impulses at
least ___ day(s) a week for ___ month(s).
4. Pt. will be free of command hallucinations telling him or her to
commit suicide for a ___-week/month period.
5. Pt. will be able to identify feelings of hopelessness, helplessness,
and frustration as they occur, AEB pt. coming to staff for support
rather than attempting to hurt self for a ___-week/month period.
6. Pt. will be able to express an understanding of the connection
between his or her feelings of hopelessness and helplessness and
pt.’s suicidal impulses.
7. Pt. will learn more appropriate methods to get needed attention
(such as verbalizing feelings or asking for attention) other than
cutting self for a ___-week/month period.
8. Pt.’s score on the Kennedy Axis V for Violence will improve from
the current score of __ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.2
3–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
monitor any changes in intensity of suicidal/self-abusive impulses. This monitoring
will allow the psychiatrist to assess the need for special precautions and to prescribe
treatment with antidepressant meds such as _______________________ or other meds
such as _________________. Lab will be as ordered, including antidepressant levels.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
help pt. understand how his or her suicidal/self-abusive behaviors act as a barrier to
discharge.
Brenda St. Martin, MSW
Psychology (or Social Work):
1. Psychologist (or social worker) will meet one-to-one with pt. for ___ minutes at least
___ time(s) weekly/monthly in supportive, problem-solving, cognitive therapy to
reduce pt.’s suicidal/self-abusive impulses.
2. Psychologist (or social worker) will lead group (e.g., suicidal prevention group or DBT
group) weekly to help pt. reduce feelings of hopelessness and helplessness and/or more
effectively deal with stress, problems, and losses.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.’s daily treatment schedule and will refer pt. to
appropriate groups to work to improve his or her self-esteem/frustration tolerance.
2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about
risk factors and how to avoid them. See weekly schedule for programs.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to pt.’s suicidal ideation and self-abusive impulses and will assist
pt. to deal with these in an appropriate, safe manner.
2. Nsg. staff will immediately redirect pt. from self-abusive behavior and discuss
appropriate alternative means to cope or get attention.
3. Nsg. staff will escort pt. to off-ward groups, programs, and other activities to ensure
that pt. does not attempt to harm self.
4. Nsg. staff will question pt. directly at least ___ time/s each shift/day/week to determine
whether pt. has any impulse to harm self.
5. If there are any concerns about pt. attempting to hurt self, at a minimum, nsg. staff
will have pt. verbally contract for safety each time he or she goes off the ward. For
safety reasons, pt. may be restricted to the ward and placed on special precautions until
psychiatrist can evaluate pt.
6. Nsg. staff will meet with pt. for ___ minutes at least ____ time/s weekly/monthly to
educate pt. about the consequences of self-abusive behavior and about alternative
means to cope or get attention.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Violence (Problem Area 3)
3–19
Sample Individual Problem Plans
CONTENTS
Suicidal Ideation and Attempts .............................................................................................................. 3–20
Suicidal Attempts.................................................................................................................................... 3–22
Anger and Explosiveness ........................................................................................................................ 3–24
Threatening and Assaultive Behavior..................................................................................................... 3–26
Homicidal Threat .................................................................................................................................... 3–28
Violence Secondary to Paranoia............................................................................................................. 3–30
Sexually Assaultive Behavior................................................................................................................... 3–32
Stalking Behavior.................................................................................................................................... 3–34
3–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Suicidal Ideation and Attempts
Name: Jones, Gerald
ID #:
Area:
Nursing Diagnosis: Risk for Self-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of attention-seeking suicidal ideation and dangerous suicidal attempts, including attempts to
hang himself, suffocate himself with a plastic bag, and, recently, to poison himself by drinking an insecticide.
Precipitants to suicidal attempts include 1) improvement with associated increased cognitive ability to appreciate
the tragedy of his illness and difficulties making real progress (“reality depression”) and 2) desire to escape
tormenting auditory hallucinations. Treatment should emphasize controlling hallucinations and helping pt. to
accept slow, gradual improvements in his progress toward goals. In the past, focusing on suicidal ideation has
increased pt.’s attention-seeking gestures.
Implement treatment of Problem 1.1 Psychotic and Depressive Symptoms, including regular and prn meds to
reduce the level of tormenting hallucinations.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will demonstrate behavioral control, such that there is no
evidence of suicidal ideation or attempts for 6 months.
01/15/04
2. Pt. will verbalize self-worth and express realistic hopes for his
future consistently for 6 months.
01/15/04
3. Pt. will be free of any suicidal ideation or attempts during 2 weeks
of overnight passes to a halfway house in the community.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will verbalize content of hallucinations,
particularly tormenting or self-destructive hallucinations,
consistently for 3 months.
07/15/03
2. Pt. will consistently approach staff to seek help when he feels
suicidal or when he is tormented by auditory hallucinations for
3 months.
07/15/03
3. Pt. will not use suicidal ideation to receive extra attention or to
avoid participation in treatment for 3 months.
07/15/03
4. Pt. will demonstrate a realistic orientation to his progress by
identifying practical steps toward his goal of discharge and acting
on them, consistently for 3 months.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
3–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1½ hours a month to assess pt.’s response to
treatment, including monitoring any changes in intensity of suicidal ideation, place pt. on
special precautions as needed, and allow increased privileges when pt. is assessed to be safe.
Victor Dyson, MD
Psychology:
1. Psychologist will meet with pt. for 45 minutes once weekly to discuss connections
between daily behavior (being out of bed, attending program) and progress toward pt.’s
goals, including discharge.
2. Staff will encourage pt. to inform staff of suicidal feelings when they occur and to help
pt. learn interventions, such as 1) focusing on his realistic goals (e.g., passes with
family, shopping trips, and discharge planning), 2) focusing on ward activities, and
3) focusing on his assets and accomplishments (e.g., hobbies, program attendance,
relatives who care for him, memories of happy experiences).
Susan Green, Psychologist
Social Work:
1. Social worker will meet with pt. for ½ hour once weekly to evaluate pt.’s readiness for
discharge.
2. Social worker will consistently offer pt. the opportunity for treatment planning
involvement.
Brenda St. Martin, MSW
Nursing Care Plan:
1. Nsg. staff will observe pt. for early signs of agitation and tormenting hallucinations.
If present, staff will inquire about reasons for distress, including content of
hallucinations. Nsg. staff will express understanding of pt.’s distress and suggest
interventions to reduce hallucinations, such as 1) redirecting into activity (e.g.,
program), 2) substituting stimulation (e.g., listening to the radio headset), or
3) requesting prn med.
2. On observing any signs of suicidal intent, nsg. staff will assess dangerousness and ask
pt. for verbal or written contract stating that he will be able to maintain control over
impulses to hurt himself.
3. Nsg. staff will continue to monitor pt. for changes in suicidal intent and will institute
special suicidal precautions as necessary.
4. Nsg. staff will notify psychiatrist as needed of any significant change in pt.’s level of
dangerousness.
5. Nsg. staff will encourage pt. to recognize and express self-worth (e.g., compliment him
when he improves his appearance).
Ronald Donahue, RN Å Nsg. Staff
Rehab:
1. Rehab staff will meet with pt. for at least ½ hour once a week to review and revise his
daily program schedule and refer him to appropriate groups to improve his self-esteem,
coping skills, and frustration tolerance.
2. Rehab staff will ensure that pt. is actively engaged in creative art therapy, an area of
strength for pt.
Albert Sanchez, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.2 Suicidal Attempts
Name: Brandt, Jennifer
ID #:
Area:
Nursing Diagnosis: Risk for Self-Directed Violence
Date: 01/15/03
Problem Description:
Two weeks following the loss of her job, pt. was found by neighbors with her wrist deeply cut. Pt. required 3 days
of medical hospitalization for treatment of blood loss and nerve injuries sustained during the suicidal attempt;
however, there appears to have been no permanent functional damage. She felt that she would not be able to get
another job. She felt that suicide was the only way to avoid her mounting bills and problems. Pt. now denies
suicidal ideation; however, she is felt to still be a serious risk of a suicidal attempt. In the past, pt. had attempted
suicide twice before by taking overdoses. The previous attempts were also associated with difficulty coping with
stress in her life.
Implement treatment of Problem 1.1 Depressive Symptoms, including meds to reduce the level of hopelessness and
helplessness.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will be free of suicidal ideation and self-destructive behavior
for 3 months.
04/15/03
2. K Axis score on Violence will improve from a current score of 40
to at least 60.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will attempt to accurately express the presence
or absence of suicidal impulses consistently for 3 weeks.
02/15/03
2. Pt. will be free of suicidal ideation or acts of self-abuse for
3 weeks.
02/15/03
3. Pt. will cooperate so that she completes the assessment of her
work skills and interests.
02/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.2
3–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1. Staff will provide family counseling to help pt.’s family understand her suicidal
attempts and help them to cope with fears that she will again attempt suicide.
Brenda St. Martin, MSW
Psychology:
1. Psychologist will meet with pt. for 1 hour once a week 1) to help pt. understand the
association between her hopelessness and helplessness and her suicidal attempts, 2) to
help pt. to verbalize her self-destructive thoughts rather than acting on them, 3) to
help her reduce feelings of hopelessness and helplessness, and 4) to help her more
effectively deal with stress in her life.
2. Staff will use psychological testing to help assess pt.’s level of dangerousness.
Susan Green, Psychologist
Rehab:
1. Staff will assess pt.’s skills and work interests to determine whether pt. has a problem
that would interfere with her getting and keeping a job.
2. Staff will assign pt. to appropriate groups to work to improve her self-esteem and selfconfidence, including suicidal prevention group.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will provide pt. with a safe, secure environment with special monitoring as
necessary.
2. Nsg. staff will observe pt. for signs that she is becoming self-destructive, such as
becoming withdrawn and verbalizing hopelessness.
3. Even when pt. is doing well, nsg. staff will provide pt. with regular one-to-one support
and reassurance at least once each shift.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.3 Anger and Explosiveness
Name: Parker, Janet
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of poor control over hostile impulses. Currently she is often angry, hostile, and threatening;
however, it has been more than 6 months since pt. was physically assaultive. Pt. is very likely to become angry
when demands are placed on her, especially concerning programs or her meds. She generally takes her anger out
on others; however, she has a history of breaking a window when angry, resulting in a serious laceration of her
hand. Pt. has been treated with a number of meds with some degree of success.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will demonstrate a maximum of one explosive, threatening
episode for 3 months.
07/15/03
2. Pt.’s Kennedy Axis V score for Violence will improve from a
current score of 50 to 60.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will show a maximum of one episode of inappropriate
expression of anger (e.g., verbal threats, screaming, demanding
behavior) per week for 1 month.
04/15/03
2. Pt. will continue to be free of physically aggressive and selfabusive behavior.
Ongoing
3. Pt. will learn appropriate alternative ways to express anger and
frustration, including seeking out staff to talk about situations
that cause her to get angry, consistently for 1 month.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.3
3–25
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will prescribe meds to help control anger and hostility, such as Clozaril,
Depakote, lithium, beta-blockers, and the like.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. one-to-one weekly to give pt. the opportunity to
discuss personal issues.
Brenda St. Martin, MSW
Psychology:
1. Psychologist will encourage pt. to appropriately verbalize anger to staff.
2. Psychologist will lead pt. in relaxation exercises.
3. Psychologist will assess pt.’s appropriateness for referral to the DTB Program.
Joseph LeBlanc, Psychologist
Rehab:
1. Staff will train pt. to improve frustration tolerance via involvement in groups such as
anger management group.
2. Staff will provide pt. with opportunities to feel empowered (i.e., give her choices as to
the activities she would like to pursue).
Albert Sanchez, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to pt.’s expressions of anger and hostility and will assist her with
expressing these in an appropriate, nonthreatening manner.
2. Nsg. staff will provide positive verbal reinforcement for appropriate expression of
anger, frustration, and the like.
3. Nsg. staff will meet with pt. for 20 minutes twice weekly to educate her about the
consequences of her hostility toward others and about alternative methods to cope
with her hostility.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–26
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.4 Threatening and Assaultive Behavior
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of being assaultive and threatening. The assaultiveness has been reduced to about once a
month. Generally the assaults are no more than pushing someone or hitting someone on the arm; however, about
a year ago he attacked and injured an attendant. The assaultiveness is associated with periods of being angry and
irritable. Recently the pt. has been moderately angry and irritable because of conflicts with his family.
Implement treatment of Problem 1.1 Psychotic Symptoms to reduce paranoid feelings.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Assaultive behavior will decrease to no more than once during
6 months.
01/15/04
2. Kennedy Axis V score for Violence will improve from a current
score of 50 to 60.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will spontaneously verbalize any thoughts of hurting others
rather than assaulting anyone, consistently for 3 months.
07/15/03
2. Pt. will be able to converse with staff for 10 minutes each shift
without threatening or attempting to assault staff for 1 month.
04/15/03
3. Pt. will be able to tolerate the frustration of cooperating with
ward routine with a maximum of one disruptive episode per
waking shift for 3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.4
3–27
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will restrict pt. to supervised privileges for at least 1 week if he is assaultive
to others.
2. Psychiatrist will administer meds as prescribed to reduce pt.’s anger and irritability.
Victor Dyson, MD
Psychology:
1. Psychologist will discuss with pt. the association between pt.’s paranoia and
assaultiveness.
2. Psychologist will discuss with pt. Stress Reduction Training and will initiate it if
appropriate.
Susan Green, Psychologist
Nursing Care Plan:
1. Nsg. staff will observe pt. for signs that he is becoming assaultive, such as becoming
angry or irritable.
2. Nsg. staff will encourage pt. to verbalize his agitation rather than becoming
oppositional or threatening.
3. If needed, nsg. staff will offer pt. prn meds to relieve irritability and acute explosive
episodes.
4. Nsg. staff will redirect pt. to a quiet area if he becomes agitated or threatening.
5. Nsg. staff will provide positive feedback to pt. for appropriate control of his hostile
impulses.
6. Even when pt. is doing well, nsg. staff will provide him with regular one-to-one
support and reassurance at least once each shift.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–28
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.5 Homicidal Threat
Name: Stewart, Allen
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
In August 2001, pt. made an attempt to kill his mother. At that time, pt. had a knife at his mother’s throat, but was
pulled away by his brother. Since August 2001, patient has continued to make threats to kill his mother; however,
since the attempt in August 2001, he has not had the opportunity to harm his mother. Currently pt. is supervised
whenever he is off the ward; there is a restraining order to prevent him from going to the area where his mother
lives.
Implement treatment of Problem 1.1 Psychotic Symptoms and Problem 3.1 Anger and Explosiveness to help reduce
the danger toward pt.’s mother.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will accurately express the absence of
homicidal thoughts toward his mother for 6 months.
01/15/04
2. Pt. will be free of any homicidal impulses toward his mother for
6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will accurately express either the presence or
absence of homicidal thoughts toward his mother consistently for
3 months.
07/15/03
2. Pt. will approach staff when he is having homicidal thoughts
toward his mother consistently for 3 months.
07/15/03
3. Pt. will not attempt to act on his impulses to hurt his mother for
3 months.
07/15/03
4. Pt. will be able to go on independent privileges for 3 months
without any evidence that he is having any impulses to hurt his
mother.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.5
3–29
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1. Nsg. staff will provide safe, secure environment using staff supervision and special
precautions as needed.
2. Nsg. staff will monitor pt. for signs of agitation and anger that may be directed toward
his mother.
3. Nsg. staff will ask pt. directly at least once each shift whether he is having any
impulses to hurt anyone, including his mother.
4. Nsg. staff will work with pt. and the rest of the team to protect pt.’s mother from pt.’s
homicidal impulses.
Linda Larkin, RN Å Nsg. Staff
Social Work:
1. Social worker will maintain contact with his mother to clarify any conflicts that she
may have with pt. and discuss possible resolution.
2. Social worker will keep pt.’s mother informed of any potential danger from pt. as
indicated under the hospital duty-to-warn policy.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–30
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.6 Violence Secondary to Paranoia
Name: Bell, Howard
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of assaultive, threatening behavior in association with paranoid thoughts. Pt. has had an
ongoing fascination with weapons and police work. Prior to the current hospitalization, pt. threatened his father
with a knife because he felt that his father was conspiring with the Mafia to have him assassinated.
Implement treatment of Problem 1.1 Psychotic Symptoms to reduce pt.’s level of paranoia.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will be free of threatening and assaultive behavior for
3 months.
10/15/03
2. Pt.’s Kennedy Axis V score for Violence will improve from a
current score of 40 to 60.
10/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt.’s home will be free of any weapons for at least 3 months.
07/15/03
2. Pt. will be free of threatening and assaultive behavior for
3 months.
07/15/03
3. Pt. will express an understanding of the connection between his
paranoia and his assaultiveness consistently for 3 months.
07/15/03
4. Pt. will agree not to attempt to purchase weapons consistently for
3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.6
3–31
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1½ hours a month to monitor any changes in
his violent impulses to make decisions concerning the need for special precautions and
level of privileges and to prescribe prn meds to help control angry impulses.
Victor Dyson, MD
Social Work:
1. Social worker will provide family counseling for 1 hour twice monthly to help pt.’s
family understand and learn to cope with pt.’s hostile, threatening episodes.
2. Social worker will encourage family members to remove all weapons from their home.
Roger Sing, MSW
Psychology:
1. Psychologist will provide one-to-one therapy for 1 hour once weekly to help pt.
understand the association between his paranoia, hostility, weapons, and
dangerousness.
2. Psychologist will encourage pt. to verbalize his hostile impulses rather than assaulting
others.
3. Psychologist will use psychological testing to help assess pt.’s level of dangerousness.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1. Nsg. staff will provide a safe, secure environment with special monitoring as necessary.
2. Nsg. staff will observe pt. for signs that he is becoming hostile, paranoid, or agitated.
3. When pt. is becoming hostile, paranoid, or agitated, nsg. staff should give him support
and reassurance by expressing acceptance of his emotional distress.
4. Nsg. staff should avoid arguments with pt. about his paranoid thinking.
5. Nsg. staff should administer prn meds as needed for agitation.
6. Nsg. staff should administer regular meds as outlined under Problem 1.1 Psychotic
Symptoms.
7. Even when pt. is doing well, nsg. staff will provide him with regular one-to-one
support and reassurance at least once each shift.
Ronald Donahue, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–32
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.7 Sexually Assaultive Behavior
Name: Jones, Stanley
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of inappropriate sexual behaviors, including public nudity, sexually inappropriate touching
of females, and masturbating in public. Pt.’s sexually assaultive behavior appeared to be under fairly good control;
however, recently pt. began openly masturbating in front of the social worker while having an individual therapy
session in her office. Pt. barred her from leaving the room until he had reached a climax. This attack was felt to
have been more of an inappropriate attempt at sexual gratification, rather than an act of hostility. Pt. appears to
have very little insight into the hostile, frightening nature of his acts toward females. Pt. has been resistive to
taking meds to help control his sexual impulses.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1. Pt. will be free of sexually assaultive episodes for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1. Pt. will be free of sexually assaultive episodes for 3 months.
07/15/03
2. Pt. will express a willingness to explore the possibility of a trial
on meds to help control his sexual impulses consistently for
3 months.
07/15/03
3. Pt. will cooperate with treatments to lower his libido AEB his
frequency of masturbating decreasing from twice a day to no
more than twice a week for 3 months.
10/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.7
3–33
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will activate an assessment process for transfer to the Intensive Treatment
Unit in the event of further sexually assaultive behavior.
2. Psychiatrist will encourage pt. to consider a trial on an SSRI, such as Paxil, or hormonal
treatment, such as Depo-Provera, to help pt. maintain better control over his sexual
impulses.
Virginia Coleman, MD
Rehab/Psychology:
1. Staff will initiate cognitive-behavioral training for socially appropriate responses to
women in a variety of heterosexual situations, using modeling and role-playing.
2. Psychologist will help pt. to understand the legal consequences of sexually assaultive
behavior.
Joseph LeBlanc, Psychologist
Albert Sanchez, Rehab
Nursing Care Plan:
1. Nsg. staff will closely observe pt. for signs of inappropriate sexual or assaultive
behavior.
2. Nsg. staff will educate pt. concerning the risks and benefits of various meds that might
be considered to help him to better control his sexual impulses.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–34
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.8 Stalking Behavior
Name: Drago, Charles
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Patient has been obsessed with one of the social workers at the hospital (Anne Stevens) since 12/01. He has been
making threatening comments to her by letter, calling her at home, and waiting for her outside her office and by
her car. Patient appears to have no insight into the threatening nature of his acts. Currently, he seems less
preoccupied by this social worker and less convinced that they share something special; however, these thoughts
do occur at times. In the past, pt. has not been able to have any significant relationship with a member of the
opposite sex.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will not harm anyone, including Anne Stevens, for 6 months.
01/15/04
2. Pt. will not demonstrate stalking behavior for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will not harm anyone, including Anne Stevens, for 3 months.
07/15/03
2. Pt. will not demonstrate stalking behavior for 3 months.
07/15/03
3. Pt. will not make any threats toward anyone for 3 months.
07/15/03
4. Pt. will be able to demonstrate a focus away from Anne Stevens
AEB his not making any plans to attempt to contact Anne or send
her a gift for 3 months.
07/15/03
5. Pt. will be able to pass by Anne when on privileges without
making an attempt to get Anne’s attention for 3 months.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.8
3–35
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1. Nsg. staff will notify Anne Stevens of any changes in pt.’s privilege status or passes.
2. Nsg. staff will notify Anne Stevens, Department of Mental Health Police, police
department from his area, state police, District Attorney’s office, pt.’s next of kin, and
the hospital’s chief operating officer (Virginia Day) if pt. escapes.
3. Nsg. staff will place duty-to-warn label on the cover of pt.’s chart so all staff will be
aware of the need to warn.
Marilyn Davis, RN Å Nsg. Staff
Psychology:
1. Psychologist will meet one-to-one with pt. for 1 hour weekly in cognitive therapy to
help pt. resolve his obsession with Anne Stevens.
2. Psychologist will lead the sex offenders group once weekly to help pt. gain insight into
the inappropriateness of his behaviors through the group process, as well as to help
him understand the legal consequences of his stalking behaviors.
Joseph LeBlanc, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
ADL–OCCUPATIONAL SKILLS
(Problem Area 4)
4–1
This page intentionally left blank
ADL–Occupational Skills (Problem Area 4)
4–3
ADL–OCCUPATIONAL SKILLS
(Problem Area 4)
CONTENTS
Kennedy Axis V for ADL–Occupational Skills............................................................................................ 4–4
This rating scale can be used to measure the outcome of treatment. It also helps to define which
problems fit into the category of ADL–Occupational Skills and can be helpful in composing a short
description of each problem.
Problem Names and Descriptions ............................................................................................................ 4–5
Examples of problem names and descriptions that may relate to ADL–Occupational Skills are listed here.
These examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 4–6
Examples of strengths that may be related to treatment and discharge in the area of ADL–Occupational
Skills are listed here.
Goals ......................................................................................................................................................... 4–6
Examples of treatment goals that may relate to problems in the area of ADL–Occupational Skills are listed
here.
Treatment Modalities ............................................................................................................................... 4–8
Examples of treatment modalities that may relate to problems in the area of ADL–Occupational Skills are
listed here.
Sample Individual Problem Plans ........................................................................................................... 4–13
A wide range of Individual Problem Plans relating to ADL–Occupational Skills are included here.
4–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—ADL–Occupational Skills
100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a
homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of
hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those
expected of a successful college graduate.
90 Good skills in all ADL–occupational activities; no more than average difficulties with any work
assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school
graduate.
80 No more than slight impairment in occupational skills or skills in school; has slight difficulty
performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork
assignments; slight impairment in workmanship.
70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following
instructions, workmanship is somewhat sloppy), but generally functioning fairly well.
60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed; however,
has trouble carrying through assignments; some difficulty problem solving or following instructions; some
difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home or
apartment).
50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more
than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following
instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using
public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating
properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call.
40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any
significant period or do routine housework due to poor work skills; failing in school due to poor academic skills);
needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food
restaurant; poor understanding of how to budget money.
30 No job and unable to independently maintain a home due to serious impairment in skills needed
to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare
simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call,
follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs
(e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire
alarm; difficulty finding way back from short errands.
20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some
supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs
supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most
simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from
short errands).
10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete
most tasks even with constant supervision; may even have to be physically assisted to complete a task, including
eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support
(e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering
into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately
respond to a fire alarm.
NR Not rated
ADL–Occupational Skills (Problem Area 4)
Problem Names and Descriptions
I.
II.
ADL–Occupational Skill Deficits Problems
A.
Broad skill deficits
1.
Skill deficits secondary to mental retardation
2.
Skill deficits secondary to dementia
3.
Inability to deal with abstract thoughts or ideas
4.
Confusion and disorientation due to organic impairment
5.
Poor memory
6.
Poor insight and judgment due to organic factors
7.
Poor insight due to limited intellect
8.
Institutionalized
B.
Specific skill deficits
1. Needs to improve money management skills
2. Has difficulty completing tasks
3. Requires frequent prompts to complete tasks
4. Has poor personal hygiene due to a lack of personal hygiene skills
5. Lacks adequate nutritional skills
6. Needs to take better care of personal clothing
7. Needs to take better care of immediate living space
8. Has sloppy workmanship due to lack of skills
9. Is unable to find way back from short errands
10. Has difficulty feeding or dressing self
11. Wets or soils clothes or bedding due to lack of ability to use the toilet
C.
Other
1.
No examples given
Poor ADL Skills Often Associated With Dangerousness
A.
General
1.
Lacks ability to perform self-preservation skills
2.
Lacks basic life survival skills
3.
Is unable to care for self
4.
Has dependent patient status
5.
Appears incapable of recognizing dangers
B.
Specific
1.
Eats in a manner that would lead to choking
2.
Has hazardous smoking habits
3.
Walks in front of cars due to a lack of understanding of the danger
4.
Wanders away
4–5
4–6
Fundamentals of Psychiatric Treatment Planning
Strengths (Brief List)
I.
ADL–Occupational Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
Has average or above average intellectual ability
Is able to read and write
Is a high school or college graduate
Is capable of independent living
Is independent in personal care
Has a job to return to
Is able to successfully work in full-time competitive employment for more than 1 year
Has technical or vocational skills for a job
Other strengths
Goals
I.
Expected Improvements in Skills and Symptoms
A.
II.
Skills that pt. will learn
1.
Pt. will learn to make his or her bed AEB making the bed without supervision for 2 weeks.
2.
Pt. will be able to complete his or her daily personal hygiene without guidance or instructions for
2 weeks.
3.
Pt. will learn to use the ashtray three out of five times he or she smokes for 1 month.
4.
Pt. will be able to consistently dress self without having to be told what to put on for 1 month.
5.
Pt. will learn to do simple tasks around the ward AEB mopping the floor without supervision for
1 month.
6.
Pt. will be able to consistently carry out three-step tasks without guidance or instructions for
1 month.
7.
Pt. will learn to do complicated multistep tasks AEB preparing a meal without supervision at least
3 days a week for 1 month.
8.
Pt. will learn to handle his or her own funds such that pt. retains sufficient money (when
working) to meet daily purchasing needs for 2 months.
9.
Pt. will demonstrate sufficient ability to function in areas of ADLs to warrant discharge home with
parent for 3 months.
Reporting of Symptoms
A.
Pt. will become more aware of ADL limitations AEB asking for help in areas where
needed for 1 month.
III. Participation in Groups, Program Activities, and Such
A.
B.
C.
Pt. will participate in on-ward group activities for 5 minutes a day for 1 month.
Pt. will attend morning ward meetings twice per week for 1 month.
Pt. will attend one off-ward group activity per week for 4 weeks.
IV. Understanding of and Compliance With Treatment Plans
A.
Medication and laboratory work
1.
Pt. will consistently discuss the benefits of taking his or her psychotropic meds as prescribed for
1 month.
2.
Pt. will express the benefits of taking meds as prescribed consistently for 1 month.
3.
Pt. will take psychotropic meds as prescribed for 3 months.
ADL–Occupational Skills (Problem Area 4)
V.
4–7
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process for
1 month.
2.
Pt. will cooperate with treatment plans, such as IQ testing and vocational evaluations.
3.
Pt. will consistently accept realistic plans for employment for 3 months.
C.
Program activities
1.
Pt. will gain insight into the need to attend program, AEB being able to consistently explain the
reasons for attending, for 1 month.
2.
Pt.’s level of compliance will improve such that pt. will attend art therapy class twice a week for
1 month.
3.
Pt. will attend the programs recommended by the treatment plan on a regular basis for 1 month.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate an understanding of his or her progress by being able to consistently explain,
for 1 month, the connections among—
a.
Dressing and attending to personal hygiene and being able to go to activities off the ward,
b.
Working in a prevocational program and getting a job in the community,
c.
Failing to learn basic ADL skills and receiving continued care at the hospital, and
d.
Failing to learn basic occupational skills and being unable to get a job.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Staff will complete rehabilitation assessment for appropriate day-program referral.
2.
Pt. will cooperate so that rehab staff can assess the degree to which apathy, lack of motivation, or
poor focal attention obscure ADL skills.
3.
Pt. will cooperate so that psychological testing can be completed.
B.
Evaluations to R/O various diagnoses
1.
Staff will complete evaluation to R/O mental retardation.
2.
Staff will complete evaluation to R/O thought disorder.
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V score for ADL–Occupational Skills will improve from a current score of 30 to
40.
B.
Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)
1.
Pt.’s K NOSIE score on Social Competency will improve from a current score of +10 to +28.
2.
Pt.’s K NOSIE score on Personal Neatness will improve from a current score of +10 to +18.
C.
Comprehensive Occupational Therapy Evaluation (COTE)
1.
Pt.’s COTE score will improve from a current score of _____ to _____.
VII. Miscellaneous
A.
Staff will maintain a safe, secure environment for (dependent) pt. while attempting to
maximize his or her functional ability.
4–8
Fundamentals of Psychiatric Treatment Planning
Treatment Modalities
I.
II.
Verbal Treatment Modalities (emphasize verbal interactions)
A.
Support and reassurance
1.
Even when pt. is doing well in the development of his or her occupational skills, staff will provide
pt. with regular one-to-one support and reassurance.
B.
Cognitive refocusing (redirect focus toward reality and realistic self-appraisal)
1.
When pt. is able to handle increased periods of pt. wage program and maintain reasonable periods
of focused activity, staff will refer pt. to day program to continue work on focused, purposeful
activity.
2.
Staff will focus pt. away from plans based on his or her psychotic thinking to realistic, achievable
occupational goals.
C.
Psychotherapy
1.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better cope with
problems on the job.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Nsg. staff will encourage pt. and provide verbal praise for performing on-ward work activities.
2.
Staff will reinforce with positive verbal praise pt.’s positive behaviors, such as following through
with daily ADL requirements.
3.
Staff will give pt. encouragement for completion of multistep tasks in the absence of ritualistic or
other bizarre behavior.
4.
Staff will spend one-to-one time daily to encourage pt.’s participation in vocational groups.
5.
Nsg. staff will accompany pt. into the bathroom to encourage and reinforce appropriate personal
hygiene habits.
6.
Staff will give pt. one extra cigarette as a reward for learning the steps of a fairly complicated
multistep task.
7.
Staff will positively reinforce pt. with canteen and cafeteria privileges for regular attendance at the
vocational training group.
B.
Negative reinforcement (including discouragement, restriction, and withholding of
reinforcement)
1.
Pt. will be restricted to supervised privileges for 24 hours when pt. fails to attend the vocational
training group.
2.
Independent privileges will be held if pt. has sloppy inappropriate dress, has not taken care of his
or her dorm area, or has not attended to personal hygiene.
C.
Extinction
1.
Nsg. staff will limit their interactions with pt. when he or she fails to work on learning how to do
multistep tasks, such as making the bed and washing clothes.
D.
Shaping and modeling
1.
Staff will provide daily modeling of ADL tasks, such as making the bed, choosing clothes, setting
the table, and such.
2.
Work supervisor and co-workers will provide modeling to improve desired work skills, such as
filing and using the copier.
3.
Staff will provide primary and secondary positive reinforcers for incremental increases in level of
vocational skills.
4.
Staff will refer pt. to day programming for involvement in tasks that require gradually increasing
skill levels.
5.
Nsg. staff will engage pt. in joint tasks around the ward with some of the higher-functioning pts.
ADL–Occupational Skills (Problem Area 4)
4–9
E.
Channeling energies
1.
Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help pt.
channel potentially aggressive behavior into work.
2.
Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help divert
pt.’s energies into acceptable channels to reduce chronic hypersexual arousal and associated sexual
assaults.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
Staff will offer verbal prompts and physical assistance needed to enable pt. to complete basic
ADLs.
2.
Staff will use the same person as consistently as possible for redirection.
3.
All staff will redirect pt. to go to his or her contact for all general questions and requests.
4.
Contact will instruct pt. to write down the job steps, and, when appropriate, contact will direct pt.
to those written steps.
5.
Staff will have clothes and self-care items set up and ready before it is time for the ADL activities.
6.
Staff will break tasks down into small, concrete, realistic steps to reduce the level of frustration and
disorganization.
7.
Staff will break down the steps of treatment into small, understandable goals reachable by pt.
8.
Staff will redirect pt. away from decisions, plans, and actions that are grossly unrealistic or overly
complicated for pt.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will encourage family involvement in support of pt.’s job plans.
2.
Staff will provide family therapy to explore reasons within pt.’s family members for their desire for
pt. to fail at independent employment.
B.
Religious treatment modalities
1.
Provide religious counseling to help pt. learn how to use religious resources to get a volunteer job
where pt. can practice and improve work skills.
2.
Pt. will do volunteer work for 2 hours 5 days weekly at the church lunch program to improve pt.’s
work skills.
C.
Other modalities
1.
Group therapy
a.
Group therapy will facilitate discussions of job-related problems.
2.
Psychodrama
a.
Role-playing for 1 hour once weekly will assist pt. in dealing with situational conflicts on the
job.
b.
Role-playing for 1 hour once weekly will teach pt. how to act during a job interview.
3.
Rehabilitation
a.
Staff will provide weekly counseling to identify work goals, to identify deficits in work skills,
and to develop plans for education and training needed to meet goals.
b.
Staff will involve pt. in the on-ward rehabilitation group at least once weekly.
c.
Staff will involve pt. in money management group for 1 hour once weekly, including
community banking.
d.
Assigned staff will redirect this dependent pt. away from decisions, plans, and actions that
place pt. in danger.
4–10
Fundamentals of Psychiatric Treatment Planning
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Rehab training should be in a quiet area because of pt.’s easy distractibility.
B.
Protective procedures (including special observations)
1.
Staff will provide safe, secure environment with special monitoring as necessary.
2.
Staff will confine pt. to Privilege Level IV (cafeteria and supervised privileges) because of pt.’s very
impaired ADL skills, including difficulty crossing streets.
3.
Staff will follow hospital procedures for dependent pt. status.
4.
Pt. will not be allowed access to cigarettes or matches because of hazardous smoking habits.
C.
Other milieu treatment modalities
1.
No examples given.
Medical Treatment Modalities
A.
Medication
1.
Staff will administer meds as prescribed.
2.
Staff will use prn meds to relieve pt. from acute episodes of tormenting hallucinations so pt. can
participate in prevocational training.
B.
Other medical treatment modalities
1.
Staff will provide a wheelchair to increase pt.’s ability to participate in prevocational training.
VI. Patient and Family Education
A.
Mental illness
1.
Staff will discuss with pt. ways of coping with mental illness while working.
B.
Medication
1.
Staff will discuss the risks and benefits of meds with the pt. and family.
2.
Staff will discuss one-to-one the need to take meds as prescribed, including how meds can
facilitate pt.’s ability to participate in vocational programs.
3.
Staff will show concrete benefits of taking meds (e.g., “You are able to stay focused and, therefore,
better able to benefit from vocational training,” “You are less paranoid on the job; therefore, you
are able to participate in on-the-job training”).
C.
Benefits and consequences of behaviors
1.
Staff will discuss connections between daily appropriate behavior (e.g., being out of bed, attending
job training) and realistic progress toward pt.’s goals (full-time competitive employment).
2.
To help pt. understand the consequences of his or her actions, staff will verbally outline for pt.,
once each morning, the steps necessary to obtain gratification (e.g., pt. must get dressed and
attend to personal hygiene to go to prevocational training; next, pt. must graduate from
prevocational training before he or she can get a part-time job in the hospital canteen).
3.
Staff will demonstrate to pt. benefits of being able to count money.
4.
At least once weekly, staff will discuss the benefits of neatness and generally good personal
hygiene.
D.
Miscellaneous patient and family education
1.
No examples given.
ADL–Occupational Skills (Problem Area 4)
4–11
VII. Evaluations and Assessments
A.
Rehabilitation assessment
1.
Staff will assess pt.’s work preferences and work skills.
2.
Staff will assess pt.’s areas of greatest interests and motivation to begin occupational training
congruent with pt.’s interests.
3.
Rehab staff will assess the degree that apathy, lack of motivation, and poor focal attention obscure
ADL skills.
4.
Staff will refer pt. to occupational therapist for formal assessment of ADL skills and interests.
5.
Pt. will participate in trial job period to assess pt.’s job skills.
6.
Staff will use work hardening (slowly increasing hours and difficulty of task) to determine
endurance and skill level.
B.
Psychological tests (and other formal verbal tests)
1.
Staff will conduct psychological testing to determine pt.’s ability to engage in treatment, including
job training.
C.
Psychiatric evaluations
1.
Staff will conduct psychotropic medication evaluation to assess the potential for medication to
facilitate pt.’s ability to learn new ADL skills.
2.
Staff will conduct psychiatric evaluation to assess the degree that side effects of pt.’s psychotropic
medication might be impairing pt.’s ADL skills.
3.
Staff will provide neuropsychiatric consultation to assess the degree that factors related to pt.’s
abnormal EEG might impair job performance.
D.
Medical tests and evaluations
1.
Staff will conduct medical tests and evaluations as needed to R/O factors that might impair pt.’s
ADL skills or ability to gain new skills.
E.
Other evaluations and assessments
1.
Nsg. staff will observe pt. doing on-ward tasks to assess pt.’s level of ADL skills.
2.
Staff will test pt.’s ability to find his or her way around the hospital.
3.
Nsg. staff will test pt.’s ability to respond to a fire alarm.
4.
Nsg. staff will complete “emergency fact sheet” on this dependent pt.
VIII. Legal Treatment Modalities
A.
Commitment
1.
Psychiatrist will seek court commitment under Sections 7 and 8 for a period up to 6 months
because of pt.’s inability to care for self because of limited ADL skills.
B.
Guardianship
1.
Psychiatrist will seek permanent legal guardian to make decisions for pt. related to his or her
medical and psychiatric condition and estate.
IX. Miscellaneous Treatment Modalities
A.
Treatment of problems affecting ADL–occupational skills (This step is optional; instead, this
information may be included in the problem description.)
1.
Staff will treat pt.’s lack of motivation to get out of bed and attend to personal hygiene, as
indicated under Problem 1.1 Psychotic Symptoms.
2.
Staff, as indicated, will treat pt.’s marked lack of motivation and apathy under Problem 1.2 Lack of
Motivation.
3.
Staff will treat pt.’s problems with interpersonal relations on the job as indicated under Problem
2.1 Poor Social Skills.
Notes
ADL–Occupational Skills (Problem Area 4)
4–13
Sample Individual Problem Plans
CONTENTS
Impaired ADL Skills ................................................................................................................................. 4–14
Impaired ADL Skills (Deferred)............................................................................................................... 4–16
Poor Work Skills ...................................................................................................................................... 4–18
Dependent Patient ................................................................................................................................. 4–20
Hazardous Smoking Habits .................................................................................................................... 4–22
4–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.1 Impaired ADL Skills
Name: Jackson, Kenneth
ID #:
Area:
Nursing Diagnosis: Self-Care Deficit
Date: 01/15/03
Problem Description:
Pt. has a history of many years of severe impairment of ADL skills due to long stays in institutions. Pt. needs
constant supervision to complete almost any task (e.g., dressing, preparing a simple meal, and returning from short
errands).
Implement treatment of withdrawn apathetic behavior and poor focal attention under Problem 1.1 Psychotic
Symptoms and Problem 1.2 Poor Focal Attention.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to perform basic ADLs without supervision four of
five mornings (i.e., dressing, grooming, showering, and morning
housekeeping activities).
01/15/04
2.
Pt.’s Kennedy Axis V score for ADL–Occupational Skills will
improve from a current score of 20 to 30.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will ask for things that he needs for his morning routine about
50% of the time for 1 month.
07/15/03
2.
Pt. will be able to independently dress himself four mornings a
week for 1 month.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.1
4–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab/Nursing Care Plan:
1.
Staff will prepare the environment before the time of the ADL activities (e.g., have
clothes and self-care utensils ready).
2.
Staff will provide one-to-one modeling of ADL tasks (e.g., making his bed, choosing
clothes, and looking for utensils).
3.
Staff will encourage and praise pt. for successful completion of various ADL tasks.
Albert Sanchez, Rehab
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.2 Impaired ADL Skills
Name: Raphael, Linda
ID #:
Area:
Nursing Diagnosis: Impaired Home Maintenance
Date: 01/15/03
Problem Description:
Pt. has marked impaired ADL skills and needs supervision to perform even basic self-care skills; however, the
impairment appears to be mostly due to her apathy and disorganized thinking. With encouragement, she is able to
perform basic ADLs in self-care and housekeeping, such as preparing a small, simple meal, sewing on buttons, or
mending a tear.
Implement treatment of apathy and disorganized thinking under Problem 1.1 Psychotic Symptoms.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
Date/Status*
Target Date
Date/Status*
Deferred: Due to a high level of psychotic symptoms, pt. is currently
not using the ADL skills she already possesses. This problem plan will
be activated when pt.’s psychotic process is under better control.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.2
4–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
Social Work:
Psychology:
Rehab:
Nursing Care Plan:
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.3 Poor Work Skills
Name: Titus, Kevin
ID #:
Area:
Nursing Diagnosis: Deficient Knowledge
Date: 01/15/03
Problem Description:
Pt. has held three jobs in the past 6 years; however, he was unable to keep any of the jobs for more than 1 month.
He was fired from one job for poor performance and quit the other two jobs because he “didn’t like them.” Pt.
appears to lack many of the basic skills necessary to keep a job. Pt. has difficulty following instructions and
difficulty performing somewhat complicated tasks, such as running the copier, filing, and stocking shelves. Pt. also
has difficulty taking public transportation and is unable to drive a car.
Implement treatment of Problems 1.2 Lack of Motivation and 1.3 Poor Focal Attention.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will get and keep a part-time job (l6 to 20 hours per week) in a
competitive work environment for at least 6 months.
01/15/04
2.
Pt.’s Kennedy Axis V score for ADL–Occupational Skills will
improve from a current score of 50 to 60.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Staff will identify areas of deficits in work skills.
02/15/03
2.
Pt. will be able to file 50 letters with no more than one misfile.
04/15/03
3.
Pt. will be able to copy standard size, single-sided letters with no
significant difficulty for 2 weeks.
04/15/03
4.
Pt. will work 10 hours per week in a work program of his choice
and will keep the job for at least 1 month.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.3
4–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in weekly individual and group counseling to identify deficits in
work adjustment in order to—
a. Address deficits in work skills
b. Identify and plan for vocational goals
c. Determine education and training needed to meet goals
2.
Staff will identify job interests to help pt. choose an appropriate work program to
increase the probability of pt. keeping a job and developing needed work skills.
a. Pt. will complete interest testing to aid in vocational decision making.
b. Pt. will participate in a 2-week trial in a job of his choice for situational
assessment.
c. Individual vocational rehab counselor will assign work according to pt.’s choice.
d. Vocational rehab counselor will monitor, address, and document work adjustment
issues on a daily basis.
3.
Work supervisor and peers will use role modeling and verbal praise to increase desired
work behaviors, such as using the copier and filing correspondence.
4.
Staff will use work hardening (slowly increasing hours and difficulty of task) to
determine pt.’s endurance and skill level.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.4 Dependent Patient
Name: Dodge, Patricia
ID #:
Area:
Nursing Diagnosis: Deficient Knowledge
Date: 01/15/03
Problem Description:
Pt. is generally unable to find her way around the hospital. If lost, it is felt that she may not be able to identify
herself or tell where she is from. It is feared that if given the opportunity she may wander away from the hospital.
Pt. appears to be able to safely cross streets; however, it is believed she is vulnerable to advances of strangers.
Without supervision, pt. does not respond to emergencies, such as fire alarms.
Implement treatment of Problem 2.1 Poor Social Skills.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to function so that she will no longer require a
dependent patient status.
01/15/05
2.
Pt. will be able to identify herself and her ward location
consistently once per day for 3 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will be able to identify herself and her location once per day
for 1 month.
07/15/03
2.
Pt. will be able to lead staff to the hospital store and back to the
ward three times weekly for 1 month.
07/15/03
3.
Pt. will be able to go to and return from the hospital store
independently and consistently for 3 months.
01/15/04
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.4
4–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will maintain a safe, secure environment while attempting to maximize pt.’s
functional ability.
2.
Nsg. staff will follow hospital procedure for dependent patients, including labeling the
outside of pt.’s chart, notifying the proper authorities if pt. is missing, and the like.
3.
Nsg. staff will ensure that pt. wears an identification bracelet or tag at all times.
4.
Pt. contact will conduct off-ward training trips twice daily to teach pt. the route to the
hospital store and back.
5.
Pt. contact will spend 5 to 10 minutes per shift working with pt. to self-identify and to
give correct ward address.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.5 Hazardous Smoking Habits
Name: Saxon, Howard
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has been a careless smoker for years. He often burns holes in his clothes, thus posing a health hazard.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt.’s smoking will improve such that he will be able to go for
6 months without burning holes in his clothes.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will use ashtray three out of five times he smokes without staff
cues for 1 month.
04/15/03
2.
Pt.’s smoking will improve such that he will be able to wear one
set of clothes each day for 1 month without burning holes in
them.
04/15/03
3.
Pt.’s smoking will improve such that he will be able to go for
3 months without burning holes in his clothes.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.5
4–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will reinforce the need for and use of an ashtray each time a cigarette is
given.
2.
Nsg. staff will remind patient not to burn holes in his clothes.
3.
If patient does not use an ashtray or if he reports for the next scheduled cigarette with
a hole in his clothes, his cigarettes will be withheld for 1 hour.
4.
If cigarettes are withheld, nsg. staff will explain why they are being held and will
remind pt. what smoking behaviors are necessary to continue hourly cigarette
schedule.
5.
Nsg. staff will educate pt. for ½ hour once weekly to help pt. understand the dangers
associated with his careless use of cigarettes.
Linda Larkin, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
SUBSTANCE ABUSE
(Problem Area 5)
5–1
This page intentionally left blank
Substance Abuse (Problem Area 5)
5–3
SUBSTANCE ABUSE
(Problem Area 5)
CONTENTS
Kennedy Axis V for Substance Abuse ....................................................................................................... 5–4
This rating scale can be used to measure the outcome of treatment. It also helps to define which
problems fit into the category of Substance Abuse and can be helpful in composing a short description
of each problem.
Problem Names and Descriptions ............................................................................................................ 5–5
Examples of problem names and descriptions that may relate to Substance Abuse are listed here.
These examples can be used to develop the Problem List and to help compose a short description of
each problem.
Strengths .................................................................................................................................................. 5–5
Examples of strengths that may be related to treatment and discharge in the area of Sobriety are listed
here.
Goals ......................................................................................................................................................... 5–5
Examples of treatment goals that may relate to problems in the area of Substance Abuse are listed here.
Treatment Modalities ............................................................................................................................... 5–7
Examples of treatment modalities that may relate to problems in the area of Substance Abuse are listed
here.
Individual Problem Plan (Frequent Entries) ........................................................................................... 5–12
An Individual Problem Plan that contains examples of information that is frequently entered into
Individual Problem Plans relating to Substance Abuse is included here.
Sample Individual Problem Plans ........................................................................................................... 5–15
A wide range of Individual Problem Plans relating to Substance Abuse are included here.
5–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Substance Abuse
100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no
use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone
who is totally free of problems with substance abuse. No symptoms.
90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social
drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and
minimal, if any, treatment needed to maintain sobriety.
80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes
daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or
caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse
(e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety
with minimal treatment needed to maintain sobriety.
70 Mild impairment in social, occupational, or school functioning due to substance abuse, but
generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription
drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy
smoker; unable to quit cigarettes despite numerous attempts.
60 Moderate difficulty in social, occupational, or school functioning because of substance
abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or
co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week;
occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust),
Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes
despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.
50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance abuse;
moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing substances
despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol or
marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions;
moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or
muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular
basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than
cigarettes) is beginning to cause some medical complications.
40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids
friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his
family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally
has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety.
30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably
impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances
without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical
hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious
neglect of children due to substance abuse.
20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin,
or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving
for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very
serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs
into his/her veins more than twice a day.
10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or
withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking
drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to
severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in
frequent medical hospitalizations; life-threatening neglect of children due to substance abuse.
NR Not rated
Substance Abuse (Problem Area 5)
5–5
Problem Names and Descriptions
I.
II.
Substance Abuse Problems (alcohol, drugs, or both)
A.
Examples
1.
Abuse of drugs, cigarettes, or alcohol
2.
Lack of insight into acute and chronic alcoholism
3.
Inability to quit the use of drugs, cigarettes, or alcohol despite desire to do so
4.
Addiction to caffeine
B.
Other
1.
Addiction to drinking excessive fluids (this problem is often included under Problem 1.1
Polydipsia, Problem 6.1 Hyponatremia Secondary to Polydipsia, or both)
Problems Associated With Substance Abuse (substance abuse often leads to other acute
or chronic problems that might be addressed under their particular problem area[s])
A.
Examples
1.
Continued abuse of drugs, cigarettes, or alcohol despite acute or chronic medical problems caused
by them
2.
Inability to quit cigarettes despite physical damage from cigarettes
3.
Multiple accidental overdoses of drugs or alcohol
4.
Hypomania triggered by excessive caffeine intake
5.
Depression and suicidal ideation secondary to chronic alcohol abuse
Strengths (Brief List)
I.
Substance Abuse Strengths (sobriety)
A.
B.
C.
D.
No significant problem with drugs or alcohol
Recently able to attain 10 years of sobriety
Has strong moral and ethical beliefs against use of drugs or alcohol
Other strengths
Goals
I.
Expected Improvements in Symptoms
A.
Evidence of increasing control over substance abuse
1.
Pt. will attend one off-ward independent activity per week for 1 month without abusing drugs or
alcohol.
2.
Pt. will engage in one independent off-ward social activity with a peer once per week for 1 month
without abusing drugs or alcohol.
3.
Pt. will use his or her independent privileges for 1 month without abusing drugs or alcohol.
4.
Pt. will not abuse drugs or alcohol for 3 months when pt. is on pass or AWA (away without
authorization) from the hospital.
5.
Pt. will be free of abuse of drugs or alcohol for 3 months despite the opportunity to use them.
6.
Pt. will continue to avoid use of drugs or alcohol.
7.
Pt. will stop smoking for 1 month.
8.
Pt. will consistently eat meals and snacks that are less likely to be associated with past patterns of
use of cigarettes or alcohol for 3 months.
5–6
II.
Fundamentals of Psychiatric Treatment Planning
Reporting of Symptoms
A.
B.
C.
Pt. will consistently discuss with staff his or her impulse to use drugs or alcohol for
1 month.
Pt. will consistently disclose to staff occasions on which pt. broke his or her agreement
not to abuse drugs or alcohol for 3 months.
Pt. will agree to sign a contract that pt. will not abuse alcohol when on pass.
III. Participation in Groups, Program Activities, and the Like
A.
B.
Pt. will attend the programs recommended by the treatment plan, including AA
meetings, 4 out of 5 weekdays for 3 months.
Pt. will participate in weekly AA and substance abuse discussion groups within the
hospital for 1 month.
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking psychotropic meds as prescribed.
2.
Pt. will express an understanding of the benefits of taking psychotropic meds as a means of
decreasing his or her impulses to use narcotics.
3.
Pt. will take psychotropic meds as prescribed for 3 months.
4.
Pt. will cooperate with spot checks of urine for toxicology screen, if substance abuse is suspected,
for 3 months.
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process
consistently for 1 month.
2.
Pt. will be willing to participate in the evaluation process.
3.
Pt. will explore potential resources and support systems available in the community.
4.
Pt. will verbalize that participation in the work program will help to improve self-esteem, reduce
boredom, and channel excess energy away from alcohol.
C.
Program activities
1.
Pt. will verbalize the benefits of attending program activities.
D.
Consequences of actions
1.
Pt. will be able to verbalize an understanding of the connections among the following:
a.
Continued drug or alcohol abuse and continued deterioration of one’s lifestyle and rejection
by family and friends;
b.
Continued abuse of illegal drugs and continued conflicts with the law;
c.
Continued abuse and neglect of basic health needs and reoccurring physical illnesses;
d.
Substance abuse, AIDS, and other serious health problems;
e.
Substance abuse and inability to retain a job; and
f.
Alcohol abuse and worsening of depression.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate with the evaluation process.
2.
Pt. will consistently cooperate with urine toxicology screens when substance abuse is suspected for
3 months.
3.
Pt. will complete rehabilitation assessment for appropriate day-program referral.
B.
Evaluations to R/O that psychiatric illnesses are self-medicated or caused by substance
abuse
1.
Pt. will cooperate with complete evaluation to R/O depression secondary to alcoholism.
2.
Pt. will cooperate with the assessment to help R/O pt.’s self-medicating an anxiety disorder with
street drugs.
Substance Abuse (Problem Area 5)
5–7
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V score for Substance Abuse will improve from a current score of 50 to 70.
VII. Miscellaneous
A.
B.
Pt. will seek a discharge environment free of street drugs and alcohol.
Pt. will work for a company that stresses employee health, including smoking cessation
and abstinence of alcohol for those with an alcohol problem.
Treatment Modalities
I.
Verbal Treatment Modalities (emphasize verbal interactions)
A.
Support and reassurance
1.
Staff will provide one-to-one supportive, problem-solving therapy to help pt. learn to cope with
life without resorting to drug abuse.
2.
Staff will provide one-to-one support when pt. presents as calm and clear but despairing.
3.
Staff will provide one-to-one contact with pt. with needed support and reassurance to give pt.
a sense that people care for pt.
4.
Nsg. staff will provide episodic one-to-one contact to give a sense that pt. is receiving attention.
5.
Staff will provide one-to-one interactions to help build a trusting relationship between pt. and
staff.
6.
Staff will express understanding of pt.’s distress and suggest interventions when pt. is suffering
from severe anxiety and depression.
7.
Nsg. staff will provide pt. with regular one-to-one support and reassurance at least once each shift,
even when pt. is doing well.
B.
Cognitive refocusing (redirect focus away from things that support substance abuse and
toward things that support sobriety)
1.
Psychologist will meet with pt. once a week to direct pt. toward considering methods other than
drinking for dealing with depression and anxiety.
2.
Staff will help pt. recognize and express self-worth (e.g., compliment pt. when his or her
appearance improves to bolster self-esteem and engage pt. in activities that pt. can succeed in and
feel comfortable doing without needing alcohol).
3.
Staff will maximize structured activities to minimize preoccupation with drugs and to help pt. stay
focused on alternative behaviors. This refocusing can be done by maximizing pt.’s involvement in
structured day programs, including open workshop, patient wage program, leisure interest group,
and community meeting.
C.
Psychotherapy
1.
Staff will provide pt. with one-to-one, insight-oriented psychotherapy once a week to help pt.
uncover the reasons why he or she turns to alcohol to cope with problems.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help pt. find alternatives
to substance abuse for coping with life’s problems.
5–8
II.
Fundamentals of Psychiatric Treatment Planning
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Ward staff will encourage and give verbal praise for pt.’s involvement in non-drug-related social
activities.
2.
Staff will provide ongoing verbal reinforcement for pt.’s decision to stop drinking.
3.
Staff will reinforce with positive verbal praise pt.’s positive behaviors, such as taking on
responsibilities and attempting self-discipline.
4.
Staff will positively reinforce pt. with trips to the canteen for involvement in the treatment
planning process.
5.
Nsg. staff will provide frequent encouragement for pt. to attend to personal hygiene and
appearance.
B.
Negative reinforcement (including discouragement, restriction, and withholding of
reinforcers)
1.
Staff will restrict pt. to supervised privileges for 1 week if pt. returns from AWA intoxicated.
Restriction will be only 3 days if there is no evidence of intoxication.
2.
Staff will discourage pt. from talking about “war stories” from his or her life of drug use on the
streets.
3.
Staff will restrict pt. to supervised privileges for at least 1 week while his or her commitment to
abstinence is assessed when pt. is found to be abusing drugs or alcohol.
C.
Extinction
1.
Nsg. staff members will limit their interactions with pt. when pt. fails to work on means of
controlling impulses to abuse drugs and alcohol.
D.
Shaping and modeling
1.
Pt. will use the “buddy” system to provide a model of non–drug use for pt. to follow.
E.
Channeling energies
1.
Pt. will be placed in a job as a salesperson at a retail store to divert pt.’s hyperactivity and high
level of energy from drug dealing to more socially acceptable behaviors.
2.
Staff will encourage pt. to spontaneously report urges to drink and will discuss alternatives to help
manage these urges.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
Staff will use the same person as consistently as possible for redirection and support.
2.
Substance abuse counselor will break down the steps of reaching and maintaining sobriety into
small, understandable goals reachable by pt.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will provide family therapy to explore family’s continued financial support of pt.’s drug use.
B.
Substance abuse groups, agencies, and help programs
1.
Staff will encourage pt. to attend a substance abuse treatment program once per week.
2.
Staff will encourage pt. to attend a relapse prevention group once weekly.
3.
Staff will refer pt. to the AA meeting in the hospital.
4.
Staff will refer pt. to the Narcotics Anonymous group in town.
5.
Staff will refer pt.’s spouse to an Al-Anon family group.
6.
Staff will give pt. an appointment with a community self-help group to help pt. with his or her
commitment to stay off cigarettes.
C.
Religious treatment modalities
1.
Provide religious services to enhance pt.’s self-esteem and feelings of meaning and community.
2.
Provide religious counseling to help pt. explore moral issues related to abusing his or her body
through the use of drugs and alcohol.
Substance Abuse (Problem Area 5)
D.
5–9
Other modalities
1.
Psychodrama
a.
Staff will use psychodrama to assist pt. to be able to say “No” when pressured by peers to use
drugs.
2.
Termination
a.
Pt. will be terminated from the program if, after 1 week, pt. shows no significant motivation
for change.
b.
Pt will be readmitted when his or her drug lifestyle is painful enough for pt. to want to
change.
3.
Significant other
a.
Staff will explore whether a significant other, such as pt.’s fiancé(e), will help pt. follow
through with a commitment to stopping drinking.
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will restrict pt. from associates and areas that have triggered drug use in the past.
2.
Staff will work at identifying and reducing triggering cues.
3.
Dietitian will work with pt. to identify eating habits that trigger smoking (or drinking).
4.
Staff will work with pt. for 1 hour once weekly to reduce cues that trigger substance abuse.
B.
Protective procedures (including special observations)
1.
Staff will provide a safe, secure, drug-free environment with special monitoring as necessary.
2.
Staff will provide a drug-free environment by—
a.
Having the pt. remain on the locked section of the Detox Unit until pt. has better control of
his or her urges to abuse drugs and alcohol;
b.
Supervising visits and searching pt. for drugs and drug utensils when pt. returns from any
unsupervised, off-ward activity;
c.
Monitoring pt.’s phone calls and screening the pt.’s letters to ensure that pt. does not
attempt to get someone to bring drugs onto the ward;
d.
Performing unannounced drug toxicology screens, randomly and when substance abuse is
suspected.
C.
Other milieu treatment modalities
1.
No examples given.
Medical Treatments
A.
Medication
1.
Staff will gradually reduce medication doses as prescribed to detox pt. off drugs and alcohol.
2.
Staff will administer vitamin supplement as prescribed.
3.
Staff will place pt. on methadone maintenance.
4.
Staff will place pt. on Antabuse (disulfiram) to help prevent relapse back into alcohol use.
5.
Staff will place pt. on nicotine gum or nicotine patch to reduce craving for cigarettes.
B.
Other medical treatments
1.
Pt. will get a physical exam and an individualized program of physical fitness to help improve
health awareness and self-esteem.
5–10
Fundamentals of Psychiatric Treatment Planning
VI. Patient and Family Education
A.
Mental illness
1.
Staff will discuss with pt. his or her addiction to drugs and alcohol.
2.
Staff will discuss with pt.’s family the nature of pt.’s addiction and the fact that pt. will not be able
to stop the abuse of drugs by himself or herself.
B.
Medication
1.
Staff will discuss with pt. the process of detoxification using methadone.
2.
Staff will discuss with the pt. and family the use of drugs like methadone and Antabuse
(disulfiram) in an aftercare program.
C.
Benefits and consequences of behaviors
1.
Staff will discuss with pt. the association between substance abuse and worsening of
hallucinations and assaultiveness.
2.
Staff will give pt. concrete examples of the effects of continued drug abuse (e.g., “Your probation
officer will revoke your probation if he or she learns of your continued drug abuse,” “You are
starting to show evidence of liver and brain damage secondary to alcohol abuse that will worsen if
abuse of alcohol is continued,” “Your depression is worsened by your chronic use of alcohol,” and
the like).
3.
Staff will work with pt. to help pt. have a clearer understanding of the effects alcohol has on
behavior.
D.
Miscellaneous patient and family education
1.
No examples given.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Staff will conduct psychological testing for addictive profile.
2.
Staff will conduct neuropsychological testing to R/O organic brain damage secondary to alcohol
and drug abuse.
B.
Psychiatric evaluations
1.
Staff will conduct a psychiatric diagnostic evaluation to R/O an underlying psychiatric illness that
pt. is self-medicating with drug abuse.
2.
Staff will conduct a psychiatric evaluation to help determine whether pt. would be better treated
in a psychiatric facility or in a drug treatment program.
C.
Medical tests and evaluations
1.
Urine toxicology screen
2.
Blood screen for liver disease
3.
Blood screen for venereal disease
a.
Blood screen for syphilis
b.
Blood screen for AIDS
4.
D.
GC (gonococcus) smear to rule out gonorrhea
Other evaluations and assessments
1.
Staff will conduct a one-to-one weekly interview to identify stimuli of substance abuse.
2.
Staff will conduct a one-to-one weekly interview to determine the nature of pt.’s anxiety about
going into a drug treatment facility.
3.
Social worker will investigate the availability and appropriateness of drug treatment programs in
the area.
4.
Staff will assess pt.’s areas of greatest interests and motivation to begin structured activities
congruent with pt.’s interests.
5.
Social worker will interview family members to assess their ability to communicate with each
other and to identify family interactions that may contribute to pt.’s alcoholism.
Substance Abuse (Problem Area 5)
5–11
VIII. Legal Treatment Modalities
A.
Court commitment
1.
Staff will initiate petition for mandatory substance abuse treatment.
IX. Miscellaneous Treatment Modalities
A.
Treatment of related problems (This is optional and can be included with the treatment
modalities or in the problem description.)
1.
Staff will treat the hopelessness and despair associated with pt.’s alcoholism as indicated under
Problem 1.1 Depressive Symptoms.
2.
Staff will treat pt.’s chronic hepatitis as outlined under Problem 6.1 Chronic Hepatitis.
5–12
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plan (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.1 Substance Abuse
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Ineffective Coping, Related to Substance
Abuse
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
Onset of symptoms and chronicity
•
•
•
Response to previous and current treatments and expected response to any proposed treatments
Precipitants (e.g., lifestyle, peer pressure, depression, anxiety, losses, other stress, boredom)
Characteristics, frequency, intensity, and variance of substance abuse behavior, including types, quantities,
and frequency of use of drugs or alcohol
Current level of substance abuse, urges to abuse substances, preoccupation with substance abuse
Barriers to treatment, such as minimizing one’s problem with substance abuse, poor motivation
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any depressive or anxious symptoms that may be driving pt.’s impulses to
abuse drugs or alcohol should be addressed in Problem Area 1 Psychological Impairment and violence
secondary to substance abuse in Problem Area 3 Violence.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
Target Date
Date/Status*
1. Pt. will be free of substance abuse for ___ week(s)/month(s).
2. Pt. will be able to go on off-grounds privileges on a regular basis
without using/abusing drugs/alcohol for ___ week(s)/month(s).
3. Pt. will participate in substance abuse meetings ___ time(s) a
week/month for ___ week(s)/month(s).
4. Pt. will complete steps _____ of the 12-step AA program.
5. Pt. will exhibit diminished denial and minimization AEB being
able to admit that drugs or alcohol are a problem in pt.’s life
consistently for a ___ -week/-month period.
6. Pt. will watch video(s) or read pamphlet(s) on substance abuse
titled __________________________________________________.
7. In substance abuse groups, pt. will be able to express an
understanding as to how substance abuse can 1) interfere with job
and functioning, 2) lead to assaultive or suicidal behavior, 3) force
one into criminal activity, and 4) adversely affect one’s mental
and/or physical health.
8. Pt. will work with a significant other for at least ___
week(s)/month(s) to help ensure that pt. will follow through with
treatment and abstinence.
9. Pt. will consistently agree to spot checks of urine for toxicology
screen if substance abuse is suspected for ___ week(s)/month(s).
10. Pt. will be able to express an understanding of the connection
between his or her depression, stress, or losses and substance abuse.
11. Pt.’s score on the Kennedy Axis V for Substance Abuse will
improve from a current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.1
5–13
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
monitor any changes in intensity of impulses to abuse drugs/alcohol and to prescribe
treatments that may help reduce the craving or sense of need for drugs/alcohol such as
___________________________. Labs as ordered, including urine toxicology screens.
Virginia Coleman, MD
Social Work:
1. Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
help pt. understand how his or her impulses to abuse drugs or alcohol act as a barrier
to pt.’s discharge.
Brenda St. Martin, MSW
Psychology (or Social Work):
1. Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
time(s) weekly/monthly in alcohol counseling to reduce pt.’s craving or sense of need
for drugs/alcohol.
2. Psychologist (social worker) will lead group (e.g., substance abuse relapse prevention
group) weekly to help reduce pt.’s craving or sense of need for drugs or alcohol and
more effectively deal with pt.’s stress, problems, and losses.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.’s daily treatment schedule and will refer pt.
to appropriate groups working to improve his or her problem with drugs/alcohol.
2. Pt. will attend AA/Narcotics Anonymous meetings ___ time(s) a week/month to learn
more about substance abuse risk factors and how to avoid them. See weekly schedule
for substance abuse programs.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to any evidence of intoxication or withdrawal and report any
significant findings to the psychiatrist or physician.
2. Nsg. staff will obtain urine toxicology screen or do Breathalyzer test if substance abuse
is suspected.
3. Nsg. staff will be alert to pt.’s impulses to abuse drugs or alcohol and med-seeking
behavior and will assist pt. in dealing with these in an appropriate, sober manner.
4. Nsg. staff will give encouragement and verbal praise for pt.’s involvement in non-drugrelated social activities.
5. Nsg. staff will escort pt. to off-ward groups, programs, and other activities to ensure pt.
does not attempt to abuse drugs or alcohol.
6. Nsg. staff will question pt. directly at least ____ time(s) each shift/day/week to
determine whether pt. has any impulses to abuse drugs/alcohol.
7. Nsg. staff will meet with pt. for ___ minutes at least ____ time(s) weekly/monthly to
educate pt. about the consequences of substance abuse and about alternative means of
relating to others, coping, or dealing with stress.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Substance Abuse (Problem Area 5)
5–15
Sample Individual Problem Plans
CONTENTS
Polysubstance Abuse .............................................................................................................................. 5–16
Substance Abuse, Mixed......................................................................................................................... 5–18
Nicotine Dependence ............................................................................................................................. 5–20
5–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.1 Polysubstance Abuse
Name: Graves, Gail
ID #:
Area:
Nursing Diagnosis: Risk for Injury
Date: 01/15/03
Problem Description:
Pt. has a history of several years of abusing substances, including alcohol, marijuana, and cocaine. At first, patient
denied abuse of drugs and alcohol; however, her extensive substance abuse problem quickly became apparent.
Abuse of drugs and alcohol appears to pervade her thinking and behavior. When given privileges, pt. would
frequently go AWA to get alcohol. During these periods, pt. places herself in potentially dangerous situations. Staff
feels that if given the opportunity, pt. would abuse drugs and alcohol on a daily basis. Pt.’s driver’s license was
revoked last year because of driving under the influence. In part, pt.’s substance abuse is seen as a method of
blocking out her feelings of low self-esteem. She has not used any drugs IV.
Pt.’s low self-esteem, which appears to be a factor in her substance abuse, will be treated as indicated under
Problem Area 1.1 Depressive Symptoms.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will be able to go on off-grounds privileges on a regular basis
without abusing drugs or alcohol for 3 months.
07/15/03
2. The pt.’s Kennedy Axis V score for Substance Abuse will improve
from a current score of 35 to 55.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will accurately discuss with staff her impulses to use drugs and
alcohol for 1 month.
04/15/03
2. Pt. will participate twice weekly in AA and substance abuse
discussion groups within the hospital for 1 month.
04/15/03
3. Pt. will be able to go on independent privileges on the hospital
grounds for 1 month without going AWA to get drugs or alcohol.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.1
5–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1½ hours each month to monitor any
changes in intensity of impulses to abuse drugs and alcohol.
2. Staff will consider prescribing medication to reduce craving for substance abuse, such
as naltrexone.
3. Psychiatrist will order urine toxicology screens to help ensure that pt. is not abusing
substances.
4. Pt. will be restricted to supervised privileges for 1 week if she returns to the ward
intoxicated or if she has a positive urine toxicology screen. During that period, staff
will reassess pt.’s commitment to sobriety, the treatment plan, and her level of
dangerousness in the community.
Victor Dyson, MD
Psychology:
1. Psychologist will meet one-to-one with pt. to direct her toward methods other than
substance abuse for relieving her depression and anxiety.
2. Staff will refer pt. to and encourage her to attend AA meetings and substance abuse
disorders group at least twice weekly in the hospital.
Joseph LeBlanc, Psychologist
Rehab:
1. Pt. will work in hospital cafe 4 hours each workday to help pt. stay focused on
alternatives to substance abuse and to improve her self-esteem.
2. Rehab staff will lead the relapse prevention group for 1 hour weekly to help pt. learn
about substance abuse risk factors and how to avoid them.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will provide encouragement and verbal praise for pt.’s involvement in nondrug-related social activities.
2. Nsg. staff will be alert to any evidence of intoxication, obtain urine toxicology screens
if substance abuse is suspected, and report any significant finding to the attending
psychiatrist.
3. Nsg. staff will meet with pt. for ½ hour once weekly to educate her about the
consequences of substance abuse and about alternative means of coping with stress
and her low self-esteem.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
5–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.2 Substance Abuse, Mixed
Name: Zachary, Maurice
ID #:
Area:
Nursing Diagnosis: Risk for Injury
Date: 01/15/03
Problem Description:
Pt. was recently transferred from our Psychiatric Acute Treatment Unit to our Substance Abuse Treatment Unit. Pt.
began abusing alcohol and marijuana around age 15. His episodic but persistent abuse of alcohol and marijuana
invariably leads to a worsening of his psychiatric symptoms. This abuse clearly impairs his functioning in his
community residence and his day treatment program. This abuse has led to multiple psychiatric hospitalizations,
including the present.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1. Patient will not abuse drugs or alcohol for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1. Pt. will acquire a willingness to examine substance abuse as a
problem in his life as demonstrated by independent participation
in a multifaceted educational and treatment program for
1 month.
04/15/03
2. Pt. will be able to consistently verbalize an understanding of
how substance abuse interferes with his daily functioning for
3 months.
07/15/03
3. Pt. will be free of drugs and alcohol for 3 months.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.2
5–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will lead medication and mental illness education group weekly to help pt.
to learn about the interaction between mental illness and substance abuse disorder.
2. Psychiatrist will monitor and document episodes of substance abuse and provide
medical/detox interventions as ordered.
Victor Dyson, MD
Social Work:
1. Social worker will lead weekly community transition group to help pt. develop plans
around living in the community and to identify support systems and resources that he
can use when he is out of the hospital.
Brenda St. Martin, MSW
Psychology/Social Work:
1. Psychologist and social worker will lead twice-weekly on-ward substance abuse group
to help pt. learn about problems created by substance abuse and to develop supports,
strategies, and alternatives to substance abuse.
2. Psychologist and social worker will lead weekly relapse prevention group for pt. to
learn ways of preventing relapse of both mental illness and substance abuse.
Joseph LeBlanc, Psychologist
Brenda St. Martin, MSW
Nursing Care Plan:
1. Nsg. staff will offer ongoing feedback and support for pt.’s decision to attain and
maintain abstinence.
2. Nsg. staff will encourage pt.’s attendance at substance abuse groups, including AA
meetings, twice weekly in the hospital and once weekly in the community.
3. Contact person will keep track of pt.’s attendance at program activities.
4. Nsg. staff will escort pt. as needed to off-ward groups to ensure that he does not
attempt to use marijuana or alcohol.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
5–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.3 Nicotine Dependence
Name: Drake, Dawn
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has been smoking one to two packs of cigarettes per day for the past 10 years. Pt. has recently begun to
experience shortness of breath. Pt. has also begun to experience a persistent, dry cough, and she occasionally
experiences upset stomach and chest tightness on days when her smoking is especially heavy (two packs per day).
Pt. has expressed a strong desire to cut down or stop smoking, but past attempts have been unsuccessful.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1. Pt. will cease cigarette smoking AEB continuous abstinence from
all tobacco products for 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1. Pt. will begin eating meals and snacks that are less likely to be
connected with previous patterns of smoking for 1 month.
04/15/03
2. Pt. will increase her interest in and awareness of health issues AEB
her participation in an exercise group three times a week for
1 month.
04/15/03
3. Pt. will work with a significant other for at least 1 month to help
ensure that she will follow through with stopping smoking.
04/15/03
4. Pt. will stop smoking for 1 month.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.3
5–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for 15 minutes once weekly to assess any changes in
pt.’s craving for cigarettes and to prescribe treatments, such as nicotine gum or
nicotine patch, that will help to reduce episodes of cigarette craving.
Victor Dyson, MD
Psychology:
1. Psychologist will meet with pt. for ½ hour once a week to identify sources of potential
relapse (e.g., cues and triggers for smoking) and to develop coping strategies to reduce
risks of returning to smoking.
2. Psychologist will run the clinic self-help group, where pt. can obtain further
information regarding the problems associated with cigarette smoking and also obtain
peer reinforcement around the decision to stop smoking and to not restart.
Joseph LeBlanc, Psychologist
Social Work:
1. Staff will explore whether a significant other, such as her fiancé, will help pt. follow
through with her commitment to stop smoking.
Brenda St. Martin, MSW
Rehab:
1. Staff will work with pt. to plan and implement an individualized program to focus on
good health maintenance, including physical fitness exercises and smoking cessation.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will encourage pt. to participate in the clinic self-help group.
2. Nsg. staff will give encouragement and verbal praise for pt.’s involvement in nonsmoking-related social activities.
3. Nsg. staff will question pt. directly every day to determine whether she is losing
control of cravings to smoke and report any significant worsening to the psychiatrist.
4. Nsg. staff will lead the on-ward smoking cessation group for ½ hour once weekly to
educate pt. about the health consequences of smoking and to help pt. develop
strategies for avoiding smoking.
Marilyn Davis, RN
Dietitian:
1. Dietitian will work with pt. to identify eating habits that trigger smoking. As the
triggers are identified, the dietitian will help pt. develop eating habits that are less
connected with previous patterns of cigarette smoking.
Louise Tallo, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
MEDICAL IMPAIRMENT
(Problem Area 6)
6–1
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Medical Impairment (Problem Area 6)
6–3
MEDICAL IMPAIRMENT
(Problem Area 6)
CONTENTS
Kennedy Axis V for Medical Impairment.................................................................................................. 6–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Medical Impairment and can be helpful in composing a short description of
each problem.
Problem Names and Descriptions ............................................................................................................ 6–5
Examples of problem names and descriptions that may relate to Medical Impairment are listed here.
These examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 6–6
Examples of strengths that may be related to treatment and discharge in the area of Medical Strengths
are listed here.
Goals ......................................................................................................................................................... 6–6
Examples of treatment goals that may relate to problems in the area of Medical Impairment are
listed here.
Treatment Modalities ............................................................................................................................... 6–8
Examples of treatment modalities that may relate to problems in the area of Medical Impairment are
listed here.
Individual Problem Plan (Frequent Entries) ........................................................................................... 6–12
An Individual Problem Plan, containing examples of information frequently entered into Individual
Problem Plans relating to Medical Impairment, is included here.
Sample Individual Problem Plans ........................................................................................................... 6–15
A wide range of individual problem plans relating to Medical Impairment are included here.
6–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Medical Impairment
100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight
problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g.,
colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical
problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a
multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms.
90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more
than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical
problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor
visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally
needs over-the-counter medication.
80 If medical problems are present, they are transient and cause minimal impairment in
social, occupational, or school functioning; somewhat more than average missing of work or school due to
medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a
prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to
organic problems.
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
60 Moderate difficulty in social, occupational, or school functioning due to medical problems;
missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma,
moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to
polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina
on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g.,
injections, blood levels, nebulizer, physical therapy); needs bladder bag.
50 Serious impairment in social, occupational, or school functioning due to medical problems;
serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing
aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for
mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR Not rated
Medical Impairment (Problem Area 6)
6–5
Problem Names and Descriptions
I.
II.
Medical Problems Often Seen in Psychiatric Patients
A.
General medical problems
1. Angina
2. Hypertension
3. Endocarditis
4. Duodenal ulcer
5. Diabetes mellitus
6. Hypoglycemia
7. Asthma
8. Seizure disorder
9. Temporal lobe epilepsy
10. AIDS
11. Positive TB skin test
12. Migraine headaches
13. Acne
14. Allergy to penicillin
B.
Psychiatric illness sequelae (secondary to overdoses, self-inflicted cuts, gunshot wounds,
jumping from high places, substance abuse, and the like)
1. Organic brain dysfunction
2. Atonic bladder with associated incontinence
3. Paralysis
4. Laceration of wrist
5. Fracture
6. Malnutrition secondary to anorexia
7. Fluid and electrolyte problems secondary to polydipsia
8. Chronic obstructive pulmonary disease
9. Cirrhosis
10. Hepatitis
11. Chronic pancreatitis
12. Frostbite
13. Bed sores
14. Poor health maintenance
C.
Psychotropic medication side effects
1. Tardive dyskinesia
2. EPS (extrapyramidal side effects)
3. Akathisia
4. Hypothyroidism secondary to lithium
5. Constipation
6. Renal dysfunction secondary to lithium
7. Agranulocytosis secondary to Clozaril (clozapine)
8. Postural hypotension
9. Tachycardia
10. Dysphagia
11. Marked weight gain
12. Diabetes mellitus associated with use of Zyprexa (olanzapine)
Special Medical Status
A.
B.
C.
D.
E.
Pt.
Pt.
Pt.
Pt.
Pt.
is pregnant.
uses birth control.
has a single kidney.
is a carrier of an unexpressed genetic disease.
has mitral valve prolapse.
6–6
Fundamentals of Psychiatric Treatment Planning
III. Dental Problems
A.
B.
C.
D.
Multiple caries
Abscessed tooth
Gingivitis
Poor dental maintenance
Strengths (Brief List)
I.
Medical Strengths
A.
B.
C.
D.
E.
F.
G.
H.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
has good physical health.
has no more than minor medical problems.
exercises on a regular basis.
is health-conscious.
sticks to a very healthy diet.
practices a healthy lifestyle.
practices safe sex.
has other medical strengths.
Goals
I.
Expected Improvements in Symptoms
A.
Medical problems secondary to psychotropic medications
1.
Pt.’s akathisia will improve so that pt. will be able to consistently sit through ½-hour groups for
1 month.
2.
Pt. will show no worsening or some remission of tardive dyskinesia for 6 months.
3.
Pt. will cooperate with the reduction of antipsychotic medication to the lowest reasonable dose to
minimize danger of tardive dyskinesia for 3 months.
4.
Pt. will return to euthyroid state (hypothyroidism secondary to lithium).
5.
Malignant neuroleptic syndrome will resolve.
B.
General medical problems
1. Pt.’s cholesterol will be reduced to below 200.
2. Pt.’s incidence of acne eruptions will reduce AEB pt.’s face appearing significantly clearer for
1 month.
3. Pt.’s blood pressure will be maintained at a safe level for 3 months.
4. Pt. FBS will be maintained within the normal range for 6 months.
5. Pt. will have a realistic goal of no further weight gain for 3 months, even though pt. is
significantly obese because of a lack of insight and a lack of motivation.
6. Pt. will maintain present optimal bladder function (considering the organic impairment of pt.’s
bladder).
7. Pt. will have no episodes of shortness of breath for 3 months.
8. Pt. will have no further deterioration in respiratory function AEB no deterioration in pt.’s
pulmonary function studies for 6 months.
9. Pt. will be free from poor skin integrity for 6 months.
10. Pt’s infections will heal without complications.
11. Pt.’s right foot will be free from infection for 6 months.
12. Pt. will continue to be free of seizures with treatment for 6 months.
13. Pt. will be free of pain and complications of hemorrhoids for 3 months.
14. Pt. will consistently report any incidences of falling for 3 months.
Medical Impairment (Problem Area 6)
II.
6–7
Reporting of Symptoms
A.
B.
C.
Pt. will report headaches or changes in symptoms consistently for 1 month.
Pt. will report any change or discomfort for 1 month.
Pt. will report any reoccurrence of bleeding for 3 months.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
Pt. will participate in the physical therapy program once weekly for 1 month.
Pt. will attend speech therapy sessions twice weekly for 1 month.
Pt. will cooperate with dental work for the next three scheduled appointments.
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking psychotropic meds as prescribed.
2.
Pt. will express the benefits of taking meds as prescribed.
3.
Pt. will take meds as prescribed for 3 months.
4.
Pt. will comply with blood work for 3 months.
B.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will cooperate with the treatment plan to restrict fluid intake for 1 week.
3.
Pt. will demonstrate cooperation with all aspects of the treatment plan for 1 month.
C.
Program activities
1.
Pt. will express the benefits of attending the physical therapy program.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate with the evaluation process for 2 weeks.
2.
Pt. will cooperate to complete the physical therapy assessment.
3.
Pt. will cooperate so that staff can determine the level of nursing care required for placement in
the community.
B.
Evaluations to R/O various diagnoses
1.
Pt. will cooperate with the complete evaluation to R/O seizure disorder.
C.
Laboratory tests
1.
Pt. will cooperate to complete the comprehensive laboratory screen.
2.
Pt. will cooperate to complete the EEG and CT scan.
3.
Pt. will cooperate to complete the ECG.
VI. Standardized Outcome Measures
A.
AIMS and AIMS Plus EPS exams
1.
Pt. will show no deterioration in tardive dyskinesia as measured by monthly AIMS Plus EPS exam
for 6 months.
2.
Pt.’s akathisia will improve as demonstrated in next month’s AIMS Plus EPS exam.
B.
Mini-Mental State
1.
Pt.’s score on the Mini-Mental State will improve from a current score of 12 to 18.
C.
Laboratory tests
1.
Pt.’s FBS will remain WNL for 3 months.
2.
Pt.’s thyroid function will remain WNL for 6 months.
6–8
Fundamentals of Psychiatric Treatment Planning
VII. Miscellaneous
A.
B.
Pt. will cooperate so that he or she can remain in an environment that protects the pt.
during the healing process.
Pt. will cooperate with the competency assessment to determine whether pt. is able to
make competent decisions about medical treatments.
Treatment Modalities
Because of the extremely broad range of the category Medical Impairment, only a brief outline of treatment
modalities is presented here. This outline focuses on the psychiatric aspects of the medical treatments. Additional
examples of treatment modalities for Medical Impairment are included on the sample Individual Problem Plans for
Medical Impairment.
I.
Verbal Treatment Modalities (emphasis on verbal interactions)
A.
II.
Support and reassurance
1.
Medical staff will work on a one-to-one relationship with pt. to increase trust.
2.
Nsg. staff will provide pt. with needed one-to-one support and reassurance that people are
concerned about pt.’s health and well-being.
3.
Rehab staff will work with pt. one-to-one to help pt. accept the significant residual impairment
following pt.’s stroke.
4.
Psychologist will meet with pt. one-to-one to enhance pt.’s self-esteem and feelings of meaning
and community to offset pt.’s despair following a diagnosis of late-stage ovarian cancer.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Nsg. staff will give pt. positive feedback and encouragement for appropriate statements and
decisions concerning pt.’s physical health.
2.
Staff will encourage pt.’s independence by giving pt. as much decision-making power as possible.
3.
Psychologist will encourage pt. to be involved in the treatment planning process.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Social worker will provide family therapy to help improve family’s willingness to help pt. follow
through with medical treatments.
B.
Religious treatment modalities
1.
Pt. will receive religious counseling for support and hope concerning pt.’s left-sided paralysis.
2.
Pt. will receive religious counseling to provide a religious perspective on the prognosis that pt. is
likely to die from cancer within 3 months.
3.
Pt. will receive religious counseling to help pt. objectively examine belief that his or her medical
illness is a punishment for sins.
C.
Other modalities
1.
Group therapy
a.
Group therapy will be used to facilitate discussion of pt.’s medical problems.
2.
Psychodrama
a.
Role-playing will be used to help reduce pt.’s anxiety about talking about his or her illness,
including the prognosis.
Medical Impairment (Problem Area 6)
6–9
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will redirect pt. from triggering events or overstimulating areas to reduce stress that may
worsen pt.’s physical symptoms.
2.
Sound-absorbing material will be added to pt.’s dorm area to help reduce noise.
3.
Nsg. staff will redirect other pts. from yelling, talking loudly, or playing their radios too loudly
near patient, to help pt. relax while healing.
B.
Protective procedures (including special observations)
1.
Staff will provide an environment that protects pt. during the healing process.
2.
Staff will keep pt. away from street drugs and alcohol to prevent further physical damage. At the
same time, pt. will be treated for substance abuse in the hope that pt. will abstain from substance
abuse once there is an opportunity to use drugs.
3.
Staff will employ escape precautions.
4.
Staff will monitor pt. closely to ensure that he doesn’t pick at sutures or wander off the ward.
C.
Other milieu treatment modalities
1.
Pt. will be placed in an environment in which pt.’s physical handicap will not be a significant
barrier to functioning.
Medical Treatment Modalities
A.
Medication
1.
Internist will prescribe meds as indicated for pt.’s physical illness.
2.
Nsg. staff will give pt. prn meds to relieve acute exacerbations of illness.
3.
Psychiatrist will reduce antipsychotic meds to the lowest reasonable dose to minimize danger of
tardive dyskinesia.
B.
Other medical treatment modalities
1.
Surgery
2.
Radiation therapy
3.
Physical therapy
4.
Chiropractic treatments
5.
Miscellaneous
a.
Acupuncture
b.
Exercise as tolerated
VI. Patient and Family Education
A.
Medical illness
1.
Nsg. staff will educate pt. about ways to cope with medical illness.
2.
Nsg. staff will meet with the pt. and family once weekly for ½ hour to teach them ways to
recognize signs of deterioration and other medical dangers.
3.
Internist will discuss with the pt. and family the nature of pt.’s medical illness and the prognosis.
B.
Medication
1.
Nsg. staff will educate pt. about the risks and benefits of meds.
2.
Nsg. staff will show pt. concrete benefits of taking meds (e.g., “The infection is clearing,” “You are
looking less pale,” “Your breathing is a lot less labored”).
3.
Pt.’s nurse or internist will discuss with pt.’s family the reasons pt. needs to take meds.
6–10
Fundamentals of Psychiatric Treatment Planning
C.
Benefits and consequences of behaviors
1.
Nsg. staff will discuss connections between daily appropriate attention to pt.’s medical care and
progress toward recovery from medical illness.
2.
Social worker will discuss with pt.’s family members the benefits of their visits and support.
D.
Miscellaneous patient and family education
1.
Nsg. staff will involve pt.’s family members in a psychoeducational program to improve their
ability to cope with pt.’s medical illness.
2.
Pt. will receive education to help pt. understand and deal with the long-term aspects of the illness.
3.
Nsg. staff will provide education to help pt. understand, recognize, and reduce some of the
underlying causes of the illness.
4.
Staff will schedule pt. for an appointment for counseling in family planning.
5.
Staff will encourage pt. to become involved in a sex education program that addresses pt.’s needs.
6.
Nsg. staff will educate pt. about pregnancy and delivery, including prenatal care and signs and
symptoms of labor.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Psychologist will perform psychological testing to determine pt.’s ability to engage in treatment
and to cope with serious illness.
2.
Staff will conduct neuropsychological testing to monitor for further deterioration in pt.’s mental
functioning.
B.
Psychiatric evaluations
1.
Staff will conduct a psychiatric diagnostic evaluation.
2.
Psychiatrist will perform a psychopharmacological assessment.
3.
Psychiatrist will perform an AIMS or AIMS Plus EPS exam every 6 months.
4.
Staff will measure EPS weekly using the AIMS Plus EPS to observe for reductions in pt.’s EPS as
Risperdal is decreased.
C.
Medical/laboratory tests and evaluations
1.
Internist will order needed urine tests and blood work.
2.
Psychiatrist will order blood levels to help determine medication compliance.
3.
Staff will monitor blood levels to determine whether meds are in the therapeutic range.
4.
Pt. will have EEG to R/O temporal lobe epilepsy.
5.
Pt. will have chest X ray to R/O pneumonia.
6.
Pt. will have CT scan to R/O organic etiology.
7.
Nsg. staff will record pt.’s seizures on the seizure flow chart.
D.
Religious evaluations and assessments
1.
Pt. will receive a religious assessment to determine whether religion will be an asset to pt.’s
recovery from illness.
2.
Pt. will receive an assessment to determine whether pt. sees self as being punished by getting this
illness and, if so, how religious/spiritual counseling can help reduce the guilt and improve pt.’s
compliance with treatment.
E.
Other evaluations and assessments
1.
Rehab staff will assess pt.’s areas of interests and motivation to begin structured activities
congruent with pt.’s interests.
2.
Social worker will interview family members to assess their ability to communicate with each
other and to give needed support to pt. during cancer treatments.
3.
Psychiatrist will refer pt. to Movement Disorder Clinic to further assess and treat pt.’s tardive
dyskinesia.
Medical Impairment (Problem Area 6)
VIII. Legal Treatment Modalities
A.
Medical guardianship
1.
Psychiatrist will seek a medical guardianship to obtain permission for the needed surgery.
IX. Miscellaneous Treatment Modalities
A.
No examples given
6–11
6–12
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plan (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.0 Health Maintenance
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
1.
Enter any significant medical history, unless it is addressed under a separate problem.
2.
List any active or significant medical problems and any meds or treatment the pt. is taking, such as
prophylactic meds, multivitamins, aspirin, and such.
3.
List minor problems (such as acne, constipation, indigestion, mild obesity, mild hyperlipidemia, mild
dysphagia, mild hyponatremia, mild dehydration, mild hypertension).
4.
List any special treatments needed to maintain pt.’s health.
5.
List any dietary requirements.
6.
List any allergies.
7.
If the treatment of a particular medical problem is very complicated, use a separate problem plan to address
that problem, such as an active breast cancer, severe diabetes, severe obesity, severe dysphagia, severe chronic
obstructive pulmonary disease (COPD), or difficult-to-manage seizure disorder.
Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will continue to maintain an optimal level of health while
hospitalized, AEB compliance with all prescribed meds, lab work,
and treatments for pt.’s medical problems.
2.
Pt. will maintain an optimal level of wellness, AEB compliance
with all prescribed meds, lab work, and treatments for pt.’s
medical problems for ____ month(s).
3.
Pt. will comply with meds, treatments, and diagnostic tests for
pt.’s medical problems for ____ month(s).
4.
Pt. will perform good basic facial cleansing daily with one verbal
prompt for ____ month(s).
5.
Pt.’s [cholesterol, weight, sodium, BP] will improve from a
current ____ to ____.
6.
Pt. will have no more than one seizure per year.
7.
Pt.’s fasting blood glucose level will be maintained for ____
week(s)/month(s) in the following range: ________________
8.
Pt. will comply with a [whole, chopped, ground] diet with no
choking episodes for ____ month(s).
9.
Pt.’s score on the Kennedy Axis V for Medical Impairment will
improve from the current score of ____ to ____.
10.
Pt.’s score on the Kennedy Axis V for Medical Impairment will be
maintained at ____.
Target Date
Date/Status*
Ongoing
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.0
6–13
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
Physician will assess [acne, constipation, indigestion, mild hyperlipidemia, mild
obesity, mild dysphagia, mild hyponatremia, mild dehydration, mild hypertension,
mild diabetes, mild ___________________] and make appropriate treatment
recommendations.
2.
Physician will order and/or perform the following health measures:
a.
Annual physical exam
b.
Annual Mantoux test
c.
Baseline ECG and chest X ray and follow-up as needed
d.
Routine screen for hepatitis
e.
Routine dental checks
f.
Podiatry consults
g.
Follow-up exams with dermatology as needed
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor pt. daily and follow up on any signs and symptoms of illness.
2.
Nsg. staff will administer all prescribed meds and treatments as ordered and will
document pt.’s compliance.
3.
Nsg. staff will assess and document pt.’s level of understanding of prescribed
treatment and provide necessary teaching at pt.’s level of understanding.
4.
Nsg. staff will prompt pt. to comply with treatments, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany pt. to
procedures. Staff will offer praise for compliance and will document compliance.
5.
Nsg. staff will prompt pt. to attend to basic daily personal hygiene, including bathing,
facial cleansing, shaving, combing hair, brushing teeth, and putting on clean clothes.
Staff will offer praise for compliance.
6.
Nsg. staff will weigh pt. q____________, take BP and pulse q_______________, and
report any significant changes to physician.
7.
Nsg. staff will monitor pt.’s fluid and food intake and urine output and will report
any significant changes to physician.
8.
Nsg. staff will encourage pt. to eat a [healthy-heart, low-fat, low-cholesterol, low-salt,
high-fiber, low- or high-calorie], [whole, chopped, ground] diet and increase or
decrease fluid intake to prevent [constipation, hyponatremia, dehydration], promote
a healthy heart, reduce or gain weight, or maintain good health.
9.
Nsg. staff will indicate in the record pt.’s allergies to ________________________.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Medical Impairment (Problem Area 6)
6–15
Sample Individual Problem Plans
CONTENTS
Hypertension .......................................................................................................................................... 6–16
Chronic Obstructive Pulmonary Disease ................................................................................................ 6–18
Diabetes Mellitus .................................................................................................................................... 6–20
Elevated Cholesterol ............................................................................................................................... 6–22
Hypothyroidism Secondary to Lithium................................................................................................... 6–24
Seizure Disorder ..................................................................................................................................... 6–26
Hyponatremia Secondary to Polydipsia ................................................................................................. 6–28
Kidney Dysfunction Secondary to Lithium . ........................................................................................... 6–30
Dysphagia ............................................................................................................................................... 6–32
EPS (Extrapyramidal Side Effects) .......................................................................................................... 6–34
Akathisia ................................................................................................................................................. 6–36
Tardive Dyskinesia .................................................................................................................................. 6–38
Family Planning ...................................................................................................................................... 6–40
Family Planning ...................................................................................................................................... 6–42
Pregnancy ............................................................................................................................................... 6–44
6–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.1 Hypertension
Name: Scott, Daniel
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has had hypertension for the last several years. His hypertension has been well controlled with a combination
of diet, exercise, and meds. This has led to a resolution of pt.’s mild obesity. There is no history of alcohol abuse or
cigarette use. Pt.’s family history is strongly positive for hypertension and heart disease. Pt.’s cholesterol and
triglycerides are WNL.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Maintain blood pressure WNL.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will be able to verbalize a reasonable understanding of
hypertension and its treatment.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.1
6–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe antihypertensives and diuretics.
2.
Internist will order blood work, including potassium and cholesterol levels.
3.
Internist will order a low-cholesterol, low-salt diet and weight control.
4.
Internist will determine level of exercise pt. can safely tolerate.
5.
Internist will order aspirin 1 po daily as a prophylactic against an MI.
Donald Mason, MD
Dietitian:
1.
Dietitian will meet with pt. once a week to help pt. continue with his healthy-heart,
low-sodium diet.
2.
Dietitian will help pt. monitor calories to help ensure that pt. maintains his weight
loss.
Sandra Anderson, Dietitian
Rehab:
1.
Rehab counselor will arrange a regular exercise program for pt. that he can safely
tolerate.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will monitor vital signs monthly.
2.
Nsg. staff will make ongoing observations of skin color, swelling, and temp. for
evidence of edema or peripheral vascular disease.
3.
Nsg. staff will continue to educate pt. to help him understand, recognize, and
continue to reduce some of the underlying risk factors, such as lack of exercise, poor
diet, and psychological stress.
4.
Nsg. staff will ensure that pt. has routine follow-ups with the internist.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.2 Chronic Obstructive Pulmonary
Disease
Nursing Diagnosis: Impaired Gas Exchange
Name: Johnson, Tiffany
ID #:
Area:
Date: 01/15/03
Problem Description:
Pt. has long-standing history of cigarette use (one to two packs a day). Six months ago, she was diagnosed as
having COPD secondary to cigarette smoking. To prevent further deterioration in her respiratory status, she
stopped smoking at that time; however, at times, pt. appears to have difficulty maintaining her abstinence from
cigarettes. At present, pt. walks freely about the ward with no significant evidence of shortness of breath; however,
pt. has great difficulty walking up a flight of stairs. Over the last few months, pt.’s pulse ox has been around 94%.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain patency of bronchial airways and facilitate
reasonable exchange of C02/02, AEB no deterioration in her
pulmonary function studies for 6 months.
01/15/04
2.
Pt.’s pulse ox will be maintained at 94% or greater for 3 months.
Ongoing
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will be able to verbalize a reasonable understanding of her
illness and the long-term importance of treatment, including
continued abstinence from smoking.
Target Date
Date/Status*
Date/Status*
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.2
6–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe bronchodilators, such as albuterol, and other respiratory meds
as ordered.
Margaret Patel, MD
Rehab:
1.
Rehab staff will provide activities as tolerated and provide an opportunity for rest as
needed.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will make ongoing observations for evidence of respiratory distress,
including changes in pt.’s skin color.
2.
Nsg. staff will assess pt.’s breath sounds weekly, as well as when she is showing any
respiratory distress.
3.
Nsg. staff will use the pulse oximeter to measure pt.’s blood oxygenation (pulse ox)
once daily.
4.
Nsg. staff will notify pt.’s internist of any significant change in pt.’s pulmonary
function.
5.
Nsg. staff will schedule pt. for routine follow-up at Pulmonary Clinic.
6.
Nsg. staff will encourage pt. to breathe deeply and to have a reasonable fluid intake.
7.
Nsg. staff will educate pt. to help her understand, recognize, and attempt to reduce
some of the underlying risk factors, such as smoking, air pollution, allergies
(including high pollen count), lack of exercise, and dehydration.
8.
Nsg. staff will educate pt. to help her understand and deal with the long-term aspects
of her COPD.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.3 Diabetes Mellitus
Name: Costello, Roger
ID #:
Area:
Nursing Diagnosis: Risk for Elevated Blood Sugar
Date: 01/15/03
Problem Description:
Pt. is a 48-year-old man who has had diabetes for the last 10 years. There is no known etiology of his diabetes,
other than having a family history that is strongly positive for adult-onset diabetes. When first diagnosed, his
diabetes was controlled with diet and low doses of oral hypoglycemics. However, for the last few years, pt. has
required insulin to control his blood sugar. Currently, pt.’s diabetes is well controlled with diet and insulin;
however, pt. does not appear to have a good understanding of his diabetes and its possible complications.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain good control of his diabetes, AEB normal blood
sugars, including absence of hyperglycemic and hypoglycemic
episodes, for 6 months.
Ongoing
2.
Pt. will consistently verbalize an understanding that treatment
of his diabetes will help prevent the development of diabetic
complications, such as recurrent cellulitis of his feet, diabetic
retinopathy, cataracts, and diabetic nephropathy, for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will consistently verbalize an understanding of the risk
factors associated with diabetes mellitus and an understanding
of the treatment modalities for 3 months.
Target Date
Date/Status*
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.3
6–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order blood sugar levels, including finger-stick blood sugar levels.
2.
Based on pt.’s blood sugar levels, internist will make needed adjustments in pt.’s
regular insulin dosage and adjust pt.’s Insulin Sliding Scale as needed.
3.
Internist will order periodic complete blood workup; urinalysis, including sugar and
acetone levels; ECG; and chest X ray.
4.
Internist will treat any diabetic complications as they occur.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will monitor pt. for evidence that he is developing diabetic complications.
2.
Nsg. staff will monitor pt.’s finger-stick blood sugars and make adjustments in his
insulin according to pt.’s Insulin Sliding Scale.
3.
Nsg. staff will monitor pt.’s weight and BP once a month.
4.
Nsg. staff will monitor pt.’s physical activity.
5.
Nsg. staff will run diabetic group 45 minutes per week for pt. education with regard
to the diabetic condition, nutrition, insulin, and risk factors and complications
associated with diabetes and insulin.
6.
Nsg. staff will ensure that pt. is seen in Podiatry Clinic at least once q 3 months.
Marilyn Davis, RN Å Nsg. Staff
Dietitian:
1.
Dietitian will provide dietary consultation as needed to maintain pt. on an
antidiabetic diet with enough calories to meet daily demands as per physical activity,
height, and weight.
Sandra Anderson, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.4 Elevated Cholesterol
Name: Schwartz, Ronald
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has a history of elevated cholesterol that was first detected in 07/02. Pt.’s cholesterol level at that time was 276.
Pt.’s diet was very high in cholesterol and saturated fats. Nursing attempts to get pt. to stick to a low-cholesterol
diet led to a reduction of pt.’s cholesterol level to around 240. Currently it is felt that pt. could benefit from
cholesterol-lowering meds, in addition to continuing his diet. Pt. does not have a good understanding of the
relationship between cholesterol and heart disease. Pt.’s family history is strongly positive for cardiovascular
disease. Pt.’s mother also has elevated cholesterol.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will achieve and maintain normal blood cholesterol level for
at least 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will be able to consistently verbalize a reasonable
understanding of the relationship between blood cholesterol
and heart disease for 1 month.
04/15/03
2.
Pt. will be able to consistently identify and avoid foods high in
cholesterol and saturated fats for 1 month.
04/15/03
3.
Pt.’s blood cholesterol will be decreased to less than 200 for
1 month.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.4
6–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order periodic blood cholesterol levels and lipid profiles.
2.
Internist will order a dietary consult for follow-up of pt.’s low-fat, low-cholesterol
diet.
3.
Internist will prescribe cholesterol-lowering meds, such as niacin (vitamin B3), Lipitor
(atorvastatin calcium), or Zocor (simvastatin).
Donald Mason, MD
Dietitian:
1.
Dietitian will educate pt. on how to identify and avoid foods that are high in
cholesterol and saturated fats, as well as how to identify foods that are a part of a
low-fat, low-cholesterol diet.
Sandra Anderson, Dietitian
Nursing Care Plan:
1.
Nsg. staff will educate pt. as to the importance of dietary compliance and help him
limit his intake of foods that are high in cholesterol and saturated fats.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.5 Hypothyroidism Secondary to
Lithium
Nursing Diagnosis: Risk for Endocrine Imbalance
Name: Russell, Maria
ID #:
Area:
Date: 01/15/03
Problem Description:
Pt. has been on lithium for many years with associated hypothyroidism. Endocrinology workup diagnosed the
problem as hypothyroidism secondary to lithium. Pt. is on thyroid replacement meds (Synthroid) and is currently
euthyroid. She does not have a goiter. Pt.’s psychiatric symptoms are clearly improved by lithium, and alternatives
to lithium are less effective. At times, pt. is reluctant to take her Synthroid because she has experienced very few
symptoms of hypothyroidism; therefore, she often argues that she does not have any problems with her thyroid
function.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will remain in a euthyroid state for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
Ongoing
Target Date
1.
Pt. will cooperate with treatment so that complications
associated with hypothyroidism will be prevented.
Ongoing
2.
Pt. will consistently verbalize an understanding of her need to
take her meds for 3 months.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.5
6–25
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order periodic follow-up by the Endocrine Clinic as needed.
2.
Internist will order blood thyroid function studies as needed.
3.
Internist will prescribe thyroid replacement medication, such as Synthroid, and adjust
the dose based on pt.’s thyroid function studies.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will educate pt. for ½ hour once weekly to help pt. understand the need to
take her thyroid replacement meds.
2.
Nsg. staff will monitor pt. for evidence of hyperthyroidism and inform pt.’s internist
of any significant findings.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–26
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.6 Seizure Disorder
Name: Harrison, Henry
ID #:
Area:
Nursing Diagnosis: Risk for Seizures
Date: 01/15/03
Problem Description:
Pt. has had seizures since age 12, including grand mal seizures that occurred 1 to 2 times a month. The seizure
activity was present at the same frequency for years despite various attempts to reduce the frequency. EEGs
revealed multiple epileptic foci. Over the last few years, using a combination of anticonvulsants, the frequency of
seizures has stabilized at the current level of less than once every 6 months. At times in the past, pt. was reluctant
to take his anticonvulsants; however, currently he appears to have a fairly good understanding of the need to
continue his anticonvulsants.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will have no more than 1 seizure q 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
Ongoing
Target Date
1.
Pt. will have no more than 1 seizure q 3 months.
Ongoing
2.
Pt. will be compliant with his taking his anticonvulsants for
3 months.
Ongoing
3.
Pt. will consistently verbalize an understanding of his seizure
disorder and the need to take his meds for 3 months.
Ongoing
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.6
6–27
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe anticonvulsants, such as Depakote (divalproex sodium) and
Neurontin (gabapentin).
2.
Internist will order periodic serum blood levels, such as Depakote (divalproex sodium)
levels.
3.
Internist will refer pt. for follow-up appointments as needed with a neurologist.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will lead seizure group once per week to help pt. maintain an
understanding of his seizure disorder and the need to take his meds.
2.
Nsg. staff will keep a flow sheet on the frequency of pt.’s seizures and will inform the
internist of any increase in the frequency of pt.’s seizures.
Linda Larkin, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–28
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.7 Hyponatremia Secondary to
Polydipsia
Nursing Diagnosis: Excess Fluid Volume
Name: Drago, Evelyn
ID #:
Area:
Date: 01/15/03
Problem Description:
Pt. has a long history of drinking water and other fluids to a dangerous excess, which results in electrolyte
imbalances. There appears to be no organic basis for the polydipsia. Two years ago, this resulted in seizures when
her blood Na+ dropped to 124 (pt. has a seizure disorder that is well controlled by anticonvulsants when pt.’s Na+
is above 130). Through monitoring and encouraging pt. to limit her fluid intake, pt. has not had seizures for years.
With monitoring, including twice-weekly Na+ levels, her Na+ is generally 134 or greater. Because of drops in her
Na+ below 130, she requires one-to-one monitoring once or twice every 6 months. Pt. appears to have a reasonable
understanding of the risk factors associated with polydipsia and the treatment modalities; however, she constantly
complains of being thirsty.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain a Na+ of 130 or greater so that she will not
require one-to-one monitoring for 6 months.
01/15/04
2.
Pt.’s Na+ levels will be maintained at an “acceptable” level
(134 or greater) for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt.’s Na+ levels will be maintained at an “acceptable” level
(134 or greater) for 3 months.
07/15/03
2.
Pt. will not gain 8 pounds or more during a 24-hour period for
3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.7
6–29
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order electrolytes twice weekly—daily if Na+ falls below 130.
2.
Internist will restrict pt. to the ward and place pt. on one-to-one monitoring if Na+
falls below 130.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will encourage pt. to limit her fluid intake and to eat solid foods and foods
high in Na+.
2.
Nsg. staff will weigh pt. bid.
3.
Nsg. staff will restrict pt. to the ward if pt. gains 8 pounds during a 12-hour period
and will have a blood Na+ drawn immediately.
4.
Nsg. staff will restrict pt. to the ward, place pt. on one-to-one monitoring, and restrict
pt.’s fluid intake to 2000 cc/24 hrs if Na+ falls below 130.
5.
When pt. is restricted to the ward, nsg. staff will maintain intake/output records and
pt.’s Na+ level will be drawn q day.
6.
Nsg. staff will provide positive reenforcement when pt. is able to maintain her blood
Na+ level at 134 or greater.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–30
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.8 Kidney Dysfunction Secondary to
Lithium
Nursing Diagnosis: Impaired Urinary Elimination
Name: Bryant, Harriet
ID #:
Area:
Date: 01/15/03
Problem Description:
During a period of dehydration in association with a weight reduction diet, pt. developed lithium toxicity. Pt. had
been toxic once before in the past, in association with skipping blood lithium levels. During the toxic episode, pt.
was immediately taken off the lithium. Following the toxic episode, it was noted that pt. had developed diabetes
insipidus secondary to lithium toxicity. Pt. is currently off lithium, and fortunately her diabetes insipidus is
expected to resolve. Pt.’s manic, aggressive behavior is being reasonably well controlled with a mood stabilizer,
Depakote. There are no plans at present to restart lithium because of pt.’s difficulty following up with her diet and
blood tests required for lithium.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt.’s kidney function will return to normal AEB normal blood
Na+, BUN, and creatinine levels and normal urine specific
gravity for 6 months.
01/15/04
2.
Pt.’s manic and aggressive behaviors will be reasonably well
controlled without having to restart pt. on lithium for
6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will have a normal blood Na+, BUN, and creatinine for
3 months.
Target Date
Date/Status*
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.8
6–31
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will get nephrology consults as needed.
2.
Internist will monitor progress of diabetes insipidus and check for evidence of renal
failure with monthly electrolytes, BUN, and creatinine.
3.
Internist will order weekly urine specific gravity checks.
4.
Internist will order meds such as hydrochlorothiazide to assist kidney function.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will ensure that pt. has adequate fluid intake to keep up with fluid loss.
2.
Nsg. staff will use an intake and output chart to monitor pt.’s fluid intake.
Marilyn Davis, RN Å Nsg. Staff
Dietitian:
1.
Dietitian will provide dietary consult if pt. decides to go on another weight-reduction
diet.
Sandra Anderson, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–32
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.9 Dysphagia
Name: Frantz, Marshall
ID #:
Area:
Nursing Diagnosis: Impaired Swallowing
Date: 01/15/03
Problem Description:
Pt. has been noted to have difficulty swallowing, which appears to have been worsened by the use of neuroleptic
meds. Pt. eats very rapidly, and his chewing is very inefficient. Yesterday he choked on a meatball. The nurse had
to perform the Heimlich maneuver to open his airway. AIMS Plus EPS exam reveals a significant amount of EPS.
Pt.’s mental status has clearly benefited from the use of neuroleptic meds.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain normal nutrition through efficient chewing
and swallowing of a regular diet as measured by his maintaining
his present weight for 6 months.
01/15/04
2.
Pt. will be free of any further choking episodes for 1 year.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will be free of any further choking episodes for 3 months.
07/15/03
2.
Pt. will be able to experience a reduction in EPS AEB a reduction
in the tightness in his neck and the stiffness in his arms for
3 months.
07/15/03
3.
Pt. will demonstrate a slowing in his eating and an increased
efficiency in chewing of his food for 3 months.
07/15/03
4.
Pt. will be switched from a chopped diet back to a regular diet
when he is determined to be able to safely eat a regular diet.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.9
6–33
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatrist:
1.
Psychiatrist will treat pt.’s EPS with a reduction in pt.’s neuroleptic meds; a change to
another neuroleptic, such as Zyprexa; or a prescription for an antidyskinetic, such as
Cogentin.
2.
Psychiatrist will do an AIMS Plus EPS evaluation in 2 weeks following the above med
changes.
3.
Psychiatrist will refer pt. to Dysphagia Clinic for possible modified barium swallow to
more fully assess pt.’s dysphagia.
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will provide one-to-one monitoring during meals by staff trained in
Heimlich maneuver.
2.
Nsg. staff will educate pt. on avoiding hard or dry foods and alternating bites of food
with fluids.
Marilyn Davis, RN Å Nsg. Staff
Dietitian:
1.
Dietitian will provide pt. with a chopped diet.
2.
Dietitian will evaluate and educate pt. in weekly one-to-one meetings concerning his
eating habits and the relationship to choking.
Sandra Anderson, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–34
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.10 EPS (Extrapyramidal Side Effects)
Name: Walsh, Ruth
ID #:
Area:
Nursing Diagnosis: Impaired Physical Mobility
Date: 01/15/03
Problem Description:
Pt. complains of stiffness of extremities. Exam reveals bradykinesia, left greater than right, cogwheel rigidity of
wrists and elbows, left greater than right 4 to 6 Hz hand tremor, shuffling gait, diminished arm swing, and foreflexed posture consistent with neuroleptic-induced extrapyramidal side effects (pseudo-Parkinsonism). These
findings were not present before reinitiation of neuroleptic treatment 6 months ago. Parkinsonism may be
associated with increased falling risk in this pt. Pt. is currently on Risperdal (risperidone) 6 mg bid. Maintenance
dose in the community had been 4 mg bid. The pt.’s psychotic symptoms have responded well to Risperdal, but
she is known to decompensate rapidly when off neuroleptics.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will have control of psychotic symptoms with least possible
extrapyramidal side effects for 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will continue to be free from episodes of falling.
Ongoing
2.
Pt. will express a feeling of a reduction in the sensation of
stiffness without a worsening of her psychotic symptoms for
1 month.
04/15/03
3.
Pt.’s score on the AIMS Plus EPS (EPS Section) will decrease from
current 12 to 6 or less, without a worsening of her psychotic
symptoms (i.e., without a decrease in her Kennedy Axis V score
for Psychological Impairment).
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.10
6–35
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will reduce Risperdal from 6 mg bid to 4 mg bid and begin Cogentin 1 mg
po bid. Increase Cogentin by 1 mg/day every 3 days until rigidity and shuffling
improve or until 6 mg/day is reached. Further changes in meds as ordered.
2.
If above interventions fail to reduce EPS in 1 month, psychiatrist will consider
changing pt. to a neuroleptic less likely to cause EPS, such as Zyprexa (olanzapine).
Virginia Coleman, MD
Psychology:
1.
Kennedy Axis V rating prior to Risperdal reduction and then monthly to capture any
deterioration in pt.’s mental status in association with the medication adjustment.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Nsg. staff will make ongoing mental status evaluations to observe for any
deterioration with decrement in Risperdal dosage.
2.
Nsg. staff will make weekly measurements using the AIMS Plus EPS exam to observe
for reductions in pt.’s EPS during the period of Risperdal reduction.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–36
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.11 Akathisia
Name: Gumble, Vincent
ID #:
Area:
Nursing Diagnosis: Impaired Physical Mobility
Date: 01/15/03
Problem Description:
Pt. complains of restlessness with difficulty sitting through 30-minute groups, sitting through meals, watching TV,
or calming down to go to sleep. Examination reveals no evidence of Parkinsonism or dystonia, but there is ongoing
motor restlessness with leg rubbing and rocking when seated, shifting from foot to foot when asked to stand still,
and a tendency to pace rapidly in the hallways. Low-potency antipsychotics and atypical antipsychotics have not
been as effective as Haldol (haloperidol) in controlling pt.’s psychotic symptoms. It is felt that reasonable control
may be maintained on a lower dose of Haldol. Also, pt.’s akathisia is suspected to be contributing to the appearance
of greater severity of his psychosis.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will be able to maintain good control of his psychotic
symptoms with minimal akathisia for 1 month.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will be able to sit through meals and 30-minute groups
consistently for 2 weeks.
Target Date
Date/Status*
04/15/03
Target Date
Date/Status*
03/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.11
6–37
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will rate the Kennedy Axis V before Haldol reduction and then weekly to
observe for any deterioration in pt.’s mental status in association with the medication
adjustment.
2.
Psychiatrist will slowly reduce Haldol and give entire dose at HS.
3.
Psychiatrist will make ongoing observations for changes in pt.’s akathisia during the
period of Haldol reduction.
4.
Psychiatrist will make weekly measurements of akathisia using the AIMS Plus EPS to
observe for reductions in pt.’s akathisia during the period of Haldol reduction.
5.
Psychiatrist will make ongoing mental status evaluations to observe for any
deterioration with the medication adjustments.
6.
Once pt. is medically cleared and if akathisia continues, psychiatrist will consider
starting pt. on a trial of beta-blockers, such as Inderal.
Virginia Coleman, MD
Internist:
1.
Internist will medically clear pt. for possible use of beta-blockers.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will make ongoing assessments of pt.’s akathisia and mental status,
especially when administering his meds.
2.
Nsg. staff will report to the psychiatrist any significant changes in pt.’s akathisia or
mental status.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–38
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.12 Tardive Dyskinesia (TD)
Name: Danavich, Debra
ID #:
Area:
Nursing Diagnosis: Impaired Physical Mobility
Date: 01/15/03
Problem Description:
AIMS exam about 2 weeks ago revealed moderate choreoathetoid movement of tongue and distal extremities
consistent with TD. Previous AIMS exams did not meet the criteria for TD. Several weeks before the current AIMS
exam, pt.’s Haldol was decreased; therefore, the current increase in the AIMS score may represent a withdrawal
emergent syndrome. In the past, pt. has decompensated when Haldol was decreased to levels significantly lower
than she is currently on. Pt. has a general understanding of the risks associated with tardive dyskinesia and
continued use of Haldol. She agrees to continue Haldol at a reduced dose, despite the risks. She is also willing to
supplement the Haldol with Zyprexa (olanzapine), which may be less likely to worsen her TD. It is hoped that the
Zyprexa can be used to replace the Haldol.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to demonstrate control of her psychotic
symptoms with the lowest reasonable neuroleptic dosage and, if
possible, use neuroleptics that are less likely to cause TD for
3 months.
07/15/03
2.
Pt. will show no worsening of her dyskinetic movements for
3 months.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will show no worsening of her dyskinetic movements for
1 month.
Target Date
Date/Status*
Date/Status*
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.12
6–39
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will decrease Haldol as Zyprexa is added to pt.’s treatment regimen.
2.
To R/O TD versus withdrawal emergent syndrome, psychiatrist will repeat AIMS exam
q month to determine whether pt.’s dyskinetic movements resolve consistent with
withdrawal emergent syndrome or persist consistent with TD.
3.
If pt. continues to meet AIMS criteria for TD more than 3 months after the reduction
of Haldol dosage, psychiatrist will refer pt. to Movement Disorder Clinic for
consideration of alternative drug treatment strategies aimed at a reduction of
dyskinesia.
4.
If pt.’s AIMS scores worsen after 3 months, psychiatrist will consider a trial of
clozapine.
5.
Pt. will be prescribed vitamin E to help minimize tardive dyskinesia.
Virginia Coleman, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–40
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.13 Family Planning
Name: Lampson, Angela
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. is a 32-year-old, twice-divorced mother of three children. All her children are in foster care. She remains sexually
active with various partners of the opposite sex and is requesting birth control. She does not want any more
children at this time. She has never practiced birth control and is not sure which method is right for her lifestyle.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will faithfully adhere to her birth control program for
3 months.
07/15/03
2.
Pt. will consistently express an understanding of the need to
immediately contact her physician with any symptoms of
sexually transmitted diseases (STDs) for 3 months.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will cooperate with a gynecological exam.
02/15/03
2.
Pt. will be able to express a reasonable understanding of birth
control, including risks and benefits, for 1 month.
03/15/03
3.
Pt. will have an awareness of the risks associated with multiple
sexual partners for 1 month.
03/15/03
4.
Pt. will express an awareness of STDs, including symptoms that
require medical attention.
03/15/03
5.
Pt. will choose a contraceptive method that fits her lifestyle and
meets her needs.
03/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.13
6–41
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will schedule appointment for gynecological exam.
2.
Family planning counselor will provide pt. with literature on family planning and
meet weekly with pt. for ½ hour for at least 2 weeks to educate pt. about the
following:
a.
The available birth control methods, including risks and benefits
b.
STDs and symptoms and when to seek help from her physician
3.
At the end of the educational program, counselor will schedule an appointment for
an additional ½ hour to assist pt. in choosing a suitable birth control method.
4.
Nsg. staff will schedule pt. for follow-up appointments at the family planning clinic
in the hospital. At discharge, a follow-up appointment will be scheduled at her local
family planning clinic.
Ronald Donahue, RN
Linda Larkin, RN (Family Planning Counselor)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–42
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.14 Family Planning
Name: Lang, Dorothy
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. is a 26-year-old, twice-divorced mother of three children. One of her children has been adopted and two are in
foster care. She has had two abortions. She remains sexually active with various partners of the opposite sex. She is
refusing birth control and is anxious to have more children. Pt. appears to have a lot of fantasies and misunderstandings concerning sexual relationships and having children. Pt.’s sexual behavior appears to be related to her
loneliness and dependency needs. Also, she does not understand the risks of STDs.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to express a reasonably informed understanding
of her sexual behavior consistently for 3 months.
07/15/03
2.
Pt. will recognize her loneliness and dependency needs and
identify more appropriate ways of dealing with them
consistently for 3 months.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will begin to develop a trusting relationship with her
counselor.
02/15/03
2.
Pt. will begin verbalizing in one-to-one therapy her thoughts,
feelings, and fantasies about having children consistently for
1 month.
04/15/03
3.
In one-to-one therapy, Pt. will explore positive and negative
aspects of her relationships with men, including identification
of needs satisfied, consistently for 1 month.
04/15/03
4.
Pt. will accept family planning counseling, including counseling
on the risk of STDs.
04/15/03
5.
Pt. will begin to participate in a sex education program.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.14
6–43
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychology:
1.
Psychologist will schedule meetings with pt. initially for 15 minutes twice a week;
meetings will be increased to ½ hour as psychologist develops a therapeutic
relationship with pt.
2.
Psychologist will gradually explore pt.’s fantasies around pregnancy and child rearing
and assist pt. in understanding the realities of pregnancy and child rearing.
3.
Psychologist will assist pt. with identifying needs met by her sexual behavior and
help pt. explore alternative means of meeting her needs.
4.
Psychologist will encourage pt. to enroll in the weekly women’s group.
5.
Psychologist will encourage pt. to become involved in a sex education program that
addresses her needs and encourage pt. to work with the Family Planning Counselor.
Susan Green, Psychologist
Rehab:
1.
Rehab counselor will lead the weekly women’s group to help pt. explore positive and
negative aspects of her relationships with men.
Jane Hoover, Rehab
Nursing Care Plan:
1.
Family planning counselor will make pt. aware that family planning counseling is
available and encourage pt.’s participation.
2.
Family planning counselor will provide family planning counseling for ½ hour once
weekly when pt. is agreeable.
Linda Larkin, RN (Family Planning Counselor)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–44
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.15 Pregnancy
Name: Duncan, Helen
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. is a 28-year-old single female who is here in the hospital in her last trimester of her first pregnancy. She carries a
diagnosis of schizophrenia and has a history of multiple psychiatric admissions. She has not been going for
prenatal care, is not taking her antipsychotic meds, and is floridly psychotic. She denies that she is pregnant. The
paternity of the child is unknown. Pt.’s mother is her legal guardian, and her mother wishes to care for the baby
once it is born. Staff feels that pt.’s mother can provide a healthy, nurturing environment for the baby, as well as
allow pt., when she is doing well, to have an ongoing relationship with her baby.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will safely deliver a full-term, healthy baby.
04/15/03
2.
Pt. will concur with the need to place her baby in the care of her
mother until she can safely care for her baby.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will see an obstetrician as soon as possible.
01/29/03
2.
Pt. will cooperate with and will receive adequate nutrition, rest,
and exercise.
02/15/03
3.
Pt. will acknowledge her pregnancy.
02/15/03
4.
Pt. will verbalize an understanding of the need for prenatal care
and verbalize an awareness of the signs and symptoms of labor.
02/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.15
6–45
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work/Nursing:
1.
Staff will discuss with pt. and her mother the placement of pt.’s infant with pt.’s
mother.
Brenda St. Martin, MSW, and Linda Larkin, OBS Primary Nurse
Nursing Care Plan:
1.
Nsg. staff will maintain pt. in an environment that is safe for her and her unborn
child.
2.
Nsg. staff will develop a trusting relationship with pt. to get pt. to cooperate with
prenatal care.
3.
Nsg. staff will monitor nutrition, elimination, rest, and activity; staff will report any
difficulties to the obstetrician.
Ronald Donahue, RN Å Nsg. Staff
4.
Nsg. staff will meet with pt. for ½ hour once weekly to provide education about
pregnancy and delivery, including signs and symptoms of labor.
Linda Larkin, RN, OBS Primary Nurse
5.
Nsg. staff will be educated to the signs and symptoms of labor so they can monitor
these signs and symptoms on a daily basis, as well as review them with pt.
Linda Larkin, OBS Primary Nurse Å Nsg. Staff
6.
Staff will collaborate to determine when pt. will be transferred to the Maternity Ward.
Ronald Donahue, RN
Linda Larkin, OBS Primary Nurse
7.
As pt.’s due date approaches, check pt. every 15 minutes for evidence of labor.
Ronald Donahue, RN Å Nsg. Staff
Other:
1.
Treatment outlined in Problem 1.1 Psychotic Symptoms, including a low-dose
antipsychotic med that is medically cleared and recommended by pt.’s psychiatrist
and obstetrician following a discussion of the risks and benefits with pt. and her
guardian.
Staff as indicated
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
ANCILLARY IMPAIRMENT
(Problem Area 7)
7–1
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Ancillary Impairment (Problem Area 7)
7–3
ANCILLARY IMPAIRMENT
(Problem Area 7)
CONTENTS
Kennedy Axis V for Ancillary Impairment ................................................................................................ 7–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Ancillary Impairment and can be helpful in composing a short description
of each problem.
Problem Names and Descriptions ............................................................................................................ 7–5
Examples of problem names and descriptions that may relate to Ancillary Impairment are listed here.
These examples can be used to develop the Problem List and to help compose a short description of
each problem.
Strengths .................................................................................................................................................. 7–5
Examples of strengths that may be related to treatment and discharge in the area of Ancillary Strengths
are listed here.
Goals ......................................................................................................................................................... 7–6
Examples of treatment goals that may relate to problems in the area of Ancillary Impairment are listed
here.
Treatment Modalities ............................................................................................................................... 7–7
Examples of treatment modalities that may relate to problems in the area of Ancillary Impairment are
listed here.
Individual Problem Plan (Frequent Entries) ............................................................................................. 7–8
An Individual Problem Plan containing examples of information relating to Ancillary Impairment is
included here.
Sample Individual Problem Plans ........................................................................................................... 7–11
A wide range of Individual Problem Plans relating to Ancillary Impairment are included here.
7–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Ancillary Impairment
100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood,
home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe
environment. No significant ancillary problems or symptoms.
90 Good life situation; has few if any ancillary problems; no more than minor problems with living
environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet
his/her needs, rare late payment on a bill, rare parking or traffic ticket.
80 If ancillary problems are present, they are transient and cause no more than minimal
difficulty with his/her living situation, financial resources, or the law; somewhat more than average
problems with his/her living environment, financial resources, or legal problems.
70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the
law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal
violence in his/her environment; however, generally safe living situation.
60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous
homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or
income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards;
evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing,
defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for
competency to make decisions concerning person, estate, and/or treatment.
50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of
moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor
but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under
the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for
placement.
40 Major problems with living situation, finances, and/or the law; some real danger of being
physically injured in his/her environment; evaluation and/or disposition is being made for very violent
criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).
30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless
or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate
physical injuries from violence in his/her environment.
20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all
of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing
or because of high level of violence in his/her environment; evaluation and/or disposition is being made for
extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).
10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack
of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment;
evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone,
very viciously harming or very viciously raping a child, arson with intent of hurting others).
NR Not rated
Ancillary Impairment (Problem Area 7)
Problem Names and Descriptions
I.
Ancillary Problems
A.
Placement difficulties
1.
Homelessness
2.
Alienation of halfway house staff members
3.
Ambivalence about leaving the hospital
4.
Appropriate placement not available
5.
Placement blocked by unresolved legal difficulties
B.
Financial problems
1.
No means of support
2.
Debts beyond ability to pay
3.
Overwhelming credit card debt
4.
Social Security Disability Income (SSDI) benefits needed
C.
Legal difficulties
1.
Court report
2.
Court assessment of competency
3.
Court permission for forcing medication
4.
Court review of use of antipsychotic meds
5.
Court review of use of an experimental drug
6.
Court review of psychosurgery
7.
Criminal charges
8.
Guardian is not properly handling pt.’s money
9.
Divorce
D.
Data collection
1.
Insufficient database
2.
No information available on pt.’s psychiatric history
3.
No information available on pt.’s current housing or legal status
E.
Other ancillary problems
1.
Dangerous homeless situation
2.
High level of violence in pt.’s environment
3.
No stable residence
4.
Abusive spouse
5.
Target of a stalker
Strengths (Brief List)
I.
Ancillary Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Community placement to return to
Safe environment to return to
Supportive family or friend who is actively involved in pt.’s care
Good community support network
Good religious support system
Economic security
Financial resources for basic needs
Private insurance
SSDI in place
Guardianship in place for psychotropic meds
Guardianship in place for person and estate
Other ancillary strengths
7–5
7–6
Fundamentals of Psychiatric Treatment Planning
Goals
I.
II.
Expected Improvements
A.
Placement
1. Pt. will be able to demonstrate basic community living skills, including the ability to use public
transportation, budget money, shop for food, and prepare a meal, for 3 months.
2. Pt. will be able to verbalize fears and ambivalence about moving into a community residence.
3. Pt. will go on a “no-strings-attached” tour of prospective halfway houses.
4. Pt. will be able to consistently express an understanding of the benefits of going into a halfway
house for 1 month.
5. Pt. will be able to begin the process of slow transition to a community setting without serious
regression.
6. Pt. will be able to successfully go to the community day program two times a week for 1 month.
7. Pt. will be placed in a structured residential setting without serious regression during the
transition.
8. Pt. will be able to transition from a locked ward to an unlocked, open ward.
9. Pt. will reduce dependency on his or her mother to the point that pt. will begin to discuss
community residential alternatives to being discharged to live with mother.
10. Pt. will express an understanding of the fact that pt. can benefit from discharge to a halfway house
rather than return to mother’s home.
11. Pt. will be discharged to the appropriately supervised residential setting.
12. Pt. will improve so that court approval can be obtained for discharge to a halfway house.
B.
Financial
1.
Pt. will begin getting SSDI benefits as a step toward being able to move out of the homeless
shelter.
2.
Pt. will be able to get a job that will provide the income necessary to stabilize pt.’s life to live
outside of the hospital.
3.
Pt. will cooperate with social worker on ways to get credit card debt under control.
C.
Legal
1.
Pt. will cooperate so that the information needed to complete the mandated court evaluation can
be gathered.
2.
Pt. will show up for the court hearing.
3.
Pt. will have a permanent legal guardian appointed by the court for financial, medical, and
psychiatric concerns.
4.
Pt. will consistently maintain communication with the guardian for 3 months.
5.
Pt. will consistently cooperate with the lawyer in gathering the necessary information for pt.’s
upcoming divorce, for 1 month.
6.
Pt. will consistently cooperate with the lawyer in pt.’s defense against the charge of attempted
murder for 3 months.
D.
Other
1.
No examples given.
Reporting of Symptoms
A.
Pt. will discuss fears about leaving the hospital.
III. Participation in Groups, Program Activities, and the Like
A.
B.
Pt. will participate in discharge transition group.
Pt. will participate in the abused spouses group.
Ancillary Impairment (Problem Area 7)
7–7
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking meds.
2.
Pt. will express the benefits of taking meds.
3.
Pt. will take meds as prescribed.
4.
Pt. will go for follow-up lab tests in the community.
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process.
2.
Pt. will be willing to participate in the court evaluation process as laid out in pt.’s treatment plan.
C.
Program activities
1.
Pt. will express the benefits of attending community transition group meetings.
2.
Pt. will consistently agree to go for follow-up at the community clinic.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate a realistic orientation toward progress such that pt. understands and explains
the connections among—
a.
Failure to work with the lawyer and legal setbacks
b.
Alienation of community staff and difficulty transitioning into the community
c.
Inconsistent program attendance, recurring setbacks, and continued care at the hospital
d.
Failure to follow through with the terms of pt.’s probation and a return to jail
Diagnostic Tests and Evaluations
A.
B.
C.
Pt. will cooperate with the evaluation of the nature of pt.’s anxiety about discharge.
Pt. will cooperate with the competency exam.
Pt. will cooperate with the treatment team to gather the information necessary to
complete mandated court evaluation.
VI. Standardized Outcome Measures
A.
Kennedy Axis V subscale for Ancillary Impairment will improve from a current score of
40 to 60.
VII. Miscellaneous
A.
B.
C.
D.
Once level of care has been determined, pt. will give staff permission to determine the
availability of appropriate discharge placement.
Pt. will allow the community case manager to be involved in the discharge planning
process.
Pt. will cooperate with determining who would be best to act as pt.’s guardian.
Pt. will demonstrate motivation for discharge by advocating for self with case
management about the fact that an appropriate placement is lacking, despite pt.’s
readiness to function in a community residence.
Treatment Modalities
Because of the extremely diverse nature of the category of Ancillary Impairment, no listing of treatment modality
examples is included. However, some examples of treatment modalities for Ancillary Impairment are included in
the samples of Individual Problem Plans at the end of this section on Ancillary Impairment. Also, the categories of
treatment modalities presented in previous sections should generally apply to the treatment of Ancillary
Impairment.
7–8
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plan (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.1 Court Evaluation (for criminal
behavior)
Nursing Diagnosis: Ineffective Community Coping
Name: Smith, John
ID #:
Area:
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
Description and date of alleged crime
•
•
•
•
•
Motive (e.g., anger, jealousy, revenge, monetary gain, sexual gratification)
Type of court evaluation (e.g., competency to stand trial, criminal responsibility)
Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor
frustration tolerance, poor impulse control, antisocial personality characteristics, pedophilia)
Brief description of criminal history (e.g., frequency and characteristics of crimes)
Outcome of previous court evaluations
Current potential for repeating the alleged crime
Barriers to the evaluation (e.g., unwillingness to cooperate, poor or distorted memory for the event, lack
of witnesses or other corroborating information)
2.
Make sure that the description relates to goals and treatment modalities.
3.
Address the description and treatment of associated problems that may have led to pt.’s alleged crime in the
appropriate problem area, such as Problem Area 1 Psychological Impairment, Problem Area 3 Violence, or
Problem Area 5 Substance Abuse.
Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will consistently cooperate with the assessment process for ___
week(s).
2.
Pt. will provide the necessary information to complete the court
evaluation.
3.
Pt. will cooperate with the forensic evaluation so that it can be
completed by the target date.
4.
Pt. will consistently provide necessary information to complete
the Forensic Evaluation for ____ week(s).
5.
Pt. will be able to express some understanding that he or she has
committed a crime and needs to act to defend self in court for
____ week(s).
6.
Pt. will cooperate with efforts to regain competency to stand trial
for ____ week(s).
7.
Pt. will regain competency to stand trial AEB working with the
attorney and demonstrate an understanding of the charges and
the role of court members for ____ week(s).
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.1
7–9
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will discuss case with the forensic team, including diagnosis, medication,
laboratory findings, physical findings, and follow-up psychiatric treatment
recommendations.
Victor Dyson, MD
Social Work:
1.
Social worker will discuss with the forensic team issues related to environmental or
social precipitants of the alleged crime and aftercare treatment services.
Brenda St. Martin, MSW
Psychology (or Social Work):
1.
Psychologist will discuss psychological testing with the forensic team.
Susan Green, Psychologist
Rehab:
1.
Rehab staff will discuss with the forensic team issues relating to how pt. is doing in
scheduled program groups.
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will discuss with the forensic team issues relating to pt.’s behavior on the
ward and any medical issues.
Marilyn Davis, RN
Forensic Team:
1.
Forensic team will gather the necessary information from the pt. and treatment team
members to complete the court-ordered forensic report.
Madison Yu, PhD, Forensic Team Leader
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Ancillary Impairment (Problem Area 7)
7–11
Sample Individual Problem Plans
CONTENTS
Placement ............................................................................................................................................... 7–12
Homelessness.......................................................................................................................................... 7–14
Court Evaluation ..................................................................................................................................... 7–16
Court Assessment of Competency.......................................................................................................... 7–18
7–12
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.1 Placement
Name: Marco, Anne
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
In the past, pt. has resided in single rooms and shelters. Historically, she abuses alcohol and behaves
inappropriately in the community. With the assistance of friends, she has been able to function fairly well in the
community; however, these friends are unable to provide pt. with regular support and care. When they are not
available, she places herself in dangerous situations. Her friends are encouraging her to consider living in a
community residential program. She has historically rejected community residential programs.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will be discharged to a safe, appropriate setting.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will go on a tour of residential placements with “no strings
attached.”
03/15/03
2.
Pt. will be able to carry on a reasonable discussion concerning
possible community residential placement consistently for
1 month.
04/15/03
3.
If pt. decides to live in a community residential program, she will
be tentatively accepted by a community residential program that
is acceptable to her.
05/15/03
4.
If agreeable to pt., she will begin transitioning into a residential
program, including going for overnight visits.
06/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.1
7–13
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Hold one-to-one session twice weekly to discuss and address placement issues with
the pt.
2.
Continue to explore supervised community residential placement, as well as
alternatives to supervised community residential placement.
3.
Coordinate with pt. and community resources, including significant others, if a
reasonable placement plan can be agreed on.
4.
Arrange for residential tours, interviews, and the like.
5.
Plan for community day-program involvement.
Roger Sing, MSW
Rehab:
1.
Assess pt.’s ability to live outside of the hospital.
John Loudon, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
7–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.2 Homelessness
Name: Wolfe, Nicholas
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
Pt. has a long history of homelessness, which began sometime before his first psychiatric hospitalization in his late
teens. He has no family support and has used alcohol and drugs when living on the streets. When not living on the
streets, he is in a shelter, a psychiatric hospital, or jail for minor legal offenses. He has refused previous attempts to
refer him to a community residence. Last winter, pt. had to be treated for medical problems suffered after exposure
to the severe weather conditions. Pt.’s judgment is increasingly impaired and he is increasingly making irrational
plans to continue living on the streets. If brought to the court, it is very unlikely that the court would honor pt.’s
request to be discharged to the streets.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will be discharged to a community residential setting after
successfully completing 1 week of overnights.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
05/15/03
Target Date
1.
Pt. will agree to work with his social worker and community case
manager concerning discharge plans.
02/15/03
2.
Pt. will agree to visit the community residences available in his
placement area.
03/15/03
3.
Pt. will be able to express at least three advantages to living in a
community residence.
03/15/03
4.
Pt. will agree to be referred to a community residence of his
choice in his placement area.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.2
7–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Social worker will meet with pt. at least 1 hour weekly to discuss discharge plans,
including the advantages of moving from the streets into a community residence.
2.
Social worker will arrange visits with pt. to appropriate community residences.
Brenda St. Martin, MSW
Social Work/Case Management:
1.
Social worker will assist pt. in establishing relationships in the community (e.g., staff
and residents in the community day program and the community residential
program).
2.
Case manager will arrange for residential tours, interviews, and the like.
Brenda St. Martin, MSW
Richard Sullivan, Community Case Manager
Other:
1.
Continue treatment of pt.’s mental illness as outlined in other sections of this
treatment plan.
Staff as indicated
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
7–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.3 Court Evaluation
Name: Robinson, James
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
Pt. faces criminal charges, including assault and battery, attempt to commit murder, and assault and battery with a
dangerous weapon. Pt. was committed for evaluation of competency to stand trial and criminal responsibility at
the time of the alleged crime. Commitment expires on 02/15/03.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will return to court with completed court-mandated
evaluation.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/15/03
Target Date
1.
Pt. will cooperate so that the treatment team can begin to gather
the information necessary to complete the court evaluation.
01/22/03
2.
Pt. will cooperate so that the forensic team can complete the first
draft of the court report.
02/07/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.3
7–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Staff will obtain community records, including police report and report from
community psychiatrist.
Brenda St. Martin, MSW
Treatment Team Evaluators:
1.
Staff will give pt. Lambe warning that information obtained in the course of this
evaluation will be used as part of the evaluation to be sent to court.
2.
Staff will complete psychosocial, psychological, psychiatric, and nursing databases.
Discipline-Specific Evaluating Staff
Nursing Care Plan:
1.
Nsg. staff will discuss with the forensic team issues related to pt.’s behavior on the
ward, including any medical issues.
Marilyn Davis, RN Å Nsg. Staff
Forensic Team:
1.
Staff will gather the necessary information from the pt. and treatment team members
to complete the court-ordered forensic report.
2.
Forensic team will present the report to the court and testify, if necessary.
Madison Yu, PhD, Forensic Team Leader
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
7–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.4 Court Assessment of Competency
Name: Ball, Paula
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
Pt. appears to be incompetent. She needs to have the courts declare her incompetent and appoint a guardian. Pt.
has a long history of being unable to care for herself. Her insight and judgment are markedly impaired. She appears
unable to make competent decisions concerning her money and medical care. She is also unable to make rational
statements as to why she needs to be in the hospital. Pt.’s mother appears to be a good candidate for pt.’s legal
guardian.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt.’s mother will be appointed permanent legal guardian,
including having the right to consent to pt.’s medical treatment
and the right to commit pt. to a mental institution.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
04/15/03
Target Date
1.
Pt. will cooperate so that the competency report can be
completed for court.
02/15/03
2.
Pt. will cooperate so that everything is ready for the court
hearing, including a court date.
03/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.4
7–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Staff will complete report on pt.’s competency to care for herself, her ability to make
decisions concerning medical treatment, and her ability to make decisions concerning
committing herself to a mental institution.
2.
Staff will testify in court as to pt.’s competency.
Victor Dyson, MD
Psychology:
1.
Psychologist will perform psychological testing to assess depressive cognition.
2.
Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive,
problem-solving therapy to improve pt.’s mood and help her function, even if
depressive symptoms persist.
Joseph LeBlanc, Psychologist
Social Work:
1.
Staff will discuss with pt.’s mother the issues surrounding her seeking legal
guardianship of pt. and the responsibilities associated with being assigned legal
guardianship of the pt.
2.
Staff will assist the legal office in obtaining necessary paperwork from pt.’s mother and
from pt.’s record.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
BLANK FORMS
BF–1
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Blank Forms
BF–3
BLANK FORMS
CONTENTS
Master Treatment Plan........................................................................................................................... BF–5
Problem List .................................................................................................................................................. BF–5
Strengths/Discharge Plan/Diagnosis ............................................................................................................. BF–6
Individual Problem Plan................................................................................................................................ BF–7
Signature Page ............................................................................................................................................... BF–9
Treatment Plan Review......................................................................................................................... BF–11
Notes
Blank Forms
BF–5
Name:
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Problem List
ID #:
Area:
Name of Facility
Date:
Date of Admission:
Problem
Number
Problem Name
Discharge
Barrier*
Date Estab. &
Status**
Date Changed
& New Status***
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
BF–6
Fundamentals of Psychiatric Treatment Planning
Name:
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #:
Strengths/Discharge Plan/Diagnosis
Area:
Date:
Patient’s Strengths (related to treatment and discharge):
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
SOC =
GAF Equivalent =
VIO =
ADL =
SAb =
MED =
Dangerousness Level =
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /___
Blank Forms
INDIVIDUAL PROBLEM PLAN
Problem # and Name:
BF–7
Name:
ID #:
Area:
Nursing Diagnosis:
Date:
Problem Description:
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
BF–8
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: ________
Date: ________
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Blank Forms
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Signature Page
BF–9
Name:
ID #:
Area:
Name of Facility
Date:
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
(Patient’s or guardian’s signature and date)
(If guardian, relation to patient)
Patient’s Comments (optional):
Staff Members’ Comments (optional):
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Date:
Print Name:
Nurse:
Date:
Print Name:
Social worker:
Date:
Print Name:
Psychologist:
Date:
Print Name:
Rehabilitation:
Date:
Print Name:
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.”
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
Notes
Blank Forms
Treatment Plan Review
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Name of Facility
BF–11
Name:
ID #:
Area:
Date:
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
AXIS II:
AXIS III:
2. Changes in Problem List:
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Check if review is continued on reverse [ ]
BF–12
Fundamentals of Psychiatric Treatment Planning
MASTER TREATMENT PLAN AND NURSING CARE PLAN REVIEW Continued
4. Changes in Treatment Plan Goals and/or Modalities:
5. Reasons for Continued Hospitalization:
6. Discharge Planning Update:
7. Continuation/Comments:
8. Level of Care: Active Treatment [ ] Extended [ ]
Awaiting SNF [ ]
9. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Date:
Print Name:
Nurse:
Date:
Print Name:
Social worker:
Date:
Print Name:
Psychologist:
Date:
Print Name:
Rehabilitation:
Date:
Print Name:
Other:
Date:
Print Name:
Patient: I participated in the review:
Date:
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
QUESTIONNAIRES
Q–1
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Questionnaires
Q–3
QUESTIONNAIRES
CONTENTS
Overview and Use of Questionnaires ...................................................................................................... Q–4
References and Acknowledgments ......................................................................................................... Q–4
Kennedy Axis V ........................................................................................................................................ Q–5
Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)............................................. Q–17
AIMS Plus EPS (Abnormal Involuntary Movement Scale Plus Extrapyramidal Side Effects)................ Q–19
Q–4
Fundamentals of Psychiatric Treatment Planning
Overview and Use of Questionnaires
The questionnaires in this manual have been developed to make them useful and practical in clinical,
nonresearch settings. Many questionnaires are developed for research purposes and are only
tangentially useful in nonresearch settings. Complex administration, scoring, and interpretation
methods may be necessary for research purposes; however, this often makes such questionnaires of little
use to the harried clinician.
Details on the Kennedy Axis V (K Axis) and the Kennedy Nurses’ Observation Scale for Inpatient
Evaluation (K NOSIE) are included in the companion book Mastering the Kennedy Axis V: A New
Psychiatric Assessment of Patient Functioning. This companion book also acts as a training manual for
both the Kennedy Axis V and the Kennedy NOSIE.
Progress notes are often the standard for measuring outcome in clinical practice, not formal
research instruments. The use of questionnaires should be based on whether they can improve on or
add to the information manageability of progress notes. These improvements have to be gained without
unduly taxing staff time and resources.
The major difference between the Abnormal Involuntary Movement Scale Plus EPS (AIMS Plus EPS)
and the original AIMS is that in addition to measuring evidence of tardive dyskinesia, the AIMS Plus EPS
also measures extrapyramidal side effects (EPS). There is tremendous overlap between the physical exam
used to assess involuntary movements and that used to assess EPS. Therefore, for clinical purposes and
ease of documentation, both are included on the AIMS Plus EPS.
If questionnaires are used to follow up treatment, predicted scores should be included on the
treatment plan as goals. However, these scores should be used along with other measurable clinical
outcomes. As shown earlier in this manual, these questionnaires can easily be integrated into the
format of a goal. For example,
The score on the K Axis subscale for Psychological Impairment will improve from a current score of
40 to 60.
The score on the K NOSIE for Irritability will improve from the current score of –12 to –6.
References and Acknowledgments
Dr. Kennedy is the author of the Kennedy Axis V and Kennedy NOSIE. These instruments are
introduced in
Kennedy JA: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning.
Washington, DC, American Psychiatric Publishing, 2003
The Kennedy Axis V and the Kennedy NOSIE are not in the public domain. For details on how to
obtain a licensing agreement to use the Kennedy Axis V or the Kennedy NOSIE questionnaires, please
contact James A. Kennedy, MD, or go online to www.kennedymd.com.
Dr. Kennedy, in conjunction with the Massachusetts State Medical Record Committee, developed
the AIMS Plus EPS. It was introduced in
Kennedy JA: Fundamentals of Psychiatric Treatment Planning. Washington, DC, American Psychiatric
Press, 1992
The AIMS and the AIMS Plus EPS are both in the public domain. The AIMS was developed at the
National Institute of Mental Health:
National Institute of Mental Health, Alcohol Drug Abuse and Mental Health Administration: Abnormal
Involuntary Movement Scale. Washington, DC, U.S. Department of Health, Education and Welfare,
1974
Questionnaires
Q–5
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Questionnaires
Q–7
Instruction Sheet
What Is the Kennedy Axis V (K Axis)?
The K Axis consists of seven subscales for Axis V: Psychological Impairment, Social Skills, Violence, ADL–
Occupational Skills, Substance Abuse, Medical Impairment, and Ancillary Impairment. These subscales capture the
clinician’s impression of the individual’s overall level of functioning during the previous week (longer if significant,
e.g., suicidal attempts).
In addition to an individual score for each of the subscales, clinicians can generate a patient profile using the
K Axis, as well as a score equivalent to the GAF. The K Axis is useful for developing Problem Lists, planning
treatment, measuring its impact, and predicting outcome. Note: If needed, each subscale can stand alone and act as
an individual questionnaire.
Using the Kennedy Axis V to Create Equivalents to the GAF Scale
•
•
GAF Equivalent (GAF Eq): Add the first four subscales and divide by four to give a score that is roughly
equivalent to a score from the GAF Scale. This score should ensure that the major areas of functioning are
not overlooked when rating the patient.
Dangerousness Level (DL): The DL is roughly equivalent to the GAF’s measure of dangerousness. The
numbers used to derive the DL are on the scoring sheet directly below each subscale score. The lowest of
these numbers becomes the DL. If the DL is 50 or less, it is often associated with the need for very high
intensity outpatient care, residential care, or even hospitalization.
Choosing Current, Discharge, and Highest Level of Functioning Ratings
•
•
•
The current rating should be based on the level of functioning at the time of the evaluation and is most
reflective of the current need for treatment or care.
The discharge rating should be based on the level of functioning at the time of discharge and, when
compared with the admission rating, is most reflective of the impact of treatment.
The highest level of functioning should be based on the highest level of functioning that lasted for at least a
few months during the last year. This score may be very predictive of outcome.
Using “Best Fit” to Capture the Clinical Impression
The rating choice should be guided by the best fit for the client, even though some of the thinking or behaviors at
that level may not be characteristic of the client. The anchor points only serve as aids and are not required for a
specific rating. Ultimately, the clinical impression is the determinant of the score, and the best fit should guide one
to that score rather than a particular anchor point.
Using Each Subscale to Measure Multiple Factors
In each subscale, rate the factor that causes the most impairment. On the Violence subscale, the best fit should be
based on suicidal factors for the suicidal client and on factors related to assaultiveness for the assaultive client. On
the Substance Abuse subscale, the best fit should be based on use of alcohol for the alcoholic patient and use of
drugs for the patient who abuses drugs. Impairments in multiple factors should help confirm a lower rating.
Factors that relate to being withdrawn or showing lack of interest or poor motivation should be rated under
Psychological Impairment rather than under Social Skills or ADL–Occupational Skills.
Measuring the Effects of Treatment, Stress, Physical Limitations, and the Like
•
•
The presence or absence of support, medication, other treatments, or even severe stress generally should not affect
the rating, unless it is covering up skills. The rating should be based on the level of functioning, and no
adjustment should be made for the presence or absence of these factors. Do not factor out the effects of
treatment, even if the patient may drop out of treatment.
The effect of physical/environmental limitations generally should be factored out of the rating. For example, factor
out not abusing drugs or not assaulting others due to being incarcerated or physically restrained; factor out
not being socially active or employed due to physical constraints of being in a wheelchair or confined to
bed. Rate how functional or dysfunctional a client would be if given reasonable opportunity—that is, do
not let physical barriers cover up skills or violence.
Q–8
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Psychological Impairment
(Problem Area 1)
100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems
never seem to lead to any significant anxiety or depression. No symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all
areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday
problems or concerns.
80 If symptoms are present, they are transient and expected reaction to psychosocial
stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild
preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The
stress is too much”); not considered to have mental problems by those who know him/her.
70
Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the
household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally
functioning fairly well; however, those who know him/her well might express some concerns about his/her mental
state.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently
preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others;
to those who know him/her well it is clear that he/she has mental problems.
50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe
phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety
attacks, moderately guarded, mild but definite manic syndrome).
40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is
at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however,
probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or
mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative
symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have
mental problems.
30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to
hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is
occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications;
inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job,
home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost
totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe
sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.
20 Thinking and communication are generally grossly impaired; manic excitement or catatonia;
largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal
personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe
food off shirt; smears feces for bizarre, delusional reasons).
10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely
incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or
minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a
few seconds; chronic, self-induced vomiting has led to a very life-threatening situation.
NR
Not rated
Questionnaires
Kennedy Axis V—Social Skills
Q–9
(Problem Area 2)
100 Superior social skills, sought out by others because of his/her outstanding social/communication skills,
has many friends and no difficulty making new friends. No symptoms.
90
Good social skills, no difficulty being pleasant and engaging, good communication skills, socially
effective.
80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to
infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.
70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show
sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally
functioning fairly well, has some meaningful interpersonal relationships.
60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other
inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate
difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with
others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of
problems with social skills; communications are understandable but vague.
50 Serious impairment in social skills; has no friends because of clearly impaired social skills;
however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers
or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great
difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear
difficulty; frequently intrusive; inappropriate, nonsexual touching.
40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing
situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately
engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the
behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from
school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others;
great difficulty recognizing that his/her sexual advances are not welcome.
30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how
to share with others, and/or how to show sympathy toward others; conversations with others are grossly
inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual
touching, and the like.
20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short
phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing
of feces or making sexual advances toward young children; however, may have some understanding that such
behavior is inappropriate.
10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent
awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others);
extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of
approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social
situations).
NR
Not rated
Q–10
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Violence
(Problem Area 3)
100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to
any inappropriate anger, frustration, or conflicts. No symptoms.
90 No significant evidence of violence to self or others; generally satisfied with life, no more than
everyday problems or conflicts (e.g., an occasional argument with family members).
80 No more than slight problems with anger and irritability; if symptoms are present, they are transient
and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild
anger after family argument); no suicidal ideation.
70
Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior;
thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning;
severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant
problems with violence or self-harm.
60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due
to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be
present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with
violence.
50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally
threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits
someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such
as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or
others; however, some precautions including close observation may be indicated.
40 Major problems with anger and irritability; some real danger of hurting self or others; violent
outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual;
occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single
suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others;
set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or
two minor fires.
30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met;
suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively
following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or
restraints may be necessary to prevent serious harm to self or others.
20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone;
attempted to very violently harm or violently rape someone within the last month; constant suicidal
preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal
attempts without clear expectation of death within the last month; close observation to prevent harm to self or
others may be required 1 or 2 days a week.
10 Persistent danger of severely hurting self or others; attempted to kill someone within the last
month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last
month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of
death; little or no control of impulses to hurt self or others; expressing loss of control of command
hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for
prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within
the last 2 years.
NR
Not rated
Questionnaires
Kennedy Axis V—ADL–Occupational Skills
Q–11
(Problem Area 4)
100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a
homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of
hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those
expected of a successful college graduate.
90 Good skills in all ADL–occupational activities; no more than average difficulties with any work
assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school
graduate.
80 No more than slight impairment in occupational skills or skills in school; has slight difficulty
performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork
assignments; slight impairment in workmanship.
70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following
instructions, workmanship is somewhat sloppy), but generally functioning fairly well.
60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed;
however, has trouble carrying through assignments; some difficulty problem solving or following instructions;
some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home
or apartment).
50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more
than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following
instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using
public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating
properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call.
40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any
significant period or do routine housework due to poor work skills; failing in school due to poor academic skills);
needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food
restaurant; poor understanding of how to budget money.
30 No job and unable to independently maintain a home due to serious impairment in skills needed
to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare
simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call,
follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs
(e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire
alarm; difficulty finding way back from short errands.
20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some
supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs
supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most
simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from
short errands).
10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete
most tasks even with constant supervision; may even have to be physically assisted to complete a task, including
eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support
(e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering
into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately
respond to a fire alarm.
NR
Not rated
Q–12
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Substance Abuse
(Problem Area 5)
100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no
use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone
who is totally free of problems with substance abuse. No symptoms.
90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social
drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and
minimal, if any, treatment needed to maintain sobriety.
80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes
daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or
caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse
(e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety
with minimal treatment needed to maintain sobriety.
70 Mild impairment in social, occupational, or school functioning due to substance abuse, but
generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription
drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy
smoker; unable to quit cigarettes despite numerous attempts.
60 Moderate difficulty in social, occupational, or school functioning because of substance
abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or
co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week;
occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust),
Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes
despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.
50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance
abuse; moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing
substances despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol
or marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions;
moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or
muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular
basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than
cigarettes) is beginning to cause some medical complications.
40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids
friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his
family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally
has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety.
30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably
impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances
without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical
hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious
neglect of children due to substance abuse.
20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin,
or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving
for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very
serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs
into his/her veins more than twice a day.
10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or
withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking
drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to
severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in
frequent medical hospitalizations; life-threatening neglect of children due to substance abuse.
NR
Not rated
Questionnaires
Kennedy Axis V—Medical Impairment
Q–13
(Problem Area 6)
100 Superior medical health; physical exam and laboratory tests are normal, including no significant
weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems
(e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to
medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a
multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms.
90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more
than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical
problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor
visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally
needs over-the-counter medication.
80 If medical problems are present, they are transient and cause minimal impairment in
social, occupational, or school functioning; somewhat more than average missing of work or school due to
medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a
prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to
organic problems.
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
60 Moderate difficulty in social, occupational, or school functioning due to medical
problems; missing no more than about 1 month a year from work or school due to medical problems (e.g.,
moderate asthma, moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia
secondary to polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia,
mild angina on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po
medications (e.g., injections, blood levels, nebulizer, physical therapy); needs bladder bag.
50 Serious impairment in social, occupational, or school functioning due to medical
problems; serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis,
glasses, hearing aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment
is needed for mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a
car.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR
Not rated
Q–14
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Ancillary Impairment
(Problem Area 7)
100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood,
home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe
environment. No significant ancillary problems or symptoms.
90 Good life situation; has few if any ancillary problems; no more than minor problems with living
environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet
his/her needs, rare late payment on a bill, rare parking or traffic ticket.
80 If ancillary problems are present, they are transient and cause no more than minimal
difficulty with his/her living situation, financial resources, or the law; somewhat more than average
problems with his/her living environment, financial resources, or legal problems.
70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the
law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal
violence in his/her environment; however, generally safe living situation.
60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous
homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or
income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards;
evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing,
defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for
competency to make decisions concerning person, estate, and/or treatment.
50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of
moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor
but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under
the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for
placement.
40 Major problems with living situation, finances, and/or the law; some real danger of being
physically injured in his/her environment; evaluation and/or disposition is being made for very violent
criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).
30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless
or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate
physical injuries from violence in his/her environment.
20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all
of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing
or because of high level of violence in his/her environment; evaluation and/or disposition is being made for
extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).
10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack
of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment;
evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone,
very viciously harming or very viciously raping a child, arson with intent of hurting others).
NR
Not rated
Questionnaires
Q–15
Kennedy Axis V: Scoring Sheet
Name:
© 1986–2003
#:
Age:
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
ÄÄ FUNCTIONAL
DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
Primarily (check one):
Not Impaired___
Antisocially Impaired___
Other Impairment___
Both___
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
Primarily (check one):
Nonviolent___
Violent to Self___
Violent to Others___
Violent to Self and Others___
4. ADL–Occupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
45
40
35
30
25
20
15
10
5
100
95
90
85
80
75
70
65
60
55
50
Primarily (check one):
Nonabuser___
Alcohol Abuser___
Drug Abuser___
Both___
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
7. Ancillary Impairment (optional)
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
GAF Equivalent:
#1
+ #2
+ #3
+ #4
=
/
4
=
Dangerousness Level (indicate only the most dangerous rating):
Signature:
Date:
Notes
Questionnaires
Q–17
Kennedy Nurses’ Observation Scale for Inpatient Evaluation
Kennedy NOSIE or K NOSIE
Copyright © 1985–2003 James A. Kennedy, MD
Patient’s Name: _______________________________________________ #: ______________________ Date: ____/____/____
Name and Title of Rater: _______________________________________________________________________________________
Note: Closely follow The Guide to the Kennedy NOSIE by James A. Kennedy, MD (available at www.kennedymd.com), to
significantly improve the reliability and validity of your ratings.
1.
Social Competence
Never
Sometimes
Often
Usually
Always
A.
Refuses to do the ordinary things expected of him/her
–0
–1
–2
–3
–4
B.
Has trouble remembering
–0
–1
–2
–3
–4
C.
Has to be reminded what to do
–0
–1
–2
–3
–4
D.
Has to be told to follow hospital routine
–0
–1
–2
–3
–4
E.
Has difficulty completing even simple tasks on
his/her own
–0
–1
–2
–3
–4
Never
Sometimes
Often
Usually
Always
Sec. #1: –______
2.
Social Interest
A.
Shows interest in activities around him/her
+0
+1
+2
+3
+4
B.
Tries to be friendly with others
+0
+1
+2
+3
+4
C.
Laughs or smiles at funny comments or events
+0
+1
+2
+3
+4
D.
Starts up a conversation with others
+0
+1
+2
+3
+4
E.
Talks about his/her interests
+0
+1
+2
+3
+4
Never
Sometimes
Often
Usually
Always
Sec. #2: +______
3.
Personal Neatness
A.
Is sloppy
–0
–1
–2
–3
–4
B.
Keeps clothes neat
+0
+1
+2
+3
+4
C.
Is messy in eating habits
–0
–1
–2
–3
–4
D.
Keeps self clean
+0
+1
+2
+3
+4
Sec. #3: ______
Subtotal: ______
Transfer subtotal to the back
Å
Enter Licensing Agreement Number Here:
Based on NOSIE–30 (Gilbert Honigfeld, Roderic D. Gillis, and C. James Klett: “NOSIE-30: A Treatment-Sensitive
Ward Behavior Scale.” Psychological Reports 19:180–182, 1966).
Q–18
Fundamentals of Psychiatric Treatment Planning
Kennedy NOSIE
(Page 2 of 2)
4.
Irritability
Never
Sometimes
Often
Usually
Always
A.
Is impatient
–0
–1
–2
–3
–4
B.
Gets angry or annoyed easily
–0
–1
–2
–3
–4
C.
Becomes easily upset if something doesn’t suit him/her
–0
–1
–2
–3
–4
D.
Is irritable and grouchy
–0
–1
–2
–3
–4
E.
Is quick to fly off the handle
–0
–1
–2
–3
–4
Never
Sometimes
Often
Usually
Always
–1
–2
–3
–4
Sec. #4: –______
5.
Manifest Psychosis
A.
Hears things that are not there
–0
B.
Sees things that are not there
–0
–1
–2
–3
–4
C.
Talks, mutters, or mumbles to self
–0
–1
–2
–3
–4
D.
Giggles or smiles to self without any apparent reason
–0
–1
–2
–3
–4
Never
Sometimes
Often
Usually
Always
Sec. #5: –______
6.
Motor Retardation
A.
Sits, unless directed into activity
–0
–1
–2
–3
–4
B.
Sleeps, unless directed into activity
–0
–1
–2
–3
–4
C.
Is slow moving and sluggish
–0
–1
–2
–3
–4
Sec. #6: –______
Final Scoring Section
I. Subtotal from front:
II. Subtotal from back:
III. Kennedy NOSIE total:
–
(Range –76 to +28)
(–76 ÄDysfunctional –––– FunctionalÅ +28)
Rating for last 3 days ________ or typical 3-day period during the last 2 weeks ________
Questionnaires
AIMS Plus EPS
Abnormal Involuntary Movement Scale
Plus Extrapyramidal Side Effects Scale
Q–19
Name:
Hosp #:
Ward:
Date:
Instructions: Rate highest severity observed. Rate movements that occur upon activation one less than those
observed spontaneously.
Code:
0 = None; 1 = Minimal, may be extreme normal; 2 = Mild; 3 = Moderate; 4 = Severe
(circle the appropriate rating below).
Tardive Dyskinesia (Do not include tremors.)
1.
Muscles of facial expression _________________________________________________________ 0
1
2
3
4
1
2
3
4
1
2
3
4
e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling,
grimacing
2.
Lips and perioral area _______________________________________________________________ 0
e.g., puckering, pouting, smacking
3.
Jaw _________________________________________________________________________________ 0
e.g., biting, clenching, chewing, mouth opening, lateral movement
4.
Tongue______________________________________________________________________________ 0
1
2
3
4
5.
Upper extremities (arms, wrists, hands, fingers)________________________________________ 0
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
include choreic movements (e.g., rapid, objectively purposeless, irregular, spontaneous), athetoid movements
(e.g., slow, irregular, complex, serpentine)
6.
Lower extremities (legs, knees, ankles, toes) ___________________________________________ 0
e.g., irregular lateral knee movement, irregular foot or heel movements
7.
Trunk movements (neck, shoulders, hips) _____________________________________________ 0
e.g., irregular rocking, twisting, or squirming or pelvic gyrations
TD Total:
Extrapyramidal Side Effects
1.
Dystonia ____________________________________________________________________________ 0
e.g., persistent spasm usually of the eyes, face, neck, or back muscles (this results in persistent abnormal
positioning of one or more extremities or of the face, neck, or trunk)
2.
Parkinsonism _______________________________________________________________________ 0
e.g., bradykinesia (decreased movement), shuffling gait, masklike facies, resting tremor, drooling
3.
Akathisia ____________________________________________________________________________ 0
e.g., restlessness, pacing, rocking, inability to sit still
4.
Rigidity _____________________________________________________________________________ 0
e.g., increased muscle tone with continuous passive resistance to movement, cogwheel rigidity
5.
Parkinsonian tremor ________________________________________________________________ 0
e.g., slow, rhythmic, present at rest (pill rolling)
6.
Akinesia_____________________________________________________________________________ 0
decreased motor movements often associated with weakness, decreased spontaneous
movements, and paresthesias
EPS Total:
Comments:
Examiner: _________________________________________________________________
Date: ___________
Q–20
Fundamentals of Psychiatric Treatment Planning
Examination Procedure
Either before or after completing the examination procedure, observe the patient unobtrusively, at rest (e.g., in
waiting room). The chair to be used in this examination should be a hard, firm one without arms.
1.
Ask patient whether there is anything in his or her mouth (such as gum or candy) and if there is, to
remove it.
2.
Ask patient about the current condition of his or her teeth. Ask if patient wears dentures. Do teeth or
dentures bother patient now?
3.
Ask patient whether he or she notices any movements in mouth, face, hands, or feet. If yes, ask patient
to describe and to what extent they currently bother patient or interfere with activities.
4.
Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire
body for movements while in this position.)
5.
Ask patient to sit with hands hanging unsupported. If male, between legs, if female and wearing a dress,
hanging over knees. (Observe hands and other body areas.)
6.
Ask patient to open mouth. (Observe abnormalities of tongue movement.)
7.
Ask patient to protrude tongue. (Observe abnormalities of tongue movement.) Do this twice.
8.
Ask patient to top thumb with each finger, as rapidly as possible for 10 to 15 seconds; separately with
right hand, then with left hand. (Observe facial and leg movements.)*
9.
Flex and extend patient’s left and right arms, one at a time.
10.
11.
Ask patient to stand up. (Observe in profile. Observe all body areas again, hips included.)
Ask patient to extend both arms outstretched in front with palms down. (Observe trunk, legs, and
mouth.)*
12.
Have patient walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice.
*Activated movements.
APPENDIX
A–1
This page intentionally left blank
Appendix
A–3
APPENDIX
CONTENTS
Focused Master Treatment Plans .............................................................................................................A–5
Rating Master Treatment Plans..............................................................................................................A–20
Rating Master Treatment Plans (Spreadsheet) ......................................................................................A–27
Nursing Diagnoses..................................................................................................................................A–28
Notes
Appendix
A–5
Focused Master Treatment Plans
Joseph L. Black, MD ,∗ suggests using focused Master Treatment Plans when there is a fairly specific
comprehensive rehabilitation goal (long-term goal) that is the focus of hospitalization. That
comprehensive rehabilitation goal should also be associated with a target date that the patient can
realistically attain in 30 days or less. Such focused treatment plans may be useful in a wide range of
treatment and evaluation settings, such as the following:
•
•
•
•
Treatment for acute detoxification
Treatment for acute psychotic decompensation
Treatment to restore competency to stand trial
Evaluation of criminal responsibility
In such cases, Dr. Black recommends having one comprehensive rehabilitation goal for most, if
not all, of the active problems. For example, when a patient has been admitted from the courts for
restoration of competency to stand trial, the comprehensive rehabilitation goal might be as follows:
Patient will return to the 15th Judicial District Court of Parker County upon demonstrating a
rational and factual understanding of the proceedings against him and sufficient ability to
consult with a reasonable degree of rational understanding.
In these focused Master Treatment Plans, Dr. Black suggests that one should attempt to defer most,
if not all, active problems that are not directly related to the comprehensive rehabilitation goal. These
deferred problems would be addressed after the comprehensive rehabilitation goal has been attained
and the patient has been discharged, transferred, or returned to court.
In these focused Master Treatment Plans, the patient should be expected to respond to treatment
for the active problems in a relatively short period of time, usually less than 30 days. Generally, the
longer the treatment that is needed, the more difficult it becomes to defer other active problems and to
focus on the comprehensive rehabilitation goal. Clearly, treatment for some active problems, especially
a medical problem such as diabetes or seizures, cannot be deferred.
On the following pages, Dr. Black presents a Kennedy Axis V rating and a focused Master
Treatment Plan for a patient, John Lightfoot, who was committed for treatment to restore competency
to stand trial.
∗
Joseph L. Black, MD: “Inpatient Treatment Plan Based on Functional Outcomes Measurement” (Session 6, #18),
American Psychiatric Association Institute on Psychiatric Services, Innovative Programs, Orlando, FL, October 12,
2001.
A–6
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V: Scoring Sheet
Name: John Lightfoot
© 1986–2003
#: F02845
Age:
24
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
ÄÄ FUNCTIONAL
DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Not Impaired___
Antisocially Impaired___
Other Impairment X
Both___
Primarily (check one):
Major psychological impairment AEB auditory and visual hallucinations, delusions of grandeur, and impaired judgment and
insight.
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
Major impairment in social relationships as evidenced by insensitivity to the feelings and needs of others and aggressive,
intrusive behaviors.
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 X 15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Nonviolent___
Violent to Self___
Violent to Others X
Primarily (check one):
Frequently violent. Pt. is in real danger of hurting others and destroying property.
Violent to Self and Others___
4. ADL–Occupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Moderate difficulty in occupational and school functioning.
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Nonabuser___
Alcohol Abuser___
Drug Abuser X
Both___
Primarily (check one):
Pt.’s behavior is considerably influenced by substance abuse, namely his frequent use of Peyote.
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Mild medical problems that may cause some difficulty in social, occupational, or school functioning, including his need to
take prescription meds on a daily basis and his need for periodic medical follow-up.
7. Ancillary Impairment (Optional)
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Major problems with the law AEB his having been found incompetent to stand trial on a charge of aggravated assault with a
deadly weapon and a charge of theft greater than $20,000.
GAF Equivalent:
#1
40
+ #2
40
+ #3
20
+ #4
60
Dangerousness Level (indicate only the most dangerous rating):
Signature:
Joseph Black, M.D.
= 160 /
4
=
40
20
Date:
01/05/03
Appendix
A–7
Name: Lightfoot, John
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Problem List
ID #: F02845
North Texas State Hospital
Area: Spruce Unit
Name of Facility
Date: 01/15/03
Date of Admission: 01/03/03
Problem
Number
Problem Name
Discharge
Barrier*
Date Estab. &
Status**
1.1
Psychotic Symptoms
Yes
01/15/03
Active
2.1
Impaired Social Skills
Yes
01/15/03
Active
3.1
Assaultive Behavior
Yes
01/15/03
Active
4.1
Impaired Occupational Skills
No
01/15/03
Deferred
5.1
Peyote Abuse
No
01/15/03
Deferred
6.0
Health Maintenance
No
01/15/03
Active
6.0a
Rule Out Seizure Disorder
No
01/15/03
Active
7.0
Court Evaluation
Yes
01/15/03
Active
Date Changed
& New Status***
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
A–8
Fundamentals of Psychiatric Treatment Planning
Name: Lightfoot, John
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: F02845
Strengths/Discharge Plan/Diagnosis
Area: Spruce Unit
Date: 01/15/03
Patient’s Strengths (related to treatment and discharge):
•
•
•
•
•
•
•
•
•
Interests: horseback riding and Native American cultures and ceremonies
Good verbal skills
Fluent in both English and Comanche languages; also speaks Spanish and Cheyenne
No self-abusive or suicidal thoughts or behaviors
Average intelligence
Has a driver’s license, though currently suspended due to driving while intoxicated
Has worked in competitive employment as a laborer for up to 6 months
Fairly good physical health
Supportive family when he is not abusing drugs
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
John Lightfoot will return to the 15th Judicial District Court of Parker County upon demonstrating a rational and
factual understanding of the proceedings against him and sufficient ability to consult with a reasonable degree of
rational understanding.
Discharge Coordinated By: Juan Sanchez, MSW
Anticipated Discharge Date: 02/05/03
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
Substance-induced mood disorder with manic features
Substance-induced psychotic disorder with delusions and hallucinations
Hallucinogen dependence (peyote) in a controlled environment
Adult antisocial behavior
AXIS II:
No diagnosis
AXIS III:
No diagnosis
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
40
SOC =
GAF Equivalent =
40
40
40
VIO =
20
ADL =
60
SAb =
Dangerousness Level =
30
MED =
70
20
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /__
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Psychotic Symptoms
A–9
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Disturbed Thought Processes
Date: 01/15/03
Problem Description:
Off and on since 2000, John has had major psychological impairment AEB auditory and visual hallucinations,
delusions of grandeur, and poor judgment and insight. Recently he has reported that he had a vision in which the
Great Spirit appointed him as the leader of his people. Pt. has also made statements to the effect that local laws do
not apply to him. He has been observed by staff to sit motionless for 12 or more hours as if he were in a trance.
John’s poor focal attention, poor judgment, and poor insight impair his taking medication as prescribed.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/05/03
Target Date
1.
John will learn to communicate in a rational, coherent, and
logical manner, AEB being able to engage in a 10-minute
conversation with staff five times a week for 1 week.
01/29/03
2.
John will seek out his unit advisor to get his needs met and to
discuss issues regarding his treatment daily for 1 week.
01/22/03
3.
John will be able to name pertinent information regarding his
medication, including its effect on psychotic symptoms,
consistently for 1 week.
01/22/03
4.
John will accept prescribed medication and necessary lab work for
2 weeks.
01/29/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–10
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Psychoactive meds per Dr. Black’s order by licensed vocational nurse (LVN) supervised
by the RN under the direction of the Nurse Manager.
Joseph Black, MD
Marilyn Davis, RN
2.
Unit advisor will talk with John for 2 hours per week.
Jane Hoover, Rehab
3.
Medication education group with LVN will meet with pt. 2 hours per week.
Marilyn Davis, RN
4.
The case coordinator will correspond with mental health assistant and primary
correspondent, once John signs consent, in order to facilitate aftercare planning.
Juan Sanchez, MSW (Case Coordinator)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.1 Impaired Social Skills
A–11
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Impaired Social Interactions
Date: 01/15/03
Problem Description:
John has major impairment in social relations AEB his insensitivity to the feelings and needs of others and his
aggressive, intrusive behaviors.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/05/03
Target Date
1.
John will learn to interact with others in a socially appropriate
manner, AEB not demonstrating any aggressive, intrusive
behaviors toward others for 2 weeks.
01/29/03
2.
John will be able to learn to consistently identify for 1 week at
least three socially inappropriate behaviors that have led to
conflicts with others and placed him at risk of losing self-control.
01/29/03
3.
John will be able to verbalize an adequate understanding of the
positive aspects, values, beliefs, cultural links, attitudes,
similarities, and differences in both North American and his own
culture and will be able to apply these concepts to increase selfesteem and identity.
01/29/03
4.
John will be able to engage in empathetic conversations with his
family consistently for 2 weeks.
02/05/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–12
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Pt. will participate in on-unit psychosocial rehab group (Social Skills Group) 2 hours
per week.
Jane Hoover, Rehab
2.
Pt. will participate in on-unit psychosocial rehab group (Relating Alternatives Group)
2 hours per week.
Jane Hoover, Rehab
3.
Pt. will participate in on-unit psychosocial rehab group (Cultural Awareness Group)
1 hour twice per week.
Juan Sanchez, MSW Å Roger Sing, MSW
4.
Pt. will participate in Problem-Solving Group with his family 1 hour per week.
Juan Sanchez, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Assaultive Behavior
A–13
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
John has a history of aggressive and assaultive behavior. He is a known gang member; he is reputed to be a gang
leader. Currently he is frequently violent. He is felt to be in real danger of hurting others and destroying property.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
02/05/03
2.
John’s K Axis score for Violence will improve from his current
score of 20 to a score of 60.
02/05/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
John will demonstrate the ability to resolve conflicts and respond
to stressors in a proper manner by using clinical time-out and
discussions with staff consistently for 1 week.
01/29/03
2.
John will learn alternative coping mechanisms to relieve stress,
rather than acting out against others, AEB not being threatening
or assaultive for 2 weeks.
01/29/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Psychoactive meds will be administered per Dr. Black’s order by the LVN/RN
supervised by the RN under the direction of the nurse manager.
Joseph Black, MD
Marilyn Davis, RN
2.
Pt. will participate in on-unit psychosocial rehab group (Stress and Anger Management
Group) 2 hours per week.
Joseph LeBlanc, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.0 Health Maintenance
A–15
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has mild medical problems, including his need to take prescription meds on a daily basis and his need for
periodic medical follow-up. Pt. may have impairment of conscious awareness due to a seizure disorder.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John will continue to maintain an optimal level of health while
hospitalized, AEB compliance with all prescribed meds, lab work,
and treatments for his medical problems.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Same as long-term goal.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.0
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
Doctor will work up John for the possibility of a seizure disorder, including EEG and
referral to Neurology Clinic, and will make appropriate treatment recommendations.
Joseph Black, MD
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor John daily and follow up on any signs and symptoms of illness.
2.
Nsg. staff will administer all prescribed medication and treatments as ordered and will
document John’s compliance.
3.
Nsg. staff will assess and document pt.’s level of understanding of prescribed treatment
and provide necessary teaching at John’s level of understanding.
4.
Nsg. staff will prompt John to comply with treatments, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany John to
procedures. Staff will offer praise for compliance and will document compliance.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.0 Court Evaluation
A–17
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
John was referred to North Texas State Hospital–Vernon pursuant to Article 46.02 Section 5(a) of the Texas Code of
Criminal Procedure after he was found incompetent to stand trial on charges of aggravated assault with a deadly
weapon (to wit: lance, revolver, and scalping knife) and of theft greater than $20,000 (horses and cattle) out of the
15th District Court of Parker County, Texas.
When local examiners evaluated him, pt. sat motionless, stared straight ahead, and refused to speak. He was
subsequently found incompetent to stand trial.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/05/03
Target Date
1.
John will demonstrate an ability to work with his attorney in
preparation of his defense and will display a factual knowledge of
the court system.
02/05/03
2.
John will be able to assist in his defense as determined by no
observations or self-reported statements that reflect poor reality
contact or lack of knowledge of the court processes.
02/05/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.0
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
The treatment team will meet with John as a part of the competency training group for
2 hours per week.
Joseph Black, MD, Team Leader
2.
Pt. will receive counseling with case coordinator 1 hour per week to reinforce realitybased statements that promote competency and discourage those that do not.
Juan Sanchez, MSW, Case Coordinator
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A–19
Name: Lightfoot, John
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: F02845
Signature Page
Area: Spruce Unit
Name of Facility
Date: 01/15/03
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
(Patient’s or guardian’s signature and date)
X
X
(If guardian, relation to patient)
Patient’s Comments (optional):
Staff Members’ Comments (optional):
John is very resistive to treatment. At times he sits motionless for 12 or more hours, as if he were in a trance.
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Joseph Black, MD
Date:
01/15/03
Print Name:
Joseph Black, MD
Nurse:
Marilyn Davis, RN
Date:
01/15/03
Print Name:
Marilyn Davis, RN
Social worker:
-XDQ6DQFKH]06:
Date:
01/15/03
Print Name:
Juan Sanchez, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/15/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Jane Hoover, Rehab
Date:
01/15/03
Print Name:
Jane Hoover, Rehab
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.”
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
A–20
Fundamentals of Psychiatric Treatment Planning
Rating Master Treatment Plans Based on the
Kennedy Treatment Planning System
Instructions
This system for rating Master Treatment Plans uses the following rating scale:
NA
0
1
2
3
=
=
=
=
=
Not applicable
Absent
Unacceptable
Mild to moderate problems
Acceptable to excellent
Rate the 10 sections of a Master Treatment Plan:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Problem List
Strengths
Discharge plan
Psychiatric diagnosis
Problem description
Long-term goals
Short-term goals
Treatment modalities
Changes in goal status and treatment modalities
Signature page
Determine the score for each section:
1.
2.
3.
4.
Rate each applicable component in that section.
Add the scores of each component that was rated.
Divide that total score by the number of rated components.
Round off this number to the nearest whole number.
Record the score for each section on the summary sheet. Determine the plan rating as follows:
1.
2.
3.
Add the scores for each section rated.
Divide that total score by the number of sections rated.
Round off this number to the first decimal place.
A set of blank Master Treatment Plan Rating Forms follows.
Appendix
A–21
SUMMARY SHEET
Master Treatment Plan Rating Form
© 2003 James A. Kennedy, MD
Patient’s Name:
ID#:
Rater’s Name:
Date of Plan:
Section
Rating
Date of Rating:
Comments
1. Problem List
2. Strengths
3. Discharge plan
4. Psychiatric diagnosis
5. Problem description
6. Long-term goals
7. Short-term goals
8. Tx modalities
9. Signature page
10. Goals and Tx modalities
status changes
Total
Comments:
________ ÷ (# of Items Rated) = Plan Rating:
A–22
Fundamentals of Psychiatric Treatment Planning
Master Treatment Plan Rating Form
© 1998–2003 James A. Kennedy, MD
Patient’s Name:
ID#:
Rater’s Name:
Date of Plan:
NA
0
1
2
3
=
=
=
=
=
Date of Rating:
Not applicable
Absent
Unacceptable
Mild to moderate problems
Acceptable to excellent
Start Rating Here (Enter section rating on summary sheet.)
PROBLEM LIST
1. Problem List
Rating
Comments
Problem number
Problem name
Discharge barrier
Date established and status
Date changed and status
Missing problems or placed
in wrong problem area
Missing Individual Problem
Plans
Total
________ ÷ (# of Items Rated) = Section Rating:
Appendix
STRENGTHS/DISCHARGE CRITERIA/DIAGNOSIS
2. Strengths
Rating
Comments
Related to treatment and
discharge
Covers Kennedy strength
areas
Includes interests
Total
3. Discharge Plan
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Discharge environment
Criteria for discharge
Target discharge date
Discharge coordinator
Total
4. Psychiatric Diagnosis
(DSM-IV-TR)
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Axis I
Axis II
Axis III
Axis IV (ancillary impairment)
Axis V (GAF-Eq)
Total
_____ ÷ (# of Items Rated) = Section Rating:
A–23
A–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLANS
5. Problem Description
Rating
Comments
Onset of problem indicated
Description of symptoms
Current severity of symptoms
indicated
Measurability of current
severity of symptoms
Total
6. Long-Term Goals
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Target behaviors indicated
Behaviors observable/
measurable
Frequency and time interval
indicated
Goals relate to problem
description, short-term goals,
and Tx modalities
Target dates present and
reasonable
Dated and numbered
Total
_____ ÷ (# of Items Rated) = Section Rating:
Appendix
INDIVIDUAL PROBLEM PLANS
7. Short-Term Goals
Continued
Rating
Comments
Target behaviors indicated
Behaviors observable/
measurable
Frequency and time interval
indicated
Goals relate to problem
description, long-term goals,
and Tx modalities
Target dates present and
reasonable
Dated and numbered
Total
8. Treatment Modalities
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Relevant disciplines are
included
Modality, time period, and
frequency are included
Related to problem
description and goals
Individual responsible is
identified
Dated and numbered
Total
_____ ÷ (# of Items Rated) = Section Rating:
A–25
A–26
Fundamentals of Psychiatric Treatment Planning
SIGNATURE PAGE
9. Signature Page
Rating
Comments
Plan signed by team members
Patient involvement indicated
Patient/guardian signed plan
or absence explained
Sources of new entries are
identifiable
Total
_____ ÷ (# of Items Rated) = Section Rating:
PLAN GOALS AND TREATMENT MODALITIES STATUS CHANGES
10. Goals and Tx
Modalities Status
Changes
Rating
Comments
If goal changed, new status
and date are indicated
Line drawn through changed
goals
New goals added as needed
Expired target dates are
updated
Modalities are updated as
needed
New modalities are added as
needed
Total
_____ ÷ (# of Items Rated) = Section Rating:
Appendix
A–27
Rating Master Treatment Plans
Example of a Summary of Results Using a Spreadsheet
Inpt./
Outpt.
P. List
Stgths.
D/C Crit.
Dx.
Albert Smith
Inpt.
3
3
3
3
3
3
David Jones
Outpt.
3
3
1
3
3
George Jones
Outpt.
3
3
3
3
Inpt.
2
3
2
3
Michael Jones
Outpt.
3
3
1
Linda Jones
Outpt.
1
3
2
Robert Jones
Outpt.
3
3
1
Name
Mary Jones
Prob.
D.
Ltg. Stg.
Tx.
Mod.
Sig.
Total
Plan
Rating
3
3
3
27
3.0
3
3
3
3
25
2.7
2
3
2
2
2
3
3
25
2.7
2
3
3
22
2.4
3
3
2
3
3
2
3
1
22
2.4
3
2
3
2
21
2.3
3
2
2
2
2
3
21
2.3
Chgs.*
Janet Jones
Inpt.
2
3
0
2
2
2
2
3
1
17
1.8
Alice Jones
Inpt.
1
3
1
3
1
1
1
1
3
15
1.7
William Jones
Inpt.
1
0
1
3
0
3
2
2
2
14
1.6
Brenda Jones
Inpt.
AVERAGE =
1
0
0
0
0
3
2
3
3
12
1.3
2.1
2.5
1.4
2.5
1.9
2.5
2.1
2.6
2.5
20.1
2.2
*This spreadsheet represents ratings of just-completed Master Treatment Plans and, therefore, does not include ratings of subsequent
changes (Chgs.) in Goals and Modalities.
A–28
Fundamentals of Psychiatric Treatment Planning
Nursing Diagnoses
The following pages list nursing diagnoses from Nursing Diagnoses: Definitions and Classifications∗ that
have been categorized according to the Kennedy Axis V subscale areas. This reference should help
nurses to locate the appropriate nursing diagnosis when incorporating the Nursing Care Plan into the
Master Treatment Plan.
This categorization system has been reviewed by Rose Mary Carroll-Johnson, MN, RN, editor,
Nursing Diagnosis: The International Journal of Nursing Language and Classification. Many of the nursing
diagnoses fit into more than one subscale area; therefore, notes in italics help to separate many of the
nursing diagnoses into two or more subscale areas. For example, Activity Intolerance is included under
the subscale areas of Psychological Impairment and Medical Impairment. Its inclusion under
Psychological Impairment is clarified as “Activity Intolerance (related to Psy. Factors)” and its inclusion
under Medical Impairment is clarified as “Activity Intolerance (related to Medical Factors).”
When using the nursing diagnosis, it is not necessary to include the additions to the nursing
diagnoses. Also, some nursing diagnoses may extend into subscale areas that have not been indicated.
This categorization includes only what is felt to be the most likely area or areas that pertain. This is a
guideline; you must use your own clinical judgment when choosing a particular nursing diagnosis, that
is, when pairing a nursing diagnosis to a particular problem name in the Individual Problem Plan
section of the Master Treatment Plan or Nursing Care Plan.
“Health Maintenance” is commonly used as a problem name in treatment planning to allow
clinicians to list treatments that are intended to maintain good or optimal physical health, even when
the patient does not have any significant medical problems. There was no equivalent nursing diagnosis
to pair with Health Maintenance; therefore, it was added to NANDA’s list. As described earlier, it is set
in italics to indicate that it is not an official NANDA-approved nursing diagnosis.
∗
Nursing Diagnoses: Definitions and Classifications 2001–2002. Philadelphia, PA, North American Nursing Diagnosis
Association, 2001.
Appendix
NANDA’S Nursing Diagnoses Categorized by the
Kennedy Axis V
1. Psychological Impairment
Activity Intolerance (related to Psy. Factors)
Activity Intolerance, Risk for (related to Psy. Factors)
Adaptive Capacity, Decreased Intracranial
Adjustment, Impaired
Anxiety
Anxiety, Death
Body Image, Disturbed
Confusion, Acute (related to Psy. Factors)
Constipation, Perceived
Coping, Defensive
Coping, Ineffective (related to Psy. Factors)
Decisional Conflict
Denial, Ineffective
Development, Risk for Delayed (related to Psy. Factors)
Diversional Activity, Deficient
Failure to Thrive, Adult
Falls, Risk for (related to Psy. Factors)
Fatigue
Fear
Fluid Volume, Deficient (related to Psy. Factors)
Fluid Volume, Deficient, Risk for (related to Psy. Factors)
Fluid Volume, Excess (related to Psy. Factors)
Fluid Volume, Imbalance, Risk for (related to Psy. Factors)
Grieving, Anticipatory
Grieving, Dysfunctional
Growth and Development, Delayed (related to Psy. Factors)
Growth, Disproportionate, Risk for Altered (related to Psy. Factors)
Health-Seeking Behaviors, Impaired (related to Psy. Factors)
Hopelessness
Incontinence, Urinary, Functional
Injury, Risk for (related to Psy. Factors)
Loneliness, Risk for
Memory, Impaired (related to Psy. Factors)
Noncompliance
Nutrition, Imbalanced: Less Than Body Requirements (related to Psy. Factors)
Nutrition, Imbalanced: More Than Body Requirements (related to Psy. Factors)
Nutrition, Imbalanced: Risk for More Than Body Requirements (related to Psy. Factors)
Pain, Acute (related to Psy. Factors)
Pain, Chronic (related to Psy. Factors)
Personal Identity, Disturbed
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
Powerlessness
Powerlessness, Risk for
Rape-Trauma Syndrome
Rape-Trauma Syndrome, Compound Reaction
Rape-Trauma Syndrome, Silent Reaction
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Performance, Ineffective
Additions to NANDA’s nursing diagnoses are in italics.
A–29
A–30
Fundamentals of Psychiatric Treatment Planning
Self-Care Deficit, Bathing/Hygiene (related to Psy. Factors)
Self-Care Deficit, Dressing/Grooming (related to Psy. Factors)
Self-Care Deficit, Feeding (related to Psy. Factors)
Self-Care Deficit, Toileting (related to Psy. Factors)
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Situational Low, Risk for
Sensory Perception, Disturbed (related to Psy. Factors)
Sexual Dysfunction (related to Psy. Factors)
Sexuality Patterns, Ineffective
Sleep Deprivation
Sleep Pattern, Disturbed
Social Interaction, Impaired (related to Psy. Factors)
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Suffocation, Risk for (related to Psy. Factors)
Thought Processes, Disturbed (related to Psy. Factors)
Ventilatory Weaning Response, Dysfunctional (related to Psy. Factors)
Wandering (related to Psy. Factors)
2. Social Skills
Communication, Verbal, Impaired
Injury, Risk for (related to Social Skills Deficits)
Social Interaction, Impaired (related to Social Skills Deficits)
3. Violence
Falls, Risk for (related to Violence to Self)
Injury, Risk for (related to Violence to Self)
Self-Mutilation
Self-Mutilation, Risk for
Suicide, Risk for
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
4. ADL–Occupational Skills
Breastfeeding, Ineffective (related to ADL Skills Deficits)
Breastfeeding, Interrupted (related to ADL Skills Deficits)
Confusion, Chronic (related to Retardation/Dementia)
Environmental Interpretation Syndrome, Impaired
Falls, Risk for (related to ADL Skills Deficits)
Health Maintenance, Ineffective
Health-Seeking Behavior, Impaired (related to ADL Skills Deficits)
Home Maintenance, Impaired
Injury, Risk for (related to ADL Skills Deficits)
Knowledge, Deficient
Memory, Impaired (related to Retardation/Dementia)
Poisoning, Risk for (related to ADL Skills Deficits)
Self-Care Deficit, Bathing/Hygiene (related to ADL Skills Deficits)
Self-Care Deficit, Dressing/Grooming (related to ADL Skills Deficits)
Self-Care Deficit, Feeding (related to ADL Skills Deficits)
Self-Care Deficit, Toileting (related to ADL Skills Deficits)
Suffocation, Risk for (related to ADL Skills Deficits)
Therapeutic Regimen Management, Effective
Additions to NANDA’s nursing diagnoses are in italics.
Appendix
Therapeutic Regimen Management, Ineffective
Thought Processes, Disturbed (related to Retardation/Dementia)
Trauma, Risk for (related to ADL Skills Deficits)
Wandering (related to Retardation/Dementia)
5. Substance Abuse
Confusion, Acute (related to Substance Abuse)
Confusion, Chronic (related to Substance Abuse)
Coping, Ineffective (related to Substance Abuse)
Development, Risk for Delayed (related to Substance Abuse)
Falls, Risk for (related to Substance Abuse)
Family Processes, Dysfunctional: Alcoholism
Health Maintenance, Ineffective (related to Substance Abuse)
Injury, Risk for (related to Substance Abuse)
Protection, Ineffective (related to Substance Abuse)
Sensory Perception, Disturbed (related to Substance Abuse)
Thought Processes, Disturbed (related to Substance Abuse)
6. Medical Impairment
Activity Intolerance (related to Medical Factors)
Activity Intolerance, Risk for (related to Medical Factors)
Airway Clearance, Ineffective
Aspiration, Risk for
Body Temperature, Risk for Imbalanced
Breathing Pattern, Ineffective
Breastfeeding, Effective
Breastfeeding, Ineffective (related to Medical Factors)
Breastfeeding, Interrupted (related to Medical Factors)
Cardiac Output, Decreased
Confusion, Acute (related to Medical Factors)
Confusion, Chronic (related to Medical Factors)
Constipation
Constipation, Risk of
Dentition, Impaired
Development, Risk for Delayed (related to Medical Factors)
Diarrhea
Disuse Syndrome, Risk for
Dysreflexia, Autonomic
Dysreflexia, Risk for Autonomic
Falls, Risk for (related to Medical Factors)
Fluid Volume, Deficient (related to Medical Factors)
Fluid Volume, Deficient, Risk for (related to Medical Factors)
Fluid Volume, Excess (related to Medical Factors)
Fluid Volume, Imbalanced, Risk for (related to Medical Factors)
Gas Exchange, Impaired
Growth and Development, Delayed (related to Medical Factors)
Health Maintenance
Health Maintenance, Enhanced
Health Seeking Behaviors (enhanced)
Hyperthermia
Hypothermia
Incontinence, Bowel
Incontinence, Urinary, Reflex
Incontinence, Urinary, Risk for Urge
Incontinence, Urinary, Stress
Incontinence, Urinary, Total
Additions to NANDA’s nursing diagnoses are in italics.
A–31
A–32
Fundamentals of Psychiatric Treatment Planning
Incontinence, Urinary, Urge
Infant Behavior, Disorganized
Infant Behavior, Disorganized, Risk for
Infant Behavior, Readiness for Enhanced Organized
Infant Feeding Pattern, Ineffective
Infection, Risk for (related to Medical Factors)
Latex Allergy Response
Latex Allergy Response, Risk for (related to Medical Factors)
Mobility, Impaired, Bed
Mobility, Impaired, Physical
Mobility, Impaired, Wheelchair
Nausea
Neglect, Unilateral
Nutrition, Imbalanced: Less Than Body Requirements (related to Medical Factors)
Nutrition, Imbalanced: More Than Body Requirements (related to Medical Factors)
Nutrition, Imbalanced: Risk for More Than Body Requirements (related to Medical Factors)
Oral Mucous Membrane, Impaired
Pain, Chronic (related to Medical Factors)
Peripheral Neurovascular Dysfunction, Risk for
Protection, Ineffective (related to Medical Factors)
Sensory Perception, Disturbed (related to Medical Factors)
Sexual Dysfunction (related to Medical Factors)
Skin Integrity, Impaired
Skin Integrity, Impaired, Risk for
Suffocation, Risk for (related to Medical Factors)
Surgical Recovery, Delayed
Swallowing, Impaired
Thermoregulation, Ineffective
Thought Processes, Disturbed (related to Medical Factors)
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective
Transfer Ability, Impaired
Urinary Elimination, Impaired
Urinary Retention
Ventilation, Impaired Spontaneous
Ventilatory Weaning Response, Dysfunctional (related to Medical Factors)
Walking, Impaired
7. Ancillary Impairment
Breastfeeding, Interrupted (related to Environmental Factors)
Caregiver Role Strain
Caregiver Role Strain, Risk of
Conflict, Parental Role
Coping, Community, Ineffective
Coping, Community, Readiness for Enhanced
Coping, Compromised Family
Coping, Disabled Family
Coping, Readiness for Enhanced Family
Development, Risk for Delayed (related to Environmental Factors)
Energy Field, Disturbed
Falls, Risk for (related to Environmental Factors)
Family Process, Interrupted
Growth and Development, Delayed (related to Environmental Factors)
Growth, Disproportionate, Risk for Altered (related to Environmental Factors)
Infection, Risk for (related to Environmental Factors)
Injury, Risk for (related to Environmental Factors)
Injury, Risk for, Perioperative Positioning
Additions to NANDA’s nursing diagnoses are in italics.
Appendix
Latex Allergy Response, Risk for (related to Environmental Factors)
Therapeutic Regimen Management, Community, Ineffective
Therapeutic Regimen Management, Family, Ineffective
Parent/Infant/Child Attachment, Risk for Impaired
Parenting, Impaired
Parenting, Impaired, Risk for
Poisoning, Risk for (related to Environmental Factors)
Suffocation, Risk for (related to Environmental Factors)
Trauma, Risk for (related to Environmental Factors)
Ventilatory Weaning Response, Dysfunctional (related to Environmental Factors)
Additions to NANDA’s nursing diagnoses are in italics.
A–33
Notes
PSYCHIATRIC TREATMENT
PLANNING
Second Edition
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FUNDAMENTALS OF
PSYCHIATRIC TREATMENT
PLANNING
Second Edition
James A. Kennedy, MD
Associate Professor of Psychiatry
University of Massachusetts Medical School
Worcester, Massachusetts
Director
Demonstration Unit
Westborough State Hospital
Westborough, Massachusetts
President
KennedyMD Consulting
Shrewsbury, Massachusetts
Washington, DC
London, England
Copyright
Copyright © 2003 American Psychiatric Publishing, Inc. ALL RIGHTS RESERVED.
Users of the manual are free to make unlimited photocopies of the following: Blank forms for the Master
Treatment Plan and Treatment Plan Review, Step-by-Step Instructions for using the blank forms, Sample Master
Treatment Plan, Quick Reference to Problem Categorization by the Kennedy Axis V, and the AIMS Plus EPS
(Abnormal Involuntary Movement Scale Plus EPS). Permission must be obtained from American Psychiatric
Publishing, Inc., to copy other parts of this manual. Use of the Kennedy Axis V and the Kennedy NOSIE (Kennedy
Nurses’ Observation Scale for Inpatient Evaluation) questionnaires requires a licensing agreement. Royalties may be
waived when these questionnaires are used for piloting or research purposes. Visit www.kennedymd.com for details
on licensing agreements.
Cautionary Note
Books published by American Psychiatric Publishing, Inc., represent the views and opinions of the individual
authors and do not necessarily represent the policies and opinions of APPI or the American Psychiatric Association.
The author has worked to ensure that all information in this manual is accurate at the time of publication
and consistent with general psychiatric and medical standards and that information concerning drug dosages,
schedules, and routes of administration is accurate at the time of publication and consistent with standards set by
the U.S. Food and Drug Administration and the general medical community. As medical research and practice
continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a
specific therapeutic response not included in this manual. For these reasons and because human and mechanical
errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care
or the care of a family member.
This manual is not presented as a standard of care. The clinical examples are just that: examples. They are not
intended to prescribe care for patients. This manual is intended to help treatment teams take a more systematic
approach to treatment planning. Each treatment team must use its own clinical judgment to decide how to use this
manual and its clinical examples. Even within this manual, the examples vary in the standard of care that they set
(i.e., some of the examples represent clearly higher standards than other examples).
The varying nature of the examples in this manual represents to some degree the wide range of treatments
available, as well as varying clinical standards for many clinical problems. Also, there are often different
interpretations of the standards set forth by various accrediting bodies. Finally, treatment teams have a limited
amount of time to complete treatment plans. Many examples are intended to represent plans taken from actual
team meetings; those examples certainly reflect to some degree that limited time.
Users should slowly replace the examples in this manual with examples developed by their own treatment
team members. These examples should better reflect the standards and treatment style expected from their own
treatment teams.
Computerized Treatment Planning
The current standard for computerized treatment planning is to generate the plan using a word processor; however,
this standard is rapidly changing. Visit www.kennedymd.com for updates on computerized treatment planning and
to download electronic copies of blank treatment planning forms.
Also available by Dr. Kennedy: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning
(Washington, DC, American Psychiatric Publishing, 2003)
Manufactured in the United States of America on acid-free paper.
07 06 05 04 03
5 4 3 2 1
Second Edition
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209
www.appi.org
Library of Congress Cataloging-in-Publication Data
Kennedy, James A., 1946–
Fundamentals of psychiatric treatment planning / James A. Kennedy.—2nd ed.
p. ; cm.
Includes bibliographical references.
ISBN 1-58562-061-0 (alk. paper)
1. Mental illness—Treatment. 2. Psychiatric records. 3. Diagnostic and statistical
manual of mental disorders. I. Title.
[DNLM: 1. Mental Disorders—therapy. 2. Patient Care Planning. WM 400 K35f 2003]
RC480.5 K445 2003
616.89′1—dc21
2002027688
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
Preface .......................................................................................................................................... vii
Acknowledgments ....................................................................................................................... viii
Identifying Patient Data.............................................................................................................. viii
Introduction.......................................................................................................................... Intro–1
Master Treatment Plan (Sample)..........................................................................................MTP–1
Psychological Impairment ......................................................................................................... 1–1
Social Skills ................................................................................................................................. 2–1
Violence ...................................................................................................................................... 3–1
ADL–Occupational Skills ............................................................................................................. 4–1
Substance Abuse......................................................................................................................... 5–1
Medical Impairment .................................................................................................................. 6–1
Ancillary Impairment .................................................................................................................. 7–1
Blank Forms ............................................................................................................................. BF–1
Questionnaires............................................................................................................................Q–1
Appendix..................................................................................................................................... A–1
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Fundamentals of Psychiatric Treatment Planning
vii
Preface
This manual forms the cornerstone for the Kennedy Approach to Psychiatric Treatment Planning. This
approach is based on the Kennedy Axis V questionnaire, which organizes psychiatric problems into
seven categories or problem areas:
•
•
•
•
•
•
•
Psychological Impairment
Social Skills
Violence
Activities of Daily Living (ADL)–Occupational Skills
Substance Abuse
Medical Impairment
Ancillary Impairment
This approach allows use of the Kennedy Axis V to capture baseline problems and baseline level of
functioning for each of these problem areas. These baseline findings can then flow directly into the
Master Treatment Plan and Nursing Care Plan via the Problem List and the problem descriptions. This
approach can then continue through Treatment Plan Reviews and Nursing Care Plan Reviews, progress
notes, and measurements of outcome.
This manual includes blank Master Treatment Plan forms, blank Treatment Plan Review forms,
sample Master Treatment Plans, and numerous sample Individual Problem Plans. In addition to this
manual and the Kennedy Axis V questionnaire, support for the Kennedy approach is available in
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric
Publishing 2003) and online.
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning is both a training manual
and a reference for the Kennedy Axis V questionnaire. It maximizes your ability to use the Kennedy Axis
V to capture, track, and profile your clinical impressions. Numerous clinical vignettes demonstrate the use
of the Kennedy Axis V.
Mastering the Kennedy Axis V also shows how the Kennedy Axis V can condense your psychiatric
outcome measures into a single clinical instrument, including using the Global Assessment of
Functioning (GAF) Equivalent to replace the GAF Scale and using the Kennedy Axis V’s subscales to
replace or act as a screening tool for other instruments that focus on specific problem area(s).
Online Support
Visit www.kennedymd.com for support and updates to the Kennedy approach to psychiatric treatment
planning and outcome measurement, including additional sample plans, training and credentialing
opportunities, updates of blank forms, and other information.
viii
Fundamentals of Psychiatric Treatment Planning
Acknowledgments
I express my gratitude to the contributors to the first edition of this manual. Their help was essential to
its success. Many aspects of the first edition continue to be vital to treatment planning, therefore, they
have been included in this edition.
Since the first edition, many clinicians have helped with numerous suggestions and clinical
examples related to treatment planning, many of which have been integrated into this second edition.
Especially useful have been recommendations relating to the integration of the Nursing Care Plan into
the Master Treatment Plan. Clinicians from a wide range of facilities, as well as visitors to
www.kennedymd.com, have provided suggestions and help.
At Worcester State Hospital, Worcester, Massachusetts, I owe thanks to many current and past
nursing and psychiatric staff who were helpful with the integration of the Nursing Care Plan into the
Master Treatment Plan. Also, staff in the Mental and Behavioral Health Services at Our Lady of the Lake
Hospital, Baton Rouge, Louisiana, were very supportive, including Frank Silva, MD, medical director,
and Cami Ledford, BSN, RNC, clinical instructor.
I express my appreciation to Rose Mary Carroll-Johnson, MN, RN, editor, Nursing Diagnosis: The
International Journal of Nursing Language and Classification. She provided vital help with the integration
of nursing diagnoses into the Master Treatment Plan.
My thanks to Gretchen H. Horner, RNC, former administrative director, Memorial Hospital,
Johnstown, Pennsylvania, and Kathy Andolina, RN, MSN, CS, at The Center for Case Management, Inc.,
South Natick, Massachusetts, for their support of the concept of using an outcome measure to help
structure and track clinical care.
Special thanks to Chris Beaudoin, CNS, for her support during my visits to work with staff on
treatment planning at Greater Bridgeport Community Mental Health Center, Bridgeport, Connecticut;
Steve Sorkin, PhD, for his support during my work with staff on treatment planning at the Northern
Virginia Mental Health Institute, Falls Church, Virginia; and Dorothy Erney, RRA, Quality Coordinator,
Binghamton Psychiatric Center, Binghamton, New York. I also express my thanks to staff from the
Hudson River Psychiatric Center, Poughkeepsie, New York, and the New Hampshire Hospital, Concord,
New Hampshire.
I appreciate Joseph Black, MD, Chief Psychiatrist, Competency Program, North Texas State
Hospital–Vernon, Vernon, Texas, for his years of support for my systematic approach to psychiatric
treatment planning, including the use of the Kennedy Axis V questionnaire. The appendix includes a
sample Master Treatment Plan provided by Dr. Black, which is organized around the Kennedy Axis V
subscales.
Finally, without the structure provided by the Kennedy Axis V questionnaire, this manual would
not be possible; therefore, I refer you to the “Acknowledgments” section in the companion manual,
Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (American Psychiatric
Publishing 2003).
Identifying Patient Data
The patient and client names and associated responsible staff and treatment facilities used in this book
are fictitious. They are intended to aid in identifying individual Master Treatment Plans, Treatment
Plan Reviews, and Individual Problem Plans being discussed among staff using this manual. Even
though patient names are fictitious, the plans are based on many years of clinical experience writing
psychiatric treatment plans and gathering case material from colleagues and conferences.
Even though the plans and reviews are not based on actual cases, they are usually composites of
actual cases; therefore, the plans should resemble plans that would be generated during actual team
meetings. Identifying data has been changed or eliminated. Any resemblance to or association with real
individuals is purely coincidental.
INTRODUCTION
Intro–1
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Introduction
Intro–3
INTRODUCTION
CONTENTS
History and Development of the Manual .......................................................................................... Intro–5
Overview ................................................................................................................................................... Intro–5
Moving From Diagnosis to Level of Functioning ...................................................................................... Intro–5
Kennedy Axis V ......................................................................................................................................... Intro–5
Abbreviations ............................................................................................................................................ Intro–6
Online Support.......................................................................................................................................... Intro–7
Rationale for Categorization of Problems by the Kennedy Axis V .................................................... Intro–8
Overview ................................................................................................................................................... Intro–8
No Perfect Fit............................................................................................................................................. Intro–9
Quick Reference to Problem Categorization by the Kennedy Axis V ........................................................ Intro–9
Quick Reference to Problem Categorization by the Kennedy Axis V .............................................. Intro–10
General Instructions for Treatment Planning.................................................................................. Intro–11
Overview ................................................................................................................................................. Intro–11
Is It Necessary to Use This System and the Forms in This Manual? ........................................................ Intro–11
Standards for Treatment Planning and Use of the Manual by Accreditors.............................................. Intro–12
Treatment Planning Depends on the Total Clinical Picture.................................................................... Intro–13
Treatment Plan Reviews .......................................................................................................................... Intro–13
Integration of the Nursing Care Plan Into the Master Treatment Plan ................................................... Intro–14
Significant Problems Should Not Be Omitted From the Problem List ..................................................... Intro–14
Tracking the Flow of Treatment .............................................................................................................. Intro–15
Date Problem Established Versus Date of Onset...................................................................................... Intro–15
Long-Term Goals and Short-Term Goals Versus Goals and Objectives ................................................... Intro–15
Treatment Goals Versus Treatment Modalities ....................................................................................... Intro–16
Treatment Modalities That Have Effects Across Problem Areas............................................................... Intro–17
Steps for Building Goals and Treatment Modalities ................................................................................ Intro–18
Individual Problem Plan for Each Active Problem .................................................................................. Intro–19
Avoiding Excessive Documentation ........................................................................................................ Intro–20
Inclusion of Milieu Staff in Treatment Planning..................................................................................... Intro–23
Master Treatment Plan Forms (Step-by-Step Instructions)............................................................. Intro–24
Problem List/Cover Sheet ........................................................................................................................ Intro–24
Strengths/Discharge Plan/Diagnosis Page ............................................................................................... Intro–30
Individual Problem Plan.......................................................................................................................... Intro–31
Signature Page ......................................................................................................................................... Intro–34
Treatment Plan Review Form .................................................................................................................. Intro–34
Notes
Introduction
Intro–5
History and Development of the Manual
Overview
First, I would like to say that I am a clinician and much of my clinical experience comes from my work
over many years primarily at Worcester State Hospital in Worcester, Massachusetts. My expertise in
treatment planning comes from developing treatment plans as a member, and often as the leader, of a
treatment team. I also act as a consultant to help other clinicians improve their treatment plans. Since
the first edition of this manual was published in 1992, it has been the standard for treatment planning
throughout the country. Before its publication, I saw numerous treatment planning systems fail because
of their inability to manage the complexity of treatment planning. This was especially true when it
came time to review and modify the plan. The first edition has helped guide clinicians and
administrators toward a much more rational and systematic approach to treatment planning. This
second edition will further efforts toward improving the quality of treatment plans and will improve
the efficiency of writing treatment plans.
As with the first edition, the second edition is built around the structure of the Kennedy Axis V
(formerly the Axis V Subscales). Outcome measurement is a vital part of the treatment planning process.
Therefore, Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning (Kennedy
2003), which introduces the latest version of the Kennedy Axis V, is released in conjunction with this
second edition of Fundamentals of Psychiatric Treatment Planning.
Moving From Diagnosis to Level of Functioning
Because of the increasing importance of treatment planning and continuing difficulties with this
process, I began attempting to develop a system that would allow our treatment teams to more
effectively plan, document, evaluate, and revise treatment. The first step in that process involved
moving from diagnosis to psychiatric symptoms and level of functioning as the basic system of
categorization used for treatment planning.
Most psychiatric treatment and nursing care planning manuals address treatment planning from
the perspective of the diagnosis. However, for many years, treatment planning has been mostly based
on a problem-oriented record. A major difficulty in organizing treatment planning around the diagnosis
is the fact that symptoms and behaviors are by no means unique to a diagnosis or even a group of
diagnoses. Also, level of functioning, not diagnosis, often determines treatment needs, including the
need for hospitalization. Therefore, this manual is based on categories of the symptoms and behaviors
that make up Problem Lists.
Kennedy Axis V
To develop this systematic approach to treatment planning, I selected Axis V from the Diagnostic and
Statistical Manual of Mental Disorders. Axis V, which measures psychiatric symptoms and level of
functioning, seemed ideal because of its focus on adaptive, problematic behaviors and outcome. In the
next step, drawing from Axis V and similar scales, I developed the Kennedy Axis V (see the
“Questionnaires” section of this manual for a copy of the Kennedy Axis V).
The Kennedy Axis V divides the symptoms and behaviors from Axis V into four problem areas:
Psychological Impairment, Social Skills, Violence, and ADL–Occupational Skills. To complete the
problem categorization, I added Substance Abuse, Medical Impairment, and Ancillary Impairment. This
categorization forms the basic structure of the manual. The categories are elaborated in the next section,
“Rationale for Categorization of Problems by the Kennedy Axis V.” In addition, the Kennedy Axis V can
be used to measure outcome of treatment in each of the subscale areas.
Intro–6
Fundamentals of Psychiatric Treatment Planning
Abbreviations
The following abbreviations are often associated with the treatment planning system presented in this
book:
AA
Alcoholics Anonymous
ADL
Activities of Daily Living–Occupational Skills
AEB
As evidenced by
AIMS Plus
EPS
AIMS Plus Extrapyramidal Side Effects
AIMS
Abnormal Involuntary Movement Scale
ANC
Ancillary Impairment
ASA
Aspirin (acetylsalicylic acid)
AWA
Away without authorization
bid
Twice a day
BP
Blood pressure
BPRS
Brief Psychiatric Rating Scale
BUN
Blood urea nitrogen
COPD
Chronic obstructive pulmonary disease
COTE
Comprehensive Occupational Therapy
Evaluation
CT scan
Computer-aided tomography scan
DBT
Dialectical behavioral therapy
DL
Dangerousness Level
ECG
Electrocardiogram
ECT
Electroconvulsive therapy
EEG
Electroencephalogram
EPS
Extrapyramidal side effects
FBS
Fasting blood sugar
GAF Eq
GAF Equivalent
GAF Scale
Global Assessment of Functioning Scale
HS
Hour of sleep
Hx
History
Hz
Hertz (cycles per second)
IPP
Individual Problem Plan
K Axis
Kennedy Axis V
LTG
Long-Term Goal
MED
Medical Impairment
meds
Medications
MHA
Mental health assistant
MHW
Mental health worker
Introduction
MRI
Magnetic resonance imaging
MTP
Master Treatment Plan
NCP
Nursing Care Plan
Nsg.
Nursing
po
By mouth, orally
prn
As needed
PSY
Psychological Impairment
pt.; pts.; pt.’s
Patient, patients, patient’s
q
Every
R/O
Rule out
SAb
Substance Abuse
SNF
Skilled nursing facility
SOC
Social Skills
SSDI
Social Security Disability Income
SSRI
Selective serotonin reuptake inhibitor
STD
Sexually transmitted disease
STG
Short-Term Goal
Sx
Symptoms
TLE
Temporal lobe epilepsy
TPR
Treatment Plan Review
Tx
Treatment
VIO
Violence
WBC
White blood cell count
WNL
Within normal limits
Intro–7
Online Support
Visit www.kennedymd.com for support and updates of the Kennedy Approach to Psychiatric Treatment
Planning and outcome measurement using the Kennedy Axis V questionnaire. Additional sample plans,
training opportunities, updates of blank forms, and other materials are also available at the website. You
can contact the author at the website and you are encouraged to make comments or ask questions
about psychiatric treatment planning.
Intro–8
Fundamentals of Psychiatric Treatment Planning
Rationale for Categorization of Problems by the
Kennedy Axis V
Overview
The purpose of this categorization system is to simplify problem identification and planning by
grouping problems using the Kennedy Axis V. The wide range of psychiatric symptoms and behaviors
are divided into the four broad categories of the Kennedy Axis V:
1.
2.
3.
4.
Psychological Impairment
Social Skills
Violence
ADL–Occupational Skills
To complete the system, the following three categories were added:
5. Substance Abuse
6. Medical Impairment
7. Ancillary Impairment
The use of the Kennedy Axis V Categorization System for problem identification and treatment
planning has several advantages:
•
•
•
•
•
These categories are not new theoretical areas. The areas are well known to clinicians and they
make a lot of clinical, intuitive sense. The areas are consistent with much of the training
received by clinicians. Because of the universal nature of the categories, they can be easily used
across disciplines. Minimal training is required to understand the categories.
By going step by step through these seven categories, practitioners can take a systematic
approach to identifying the problems. When one has proceeded through these seven
categories, one is very unlikely to have overlooked significant clinical areas.
Many symptoms and behaviors cluster together in syndromes that can be found within each of
the seven areas. Therefore, treatment can be directed at the syndrome within a problem area,
rather than at several individual problems. For example, use “depressive symptoms” rather
than “sadness,” “loss of appetite,” “insomnia,” and “lethargy.”
Training can be directed toward the individual categories as well as toward the categories as an
interactive system.
Finally, the Kennedy Axis V can be used to measure baseline functioning and the outcome of
treatment.
The Kennedy Axis V Categorization System allows the clinician to set a reasonable balance
between being too broad when defining problems and being too specific. Problem Lists that are broken
up into a lot of individual, discrete problems often lead to treatment plans and progress notes that are
choppy and disconnected. Defining a problem somewhat broadly allows clinicians to more easily
integrate what is happening in a clinically meaningful way. Progress notes tracking treatment and its
outcome are often more coherent and useful when directed at syndromes consisting of discrete
problems. However, the use of very discrete problems can tighten up one’s thinking and planning.
There are certainly advantages to directing treatment toward individual, discrete problems as opposed
to very broad groups of problems. Again, the Kennedy Axis V Categorization System allows clinicians to
set a reasonable balance between discrete versus broad problem names based on one’s clinical
judgment.
The system discourages collapsing problems from separate subscale areas into a single problem,
even though there may be a clear relationship between the problems. For example, “depressive
symptoms” and “suicidal ideation” should not be collapsed into a single problem, nor should “cocaine
Introduction
Intro–9
abuse” and “assaultiveness” be collapsed into a single problem, even if there is a clear relationship
between the problems.
If a problem area consists of a single, specific symptom or behavior, a broad problem name should
not be used. For example, “psychotic symptoms” should not be used if the patient’s only symptom of
psychosis is paranoia.
No Perfect Fit
Any classification system that attempts to divide human behaviors into their component parts will
quickly run into areas in which the components do not fit cleanly into one problem area or “box.” In
such systems, ambiguity and disagreement about where particular symptoms and behaviors should be
placed is unavoidable. Despite the drawbacks and difficulties of classifying human behavior, use of the
Kennedy Axis V Categorization System serves to organize the complexity of clinical features that
patients present.
As indicated earlier, if a syndrome does not fit into one problem area, the syndrome should be
broken down so its components can fit into the appropriate problem areas. For example, “suicidal
ideation“ should be removed from “depressive symptoms” and placed under the subscale area of
Violence. “Lack of motivation” should be removed from the problem of “poor job skills” and placed
under the subscale of Psychological Impairment. Further, “lack of motivation” may be placed under the
problem name of “depressive symptoms” or “psychotic symptoms.”
Quick Reference to Problem Categorization by the Kennedy Axis V
The next page in this manual, “Quick Reference to Problem Categorization by the Kennedy Axis V,” can
be copied and used as a reference guide to problem names. Additional listings of problem names and
descriptions classified by the Kennedy Axis V can be found at the beginning of each chapter on the
individual subscale areas of the Kennedy Axis V.
Intro–10
Fundamentals of Psychiatric Treatment Planning
Quick Reference to Problem Categorization
*
by the Kennedy Axis V
This classification system serves to simplify problem identification and treatment planning by
categorizing problems using the Kennedy Axis V subscales. The wide range of psychiatric and medical
symptoms, syndromes, and issues are divided into the following seven problem areas. Listed below are
some examples of problems from each of the seven areas.
1.
Psychological Impairment
Psychotic symptoms
Poor motivation
Mood disturbance
Personality disturbance
Poor focal attention
Eating disturbance
2.
Social Skills
Limited interpersonal skills
Poor communication skills
Lack of awareness of social norms
Sexually inappropriate behavior
3.
Violence
Threatening and assaultive
Suicidal
Homicidal
Sexually violent
Arsonist
4.
ADL–Occupational Skills
Poor job skills
Lack of skills to care for self
Poor workmanship
Lack of basic survival skills
Poor personal hygiene skills
5.
Substance Abuse
Alcohol abuse
Cocaine abuse
Polysubstance abuse
Nicotine addiction
6.
Medical Impairment
Hypertension
Allergy to penicillin
Diabetes
Family planning concerns
Tardive dyskinesia
Dental problems
7.
Ancillary Impairment
Homelessness
Financial problems
Abusive spouse (domestic violence)
Legal problems
Incarceration
Need for guardianship
Permission granted by American Psychiatric Publishing, Inc., and James A. Kennedy, MD, to copy this page.
Introduction
Intro–11
General Instructions for Treatment Planning
Overview
These instructions are intended to address a few of the key issues often raised when doing treatment
planning, including nursing care planning. This manual is based to a great degree on treatment
planning for long-term-care patients. However, the principles and methods can be generalized to any
psychiatric treatment setting or population. This manual is based on the assumption that the Master
Treatment Plan (MTP) can form the working center of the patient’s record (see Figures 1 and 2). It can
guide staff through complicated, interdisciplinary treatment processes.
Certainly it is hoped that the manual will be used as a reference and teaching guide outside the
treatment team; however, its main function is to assist team members during the actual planning
process. To this end, I attempted to make the manual thorough, but brief. Further, the organization of
the manual is intended to allow rapid access to needed material during the actual treatment team
meeting. Quick access to information is critical during the limited time for a team meeting. Therefore,
tabbed divider pages and separate numbering for each section facilitate access to information.
Comprehensive lists of problems, goals, and treatment modalities characterize the manual. To a
great degree, the complexity of human symptoms and behaviors, as well as the limitless range of goals
and the numerous treatment approaches, drove the length of these lists. A close look at the lists reveals
many entries that should apply to patients whose MTPs you are currently writing.
Finally, it is suggested that you explore using the Kennedy Approach to Psychiatric Treatment
Planning across inpatient and outpatient care providers. A standard MTP approach across treatment
providers can be very helpful to ensure continuity of care.
Database Assessments
Psychological
Tests
Master Treatment Plan
Consults
&
Laboratory Tests
Nursing Care Plan
Progress Notes
&
Legal
Treatment Plan Reviews
Physician’s
Orders
Figure 1. Treatment plans do not stand alone. The treatment plan, including the Nursing Care Plan, is the engine that
drives the treatment process; however, it must work in conjunction with the rest of the patient’s record. Only when the
treatment plan is working effectively with the other sections of the patient’s record will it be acceptable to the accreditors
as well as to the clinicians who use the plan.
Is It Necessary to Use This System and the Forms in This Manual?
What if you do not want to change to this system or use the forms included in this manual? Because
almost all accreditors require treatment plans with behaviorally oriented problem definitions,
measurable treatment goals, and treatment modalities, this manual will be useful even when the
Intro–12
Fundamentals of Psychiatric Treatment Planning
clinicians are not using the systematic approach and forms in this manual. The audience to which this
manual is addressed includes staff at psychiatric hospitals, halfway houses, and community mental
health centers and students in academic programs—that is, anyone working where treatment planning
or nursing care planning is practiced or taught.
Problem List
Problem
Description
Goals and Target
Dates
Master Treatment Plan
Strengths
&
Treatment
Modalities
Nursing Care Plan
Diagnosis
&
Discharge
Planning
Treatment Plan Reviews
Signatures
Status and Status Changes
Figure 2. The parts of the treatment plan, including the Nursing Care Plan, must work together as a unit. The goals and
treatment modalities should reflect the problem description. The treatment modalities should consist of treatments that
will help attain the goals. The signatures should reflect real contributions to the interdisciplinary plan. The plan should be
able to easily and accurately reflect any changes or additions in the goals, treatment modalities, target dates, and so
forth. Without these capabilities, it will not be an effective tool for clinicians.
Standards for Treatment Planning and Use of the Manual by Accreditors
The treatment planning system presented in this manual is increasingly becoming the standard for
psychiatric treatment planning. This is evidenced as accreditors and consultants use this manual as a
standard for comparison when checking psychiatric treatment plans. Also, the manual is well known to
many reviewers and consultants who use it when making decisions and recommendations concerning
psychiatric treatment planning. For example, an accreditor could compare a patient’s plan on “suicidal
ideation” with an Individual Problem Plan (IPP) on suicidal ideation in the Violence subscale section of
this manual. In the same section, the accreditor could compare the plan against lists of goals and
treatment modalities that address the suicidal patient, as well as suggestions on what would be expected
in the problem description of a patient with suicidal ideation.
Use of this manual makes it much easier for an accreditor to discuss how treatment planning
deviates from what he or she sees as acceptable. In addition, by using this manual, the mental health
facility can more intelligently respond to any criticism by the accreditor and more easily implement
corrective actions within the facility. The accreditors may also modify this manual so that it
approximates the standard of care expected in a specific type of facility.
Increasingly, there are accepted standards of treatment for various psychiatric symptoms and
behaviors. This manual will continue to be a part of the process of developing such standards in
treatment planning. As a part of those standards, it is hoped that increasingly there will be support for
the integration of formal outcome measures into the treatment planning process. The Kennedy Axis V
questionnaire is presented as ideal for meeting such a standard.
Introduction
Intro–13
Treatment Planning Depends on the Total Clinical Picture
Treatment planning cannot be conducted in a vacuum (see Figure 1). It touches on and interacts with
all aspects of the clinical process. Of special importance is the interaction between the treatment plan
and the discipline assessments and progress notes. The need for thorough assessments and good
progress notes cannot be overstated. Without accurate, complete clinical evaluations by the various
disciplines, rational treatment planning and reviewing are impossible. Once the assessments are
completed, a consistency must be established between the assessments and the MTP. This consistency
must then continue between the plan and progress notes. Accreditors often cite inconsistencies between
the treatment plan and the assessments or progress notes as deficiencies.
Treatment Plan Reviews
Once the MTP has been completed, subsequent changes in the plan must be documented. This is done
through formal Treatment Plan Reviews during a treatment team meeting and through less formal
documentation, such as using progress notes to document changes. The day-to-day changes in the
patient’s status and progress toward goals are generally captured in the progress notes. These changes
are then summarized in subsequent Treatment Plan Reviews.
Accreditors, such as the Joint Commission on Accreditation of Healthcare Organizations and CMS
(Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration
[HCFA]), generally require formal treatment plan reviews in the following situations:
•
•
•
•
When the patient is admitted, transferred, or discharged
When a major change occurs in the patient’s clinical condition
When the patient has successfully completed any treatment goals
When the patient fails to reach treatment goals despite reasonable clinical care
These formal Treatment Plan Reviews are generally used to review, summarize, and update changes.
These formal reviews are also used to ensure that changes in treatment are added or have been added to
the MTP itself.
Scheduling team meetings to immediately review changes is often impossible. The inability to hold
a treatment team meeting each time a review is needed or a change is made in the treatment plan is
often dealt with in one of two ways:
1. A team member who wants a change in the treatment plan discusses the change with available,
relevant team members. The patient should also be included in this process to the degree that
is clinically appropriate. If it is decided that the plan should be changed, the team member
enters the change on the MTP and dates and initials the change. The team member enters
details of the change and the rationale for the change in the progress notes. At the next
treatment team review, the change is discussed with the entire treatment team.
2. The same as #1, except no entry is made on the treatment plan until the next Treatment Plan
Review meeting. As in #1, a team member enters details of the change and the rationale for the
change in the progress notes.
When a change in the plan occurs, it is unacceptable not to make an entry in one of the following: the
Master Treatment Plan, the Treatment Plan Review, or the Progress Notes.
Finally, the clinical team may be so conservative in its definition of “major changes” or
“reasonable clinical care” that few, if any, formal Treatment Plan Reviews occur. Therefore, to ensure
that treatment reviews occur at least with some minimal frequency, it is recommended to use a
combination of reviews according to the four clinical requirements mentioned earlier, as well as
scheduled periodic reviews. For example, for a very stable patient, Treatment Plan Reviews might be
scheduled for every 3 months. If a review were done before 3 months, then the next review would be
rescheduled for 3 months following the last completed review. This schedule would ensure that a
review is done at least every 3 months, as well as when clinically indicated by the clinical criteria.
Intro–14
Fundamentals of Psychiatric Treatment Planning
The minimal frequency for formal Treatment Plan Reviews should be based on the usual rate of
change in the patients’ clinical treatment/status within a particular facility or unit within the facility.
For many facilities, it seems reasonable to have a scheduled review every month for the first 6 months
to 1 year and every 2 to 4 months thereafter. One may also want to make allowances for patients
readmitted after only a short time out of the hospital.
Integration of the Nursing Care Plan Into the Master Treatment Plan
There is tremendous overlap between the MTP and the Nursing Care Plan (NCP). The description of the
problems (nursing diagnoses), including response to previous treatments, should be identical. The
nursing interventions on the NCP and the MTP should be essentially identical; therefore, simply
consolidating them into the MTP can eliminate the redundancy. All members of the team should be
working toward the same long-term goals and short-term goals (objectives), even though specific team
members may be more focused on particular goals. Therefore, it is recommended that nursing staff
integrate the NCP into the MTP rather than have separate plans.
Because the nursing interventions (nursing treatment modalities) often form the main component
that differentiates the MTP from the NCP, it is suggested that the nursing interventions (treatment
modalities) in the MTP be labeled as the “Nursing Care Plan.”
Another equally important reason for integrating the NCP into the MTP is to encourage nursing
staff to be more actively involved with the development and implementation of the MTP. It is not
unusual for nursing staff members to complete their NCP and feel they have met their obligations to
the treatment planning process. They may then move forward with implementing their plan with
minimal investment in the MTP—that is, they feel little ownership of the MTP because they already
have their own plan.
Nursing staff may even see the NCP as a means of separating themselves from the problems,
difficulties, and even at times the chaos that can be associated with poorly developed MTPs. With their
own plan, nursing staff members may not have to worry about the difficulties of becoming an
integrated member of the team process. They have their separate, defined role as outlined in their NCP.
If there are problems with the MTP, those problems can be seen as problems for other team members.
Because they have their own plan, nursing staff members may have little vested interest in the MTP.
Finally, it is suggested that the inclusion of the NCP in the MTP be the “standard of care.”
Throughout this manual, it is assumed that the NCP has been integrated into the MTP. Often in this
manual, you will see that the NCP has been clearly indicated as part of the MTP; however, even when
not clearly indicated, it should be understood that the NCP has been integrated into the MTP.
Significant Problems Should Not Be Omitted From the Problem List
If the Problem List is complete, clinicians will not be surprised by significant clinical issues or problems
lost or buried in the patient’s chart. Generally the Problem List is the only place in the chart where
there is a comprehensive, condensed, and updated outline of all significant clinical issues. This list is a
key part of any clinical chart. The Problem List is one of the first places clinicians should go when
attempting to get a quick overview of the patient’s clinical situation.
To help ensure that significant problems are not overlooked, when determining the Problem List
you should work your way systematically through each problem area, starting with Problem Area 1
Psychological Impairment and ending with Problem Area 7 Ancillary Impairment.
The Problem List should contain all significant clinical problems. In addition to the obvious
problems, the Problem List should contain items such as history of assaultive behavior, history of
suicidal attempt, allergy to penicillin, single kidney, and so on. These problems should not be listed if
they are felt to be of no clinical significance (e.g., if the suicidal attempt was an isolated incident that
occurred years ago and is of no future clinical relevance to the case). Problems should not be listed if
they are already incorporated into an active problem. Allergies do not need to be included on the
Problem List if there is already a system in place to prominently display allergies in the patient’s record.
Also, in addition to problems, the list should contain other clinical factors that require treatment
or clinical resources, such as pregnancy, criminal charges, Tarasoff warning, placement, health
Introduction
Intro–15
maintenance, and so on. This is the treatment plan, not the problem plan; therefore, important areas
involving treatment should not be omitted from the treatment plan simply because they are not seen as
a “problem.”
Tracking the Flow of Treatment
A very important feature of the treatment planning system in this manual is the innovative ability of
the IPP forms to illustrate the flow of treatment. The clinical process is a fluid process; therefore, the
treatment planning system and forms must be able to reflect the progressive changes that occur in the
clinical process. This system is able to capture the changes in treatment when the patient progresses to
the point that new treatments are clinically useful. It can also capture any changes in treatment when
the desired results are not obtained. The details on the use of the IPP forms to track the flow of
treatment are presented in the “Master Treatment Plan Forms (Step-by-Step Instructions)” section
presented later in this chapter.
Date Problem Established Versus Date of Onset
There is often confusion over the difference between the “date established” for the problem and the
“date of onset” of the problem. The date established serves the purpose of marking how far back into
the chart one should search to review the documentation on a problem. Without a date established, the
entire chart might have to be searched to find all the information on a problem. In a long-term-care
facility, this could mean unnecessary searching through years of records.
The date of onset of the problem means exactly what it says. The date of onset is often at or near
the date the problem was established. However, these two dates can often be very different. There are
often major problems in psychiatry determining the date of onset of a problem. The onset of many
psychiatric problems is insidious. It is not unusual for the onset to span a period of years. Attempting to
establish an exact date for onset of a problem often leads to long, nonproductive arguments within the
treatment team. The date of onset of the problem is certainly important and, if known, can be included
in the description of the problem. Figure 3 shows a few examples.
1.1 Depressive Symptoms
Problem Description: Over the last several months, there has been a progressive return of patient’s
depression. About 2 weeks ago, there was a marked worsening in association with several arguments
with his wife …
3.1 Suicidal Attempt
Problem Description: Patient’s first suicidal attempt was at age 13; however, about 8 years passed
before his next attempt just before his current hospitalization …
6.1 Laceration of Left Forearm
Problem Description: The laceration on the patient’s left forearm occurred on 01/01/03 as a result of
his suicidal attempt with a razor …
Figure 3.
Examples of the date of onset.
In these examples, except for “laceration of left forearm,” various arguments could be put forth as
to which date to include as the date of onset. These arguments can be very time consuming. Including
this information in the problem description allows the clinicians the opportunity to explain the
progression of the development of a problem and often eliminates the arguments and confusion.
Long-Term Goals and Short-Term Goals Versus Goals and Objectives
In this system, long-term goals and short-term goals are used to track outcome of treatment. In other
treatment planning systems, especially NCPs, the terms “goals” and “objectives” are substituted for
“long-term goals” and “short-term goals.”
Intro–16
Fundamentals of Psychiatric Treatment Planning
Use of either pair of outcome measures is acceptable; however, the use of long-term goals and
short-term goals has several advantages.
• The phrases “long-term goals” and “short-term goals” are unambiguous. Little or no training is
needed to have at least some working understanding as to the meaning of these phrases.
However, the term “objective” has a wide range of commonly used meanings. Due to its wide
range of definitions, the introduction of “objective” can be confusing to the writer and anyone
who reads the plan. This confusion leads to the need for additional training, which can be timeconsuming and expensive.
• The concepts of long-term goals and short-term goals fit very well along a continuum. However,
goals and objectives do not intuitively fall along a continuum. The terms imply much more of a
qualitative difference than should exist between them.
• Separate categories of possible long- and short-term goals are not necessary. Depending on the
clinical situation, a long-term goal can be a short-term goal and vice versa. For example,
“patient will be free of assaultive behavior for a 1-week period” can be a long-term goal in an
acute setting if freedom from assaultive behavior for 1 week is determined to indicate that the
problem is no longer active or is adequately treated so that the patient can be discharged from
the acute setting. The same goal may be a short-term goal in a chronically assaultive patient if it
is determined that being assault-free for 1 week simply indicates improvement; however, a
much longer assault-free period is felt necessary to indicate that the problem is no longer active
or that adequate improvement has occurred for discharge.
As a rule of thumb, long-term goals are essentially the same as goals, and short-term goals are
essentially the same as objectives. Of course, all outcome measures, regardless of how they are named,
need to comply with rules that ensure they are observable and measurable. See “Master Treatment Plan
Forms (Step-by-Step Instructions)” later in this chapter for further information on long- and short-term
goals and target dates.
Treatment Goals Versus Treatment Modalities
Several issues are frequently raised concerning treatment goals and treatment modalities
(interventions):
Differentiating Goals and Treatment Modalities
The difference between goals and treatment modalities seems very simple: goals equal “ends” and
modalities equal the “means” by which the goals are attained. However, the picture clouds when goals
are further defined as “targeted, measurable” changes that occur in the patient. Completing a test or
procedure can be seen as a goal or an end point; however, such tests or procedures cannot be seen as
“targeted, measurable” changes in the patient.
When deciding whether to define an item as a goal rather than a treatment modality, one may
also want to consider that goals have target dates. If the item is defined as a goal, target dates can be
easily assigned and a mechanism is in place to track whether the test or procedure has been completed.
For certain items, especially tests and evaluations, these target dates can be very useful.
A rule of thumb that many clinicians find helpful to distinguish goals from modalities is the fact
that most goals can be stated as “Patient will …,” whereas most treatment modalities can be stated as
“Staff will …” However, this manual does not make an inflexible distinction between goals and
modalities. One is, therefore, encouraged to use his or her clinical judgment as to whether particular
items should be defined as goals or modalities.
Establishing the Importance of Treatment Modalities
Treatment modalities are generally real, actual occurrences. Even well thought out goals can often turn
out to be the clinician’s “wish list.” This is especially true for the long-term-care patient. For this reason,
it is often argued that more emphasis should be placed on treatment modalities. Another reason for the
emphasis on modalities is that staff members frequently go to treatment plans to get an update on
Introduction
Intro–17
treatments for various problems. Though certainly important, goals have never seemed to gain the
clinical usefulness to the staff that treatment modalities have.
Further, if the goals are reached, but the treatment modalities are unclear, it may appear as if one
accidentally stumbled into attaining the goals. Finally, it is much easier to defend inaccurate goals and
inaccurate target dates than to defend inaccuracies in the treatment modalities. Predicting the future is
difficult; however, failing to accurately represent what is happening in the present, such as treatment
modalities, can leave one open to criticism.
Working Backward From Treatment Modalities to Goals
In filling out treatment planning forms, one major argument concerning the sequence is often raised.
That argument relates to whether one should enter the treatment modalities before the goals. Logically,
it seems to make a lot of sense to start with the goals; however, clinically, it is sometimes much more
useful to start with the treatment modalities. It is not unusual for the availability of resources to drive
treatment to a greater degree than the goals do. This is especially true for the long-term patient who has
exhausted many of his or her resources, including family supports. The availability of specific
treatments, including the expertise needed for those treatments, can markedly affect the development
of realistic goals and realistic target dates. Therefore, once treatment modalities have been determined,
the modalities can be surprisingly helpful when attempting to write realistic treatment goals.
Treatment Modalities That Have Effects Across Problem Areas
Psychotropic medications often have effects in several problems areas; however, in some areas, the
effects are brought about primarily by improvements made by the medications in other areas.
Therefore, it is recommended that medications be listed only within the one or two problem areas in
which they are expected to have their primary effects.
For example, even though antipsychotics and antidepressants can have significant direct and
indirect effects in Problem Area 2 (Social Skills), Problem Area 4 (ADL–Occupational Skills), Problem
Area 5 (Substance Abuse), and Problem Area 7 (Ancillary Impairment), the improvements are often due
to the secondary effects of improvements in energy, motivation, focal attention, paranoia, and
hostility. These medications are often given primarily as a treatment for Problem Area 1 (Psychological
Impairment) and Problem Area 3 (Violence), even though they have clear, important roles in other
problem areas. Therefore, it is recommended that antipsychotics and antidepressants be listed under
Problem Area 1 and Problem Area 3, if Problem Areas 1 and 3 are the primary problem areas being
targeted by these medications.
This pervasive effect is also true for many nonmedication treatments. Treatment should be listed
only in the one or two primary problem areas to which it is being targeted. For example, a substance
abuse group may have significant effects on the patient’s depressive symptoms and social skills; however,
its primary target is substance abuse. Therefore, generally the substance abuse group would only be listed
on an IPP under Problem Area 5 (Substance Abuse). Other groups and treatments would probably be used
to treat the patient’s depressive symptoms and problems with social skills. These other groups and
treatments would then be listed as the treatments for the depressive symptoms and social skills problems,
rather than the substance abuse group.
Intro–18
Fundamentals of Psychiatric Treatment Planning
Steps for Building Goals and Treatment Modalities
In this section, simple steps are presented as a “rule-of-thumb” for writing goals and treatment
modalities. These steps will guide you through writing basic goals and treatment modalities and help
ensure that important components of goals and treatment modalities are not overlooked. When you
have decided on the components, you do not have to follow the same sequence when actually entering
them; however, the sequence often flows easily into the goal or treatment modality.
Use four steps to write goals (Figure 4):
1. “Pt. will ______ [plus active verb]”: Document that the patient is the one expected to accomplish
the goal. This goal includes an active verb, which indicates the patient’s action to accomplish
the goal.
2. Behavior expected [observable and measurable]: Present and write the target behavior in observable
and measurable terms. The more effective one is in writing the goal in observable and
measurable terms, the more likely it will be that it is clear when the goal has been attained.
3. Target frequency: Enter the expected frequency for the expected behavior when the goal has
been attained.
4. Time period: Enter the expected length of time it should take the patient to attain the goal.
Four Steps for Building Goals
1. Patient will ...
[plus active verb]
2. Behavior expected
[observable/measurable]
Pt. will make …
3. Target frequency
4. Time period
at least one nondelusional, relevant
comment in community meeting …
twice a week …
for 1 month.
Pt. will discuss …
the importance of taking his meds as
prescribed …
for 15 minutes twice weekly …
for 1 month.
Pt. will cooperate …
with at least one treatment team
member in the treatment planning
process …
once daily …
for 1 week.
Pt. will maintain …
relevance and focus on topics
beyond the first two sentences of a
conversation …
three times a week …
for 1 month.
Pt.’s motivation will
improve such that she
will have …
her personal dorm area in acceptable
order …
at least 3 out of 5 weekdays …
for 1 month.
Pt. will cooperate with
discharge plans so that
he is accepted …
into a halfway house program.
[not needed]
[not needed]
[not needed]
[not needed]
Pt.’s score on the
from the current score of 40 to 60.
Kennedy Axis V
subscale Social Skills will
improve …
Figure 4.
Examples of goals generated using the four steps.
Introduction
Intro–19
Also use four steps to write treatment modalities (interventions):
1. “Staff will ________ [plus active verb]”: Document that the staff will be providing the treatment.
This step includes an active verb that indicates the action that the staff will take to provide the
treatment.
2. Time period: Enter the length of time that the staff will use to provide the treatment.
3. Frequency: Enter the frequency with which the staff will provide the treatment.
4. Modality: Enter the treatment. At this point, you may also want to enter a reason for
recommending this particular treatment modality.
Figure 5 illustrates examples of treatment modalities generated using these four steps.
Four Steps for Building Treatment Modalities
1. Staff will ...
[plus active verb]
2. Time period
3. Frequency
4. Modality
Nurse will meet with pt. for at least 15 minutes … once weekly …
…
to educate pt. about her illness and the
importance of taking her meds.
Psychologist will lead
pt. …
1 hour …
once weekly …
in anger management group to help him
understand how his violent behavior acts as
a barrier to his discharge.
Nursing staff will assess
pt. …
[time necessary]
when she returns
from passes …
for any evidence of intoxication and will
report significant findings to the
psychiatrist.
Rehab staff will
schedule pt. …
for 1 hour …
twice weekly …
for AA meetings to learn more about alcohol
abuse risk factors and how to avoid them.
Psychiatrist will rate
pt. …
[time necessary]
once every
6 months …
on the Kennedy Axis V to help track pt.’s
level of assaultiveness.
Nurse will begin …
[as soon as clinically
reasonable]
[as often as clinically to assess pt.’s level of understanding of
reasonable]
antidepressant medication and his readiness
to learn before educating him.
Psychiatrist will meet
with pt. ...
for at least 35 minutes … once weekly …
to assess pt.’s level of psychosis and to
prescribe medications such as Zyprexa
(olanzapine).
Nursing staff will
encourage pt. …
[as needed]
to attend program activities and provide
escort, if needed.
Figure 5.
[on an ongoing
basis]
Examples of treatment modalities generated using the four steps.
Individual Problem Plan for Each Active Problem
It is recommended that one have a separate IPP sheet for each active problem on the Problem List.
There are several reasons why this is important to a good, comprehensive treatment planning system:
Ease of Documentation of Treatment Progress and
Rapid Access to Current Status of Treatment
An individual sheet for each active problem allows changes for each problem to be entered easily. The
clinical process is a fluid process; the treatment planning system needs to be able to reflect the flow of
Intro–20
Fundamentals of Psychiatric Treatment Planning
that clinical process. A benefit of including the IPP forms in this manual is their ability to reflect these
shifts in the clinical process. As a result, IPPs can allow a clinician to quickly determine the current
status of treatment for particular problems. The clinician can also quickly review the progress of the
treatment that has led to the current IPPs. It is not necessary to move back and forth between the
original MTP, Treatment Plan Reviews, and progress notes to determine the general progress and
current standing of the treatment.
Sharing of IPPs
IPPs are critical to the sharing and exchange of ideas on treatments for individual problems. If a good
plan is developed for a particular problem, then the IPP for that problem can be removed from the MTP
and copied and distributed as a guide for members of other treatment teams. Also, as indicated earlier,
IPPs could be written by experts in various areas and made available to users of the manual. These new
IPPs and shared plans can be added to the manual for quick reference.
Training
Training can be done for problem areas using IPPs. For example, IPPs on suicide and suicidal ideation
could form the basis for training related to treatment planning for the suicidal patient. IPPs on
symptoms and behaviors of the psychotic patient could be used for training related to treatment
planning for the psychotic patient.
No Increase in Documentation
Finally, there should be no significant increase in the amount of documentation. The information
required by the accreditors is the same regardless of whether the documentation is collapsed into one
central document or organized in a different manner. There may be more pages in a plan that requires a
page for each active problem; however, because both systems contain the same required information,
there should be no difference in the amount of documentation needed. This can create a problem
because there is a tendency by clinicians to want to completely fill any blank areas based on the size of
the blank area rather than the amount of information needed. Staff members need to be trained to
write briefly and concisely, regardless of the size of the blank areas.
Avoiding Excessive Documentation
Staff members want to provide clinically good treatment planning while avoiding excessive
documentation and use of valuable team time. Determining the necessary level of documentation is
often a difficult clinical decision. The following guidelines suggest where cuts can and cannot be made
as well as the costs and benefits of these decisions.
Situations in Which Cuts Are Not Recommended
An IPP is requested for each active problem. Also, taking a thorough, systematic approach to listing the
problems can lead to an increase in the number of problems identified. However, when a thorough
treatment planning process leads to a dozen separate sheets of paper, the patient obviously has multiple
impairments. In such cases, a good, comprehensive treatment plan can be very helpful and can save
time. These plans act as effective, clinical blueprints for integrating and working with a complex group
of goals and treatments.
It is not unusual for clinicians to exclude even active problems from the treatment plan. This is
unacceptable. A practitioner should not discover after reading the treatment plan that important
symptoms and behaviors (or even medical problems) have been excluded. These “surprises” can have
dangerous consequences.
Treatment planning without cutting corners or making major compromises can be timeconsuming and expensive. These high costs are up front and obvious. The savings gained by making
major compromises in treatment planning are often clearly evident, and the hidden costs may be
almost totally obscured. This illusion has led to an almost knee-jerk reaction to opt for major cuts and
compromises when developing the MTP; however, without the solid foundation of a good MTP,
subsequent treatment planning and reviews can be disorganized and confusing.
Introduction
Intro–21
A major contributor to this knee-jerk reaction is the fact that many clinicians falsely believe that
treatment planning has no clinical value. These are often responsible clinicians who think treatment
planning is necessary for satisfying accreditors but for little else. This attitude is fueled by years of
frustration with the poor results of even genuine attempts to generate good, useful treatment plans.
One of the primary purposes of this manual is to assist clinicians in their attempts to quickly generate
clinically effective treatment plans. If successful, it will help to reduce some of the frustration, anger,
and cost of treatment planning, while helping to improve the quality of care.
Situations in Which Cuts Are Recommended
There are certainly many ways to achieve direct compromises and cost-cutting measures. There are
situations in which such cuts and compromises can lead to better staff acceptance and more appropriate
treatment plans.
• Anticipated length of hospitalization. Certainly there may be less need for a comprehensive
treatment plan in an acute setting in which the average stay of the patient is only 8 to 10 days.
Many treatment decisions may be fresh in the minds of the clinicians; therefore, there may be
less of a need to refer to a comprehensive treatment plan. This is especially true if the treatment
team relies almost exclusively on other parts of the record for clinical information and
documentation of the clinical progress, for example, the progress notes.
The opposite is often true of the long-term-care patient. In the long-term-care patient,
treatment may be no more complicated than treatment for the acute-care patient; however, the
treatment is often much more unconventional and individualized. These patients have
generally failed to respond to the initial, somewhat standardized treatment strategies. As plans
get increasingly individualized, comprehensive treatment plans become increasingly important
to keep the team informed and working together. Also, as the length of hospitalization
increases, treatment planning decisions will no longer be fresh in the minds of the clinicians;
therefore, a comprehensive treatment plan can be helpful to remind staff of their roles with a
particular patient.
Problems in the long-term-care setting that are often deferred in the acute-care setting also
have to be addressed. For example, deficits in work skills may not be addressed at all in an
acute-care setting. However, these same deficits in work skills may be the primary focus of
treatment in a long-term-care facility.
• Degree to which the rest of the record effectively reflects treatment and its progress. If the
treatment planning information is well organized and easily accessed in the rest of the record,
the team may be less dependent on having a very comprehensive treatment plan. However, if
information about the team’s treatment plan and its outcome is buried in the record and
difficult to locate, then a comprehensive treatment plan can be extremely helpful with keeping
the team focused on their common goals and the methods to achieve those goals.
• Clinical style of the treatment team. Clinical styles vary greatly in the development and use
of MTPs. Some clinical styles may work better with an abbreviated, short plan. This manual and
its forms do not limit the use of the system to clinicians with a particular style. Therefore, if the
clinician wants to do a short, quick MTP, the system will allow for it. If the clinician wishes to
write a comprehensive plan, the system will continue to satisfy the needs of the clinician. The
system also allows clinicians and the quality assurance department a lot of flexibility to impose
their clinical judgments and standards onto what should be included in the treatment plan.
• Time constraints for a hurried treatment team. Obviously, if the team is not provided with
adequate time to prepare a reasonable treatment plan, the plan may lack many critical elements
or the plans may be extremely “canned” as clinicians take desperate steps to meet various
deadlines. It has been my experience that it is not unusual for clinicians to be expected to write
comprehensive treatment plans without the minimal time and staff needed to write reasonable
plans. I have seen this lead to anger and frustration among the staff.
Intro–22
Fundamentals of Psychiatric Treatment Planning
Clinically Appropriate Cuts
Finally, the following discussion covers several clinically appropriate ways to limit the size of a
treatment plan and to decrease the amount of team time needed to complete a plan.
• Limit the number of active problems that will require an IPP. This limit can result in a
clinically effective plan as short as three or four pages. Two methods can be used to achieve this
goal:
1. Collapse related problems under one name (e.g., delusions, hallucinations, and bizarre
behavior can be treated under the problem “psychotic symptoms”). The problem
description would contain an explanation of the symptoms and behaviors being addressed
by the problem “psychotic symptoms.” In this way, individual symptoms and behaviors are
retained in the plan without the plan being overwhelmed by the number of problems. The
system allows for collapsing of problems within the same subscale area; however, one
should not collapse problems from different subscale areas. For example, one should not
collapse the problem of suicidal attempts from the subscale area of Violence into depressive
symptoms because depressive symptoms should be under the subscale Psychological
Impairment.
2. Defer the treatment of active problems, if they do not require acute attention (“Deferred”
should be written in the problem status column of the Problem List). This can be especially
useful in acute-care settings.
• Delegate parts of the treatment plan to individual team members. Once these individuals
have completed drafts of their sections, the team should meet to finalize the plan. The full team
should meet to quickly put together a Problem List and Strength List by systematically going
through the seven problem areas and then assign the active IPPs to specific team members.
Generally speaking, IPPs from Problem Area 1 (Psychological Impairment) and Problem
Area 3 (Violence) might go to the psychiatrist or psychologist. IPPs from Problem Area 2 (Social
Skills) and Problem Area 4 (ADL–Occupational Skills) might go to the team member from
rehabilitation or to nursing. IPPs for Problem Area 5 (Substance Abuse) might go to the
individual or discipline that is most involved in substance abuse treatment. IPPs for Problem
Area 6 (Medical Impairment) may go to the psychiatrist, nurse, or the primary care physician.
IPPs for Problem Area 7 (Ancillary Impairment) often address placement or financial issues and
often go to the social worker. Legal problems under Problem Area 7 may go to the psychiatrist,
psychologist, or social worker.
The assigned clinicians then enter the problem description and goals. They enter only the
treatment modalities for treatment that they will provide. They do not write any treatment
modalities for other disciplines. When the team meets to finalize the plan, the clinicians
responsible for implementing the remaining treatment modalities can then enter those
modalities. At that time, the nurse(s) could also complete the NCP section of the treatment
modalities.
• Be brief and to the point with the problem description, treatment goals, and treatment
modalities. As mentioned earlier, there is a tendency by clinicians to fill blank areas based on
the size of the area rather than the amount of information needed. Staff members need to be
trained to write briefly and concisely, regardless of the space available.
• Don’t reinvent the wheel. When you write IPPs on active problems in your patient’s MTP,
refer to this manual or go online at www.kennedymd.com for sample IPPs. This resource is
especially helpful if there is a sample IPP similar to the IPP that you are about to enter into your
patient’s MTP. If an earlier MTP is available on your patient, it is likely to be similar to the new
MTP that the team is going to write. I recommend that the earlier plan be photocopied. The
team can often quickly update the copy and then type the edited copy onto the MTP forms to
create the new plan. If an electronic version of an earlier plan is available, the editing could be
Introduction
Intro–23
done directly on the electronic version and then stored, printed, or both. I also recommend that
IPPs created within your facility be categorized by the Kennedy Axis V and placed in a binder
for later reference. As more IPPs are added, this binder can be an invaluable resource for writing
future plans.
Inclusion of Milieu Staff in Treatment Planning
Even though the milieu staff members often form the backbone of treatment, they are frequently excluded from the treatment planning process. This exclusion will certainly alienate them from this
process. If the milieu staff members disagree with a plan, the plan is often doomed from the beginning.
Therefore, a critical part of an effective plan is the working relationship between the treatment team
and the milieu staff. In developing this working relationship, it is vital to include the milieu staff as
much as possible in relevant parts of the treatment planning process.
Intro–24
Fundamentals of Psychiatric Treatment Planning
Master Treatment Plan Forms
(Step-by-Step Instructions)
These instructions are intended to walk the reader through the process of completing the MTP and the
Treatment Plan Review forms. The instructions follow the sequence of the forms. In the next section is
a sample of a completed MTP with five Treatment Plan Reviews. It may be helpful to follow that sample
plan and its reviews when going through these instructions.
I.
Problem List/Cover Sheet
A.
Date of Admission
Enter the date of the current admission.
B.
Patient Identification Data
In the upper right corner, place the patient’s name, hospital ID number, ward (area), and the
current date.
C.
Problem Number
Enter the number of the problem. A suggested numbering system is a categorization in which
all problems are placed into one of seven categories (based on the Kennedy Axis V subscales).
This is the numbering system used in this manual:
1.
2.
3.
4.
5.
6.
7.
Psychological Impairment
Social Skills
Violence
ADL–Occupational skills
Substance Abuse
Medical Impairment
Ancillary Impairment
The following sample Problem List is based on this system:
1.1
3.1
3.2
6.0
6.1
6.2
6.3
7.0
Depressive Symptoms
Suicidal Ideation
Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
Placement
In the above numbering system the period (.) separates the problem area from the designation of a specific, individual problem within that problem area. The problem numbers
should be entered in numerical order when developing the Problem List. As additional
problems are added, they would be added in the next available row at the bottom of the list
and assigned the next available number within that problem area.
In the Problem List example, if all the problems were active, seven IPPs would have to be
completed. However, in two subscale areas, there is more than a single problem number:
3.1
3.2
6.0
6.1
Suicidal Ideation
Homicidal Ideation
Health Maintenance
Diabetes
Introduction
Intro–25
6.2 Hypertension
6.3 Kidney Failure
Whenever clinically reasonable, problems within a subscale area should be covered under a
single problem number. This can reduce the complexity of the MTP by decreasing the
number of IPPs that have to be tracked separately. Therefore, if it is clinically reasonable to
collapse the above problems into a single number within their respective subscale areas, the
list may appear as follows:
1.1
3.1
6.0
6.0a
6.0b
6.0c
Depressive Symptoms
Suicidal and Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
Even if all the problems listed were active, only three IPPs would need to be completed for
this list. Because the hypertension and kidney failure may be secondary to diabetes, the list
could also be collapsed as follows:
1.1
3.1
6.0
6.1
6.1a
6.1b
Depressive Symptoms
Suicidal and Homicidal Ideation
Health Maintenance
Diabetes
Hypertension
Kidney Failure
In this example, four IPPs would be needed. Problems 6.1a and 6.1b would be collapsed into
problem 6.1 Diabetes. The “.0” position, as illustrated in the example, is reserved for a special
problem within a problem area. No other problem would be assigned the “.0” position, even
if it were not used on a particular plan. Currently two such problem names are often
associated with the “.0” position:
6.0 Health Maintenance
7.0 Placement
It is common for a 6.0 to be entered into the Problem List of every patient being treated at a
particular facility and given an active status, even when a patient has no significant medical
problems. This listing allows for tracking of routine health issues, as well as relatively minor
health problems. Serious health problems should generally be given a separate problem
number, for example, a serious case of diabetes could be assigned 6.1 Diabetes, rather than
being collapsed under 6.0. A case of diabetes that is stable and well controlled by diet and an
oral hypoglycemic medication may be easily tracked under 6.0 Health Maintenance.
The problem number should follow revisions of the problem name, if it continues to be
essentially the same problem. For example, in the original MTP “psychotic symptoms” may
have been identified; however, later the patient was determined to have bipolar symptoms.
This would lead to the following changes in the Problem List:
Problem
Number
1.1
1.1
Problem Name
Psychotic Symptoms
Bipolar Symptoms
Discharge
Barrier
Date Estab. &
Status
Yes
01/15/03
02/15/03
Active
Revised to 1.1
Yes
01/15/03
Active
Date Changed
& New Status
Intro–26
Fundamentals of Psychiatric Treatment Planning
In a similar example, “hostile and threatening” may be revised to “assaultive:”
Problem
Number
Problem Name
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
02/15/03
Revised to 3.1
3.1
Hostile and Threatening
Yes
01/15/03
Active
3.1
Assaultive
Yes
01/15/03
Active
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
02/15/03
Revised to 6.1
Another example:
Problem
Number
Problem Name
6.1
Hypothyroidism
No
01/15/03
Active
6.1
Hypothyroidism Secondary to Lithium
No
01/15/03
Active
At the time of a rewrite of the MTP (often annually), it may be reasonable to redo the
problem numbers to allow the most prominent problem in a problem area to be moved to
the numerical top of the problem area. For example, at the time of the rewrite on 01/15/04,
the old Problem List for the Violence area would appear as follows:
Problem
Number
Problem Name
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
3.1
Hx of Suicidal Attempt
No
01/15/03
Noted
01/15/04
Revised to 3.2
3.2
Assaultive Behavior
Yes
02/15/03
Active
01/15/04
Revised to 3.1
In the new MTP on 01/15/04, “assaultive behavior” can be moved to the numerical top:
Problem
Number
Problem Name
Discharge
Barrier
Date Estab. &
Status
3.1
Assaultive Behavior
Yes
02/15/03
Active
3.2
Hx of Suicidal Attempt
No
01/15/03
Noted
Date Changed
& New Status
Similarly, if information was gathered concerning the patient’s suicide attempt and on
04/15/03 it was determined to have been fabricated by family to get needed treatment for
their mentally ill family member, then on 04/15/03, “Hx of suicidal attempt” could be
canceled:
Introduction
Problem
Number
Problem Name
Intro–27
Discharge
Barrier
Date Estab. &
Status
Date Changed
& New Status
04/15/03
Canceled
3.1
Hx of Suicidal Attempt
No
01/15/03
Noted
3.2
Assaultive Behavior
Yes
02/15/03
Active
In the annual rewrite of the MTP on 01/15/04, “assaultive behavior” can be moved to the
numerical top and “Hx of suicidal attempt,” which was canceled, would not appear on the
Problem List:
Problem
Number
3.1
D.
Problem Name
Assaultive Behavior
Discharge
Barrier
Date Estab. &
Status
Yes
02/15/03
Active
Date Changed
& New Status
Problem Name
Write the name of the problem in this column. The name should be brief, generally no
longer than three words. The name is intended to be a quick, concise way of identifying the
problem. For example, use “suicidal ideation” rather than “suicidal ideation because of recent
job loss.” Document descriptive and interpretive statements related to the problem, such as
“because of recent job loss,” in the problem description section on the IPP sheets.
As indicated earlier, to help ensure that significant problems are not overlooked, when
determining the Problem List work your way systematically through each problem area,
starting with Problem Area 1 (Psychological Impairment) and ending with Problem Area 7
(Ancillary Impairment).
The Problem List should contain all significant clinical problems. In addition to the
obvious problems, the Problem List should contain items such as history of assaultive
behavior, history of suicidal attempt, allergy to penicillin, single kidney, and so on. These
problems should not be listed if they are thought to be of no clinical significance (e.g., if the
suicidal attempt was an isolated incident that occurred years ago and is of no future clinical
relevance to the case). Problems should not be listed if they are already incorporated into an
active problem. Allergies do not need to be included on the Problem List if there is already a
system in place to prominently display allergies in the patient’s record.
Also, in addition to problems, the Problem List should contain other clinical factors that
require treatment or clinical resources, such as pregnancy, criminal charges, Tarasoff warning,
placement, health maintenance, and so on. This is the treatment plan, not the problem plan;
therefore, important areas involving treatment should not be omitted from the MTP simply
because they are not seen as a “problem.”
If the Problem List is complete, clinicians will not be surprised by significant clinical
issues or problems lost or buried in the patient’s chart. Generally, the Problem List is the only
place in the chart where there is a comprehensive, condensed, and updated outline of all
significant clinical issues. This is a key part of any clinical chart and is one of the first places
clinicians should go when attempting to get an overview of the patient’s clinical situation.
Intro–28
E.
Fundamentals of Psychiatric Treatment Planning
Discharge Barrier
Enter “Yes” or “No” as appropriate:
Yes—This problem is a significant barrier to discharge.
No—This problem is not a significant barrier to discharge.
There is no column to indicate a status change in the discharge barrier. When the
problem is no longer active, it is assumed to no longer be a discharge barrier. If needed, one
can revise the problem on the Problem List to the same problem number and enter the
revised problem on the next available row on the Problem List. You can then indicate that
the problem is no longer a discharge barrier or indicate that it is now a discharge barrier.
Finally, it is important to note that if a problem is not a barrier to discharge, funding
sources may mandate that any treatment of that problem be deferred.
F.
Date Established and Status
The date established should be the date that the problem was entered into the treatment
plan. This date will frequently not correspond to the date that the problem started. The date
the problem actually started may be documented on the IPP sheet under problem description.
The status of the problem can be any of the following: Active, Inactive, Inactive With Tx,
Deferred, or Noted. Section H contains a brief explanation of each status.
G.
Date Changed and New Status
This column is intended to allow anyone reviewing the Problem List to quickly determine the
current status of all problems. The treatment team should indicate the date that the status
changed and the new status. The date that the team changed the status should be entered
here. The actual date that the change in the problem occurred should be documented in the
progress notes, the Treatment Plan Review, or both.
The status changes include all of the statuses listed for the previous column (Active,
Inactive, Inactive With Tx, Deferred, and Noted) plus Resolved, Revised, and Canceled. The
next section briefly explains each status.
H.
Brief Explanation of Each Status
1. Active Problem: A problem that would require active assessment, treatment, or both. An IPP
sheet is required, and progress notes should be written on active problems.
2. Inactive Problem: A problem that is inactive and requires no treatment; however, it should
be noted because it is likely that it may become active or it could have some significant
impact on treatment. Some examples include history of homicidal attempt, history of
suicidal attempts, allergy to penicillin, only one functioning kidney, abnormal ECG. No
IPP is required.
3. Inactive With Tx: A problem that is inactive; however, continued treatment is required to
prevent the recurrence of the problem. An example includes assaultiveness under control
with lithium and present when lithium is withdrawn. Therefore, continued treatment
would be indicated for this inactive problem. An active problem should not be changed to
“Inactive With Tx” until you are fairly certain that the change in status is real and not just
a fairly temporary state. The IPP for the active problem would continue to be used;
however, all goals, including long-term goals, would have been Attained or Canceled. Any
changes in treatment would be documented in the same way that changes were documented for the active state for the problem, including writing progress notes to document
the continued treatment and with hope, continued control of symptoms.
Introduction
Intro–29
4. Noted Problem: Similar to an inactive problem; however, it is even less likely to become
active or to require treatment. Noted problems fit along the following continuum:
Active or Inactive With Tx
Å
Inactive
Å
Noted
Å
Resolved
For example, a fractured arm will be an “Active” problem while it is in the cast
healing and being followed up. After a few weeks, when the arm is taken out of the cast
and appears to have healed and no follow-up is recommended, the problem may be
changed to “Inactive.” After a few months, if there is a rewrite of the MTP, the problem
may be “Noted” on a treatment plan. After about 6 months or longer, if the arm continues
to appear to have healed well and the patient does not appear to be at risk for another
fracture, the problem may be listed as “Resolved.” If “Resolved,” it would be taken off the
Problem List at the next rewrite of the MTP.
Of course, no IPP is needed for a “Noted” problem.
5. Resolved Problem: This status is used when a problem has reached a state whereby it is felt
to be of little or no clinical significance. For example, as indicated in the last example, a
well-healed fracture of an arm that in no way predisposes the patient to future fractures
would be considered “Resolved.” No IPP is required once a problem has resolved and as
indicated above, it would be removed from the Problem List at the next rewrite of the
MTP.
6. Revised Problem: This status is used when a change is made in the problem name, number,
or in rare cases the discharge barrier. This revision is intended to clear up any confusion or
misunderstanding in the present problem name or number. Revisions in the problem
name include better wording for clarity, changes in the name to reflect changes in the
nature of the problem itself, and so on. For example, “allergy to Risperdal” could be
revised to “severe EPS on Risperdal,” if it were determined that rather than an allergy, the
patient had severe EPS when on Risperdal.
If the problem is revised for inclusion with one or more other problems, the resultant
problem could be assigned a number already held by one of the problems or it could be
assigned a new number. Problems losing their numbers would be “Revised” to the chosen
number.
If there were a change in the status of the revised problem, the need for an IPP would
depend on the final status assigned to the problem. For example, if the Revised status was
an Active status, an IPP would be required. If the problem were revised to an Inactive
status, no IPP would be needed.
7. Deferred Problem: An active problem whose assessment, treatment, or both have been
postponed until a later time or another place. For example, treatment of a learning
disability may be deferred in an acutely psychotic or acutely suicidal individual. A deferred
problem could also be an active problem that for various reasons would probably never be
treated or require further assessment. In addition, a deferred problem could be a problem
that is being actively treated; however, a decision to stop treatment is made for various
reasons and any further treatment is deferred until a later time or another place.
As indicated earlier, it is important to note that if a problem is not a barrier to
discharge, funding sources may mandate that any treatment of the problem be deferred.
No IPP is required on deferred problems; however, a partial IPP can be completed at
the discretion of the treatment team. On such a partial IPP, one would enter the
description of the problem. “Deferred problem” and the reason for deferral could then be
written in the area for the long-term goal. Later, if the problem changes to an Active status, a line could be drawn through “Deferred problem” and the rest of the form could
then be updated and completed.
Intro–30
Fundamentals of Psychiatric Treatment Planning
8. Canceled Problem: This status should be used to cancel out a problem that may have been
incorrectly identified as a problem for the patient. For example, “suicidal ideation” would
be canceled if it were determined that the patient is not and has never been suicidal or
self-abusive. Of course, no IPP would be needed for a canceled problem.
II.
Strengths/Discharge Plan/Diagnosis Page
A.
Patient’s Strengths
Enter either a list of the patient’s strengths or a narrative statement listing and integrating the
patient’s strengths. These strengths should be related to treatment and discharge. As with the
Problem List, to help ensure that significant strengths are not overlooked, it is suggested that
you work systematically through each strength area as defined by the Kennedy Axis V subscale
problem areas as shown in Table 1.
Table 1.
Kennedy Axis V Categorization System for problems and strengths
PROBLEMS
STRENGTHS
1. Psychological Impairment
1. Psychological Strengths
2. Social Skills (Deficits)
2. Social Skills (Assets)
3. Violence
3. Nonviolence
4. ADL–Occupational Skills (Deficits)
4. ADL–Occupational Skills (Assets)
5. Substance Abuse
5. Sobriety
6. Medical Impairment
6. Medical Strengths
7. Ancillary Impairment
7. Ancillary Strengths
As with the problems, once you have gone through the strengths areas it is unlikely that
significant strengths will be overlooked.
B.
Discharge Criteria/Planning
Discharge criteria are often equated with the long-term goals of the problems that are
discharge barriers; therefore, you may want to work backward from the long-term goals to the
discharge criteria.
Prediction of placement should be realistic (i.e., based on the patient’s strengths and
weaknesses and the availability of resources in the community). Enter here the realistic
placement plans, rather than the idealistic ones. Also enter concerns about the lack of
availability of appropriate community resources. If needed, complete an IPP on placement.
Such a problem plan helps the social workers to document in the progress notes their efforts
to place the patient. This also makes it easier to locate information in the progress notes
concerning placement that has been written by social work staff, as well as non–social work
staff.
Enter the target discharge date here. It is rare for the target discharge date to be beyond
1 year; however, if realistic, it is acceptable to indicate a discharge date of 2 or 3 years or even
“indefinite.” Be sure to document one’s clinical reasons for such an extensive length of stay.
Introduction
C.
Intro–31
Psychiatric Diagnosis
Enter the patient’s DSM-IV-TR diagnosis at the time of the MTP. The Kennedy Axis V should
be used for both Axis IV and Axis V (Kennedy 2003). Figure 6 shows an example of a
psychiatric diagnosis.
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
Major Depression, Recurrent, Severe Without Psychotic Features
AXIS II:
Obsessive-Compulsive Personality Disorder
AXIS III:
Insulin-Dependent Diabetes Mellitus
AXIS IV:
Ancillary Impairment = 45 (Divorce)
AXIS V:
PSY = 40 + SOC = 65 + VIO = 40 + ADL = 75 = 220/4 = 55
Figure 6.
Psychiatric diagnosis.
III. Individual Problem Plan
A.
Problem Number and Name
Enter the number and name of the problem directly from the Problem List.
B.
Nursing Diagnosis
As a part of the integration of the NCP into the MTP, enter the nursing diagnosis below the
†
problem name. To assist with this task, nursing diagnoses have been categorized by the
Kennedy Axis V (see Appendix).
C.
Patient Identification Data
In the upper right corner, place the patient’s name, hospital ID number, ward (area), and
current date. Enter the date the IPP was completed. For most problems, this date will be the
same as the date for the MTP. However, following the completion of the MTP, new problems
may be entered. The date entered on each new IPP should reflect the date that IPP was
completed and placed in the chart.
D.
Problem Description
Enter a brief description of the problem. The following six components are often seen in
problem descriptions:
1.
2.
3.
4.
†
Onset of symptoms and chronicity
Precipitants (e.g., noncompliance with treatment, command hallucinations, substance
abuse, losses, stress, poor frustration tolerance, poor coping mechanisms, peer pressure,
lifestyle)
Characteristics, frequency, intensity, and variance of symptoms
Response to previous and current treatments and expected response to any proposed
treatments
Nursing Diagnoses: Definitions and Classifications 2001–2002. Philadelphia, PA, North American Nursing Diagnosis
Association, 2001.
Intro–32
Fundamentals of Psychiatric Treatment Planning
5.
6.
Presence of need for psychotropic medication guardianship, guardianship of person
and/or estate, or any other related legal issues
Current level of symptoms, activity level, including frequency of attendance at
therapeutic activities
These components should relate to goals, treatment modalities, and target dates.
E.
Long-Term Goal(s) (Discharge Criteria)
Indicate reasonable expectations of what the patient is thought to be capable of achieving
1) at discharge or 2) within 1 year for patients expected to remain in treatment for 1 year or
longer.
Goals must be obtainable, measurable outcomes. The measures of outcome should
address 1) frequency, 2) duration, or 3) change in condition or status. The outcome measures
should allow the clinician to ascertain, at any time, whether the goal has been obtained.
Standardized questionnaires should be considered as an ongoing part of the measurement of
outcome.
Often there is only one long-term goal for each problem. The Kennedy Axis V score is
suggested for consideration as a second long-term goal. For example, long-term goals for
psychotic symptoms could be as follows:
1.
2.
Pt.’s psychotic symptoms will decrease such that she can participate in full-time program
activities for 1 month without serious disruption by psychotic process.
Pt.’s Kennedy Axis V for Psychological Impairment will improve from a score of 30 to
50.
At a minimum, the long-term goal(s) should reflect the intention of preventing further
deterioration in the patient’s mental or physical condition. One exception would be a
problem that is part of a progressive disease process. In such a disease, there may be no
treatment that will fully stop the progressive nature of the illness (e.g., the cognitive
deterioration associated with Alzheimer’s disease). The goals for these progressive problems
should reflect realistic attempts to minimize the deterioration.
No active problem should be without a long-term goal.
F.
Target Date
Indicate the anticipated date when the long-term goal(s) or the short-term goal(s) will be
achieved. Attempt to make these dates realistic. The treatment team should take into account
the various expected delays and difficulties. The date should not reflect an “ideal” date or a
“best-case scenario.” Generally the treatment team should set up long-term goals that are
thought to be achievable before discharge or within 1 year for patients who are expected to
remain in the hospital for 1 year or longer. The target date for the short-term goals may vary
widely depending on many clinical factors. Generally, the date should not be longer than
6 months for short-term goals.
If a target date has to be extended, draw a line through the target date and place the new
target date below the old target date. Initial the change and document the reason for the
change in the progress notes, the Treatment Plan Review, or both.
“Ongoing” as a target date for an attained goal can be useful. Ongoing reflects that the
goal has been attained; however, the team does not want to eliminate the goal from the plan
because it helps to convey that the patient has achieved a specific level of functioning. An
additional goal would not have to be added to the plan to replace this attained goal if the
team is satisfied that the level of functioning achieved is adequate for discharge. The team
would work on at least maintaining the patient at the level of the “ongoing” goal. For
example, if an assaultive patient has attained a goal of being assault free for 6 months and
this is adequate for discharge, the team may want to simply indicate “ongoing” as the target
date. At the time of the MTP rewrite, the “ongoing” goal could be moved forward or
Introduction
Intro–33
incorporated into the problem description to document the current level of functioning for
the problem.
Ongoing can also be useful for problems that are “Inactive With Tx” because use of the
term allows the level of functioning necessary for the patient to have achieved the “Inactive
With Tx” status to be clearly documented, as well as the level of functioning needed to
maintain the status of “Inactive With Tx.”
G.
Date/Status
Indicate status change and date of that change in this column. The status changes include
Attained, Canceled, and Revised (see Section J). Draw a line through the long-term goal when
its status has changed. If this is the only long-term goal and the problem is not Inactive,
Inactive With Tx, Deferred, or Resolved, then another long-term goal or a revised long-term
goal should be added.
H.
Short-Term Goal(s) (Objective[s])
A short-term goal is an expected or desired change in a current patient behavior, condition,
or situation. As with the long-term goal, it should be stated in observable, measurable terms.
The following system can be helpful in identifying short-term goals: First, establish
where the patient is currently with respect to the problem and where the patient is expected
to ultimately be as defined by the long-term goal. Then describe the next step that would
have to occur if the patient were to make progress toward the long-term goal. This next step
can often be used as a short-term goal. This next step must be converted into observable,
measurable behaviors or symptoms that could signify to the team that the improvement has
occurred.
Additionally, it may be useful to focus first on the treatment modalities before determining the short-term goals. Once some of the treatment modalities have been laid out, the
short-term goals may become obvious.
Two or three short-term goals should be used for a problem. If it is not used as one of
the long-term goals and if it is appropriate, a Kennedy Axis V score might be used as a shortterm goal. Each short-term goal should have its own target date.
I.
Treatment Modalities (Interventions)
Treatment modalities, also known as “interventions,” are specific services, treatments,
therapies, or other active interventions that the patient will receive or participate in or a staff
action taken on the patient’s behalf.
Treatment modalities may be Completed, Canceled, or Revised (see Section J). Draw a
line through any treatment modality that has been Completed, Canceled, or Revised.
Include the name and discipline of staff members who will either directly provide or
supervise a treatment, therapy, or staff action. If someone is responsible for supervising or
overseeing others in implementing the treatment modality, use an arrow to indicate the
person(s) being supervised. For example,
Linda Larkin, RN Å Ward Staff
This arrow indicates that Linda Larkin, RN, will be responsible for supervising the ward
staff with the particular treatment modality. This documentation indicates the responsible
person(s) and the person(s) actually providing the treatment. Both are certainly important.
If helpful, place the identifying number of associated short-term goals after each
treatment modality to indicate which short-term goals are being addressed by each treatment
modality. However, because it is often obvious which goals are associated with which
treatment modality and because of the limited time to complete treatment plans, this
numbering is discouraged.
Intro–34
J.
Fundamentals of Psychiatric Treatment Planning
Status
The goals may be Attained, Canceled, or Revised, depending on the patient’s response to
treatment and additional information obtained. A treatment modality can be Completed,
Canceled, or Revised. Draw a line through a goal or treatment that has been Attained,
Completed, Canceled, or Revised:
1.
2.
3.
K.
Attained goal or completed treatment: This status indicates that the goal or treatment has
been reached or completed. Enter a date and status change and draw a line through the
goal or treatment. If appropriate, enter another goal or treatment, along with a target
date for each new goal.
Revised goal or treatment: This status indicates that a change has been made in the goal or
treatment. Enter a date and status change and draw a line through the goal or treatment
to be revised. In the appropriate column, enter the revised goal or treatment. If a goal is
being revised, enter a target date in the column next to the new goal.
Canceled goal or treatment: This status indicates that a goal or treatment has been
canceled. At this time, enter the appropriate date and status change and draw a line
through the goal or treatment that is being canceled.
Date Treatment for the Problem Ended and Final Status
Indicate the date that the treatment ended for the overall problem (not the end of treatment
for a specific goal) by drawing a line across the front of the IPP. Around the middle of the
line, enter the date and change in problem status that led to the discontinuation of treatment
for the problem. Possible changes in status include Resolved, Revised, Inactive, Canceled, or
Deferred. This change in status would also be indicated on the MTP’s Problem List.
IV. Signature Page
V.
A.
Patient Participation in Treatment Planning
Indicate the level of participation by the patient in the development of the MTP. Areas are
available for patient and staff comments. If the patient refuses to sign the plan, the team
should indicate the reason for the patient’s refusal, if known, in “Staff Members’ Comments.”
B.
Treatment Team Members
The signatures entered here should document the treatment team members who were involved in developing and completing the MTP. Everyone involved in the planning should
sign; however, the accreditors require only the signatures of the physician, nurse, and social
worker.
Treatment Plan Review Form
A.
Patient Identification Data
In the upper right corner, place the patient’s name, hospital ID number, ward (area), and
current date.
B.
Psychiatric Diagnosis (DSM-IV-TR)
Enter the patient’s DSM-IV-TR diagnosis as of the time of the Treatment Plan Review. If the
diagnosis has changed, enter any changes here. On the Strengths/Discharge Plan/Diagnosis
page of the MTP, enter the date of the Treatment Plan Review, which documents the changes
and the reason for the change. It is also recommended that you enter the changes directly
onto the diagnosis section of the Strengths/Discharge Plan/Diagnosis page and date and
initial the changes. This documentation will allow you to go directly to the MTP for the
current diagnosis without having to go to the Treatment Plan Reviews. If more information is
needed about the change in diagnosis, you could then go to the appropriate Treatment Plan
Review. If there are no changes in the Problem List, simply indicate “no change” in this area.
Introduction
Intro–35
C.
Changes in the Problem List
Enter any changes in the Problem List in this section. These changes should also be entered
onto the MTP’s Problem List. If there are no changes, simply indicate “No Change” in this
area.
D.
Evaluation of Progress and Plan’s Effectiveness in
Achieving Goals for Active Problems
Enter the summary of the progress for each active problem made by the patient since the last
MTP or the last Treatment Plan Review. If there are no changes, indicate the reasons for the
lack of progress, rather than simply indicating “no change” in this area.
E.
Changes in Treatment Plan Goals or Modalities
Enter changes in the MTP directly onto the MTP, then date and initial the entry. Enter the
summary of those changes, including goals that have been attained or added or modalities
that have been completed or added. If there are no changes, simply indicate “no change” in
this area.
F.
Reasons for Continued Hospitalization
Enter the summary of the reasons for continued hospitalization, especially issues related to
violence and other forms of dangerousness. The Kennedy Axis V’s “Dangerousness Level”
may be helpful with documenting the reasons for continued hospitalization. Also use this
section to address any obstacles to securing an appropriate community placement when the
patient is clinically ready for discharge.
G.
Discharge Planning Update
Enter the update to discharge planning, including progress toward overcoming various
obstacles to discharge. If there are no changes, indicate the current status of discharge
planning.
H.
Continuation/Comments Section
This area provides additional space if adequate space is not available in the previous sections.
Patient or staff comments can also be entered here.
I.
Level of Care
This section can be useful for Medicare and Medicaid billing purposes by indicating the
following:
Active Treatment [ ]
Extended [ ]
Awaiting SNF [ ]
Refer to the Centers for Medicare and Medicaid Services (formerly HCFA) for details and help
with Medicare and Medicaid billing (SNF, skilled nursing facility).
J.
Treatment Team Members
The signatures entered here should document the treatment members who were involved in
developing and completing the Treatment Plan Review. For clinical purposes, all participants
involved in the Treatment Plan Review must sign it; however, the accreditors require as a
minimum the signatures of the physician, nurse, and social worker.
The patient should also be asked to read and sign the Treatment Plan Review to indicate
that he or she participated in the review and is aware of its content. The patient’s signature
on the review does not indicate that he or she agrees with the review. If the patient does not
agree with the review, the patient should be encouraged to enter his or her concerns in the
“Continuation/Comments” section.
Notes
MASTER TREATMENT PLAN
(Sample)
MTP–1
This page intentionally left blank
Master Treatment Plan (Sample)
MTP–3
MASTER TREATMENT PLAN
(Sample)
CONTENTS
Kennedy Axis V: Scoring Sheet ...........................................................................................................MTP–4
The sample Master Treatment Plan is based on a Kennedy Axis V rating of a fictitious patient, Derek
Rossi. The Kennedy Axis V organizes information that can then flow into Master Treatment Plans.
Master Treatment Plan (Sample) ........................................................................................................MTP–5
This sample Master Treatment Plan will help demonstrate the treatment planning system used in this
book, including how the Kennedy Axis V can help organize information that is often critical to good
treatment planning.
Treatment Plan Reviews (Samples) ...................................................................................................MTP–17
These sample Treatment Plan Reviews demonstrate how the Treatment Plan Reviews act with the
Master Treatment Plan to capture the flow of treatment. The sample Treatment Plan Reviews will
take one through about half of the patient’s hospitalization.
MTP–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V: Scoring Sheet
Name: Derek Rossi
© 1986–2003
#: 12345
Age:
26
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
ÄÄ FUNCTIONAL
DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Primarily (check one):
Not Impaired___
Antisocially Impaired___
Other Impairment X
Both___
Derek’s current depression is characterized by feelings of hopelessness and worthlessness. He is anxious, lethargic, socially
isolated, and frequently up most of the night. His depression is also associated with self-deprecating and command
hallucinations.
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
Derek’s attempts to be pleasant and engaging are usually awkward. He has a couple of friends; however, he does see them often.
He often gets into conflicts due to inappropriate social behavior.
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 X 40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Primarily (check one):
Nonviolent___
Violent to Self X
Violent to Others___
Violent to Self and Others___
Derek has a long history of suicidal attempts, gestures, and manipulations. He has made serious attempts to hurt himself in
response to command hallucinations, including taking overdoses of meds and attempting to hang himself. Since he stopped
drinking 2 years ago, he has not acted on any suicidal impulses. Currently he continues to have command hallucinations and
suicidal ideation; however, he reports that he would not actually attempt to harm himself.
4. ADL–Occupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Derek is a high school graduate with average intelligence. He has some mild difficulty following instructions on his job as an
office assistant. He has a driver’s license and has no more than mild difficulty maintaining his own apartment. Overall he has
fairly good independent living skills.
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Primarily (check one):
Nonabuser___
Alcohol Abuser X
Drug Abuser___
Both___
Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and self-medicating his
depression. He had some very serious problems with alcohol that led to serious attempts to hurt himself when intoxicated,
including taking overdoses of meds and attempting to hang himself. Generally, since he stopped drinking 2 years ago, he has had
much better control of these impulses. He goes to AA on a weekly basis and is committed to continued sobriety. Derek smokes
one pack of cigarettes a day.
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 X 60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Derek is in fairly good physical health, even though he has mild reflux esophagitis secondary to a hiatal hernia. This disorder is
fairly well controlled with a prescription med to reduce stomach secretions; however, currently he drinks 8 to 12 carbonated
beverages every day and eats other foods that exacerbate his heartburn.
7. Ancillary Impairment (optional)
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Derek has his own apartment that his family maintains if he is unable to pay the rent. He has some mild difficulties paying his
credit card bills. He is not in trouble with the law.
GAF Equivalent:
#1
40
+ #2
60
+ #3
45
+ #4
70
Dangerousness Level (indicate only the most dangerous rating):
Signature:
Victor Dyson, MD
=
215
/
4
=
55
45
Date:
01/05/03
Master Treatment Plan (Sample)
MTP–5
Name: Rossi, Derek
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Problem List
ID #: 12345
Lakeview Hospital
Name of Facility
Area: West Unit
Date of Admission: 01/15/03
Problem
Number
Problem Name
Date: 01/15/03
Discharge
Barrier*
Date Estab. &
Status**
1.1
Depressive and Psychotic Symptoms
Yes
01/15/03
Active
2.1
Impaired Social Skills
No
01/15/03
Deferred
3.1
Suicidal Ideation
Yes
01/15/03
Active
5.1
Alcohol Abuse
No
01/15/03
Inactive With Tx
6.0
Health Maintenance
No
01/15/03
Active
6.0a
Reflux Esophagitis
No
01/15/03
Active
Date Changed
& New Status***
02/12/03
Inactive With Tx
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
MTP–6
Fundamentals of Psychiatric Treatment Planning
Name: Rossi, Derek
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Strengths/Discharge Plan/Diagnosis
Area: West Unit
Date: 01/15/03
Patient’s Strengths (related to treatment and discharge):
•
•
•
•
•
•
•
•
•
•
•
Interests: watching TV, especially sports
Motivated for treatment
Good verbal skills
No history of assaultive behavior
Fairly good independent living skills
High school graduate with average intelligence; holds job as an office assistant
Alcohol-free for 2 years and is motivated to continue sobriety
Fairly good physical health
Supportive family
Apartment in the community
Good working relationship with community case manager
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
Derek Rossi will be free of any suicidal ideation or any command hallucinations to harm himself for 4 weeks. Derek
will be able to participate in a full schedule of program activities for 2 weeks. Plans will be in effect for Derek to
return to his job in the community immediately following discharge. Derek will complete three overnight passes
back to his apartment without any return of suicidal ideation. Derek will continue to participate in community AA
meetings after discharge.
Discharge Coordinated By: Brenda St. Martin, MSW
Anticipated Discharge Date: 04/15/03
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
Depressive disorder with psychotic features; history of alcohol abuse
AXIS II:
No diagnosis
AXIS III:
Reflux esophagitis and hiatal hernia
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
40
SOC =
GAF Equivalent =
70
60
55
VIO =
45
ADL =
70
SAb =
70
Dangerousness Level =
MED =
65
45
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /__
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Depressive and Psychotic Symptoms
MTP–7
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Disturbed Thought Processes
Date: 01/15/03
Problem Description:
Derek has a long history of depressive symptoms that began during his senior year of high school following a
breakup with a girlfriend. His current depression appears to be associated with his stopping his meds and his
perception that he was not doing a good job at work. However, his employer reports being satisfied with Derek’s
performance. Pt. reports being a loner with lots of feelings of hopelessness and worthlessness. He is anxious,
lethargic, and frequently up most of the night. His depression is also associated with self-deprecating and
command hallucinations. The hallucinations generally occur only during periods of decompensation and disappear
when he is doing fairly well. Derek’s compliance with aftercare is poor, despite his having a reasonable
understanding of his meds. Last week, he started taking his meds as prescribed. Social isolation is felt to be a
significant contributor to his depressive symptoms and associated noncompliance with his meds. In the past, Derek
has responded well to a combination of Risperdal and Effexor. His hospitalizations usually last about 2 to 3 months
before he has recompensated to the point that he is ready for discharge.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Derek will complete at least three overnight passes into the
community, including returning part-time to his job in the
community.
04/15/03
2.
Pt. will comply with a full schedule of program activities,
including social activities, for 2 weeks.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Derek will accept prescribed meds and lab work for 2 weeks.
Date/Status*
Target Date
Date/Status*
01/29/03
01/29/03
Attained
2.
Derek will be free of auditory hallucinations for 2 weeks.
02/29/03
3.
Derek will engage in 5-minute conversations twice daily with
staff in which he makes at least two positive self-statements for
2 weeks.
02/29/03
4.
Derek will be free of feelings of hopelessness and worthlessness
for 2 weeks.
02/29/03
5.
Derek’s anxiety, lethargy, and social isolation will improve such
that he will complete one scheduled program activity at least 4
of 5 weekdays for 2 weeks.
02/29/03
6.
Derek will be able to consistently and realistically report the fact
that he is an asset at his job in the community for 2 weeks.
03/15/03
7.
Derek’s score on the Kennedy NOSIE score will improve from
his current score of –11 to at least +4.
03/15/03
02/12/03
Attained
02/05/03
Attained
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–8
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any
changes in Derek’s psychotic and depressive symptoms in order to monitor Derek’s
response to being restarted on a combinations of antipsychotic meds such as
Risperdal and an antidepressant such as Effexor. Labs will be ordered as needed.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with Derek twice weekly for 30 minutes to discuss his
depression and psychotic symptoms and the effect on his discharge. She will evaluate
Derek’s readiness for discharge and discuss discharge options with Derek. She will also
help Derek work on a list of activities to help structure his life.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive
therapy sessions to direct Derek back to reality and to help improve Derek’s ability to
identify stressors, including dispelling stressors that are not real, and helping improve
his ability to better cope with those stressors that are real.
Joseph LeBlanc, PhD
Rehab:
1.
Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to
review his daily treatment schedule and refer him to appropriate groups to improve
his contact with reality and self-esteem, increase his social interactions, and develop
structure in his daily routine. His groups will include stress management group and
socialization group (see weekly Rehab Schedule for details).
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will redirect and refocus Derek to reality issues. When derogatory
hallucinations are present, nsg. staff will express an understanding of Derek’s distress,
give reassurance, suggest interventions, and if indicated, offer prn meds to help
relieve his distress. Nsg. staff will provide support and praise for reality-based
statements.
2.
Nsg. staff will encourage Derek to attend morning meeting, other on-ward activities,
and rehab groups; staff will provide escort, if needed.
3.
Building on Derek’s understanding of the need to take his meds, nsg. staff will
explore with Derek his difficulty continuing his meds in the community and help pt.
develop a plan for him to work with his community case manager to correct this
problem.
4.
Nsg. staff will rate the Kennedy NOSIE once per week to help track Derek’s response
to treatment.
5.
Nsg. staff will encourage appropriate interactions with his peers.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Suicidal Ideation
MTP–9
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Risk for Self-Directed Violence
Date: 01/15/03
Problem Description:
Derek has a long history of suicidal attempts, gestures, and manipulations beginning at age 17 when he was a
senior in high school. When decompensated, he has command hallucinations to hurt himself. In the past, when
intoxicated, he has made serious attempts to hurt himself in response to command hallucinations, including taking
overdoses of meds and attempting to hang himself. Since he stopped drinking 2 years ago, Derek has not attempted
to hurt himself and overall has had much better control of these impulses. Immediately before this hospitalization,
Derek was having command hallucinations to harm himself, including commands to jump from the fourth floor at
work. He was concerned that he was losing control of these impulses. Currently he continues to have command
hallucinations and suicidal ideation; however, he reports that he would not actually attempt to harm himself.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Derek will be free of any suicidal ideation or command
hallucinations to harm himself for 4 weeks.
04/15/03
2.
Derek’s K Axis score on Violence will improve from his current
score of 45 to a score of 60.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
2.
3.
4.
Derek will be able to consistently identify at least three coping
mechanisms to help direct him away from self-destructive
impulses for 1 week.
Derek will be able to identify feelings of worthlessness,
hopelessness, and frustration as they occur, AEB his coming to
staff for support rather than attempting to hurt himself for
2 weeks.
Derek will be free of any command hallucination to harm
himself for 2 weeks.
Derek will be free of any suicidal ideation for 2 weeks.
02/19/03
5. Derek will be able to go safely on three independent day passes into the community during
1 week.
VD
Date/Status*
Target Date
Date/Status*
02/29/03
02/05/03
Attained
02/29/03
02/29/03
02/19/03
Attained
02/29/03
03/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–10
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek for at least 35 minutes once weekly to monitor any
changes in Derek’s suicidal impulses, including command hallucinations to hurt
himself. This will allow the psychiatrist to assess the need for special precautions.
This meeting will also allow the psychiatrist to prescribe treatment with antipsychotic
meds such as Risperdal and an antidepressant such as Effexor (as outlined under
Problem 1.1).
Victor Dyson, MD
Social Work:
1.
Social worker will meet with Derek twice weekly for 30 minutes to discuss his suicidal
impulses and the effect on his discharge. Social worker will evaluate Derek’s readiness
for discharge, discuss discharge options with Derek, and help him to locate
community supports that will help him to remain free of suicidal ideation following
his discharge.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will meet with Derek one-to-one twice weekly for 45-minute cognitive
therapy sessions to help Derek develop strategies to more effectively cope with
stressors rather than becoming suicidal.
2.
Psychologist will lead the suicide prevention group once weekly for 45 minutes to
help pt. reduce feelings of hopelessness and worthlessness and more effectively deal
with stress.
Joseph LeBlanc, PhD
Rehab:
1.
Rehab staff will meet with Derek one-to-one for 30 minutes at least once weekly to
review his daily treatment schedule and refer him to appropriate groups to decrease
his self-destructive impulses and frustration tolerance, including stress management
group and anger management group (see weekly Rehab Schedule for details).
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will immediately redirect and refocus Derek away from self-destructive
impulses and discuss appropriate alternative means of coping.
2.
Nsg. staff will question Derek at least once each shift to determine whether he is
having impulses to hurt himself.
3.
When command hallucinations are directing him to harm himself, nsg. staff will give
reassurance, suggest interventions, and if indicated, offer prn meds to help relieve his
impulses to harm himself.
4.
If there are any concerns about Derek attempting to hurt himself, at a minimum, nsg.
staff will have him verbally contract for safety each time he goes off the ward. For
safety reasons, pt. may be restricted to the ward and placed on special precautions
until the psychiatrist can evaluate him.
5.
Nsg. staff will provide support and praise when Derek is demonstrating appropriate
coping skills to maintain safe behaviors.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.1 Alcohol Abuse
MTP–11
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Ineffective Coping
Date: 01/15/03
Problem Description:
Derek began using alcohol as a senior in high school as a means of fitting in with his peer group and selfmedicating his depression. He had some very serious problems with alcohol that led to serious attempts to hurt
himself when intoxicated, including taking overdoses of meds and attempting to hang himself. Generally, since he
stopped drinking 2 years ago he has had much better control of these impulses. He goes to AA on a weekly basis
and is committed to continued sobriety. Derek smokes one pack of cigarettes a day; however, he has no interest in
quitting smoking.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Derek will continue to be free of alcohol for at least 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Derek will continue to demonstrate his commitment to
maintain sobriety by going to AA meetings once a week for at
least 1 month.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–12
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with Derek weekly and as needed to monitor for any evidence
of intoxication and any changes in intensity of impulses to abuse alcohol. If needed,
psychiatrist will order Breathalyzer to ensure that pt. has not been abusing alcohol.
Victor Dyson, MD
Rehab:
1.
Derek will attend AA meetings once weekly to help support his continued sobriety.
Derek will start the AA meetings in the hospital; however, when it is safe for him to
go into the community, rehab staff will take him to AA meetings in the community.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will monitor Derek for any evidence of intoxication and report any
significant findings to the psychiatrist.
2.
Nsg. staff will do a Breathalyzer test if substance abuse is suspected.
3.
Nsg. staff will be alert to a return of any impulses to abuse alcohol and, if present, will
assist him to deal with these in an appropriate, sober manner.
4.
Nsg. staff will give encouragement and verbal praise for Derek’s involvement in
non-drug-related social activities.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.0 Health Maintenance
MTP–13
Name: Rossi, Derek
ID #: 12345
Area: West Unit
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Derek’s physical exam revealed no significant abnormality. Derek’s medical history reveals that he has mild
heartburn due to reflux esophagitis, which is fairly well controlled with Zantac (ranitidine) 150 mg po bid.
However, currently he drinks 8 to 12 carbonated beverages every day and eats other foods that exacerbate his
heartburn.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Derek will maintain an optimal level of health while
hospitalized, AEB his compliance with all prescribed meds, lab
work, and treatments for his medical problems.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Derek will eat a diet that will help promote control of his reflux
esophagitis, AEB no heartburn for 2 weeks.
Target Date
Date/Status*
02/29/03
Ongoing
Target Date
Date/Status*
02/29/03
Attained
02/12/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
MTP–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.0
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
MD will treat Derek’s reflux esophagitis with Zantac (ranitidine) and monitor him as
needed for any burning in his stomach. MD will request a dietary consult to assess
Derek’s diet and make needed recommendations.
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor Derek daily and follow up on any signs and symptoms of
illness.
2.
Nsg. staff will work with Derek and the dietician on developing a dietary plan to help
control Derek’s heartburn.
3.
Nsg. staff will administer all prescribed meds and treatments as ordered, including
dietary recommendations, and will document Derek’s compliance.
4.
Nsg. staff will assess and document pt.’s level of understanding of prescribed
treatments, including diet, and will provide necessary teaching at Derek’s level of
understanding.
5.
Nsg. staff will prompt Derek to comply with treatments, diet, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany Derek to
procedures. Staff will offer praise for compliance and document compliance.
Marilyn Davis, RN Å Nsg. Staff
*Status:
Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Master Treatment Plan (Sample)
MTP–15
Name: Rossi, Derek
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Signature Page
Lakeview Hospital
Name of Facility
Area: West Unit
Date: 01/15/03
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
X
X
X
Derek Rossi
01/15/03
(Patient’s or guardian’s signature and date)
(If guardian, relation to patient)
Patient’s Comments (optional):
Staff Members’ Comments (optional):
Derek appears to have a reasonably good understanding of his Master Treatment Plan. He is motivated to work
with the team on his problems, especially on getting rid of the voices. At discharge, Derek hopes to return to his
own apartment; however, he does not believe that his employer wants him back because pt. feels that his
performance at work was inadequate.
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/15/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/15/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/15/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/15/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
01/15/03
Print Name:
Albert Sanchez, Rehab
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.”
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
Notes
Master Treatment Plan (Sample)
MTP–17
Treatment Plan Reviews
(Samples)
The following sample Treatment Plan Reviews (TPRs) demonstrate how the TPRs act with the Master
Treatment Plan (MTP) to capture the flow of treatment. The sample TPRs take the reader through about
half of the patient’s (Derek Rossi’s) hospitalization.
MTP–18
Fundamentals of Psychiatric Treatment Planning
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 01/22/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to take his meds. Yesterday he started going to some program activities. However,
he continues to have lots of feelings of hopelessness and low self-esteem.
Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself;
however, they may be decreasing somewhat. Derek continues to feel that he has control of the impulses to hurt
himself.
Problem 6.0. Nsg. staff and the dietitian are working with Derek on getting him to cooperate with moving toward a
bland diet to help control his heartburn.
4. Changes in Treatment Plan Goals and/or Modalities:
Continue to titrate pt.’s Risperdal and Effexor upward.
5. Reasons for Continued Hospitalization:
Due to continued suicidal ideation, pt. is unsafe to be discharged.
6. Discharge Planning Update:
When ready, Derek is to be discharged back to his apartment with support from Case Management.
7. Level of Care: Active Treatment [ X ] Extended [ ]
Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/22/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/22/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/22/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/22/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
01/22/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
01/22/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
Master Treatment Plan (Sample)
MTP–19
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 01/29/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to cooperate with treatment, including taking his meds and going to at least one
program every day. However, he continues to have lots of feelings of hopelessness and low self-esteem.
Problem 3.1. Derek continues to have suicidal ideation and associated command hallucinations to hurt himself.
Recently Derek has been having problems with feeling that he is losing control of the impulses to hurt himself;
however, he has not made any plans to hurt himself.
Problem 6.0. Derek’s heartburn appears to be responding to a bland diet, including cutting back on carbonated
beverages.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 1.1 Short-Term Goal attained. Continue to titrate patient’s Risperdal and Effexor upward. Special one-onone close observation may be needed, if Derek’s suicidal impulses worsen.
5. Reasons for Continued Hospitalization:
Due to worsening suicidal impulses, patient is unsafe to be discharged.
6. Discharge Planning Update:
When ready, Derek will be discharged back to his apartment with support from Case Management.
7. Level of Care: Active Treatment [ X ] Extended [ ]
Awaiting SNF [ ]
8. Treatment Team Members (All participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
01/29/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
01/29/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
01/29/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/29/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
01/29/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
01/29/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP–20
Fundamentals of Psychiatric Treatment Planning
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/05/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek is continuing to cooperate with treatment and has completed 1 week of at least 4 days/week of
program activities. He is having much fewer feelings of hopelessness and low self-esteem. The hallucinations are
decreasing.
Problem 3.1. Derek has done better for the last few days; however, he continues to have some suicidal ideation. For
the last couple of days, the command hallucinations have stopped, and for the last week, pt. has been able to
identify ways to help direct himself from self-destructive impulses.
Problem 6.0. Derek’s heartburn appears to be responding to a bland diet, including cutting back on carbonated
beverages. He denies having any heartburn for about 1 week.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 3.1 Short-Term Goal 1 was attained. Increase Risperdal to 8 mg/day and continue current dose of Effexor
150 mg/day.
5. Reasons for Continued Hospitalization:
Pt. continues to be a risk for a suicidal attempt; therefore, patient is unsafe to be discharged.
6. Discharge Planning Update:
When ready, Derek will be discharged back to his apartment with support from case management.
7. Level of Care: Active Treatment [ X ] Extended [ ]
Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/05/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/05/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/05/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
02/05/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
02/05/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
02/05/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
Master Treatment Plan (Sample)
MTP–21
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/12/03
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
Problem 6.0a was changed from Active to Inactive With Treatment.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek’s spirits are improving and he is no longer having feelings of hopelessness and low self-esteem.
Next week, he is expected to participate in a full schedule of program activities. For the last couple of days, all
hallucinations stopped completely.
Problem 3.1. Derek reports that he in now free of both suicidal ideation and command hallucinations.
Problem 6.0. Derek’s heartburn appears to have responded very well to a bland diet, including cutting back on
carbonated beverages. He denies having any heartburn for about 2 weeks.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 1.1 Short-Term Goals 3 and 5 were attained. Problem 6.0a Short-Term Goal 1 was attained. Problem 6.0
Long-Term Goal 1 was changed to ongoing. Continue current meds, including Risperdal 8 mg/day and Effexor 150
mg/day.
5. Reasons for Continued Hospitalization:
Suicidal impulses appear to be just getting under control; however, without further progress, Derek is very likely to
quickly relapse. Staff is continuing to work with him on ways to help prevent a return of suicidal impulses.
6. Discharge Planning Update:
When ready, Derek will be discharged back to his apartment with support from case management.
7. Level of Care: Active Treatment [ X ] Extended [ ] Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/12/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/12/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/12/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
02/12/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
02/12/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
02/12/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
MTP–22
Fundamentals of Psychiatric Treatment Planning
Treatment Plan Review
Name: Rossi, Derek
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: 12345
Area: West Unit
Lakeview Hospital
Name of Facility
Date: 02/19/03
1. Changes in Psychiatric Diagnosis (DSM-IV):
AXIS I:
No change in diagnosis
AXIS II:
AXIS III:
2. Changes in Problem List:
No change in Problem List.
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Problem 1.1. Derek’s spirits continue to be good and he continues to be free of feelings of hopelessness and low
self-esteem. For the last few days, he has participated in a full schedule of program activities. No hallucinations
since 02/10/03.
Problem 3.1. Derek reports that for the last week he has been free of suicidal ideation and impulses to hurt himself.
The command hallucinations to hurt himself stopped more than 2 weeks ago.
Problem 6.0. Derek continues to be free of any heartburn or any other medical complaints.
4. Changes in Treatment Plan Goals and/or Modalities:
Problem 3.1 Short-Term Goal 3 was attained and Short-Term Goal 5 was added.
5. Reasons for Continued Hospitalization:
Suicidal impulses continue to be under control; however, without further progress, Derek continues to be at risk to
relapse shortly after discharge. Staff is continuing to work with him on ways to help prevent a return of depression,
psychosis, and suicidal impulses.
6. Discharge Planning Update:
Pt.’s case manager will be contacted to discuss Derek’s returning part-time to his job in the community and to
begin plans for him to go for an overnight to his apartment.
7. Level of Care: Active Treatment [ ] Extended [ X ] Awaiting SNF [ ]
8. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Victor Dyson, MD
Date:
02/19/03
Print Name:
Victor Dyson, MD
Nurse:
Marilyn Davis, RN
Date:
02/19/03
Print Name:
Marilyn Davis, RN
Social worker:
%UHQGD6W0DUWLQ06:
Date:
02/19/03
Print Name:
Brenda St. Martin, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
02/19/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Albert Sanchez, Rehab
Date:
02/19/03
Print Name:
Albert Sanchez, Rehab
Other:
Patient: I participated in the review:
Date:
Derek Rossi
Print Name:
Date:
02/19/03
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
Check if review is continued on reverse [ ]
PSYCHOLOGICAL IMPAIRMENT
(Problem Area 1)
1–1
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Psychological Impairment (Problem Area 1)
1–3
PSYCHOLOGICAL IMPAIRMENT
(Problem Area 1)
CONTENTS
Kennedy Axis V for Psychological Impairment......................................................................................... 1–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Psychological Impairment and can be helpful in composing a short
description of each problem.
Problem Names and Descriptions ............................................................................................................ 1–5
Examples of problem names and descriptions that may relate to Psychological Impairment are listed here.
These examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 1–7
Examples of strengths that may be related to treatment and discharge in the area of Psychological
Strengths are listed here.
Goals ......................................................................................................................................................... 1–7
Examples of treatment goals that may relate to problems in the area of Psychological Impairment are
listed here.
Treatment Modalities ............................................................................................................................. 1–10
Examples of treatment modalities that may relate to problems in the area of Psychological Impairment
are listed here.
Individual Problem Plans (Frequent Entries).......................................................................................... 1–16
Two Individual Problem Plans that contain examples of information frequently entered into Individual
Problem Plans for Psychological Impairment are included here.
Sample Individual Problem Plans ........................................................................................................... 1–21
A wide range of Individual Problem Plans relating to Psychological Impairment are included here.
1–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Psychological Impairment
100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems
never seem to lead to any significant anxiety or depression. No symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all
areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday
problems or concerns.
80 If symptoms are present, they are transient and expected reaction to psychosocial
stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild
preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The
stress is too much”); not considered to have mental problems by those who know him/her.
70 Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the
household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally
functioning fairly well; however, those who know him/her well might express some concerns about his/her mental
state.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently
preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others;
to those who know him/her well it is clear that he/she has mental problems.
50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe
phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety
attacks, moderately guarded, mild but definite manic syndrome).
40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is
at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however,
probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or
mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative
symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have
mental problems.
30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to
hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is
occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications;
inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job,
home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost
totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe
sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.
20 Thinking and communication are generally grossly impaired; manic excitement or catatonia;
largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal
personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe
food off shirt; smears feces for bizarre, delusional reasons).
10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely
incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or
minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a
few seconds; chronic, self-induced vomiting has led to a very life-threatening situation.
NR Not rated
Psychological Impairment (Problem Area 1)
Problem Names and Descriptions
I.
II.
Mood Disturbance Problems (depressive symptoms, manic symptoms,
anxious symptoms)
A.
Sadness
1.
Low self-esteem
2.
Extremely fragile and brittle self-esteem
3.
Depression with persecutory delusions
4.
Difficulty accepting significant loss
5.
Preoccupation with perceived rejection
B.
Anxiety and tension
1.
Hyperactivity
2.
Agitation and restlessness
3.
Chronic tension
4.
Apprehensiveness about changes in routine or environment
5.
Work-related anxiety
C.
Lethargy and lack of motivation
1.
Loss of interest in surroundings
2.
Loss of interest in hobbies or usual activities
3.
Slow moving and sluggish
4.
Marked lethargy
5.
Fatigue
6.
Lack of motivation for ADLs
7.
Lack of motivation for care of personal hygiene
8.
Indifference to personal appearance
D.
Other
1.
Insomnia
2.
Disturbance in eating habits
3.
Poor attention span
4.
Rumination or racing thoughts
5.
Mood swings
6.
Manic episodes, elation, grandiosity
Thought Disorder Problems (psychotic symptoms)
A.
Primary psychotic symptoms
1.
Delusions
2.
Fixed paranoid delusions
3.
Auditory or visual hallucinations or both
4.
Marked distraction by hallucinations and delusions
5.
Disorganized, confused cognition caused by psychotic process
6.
Psychotically impaired judgment and insight
7.
Inappropriate affect
8.
Periods of psychotic decompensation
9.
Work or social adjustment difficulty secondary to paranoia
B.
Withdrawal and apathy
1.
Is withdrawn, reclusive
2.
Has minimal interpersonal interactions
3.
Is noncommunicative
4.
Will not initiate social interactions
5.
Has no hobbies or normal interests
1–5
1–6
Fundamentals of Psychiatric Treatment Planning
6.
7.
Wants to be left alone
Has limited motivation to improve and leave the hospital
C.
Bizarre behaviors
1.
Bizarre behavior such as lying on the floor or exhibiting constant rocking, head banging, and
stereotypical movements
2.
Bizarre, inappropriate dress
3.
Bizarre compulsive eating or drinking habits (e.g., occasionally drinking from the toilet, eating
feces)
4.
Bizarre episodes of screaming and yelling
D.
Other
1.
Poor attention span
2.
Agitation and restlessness
III. Miscellaneous Psychological Impairment Problems
A.
Personality disturbances
1.
Obsessive-compulsive behaviors
2.
Ritualistic, compulsive mannerisms
3.
Overemphasis on cleanliness and neatness
4.
Psychosomatic symptoms and conversion reactions
5.
Stealing and other antisocial behaviors toward property
6.
Dependent personality style
7.
Overly dependent on others for decision making and support
8.
Resistant to independent functioning
9.
Passive-aggressive manipulation
B.
Eating disturbances
1.
Anorexia (inadequate food or fluid intake or both)
2.
Obesity
3.
Bulimia (gorging and vomiting)
4.
Polydipsia (drinking fluids to dangerous excess)
5.
Pica (persistent and compulsive craving to eat nonfood items such as dirt, clay, coffee grounds, or
cigarettes)
C.
Other
1.
Noncompliance with treatment
2.
Escape risk
3.
Nocturnal enuresis secondary to psychological factors
4.
Gender identity confusion
5.
Manipulative behavior
6.
Nonviolent attention seeking
Psychological Impairment (Problem Area 1)
1–7
Strengths (Brief List)
I.
Psychological Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Has no thought disorder
Has insight into problems
Copes well with stress
Has good self-esteem
Has satisfactory sense of social and family belonging
Is motivated to work on realistic treatment goals and returning to the community
Is interested in relating to others in a therapeutic relationship
Has had good response to past treatments
Is treatment and medication compliant
Is able to appropriately advocate for self
Is motivated for leisure or recreational activities
Participates in leisure interests
1.
Sports
2.
Exercise
3.
Reading
4.
Socializing, developing friendships, developing relationships
5.
Watching TV, movies
6.
Listening to radio, music, concerts
7.
Shopping trips
8.
Computers, Internet, computer games
M.
Other
Goals
I.
Expected Improvements in Symptoms
A.
Thought disorder
1.
Pt. will make at least one nondelusional, relevant comment in community meeting twice a week
for 1 month.
2.
Pt. will be able to engage in one 2-minute conversation during the 7-to-3 shift with no evidence of
delusional content three times weekly for 1 month.
3.
Pt. will complete a two-step task successfully without performance being impeded by ritualistic
behavior or delusional speech twice weekly for 1 month.
4.
Pt. will gain insight into delusions and hallucinations so that he or she will suspect that they are a
part of the illness for 1 month.
B.
Mood disturbance
1.
Pt. will consistently verbalize a sense of self-worth and express realistic hopes for his or her future
for 1 week.
2.
Pt. will be able to participate in a program activity without extreme mood swings at least four
times a week for 1 month.
3.
Pt. will be free of depressive or manic symptoms for 1 week.
C.
Focal attention
1.
Pt. will maintain relevance and focus on topics beyond the first two sentences of a conversation
consistently for 1 week.
2.
Pt.’s focal attention will improve to the point that pt. will be able to maintain involvement in one
day-program activity each weekday for 1 month.
3.
Pt.’s focus will improve such that he or she will consistently carry out three-step tasks with only a
single prompt for 1 week.
1–8
II.
Fundamentals of Psychiatric Treatment Planning
D.
Apathy and motivation
1.
Pt.’s motivation will increase to the point that he or she will get out of bed at least 3 days a week
with a single prompt for 1 month.
2.
Pt.’s motivation will increase to the point that the pt. will have his or her personal ward dorm area
in acceptable order at least 3 out of 5 weekdays for 1 month.
3.
Pt. will shave and dress self 4 out of 7 days a week for 1 month.
4.
Pt.’s apathy will diminish such that he or she will use independent privileges once daily for
1 week.
5.
Pt.’s motivation will improve such that he or she will attend two art therapy classes a week for
1 month.
E.
Social withdrawal
1.
Pt. will initiate at least a one one-word greeting daily for 1 month.
2.
Pt. will initiate and sustain a 5-minute conversation once each shift for 1 week.
3.
Pt. will spontaneously initiate a request to go on “buddy” privileges with one of the other pts.
F.
Other
1.
Psychosomatic complaints will be reduced such that these complaints will interfere with assigned
program no more than once per week for 1 month.
2.
Pt. will attempt to escape no more than once per month during a 3-month period.
3.
Pt. will be able to go on supervised privileges with staff once a day for 1 week without attempting
to escape.
4.
Pt. will decrease his or her excessive fluid intake, such that his or her blood Na level remains WNL
for 3 months.
5.
Pt.’s anorexia will improve, AEB gaining 2 pounds per month for 2 months.
6.
Pt. will cooperate with staff requests to toilet self for 1 week.
7.
Pt.’s incidences of nocturnal enuresis will decrease to fewer than three times per week for
1 month.
Reporting of Symptoms
A.
B.
C.
D.
E.
Pt. will verbalize any return of hallucinations for 1 week.
Pt. will verbalize any return of hallucinations for 1 week AEB pt. not being noted to be
responding to hallucinations without having notified staff of the return of
hallucinations.
When tormented by hallucinations, pt. will learn to approach staff and try
interventions for reducing the hallucinations.
In psychotherapy, pt. will express feelings of sadness and loss, if present, once weekly
for 1 month.
Pt. will not feign or exaggerate symptoms for 1 week.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
D.
E.
F.
G.
Pt. will consistently remain in the group activity area with minimal redirection for at
least ½ hour per weekday for 1 month.
Pt. will attend two program activities per week for 1 month.
Pt. will attend art therapy twice a week for 1 month to help improve self-esteem.
Pt. will participate in a full-time load of day-program activities for 1 month.
Pt. will start a supportive job in the hospital gift shop.
Pt. will start a job in the community.
Pt. will attend assigned programs (with medical clearance), despite psychosomatic
complaints, at least once per weekday for 1 month.
Psychological Impairment (Problem Area 1)
1–9
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the importance of taking meds as prescribed once a week for 1 month.
2.
Pt. will spontaneously state the benefits of taking antipsychotic meds twice during 1 month.
3.
Pt. will take antipsychotic meds as prescribed for 1 month.
4.
Pt. will comply with blood and other laboratory work for 3 months.
5.
Pt. will understand the possible benefits of Clozaril AEB cooperating with the necessary workup
for a trial on Clozaril.
B.
Program activities
1.
Pt. will state the benefits of attending program twice weekly for 2 weeks.
2.
Pt.’s level of compliance will improve such that he or she will attend art therapy class twice a week
for 1 month.
C.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process for
1 week.
2.
Pt. will be willing to participate in the evaluation process AEB meeting with the psychologist
weekly for 1 hour.
3.
Pt. will demonstrate cooperation with all aspects of the treatment plan, including meds and blood
work, for 1 month.
4.
Pt. will be free of unrealistic, grandiose discharge plans for 1 month.
D.
Consequences of actions
1.
Pt. will demonstrate a realistic orientation toward his or her progress such that the pt. understands
and explains the connections between the following:
a. Rational, trusting behavior; program attendance; medication compliance; and the ability to be
discharged from the hospital
b. Bizarre, paranoid thinking; inconsistent program attendance; medication noncompliance; and
recurring setbacks, including the need for continued care at the hospital
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate so that psychological tests can be completed.
2.
Pt. will cooperate so that rehabilitation assessment for an appropriate day-program referral can be
completed.
B.
Evaluations to R/O various diagnoses
1.
Pt. will cooperate so that he or she can complete evaluation to R/O psychotic process.
2.
Pt. will complete evaluation to R/O borderline personality disorder.
3.
Pt. will cooperate with psychological testing to R/O organic etiology for psychosis.
4.
Pt. will overcome fears to complete evaluation to R/O cardiac disease.
C.
Laboratory tests
1.
Pt.’s medication compliance will improve so that the medication blood level is in the therapeutic
range for 3 months.
2.
Pt. will control his or her drinking of excessive fluids AEB maintaining a proper electrolyte balance
for 3 months.
1–10
Fundamentals of Psychiatric Treatment Planning
VI. Standardized Outcome Measures
A.
Kennedy Axis V (K Axis)
1.
Pt.’s K Axis score on Psychological Impairment will improve from a current score of 30 to 40.
B.
Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)
1.
Pt.’s K NOSIE score on Manifest Psychosis will improve from a current score of –20 to –12.
2.
Pt.’s K NOSIE score on Social Interest will improve from a current score of +12 to +20.
3.
Pt.’s K NOSIE score on Motor Retardation will improve from a current score of –16 to –10.
C.
Mini-Mental State Exam
1.
Pt.’s score on the Mini-Mental State Exam will improve from a current score of 12 to 18.
D.
Brief Psychiatric Rating Scale (BPRS)
1.
Pt.’s score on the BPRS will improve from a score of 62 to 40.
E.
Beck Depression Inventory
1.
Pt.’s score on the Beck Depression Inventory will improve from a score of 35 to 18.
Treatment Modalities
I.
Verbal Treatment Modalities (emphasis on verbal interactions)
A.
Support and reassurance
1.
Staff will provide one-to-one supportive problem-solving therapy for 1 hour once weekly.
2.
Staff will provide one-to-one relationship to increase trust in staff, to build a trusting relationship,
and to reduce paranoia.
3.
Staff will provide one-to-one contact to provide pt. with needed support and reassurance that
people care for him or her for 1 hour once weekly.
4.
Staff will reassure and reality test with pt. about his or her delusions that the pt.’s thoughts can
kill.
5.
Staff will express understanding of pt.’s distress and suggest interventions when tormenting
hallucinations are present.
B.
Cognitive refocusing (redirecting focus toward reality and realistic self-appraisal)
1.
Staff will treat drops in pt.’s self-esteem by helping pt. focus on his or her assets and
accomplishments (e.g., program attendance, hobbies, relatives who care for the pt., memories of
happy experiences).
2.
Staff will help pt. recognize and express self-worth (e.g., compliment pt. when appearance
improves to bolster self-esteem; engage pt. in activities in which he or she can succeed).
3.
Staff will intervene to refocus, redirect, and orient to reality whenever pt. is confused and disorganized.
4.
Staff will redirect pt. away from behavior based on delusional thinking toward adaptive
requirements of the moment.
5.
Staff will maximize structured activities to minimize regressive episodes by helping the pt. to stay
focused away from psychotic processes, including delusions and hallucinations. This can be done
by maximizing the pt.’s involvement in structured day program, including open workshop,
patient wage program, leisure interest group, and community meeting.
6.
Staff will engage the pt. in two sessions weekly of 30 to 45 minutes in woodworking, using one-toone with pt. to maintain maximum focus.
7.
Staff will focus pt. away from plans based on pt.’s psychotic thinking to plans based on realistic,
achievable goals (e.g., passes with family, shopping trips, and discharge to a halfway house).
8.
Staff will use a substitute stimulation (e.g., listening to radio headset) to help pt. focus away from
tormenting hallucinations.
Psychological Impairment (Problem Area 1)
C.
II.
1–11
Psychotherapy
1.
Staff will meet with pt. for one-to-one, insight-oriented psychotherapy once a week to help work
through psychological conflicts that result in high levels of anxiety.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help the pt. more
effectively cope with day-to-day problems.
3.
Social worker will provide weekly one-to-one dialectic behavior therapy (DBT) counseling for pt.
and lead weekly DBT skills practice group to help reduce pt.’s depressive symptoms.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Staff will give pt. positive feedback and encouragement for coherent, reality-based
communications.
2.
Staff will praise pt. for reality-based speech.
3.
Staff will provide positive verbal reinforcement for independent action when around the ward or
when in program (to reduce apathy and lack of motivation).
4.
Staff will provide constant encouragement to help relieve pt.’s lack of motivation to wash face,
comb hair, wipe nose, and so on.
5.
Staff will give positive reinforcement for any spontaneous activity other than going to bed.
6.
Staff will give positive verbal reinforcement for each step toward greater involvement in ward activities.
7.
Staff will encourage pt. to be involved in the treatment-planning process.
8.
Staff will give pt. reinforcement for accumulating points for specific compliant acts (e.g., making
bed, dressing appropriately, going to program). When pt. receives 10 points, he or she will be
given an identified reinforcer. (See attached behavioral plan for details.)
9.
Staff will give pt. money, clothes, and gym activities to richly reinforce independent, self-initiated
behaviors such as getting dressed, making bed, and going to program.
B.
Negative reinforcement (including discouragement, restriction, and withholding of reinforcement)
1.
Staff will restrict pt. to supervised privileges for 24 hours if he or she fails to go to morning
program activities.
2.
Pt.’s independent privileges will be held for 1 week following his or her return from escape.
During the 1-week period, pt. will be assessed for the safety of restarting independent privileges.
3.
Pt. will lose smoking privileges for 24 hours when he or she steals from other pts.
C.
Extinction
1.
All staff will ignore bizarre and delusional speech, thus helping to extinguish this psychotic
behavior.
2.
Staff will acknowledge psychosomatic complaints but will encourage pt. to attend assigned
program.
3.
Staff will disregard delusional speech.
D.
Shaping and modeling
1.
Staff will provide primary and secondary positive reinforcers for incremental increases in focal
attention.
2.
To improve focal attention, pt.’s contact will involve pt. at least twice daily in 15-minute sessions,
such as tossing and catching a ball, playing pool, and so on.
3.
Nsg. staff will assign pt. on-ward activities with gradually increasing focal requirements as pt.’s
focal attention improves.
4.
Rehab staff will refer pt. to day programming for involvement in tasks that require gradually
increasing amounts of time attending to the task.
5.
Staff will promote pt.’s independence by gradually increasing his or her decision-making
responsibilities.
1–12
Fundamentals of Psychiatric Treatment Planning
E.
Channeling of energies
1.
Staff will channel pt.’s high level of anxiety into structured day-program activities, including
exercise group.
F.
Task simplification (reducing confusion and frustration by simplifying tasks and providing
consistency and assistance)
1.
Nsg. staff will use the same person as consistently as possible for redirection.
2.
All staff will be as consistent as possible in redirecting pt. away from inappropriate, bizarre
behavior.
3.
To reduce level of dependency, contact will help pt. write down all basic answers and procedures
to questions and routines that confuse him or her. When appropriate, contact will direct pt. to
these written lists.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family/couple treatment modalities
1.
Family will engage in therapy to help improve the pt.’s feelings of inadequacy.
2.
Social worker will provide pt. with family therapy once a month for 1 hour to help pt. and his or
her family to cope better with pt.’s delusions.
3.
Psychologist will work with pt. and his or her significant other for 1 hour each week on
recognizing and coping with pt.’s manic episodes.
B.
Religious treatment modalities
1.
Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling for support and hope
in relation to depression once weekly for 1 hour.
2.
Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling to help pt. get a
religious perspective on his or her delusions of demonic possession.
3.
Spiritual leader (e.g., priest, rabbi, minister) will provide religious counseling to help pt.
objectively examine his or her guilt and to give appropriate assurance of forgiveness, as needed.
4.
Religious services will be provided to enhance pt.’s self-esteem and feelings of meaning and
community twice weekly for 1 hour.
C.
Other modalities
1.
DBT
a.
Social worker trained in DBT will meet with pt. for therapy and training on means of
managing his or her impulsive behaviors for 1 hour twice a week.
b.
Because of failure to respond to treatment, the team will refer pt. to the DBT ward for
treatment of his or her problems with borderline personality disorder.
2.
Group therapy
a.
Group therapy to facilitate discussion of problems and to learn means of more appropriately
coping with those problems will be undertaken once weekly for 1 hour.
3.
Psychodrama
a.
Role playing will be used to help reduce pt.’s anxiety about talking about his or her illness
once weekly for 1 hour.
4.
Behavioral plan
a.
Psychologist will oversee behavioral plan to change specific behaviors (see attached
behavioral plan).
5.
Desensitization
a.
Psychologist will develop a plan to help desensitize the pt. to his or her fear of driving.
b.
Rehab staff will provide activities that pt. can successfully complete to help relieve pt.’s fear
of failure.
c.
Recreational therapist will work with pt. in bowling group to reduce anxiety associated with
participating in groups.
Psychological Impairment (Problem Area 1)
1–13
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will redirect pt. from triggering events or overstimulating areas to reduce level of
hallucinations.
2.
Sound-absorbing material will be added to pt.’s dorm area to help reduce noise.
B.
Protective procedures (including special observations)
1.
Staff will keep pt. away from street drugs and alcohol to prevent further neuropsychological
damage and associated bizarre behavior. At the same time, pt. will be treated for substance abuse
(as outlined under Problem 5.1 Polysubstance Abuse) in the hopes that pt. will abstain from
substance abuse once pt. has the opportunity to use drugs again.
2.
Nsg. staff will use escape precautions when pt. is on the ward.
3.
Staff will closely monitor pt. whenever pt. is off the ward to minimize escapes.
4.
Staff will install a locating device in pt.’s car to locate pt. when he or she takes off in the car
during a manic episode.
C.
Other milieu treatment modalities
1.
Staff will use increased lighting and brighter colors in the pt.’s day area.
2.
Staff will move pt. to a semiprivate room, and pt. will be allowed to bring in items to give the
room a “home” look and feel.
Medical Treatment Modalities
A.
Medication
1.
Psychiatrist will prescribe antipsychotic meds to reduce intensity of persecutory beliefs.
2.
Nsg. staff will give pt. prn meds to relieve pt. from acute episodes of tormenting hallucinations.
B.
Other medical treatment modalities
1.
Electroconvulsive therapy (ECT)
a.
Intractable depressive symptoms will be treated at St. John’s Hospital with a series of ECT
followed by maintenance ECT.
2.
Light therapy
a.
Pt.’s seasonal depressive symptoms will be treated using light therapy for 1 hour daily.
3.
Psychosurgery
a.
Pt.’s severe unremitting depression will be treated using psychosurgery.
b.
Severe, incapacitating obsessive-compulsive symptoms will be treated at a general hospital
by psychosurgery.
4.
Miscellaneous
a.
Restrict fluids to 350 cc following dinner to prevent nocturnal enuresis.
b.
Nsg. staff will toilet pt. every 2 A.M. to help reduce nocturnal enuresis.
c.
Staff will provide wheelchair to increase pt.’s independence around the ward.
VI. Patient and Family Education
A.
Mental illness
1.
Staff will discuss ways to cope with mental illness with pt. for 1 hour once weekly.
2.
Staff will teach pt. and the family ways to recognize the signs of manic decompensation.
3.
Staff will discuss the nature of pt.’s mental illness and its prognosis with the pt. and family.
B.
Medication
1.
Psychiatrist will discuss the risks and benefits of meds with pt. once weekly for ½ hour.
2.
Nsg. staff will point out concrete benefits of taking meds (e.g., “There is a decrease in the
hallucinations,” “You are more focused on tasks,” “You are less paranoid”).
3.
Pt.’s psychiatrist will discuss with pt.’s family the reasons pt. needs to take meds.
1–14
Fundamentals of Psychiatric Treatment Planning
C.
Benefits and consequences of behaviors
1.
Staff will discuss connections between daily appropriate behavior (such as being out of bed,
attending program) and realistic progress toward pt.’s goals, including passes, shopping trips, and
discharge planning.
2.
Psychiatrist will discuss with pt. alternative means of gaining freedom (demonstrating ability to
appropriately use pt.’s independent privileges within the hospital and off the grounds) rather than
escaping.
3.
Staff will discuss for ½ hour once a week the benefits of neatness and good personal hygiene to
improve pt.’s motivation to attend to daily personal hygiene.
4.
The social worker will discuss with pt.’s family members the benefits of their visits, their support,
and their money for pt.’s shopping trips.
D.
Miscellaneous
1.
Staff will involve pt.’s family in a psychoeducational program to improve their ability to cope with
pt.’s psychotic symptoms.
2.
Psychologist will meet to educate pt.’s parents about the effect that lack of monitoring and lack of
discipline has on the pt. for 1 hour once a month.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Psychological testing for personality assessments
2.
Psychological testing to assist in the diagnostic evaluation
3.
An inventory of reinforcements, including activities, money, relationships with significant others,
and so forth
4.
Psychological testing to determine pt.’s ability to engage in treatment
5.
Neuropsychological testing
B.
Psychiatric evaluations
1.
Psychiatric diagnostic evaluation
2.
Psychiatric medication evaluation
3.
Neuropsychiatric evaluation
4.
AIMS or AIMS Plus EPS exam, as needed
C.
Medical/laboratory tests and evaluations
1.
Urology consult to determine if there is an organic basis for pt.’s bed-wetting
2.
Blood levels to help determine medication compliance
3.
Blood levels to determine whether the psychotropic medication is in the therapeutic range
4.
EEG to R/O temporal lobe epilepsy
5.
CT scan/MRI to R/O organic etiology
6.
Incontinence chart to follow enuresis
D.
Other evaluations and assessments
1.
Rehab staff will assess pt.’s areas of interests and motivation to assign structured activities
congruent with pt.’s interests.
2.
Social worker will interview family members to assess their ability to communicate with each
other and to identify areas of significant conflict.
3.
Social worker will complete the Residential Care Scale for level of care needed at discharge.
4.
Conduct weekly one-to-one meetings with pt. and monthly meetings with family to determine
pt.’s ability to tolerate increased involvement with family.
5.
Conduct vocational assessment to develop a step-by-step plan to reengage pt. in vocational
activities.
6.
Psychologist will meet with pt. once a week for ½ hour to attempt to understand pt.’s stealing
behavior.
7.
Nsg. staff will monitor pt. for evidence that pt. is planning an escape.
8.
Conduct religious assessment to determine consistency of potentially delusional thinking with
pt.’s religious community.
Psychological Impairment (Problem Area 1)
9.
1–15
Conduct religious assessment to evaluate validity of pt.’s guilt feelings from a religious
perspective.
VIII. Legal Treatment Modalities
A.
Court commitment
1.
Psychiatrist will seek court commitment under Sections 7 and 8 for a period of up to 6 months
because pt. is unable to safely function in the community due to her poor insight and judgment.
2.
Psychiatrist will initiate petition for mandatory outpatient commitment and treatment under
Section 23c.
B.
Court approval for forcing meds
1.
Team will seek court approval for the use of antipsychotic meds for treatment of pt.’s disabling
psychosis.
IX. Miscellaneous Treatment Modalities
A.
Treatment of related problems (optional and can be included with the treatment
modalities or in the problem description)
1.
Treat pt.’s problem with suicidal ideation as indicated under Problem 3.1 (Suicidal Ideation).
2.
Treat pt.’s problem with assaultiveness as indicated under Problem 3.1 (Violence Secondary to
Paranoia).
3.
Treat pt.’s problem with substance abuse as indicated under Problem 5.1 (Polysubstance Abuse).
1–16
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plans (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Psychotic Symptoms
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
•
•
•
•
2.
3.
4.
Onset of symptoms and chronicity
Precipitants (e.g., noncompliance with treatment, substance abuse, stress)
Characteristics, frequency, intensity, and variance of symptoms
Response to previous and current treatments and expected response to any proposed treatments
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
Make sure that the above relate to goals and treatment modalities.
If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it
into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment.
Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem
Area 3, Violence.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
1.
Pt. will participate in _______________________ group(s) at least ___
out of ___ days a week for ___ month(s).
2.
Pt. will be involved in at least ___ hours per day of either
treatment programs or vocational programs for a ___-week/month
period without significant interference from psychotic symptoms.
3.
Pt. will be free of overt psychosis AEB not acting on delusions or
hallucinations for ___ week(s)/month(s).
4.
Pt. will accept prescribed meds and lab work for a ___-week/month
period.
5.
Pt. will engage in reality-based, ___-minute conversations with
staff without evidencing delusional ideas at least ___ time(s) per
week for ___ month(s).
6.
Pt. will cooperate with a least one treatment team member in the
treatment planning process.
7.
Pt. will be able to explain the nature of his or her illness and its
treatment in a fairly rational, fairly accurate manner.
8.
Pt. will tolerate ___ overnight visits to a community residence
without significant interference from psychotic symptoms.
9.
Pt.’s score on the Kennedy Axis V Psychological Impairment will
improve from the current score of ___ to ___.
Target Date
Date/Status*
10. Pt.’s score on the Kennedy NOSIE’s Manifest Psychosis and Social
Interest will improve from the current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
1–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ____ minutes at least ______ time(s) weekly/monthly to
monitor any changes in psychosis to prescribe treatment with antipsychotic meds,
______________, and _____________ for EPS. Lab (blood levels, WBCs). AIMS q 6 months.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
discuss the effect of pt.’s psychosis on discharge, to evaluate pt.’s readiness for
discharge, and to discuss discharge options with pt.
Brenda St. Martin, MSW
Psychology (or Social Work):
1.
Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
times weekly/monthly in supportive, problem-solving, cognitive therapy to direct pt.
back to reality or help pt. function, even if psychotic symptoms persist.
2.
Psychologist (social worker) will rate the Kennedy Axis V quarterly/annually.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise the daily treatment schedule. Staff will refer pt. to
appropriate groups working to improve contact with reality, self-image, motivation,
and focal attention and to develop structure in pt.’s daily routine.
2.
Staff will work with pt. in _____________________ group program for ___ hour(s) a
day/week to help improve pt.’s (contact with reality, self-image, motivation, focal
attention, ____________________).
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will provide decreased stimulation, verbal redirection, and refocusing to
reality issues. If tormenting hallucinations or paranoid thoughts are present, nsg. staff
will express understanding of pt.’s distress, give reassurance, suggest interventions and,
if indicated, offer prn meds to help relieve pt.’s distress.
2.
Nsg. staff will encourage attendance at morning meeting (staff will encourage role
modeling of appropriate behavior), other on-ward activities, and rehab groups. Staff
will provide escort if needed. Nsg. staff will document frequency of attendance.
3.
Nsg. staff will offer support and praise for appropriate, reality-based interactions.
4.
Nsg. staff will begin to assess pt.’s level of understanding of antipsychotic meds and his
or her readiness to learn before educating pt.
5.
Nsg. staff will meet with pt. for ___ minutes at least ___ time(s) a week/month to
educate pt. about his or her illness and the importance of taking his or her meds. This
process will be simple, clear, concrete, and according to pt.’s ability to understand.
Nsg. staff will request feedback from pt. to validate pt.’s level of comprehension.
6.
Nsg. staff will rate the Kennedy NOSIE once weekly/monthly/quarterly.
7.
Nsg. staff will prompt pt. to perform ADLs and will document compliance.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.2 Depressive Symptoms
Name: Smith, Jane
ID #:
Area:
Nursing Diagnosis: Chronic Low Self-Esteem; Hopelessness;
Powerlessness
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
•
•
•
•
2.
3.
4.
Onset of symptoms and chronicity
Precipitants (e.g., noncompliance with treatment, substance abuse, stress)
Characteristics, frequency, intensity, and variance of symptoms
Response to previous and current treatments and expected response to any proposed treatments,
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
Make sure that the above relate to goals and treatment modalities.
If the treatment of a particular problem is very complicated or lengthy, the practitioner may want to divide it
into two problems, for example, 1.1 Psychotic Symptoms and 1.2 Noncompliance With Treatment.
Indicate psychotic impulses to hurt self or others or command hallucinations to hurt self or others in Problem
Area 3, Violence.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
1.
Pt. will be able to engage in a _____-minute conversation without
any evidence of helplessness or hopelessness.
2.
Pt. will be able to discuss options for the future beyond feelings
of helplessness and hopelessness for a _____-day/week period.
3.
Pt. will be able to report improvement in his or her depressive
symptoms consistently for a ___-day/week period.
4.
Pt.’s motivation will improve to the point that pt. will get out of
bed and have his or her dorm area in acceptable order at least ___
weekdays per week for a ___-week/month/period.
5.
Pt.’s energy and motivation will improve so that he or she will
be involved in a least ___ hours per day ___ days per week of
either treatment programs or vocational programs for a
___-week/month period.
6.
Pt.’s depressive symptoms will improve to the extent that he or
she will be able to successfully function during ___ overnight
visit(s) to community residence or home.
7.
Pt.’s score on the Beck Depression Inventory will improve from
the current score of ___ to ___.
8.
Pt.’s score on the Kennedy Axis V Psychological Impairment will
improve from the current score of ___ to ___.
9.
Pt.’s score on the Kennedy NOSIE’s Social Interest and/or Motor
Retardation will improve from the current score of ___ to ___.
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.2
1–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to
monitor any changes in depression to prescribe treatment with antidepressant meds,
such as _______________________ . Labs as ordered, including antidepressant levels.
Victor Dyson, MD
Social Work:
1.
Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
discuss pt.’s depression’s affect on discharge, to evaluate pt.’s readiness for discharge,
and to discuss discharge options with pt.
Brenda St. Martin, MSW
Psychology (or Social Work):
1.
Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
time(s) weekly/monthly in supportive, problem-solving cognitive therapy to improve
pt.’s mood and/or help pt. function, even if depressive symptoms persist.
2.
During these meetings, drops in pt.’s self-esteem will be treated by helping pt. focus on
his or her assets and accomplishments (e.g., career accomplishments, relatives who
care for pt., hobbies, memories of happy experiences).
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.s’ daily treatment schedule. Staff will refer pt.
to appropriate groups working to improve his or her contact with reality, self-image,
motivation, and sense of helplessness or hopelessness (see weekly schedule).
2.
Staff will work with pt. in _____________________ group program for ___ hour(s) a
day/week to help improve pt.’s ______________ (self-esteem, self-image, motivation, and
sense of helplessness or hopelessness).
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive
aspects of his or her life. Nsg. staff will help pt. learn ways to resolve or cope with
negative aspects of his or her life.
2.
Nsg. staff will begin to assess pt.’s level of understanding of antidepressant meds and
his or her readiness to learn before educating pt.
3.
Nsg. staff will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
educate pt. about his or her illness and the fact that pt.’s meds can help to reduce his
or her sadness and sense of hopelessness or helplessness. Nsg. staff will request
feedback from pt. to validate pt.’s level of comprehension.
4.
Nsg. staff will begin to assess pt.’s level of understanding of antipsychotic meds and his
or her readiness to learn prior to educating pt.
5.
Nsg. staff will offer support and praise for realistic, positive interactions or statements
about self or about pt.’s future.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Psychological Impairment (Problem Area 1)
1–21
Sample Individual Problem Plans
CONTENTS
Depressive Symptoms............................................................................................................................. 1–22
Manic-Depressive Symptoms ................................................................................................................. 1–24
Depressive and Psychotic Symptoms ..................................................................................................... 1–26
Psychotic Symptoms............................................................................................................................... 1–28
Residual Psychosis................................................................................................................................... 1–30
Apathy and Lack of Motivation .............................................................................................................. 1–32
Poor Focal Attention............................................................................................................................... 1–34
Noncompliance With Treatment............................................................................................................ 1–36
Resists Independent Functioning ........................................................................................................... 1–38
Escape Risk.............................................................................................................................................. 1–40
Stealing ................................................................................................................................................... 1–42
Psychosomatic Complaints ..................................................................................................................... 1–44
Work-Related Anxiety............................................................................................................................. 1–46
AIDS-Related Distress ............................................................................................................................. 1–48
1–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Depressive Symptoms
Name: Williams, Alice
ID #:
Area:
Nursing Diagnosis: Hopelessness
Date: 01/15/03
Problem Description:
Pt. presents with consistent attitude of hopelessness and helplessness about situation. She has no plans for future
and views her immediate situation as totally beyond her control. Behavior has adolescent quality in that negative
behaviors are used as retaliatory measures against others and to keep others at a distance. Pt. will be able to discuss
options for future.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Patient will be able to discuss options for future beyond feelings
of helplessness and hopelessness.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will be able to engage in a 5-minute conversation without any
evidence of helplessness or hopelessness.
04/15/03
2.
Pt. will cooperate with at least one treatment member in the
treatment planning process.
04/15/03
3.
Pt. score on the Beck Depression Inventory will improve from the
current 30 to 18.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
1–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for at least ½ hour once weekly to monitor any changes
in depression to prescribe treatment with antidepressants, such as Zoloft (sertraline).
Order labs, including antidepressant levels.
Victor Dyson, MD
Psychology:
1.
Psychologist will perform psychological testing to assess depressive cognition.
2.
Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive,
problem-solving therapy to improve pt.’s mood and help her function even if
depressive symptoms persist.
Joseph LeBlanc, Psychologist
Social Work:
1.
Social worker will meet with pt. for ½ hour once weekly to evaluate pt.’s readiness for
discharge.
2.
Social worker will consistently offer pt. the opportunity for treatment planning
involvement.
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will meet with pt. as needed to review and revise her daily treatment
schedule and will refer her to appropriate groups working to improve her self-image,
motivation, and sense of helplessness and hopelessness (see weekly schedule).
Jane Hoover, Rehab
Nursing Care Plan:
1.
Staff will verbally reward pt. for cooperative acts on ward and toward other pts.
2.
Staff will discuss with pt. the fact that the meds reduce her sense of hopelessness and
helplessness.
3.
Nsg. staff will offer support and praise for positive interactions, positive statements
about herself, or positive statements about her future.
Ronald Donahue, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.2 Manic-Depressive Symptoms
Name: Chabot, Joe
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
For the last several years, pt. has been having increasing problems with mood swings, which occur every few
months. During the depressive phase, pt. experiences motor retardation and low self-esteem and becomes
withdrawn. During the manic episodes, pt. experiences euphoric mood, marked insomnia, hyperactivity,
intrusiveness, marked irritability, and assaultiveness. Pt. often feels that the moods are related to external events,
and he is reluctant to take his lithium on a regular basis. When pt. takes his lithium as prescribed, there is a marked
reduction in the severity of his mood swings. Tremors appear to be the only significant side effect of the lithium.
Treatment of irritability as outlined under Problem 3.1 Assaultive, Irritable Behavior.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt.’s manic-depressive symptoms will be controlled to the point
that he can be discharged back to an independent living situation
in the community.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt.’s mood will stabilize such that he gets at least 6 hours of sleep
each night for 1 month.
03/15/03
2.
Pt. will be able to express an understanding of his illness,
including his own “first signs” of manic and depressive trends
and the need to take his meds.
03/15/03
3.
Pt.’s mood will stabilize such that he maintains a normal level of
activity (i.e., reasonably socially outgoing and involved in
recreational activities for 1 month).
04/15/03
4.
Pt. will be free of any significant side effects from the lithium for
1 month.
03/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.2
1–25
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for at least 1 hour and 35 minutes monthly to monitor
any changes in manic-depressive symptoms and to prescribe treatment with mood
stabilizer (such as lithium or Depakote) and beta-blockers (such as Inderal) to help
relieve tremors secondary to the lithium therapy.
2.
Psychiatrist will conduct periodic lab tests to monitor lithium levels and to detect
possible adverse effects of lithium on the thyroid gland, kidney, and the like.
Victor Dyson, MD
Nursing Care Plan:
1.
Nsg. staff will lead medication group once weekly to help pt. understand the nature of
his cyclic mood disturbance, to help him monitor signs of changing mood, and to help
him recognize the benefits of medication for relieving his symptoms.
2.
Nsg. staff will encourage attendance at morning meeting and program activities. Nsg.
staff will document frequency of attendance.
Ronald Donahue, RN
Rehab:
1.
Staff will engage pt. in meaningful activities to redirect excessive energy when pt. is
manic and to minimize withdrawal and drifting when pt. is depressed.
Albert Sanchez, Rehab
Social Work:
1.
Social worker will hold a family meeting once weekly to address pt.’s brothers’
concerns about pt. illness, to educate them regarding his cyclic mood disturbance, and
to support them in coping with his behavior.
Brenda St. Martin, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–26
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.3 Depressive and Psychotic Symptoms
Name: Murphy, John
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
Pt. has a long history of depressive and psychotic symptoms, including persecutory delusions, constant auditory
hallucinations, disorganized thinking, marked sadness, and marked apathy. Exacerbation of depressive and
psychotic symptoms often occurs in association with stress, noncompliance with his meds, or both. Currently pt. is
actively psychotic and very unmotivated. He rejects most interpersonal contact, including that of family members.
Pt. often appears depressed and at times self-reports feelings of depression. The depression is reflected in his lack of
motivation to attend to personal hygiene and his appearance, as well as a generalized appearance of sadness.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will improve to the extent that he can participate in two offward groups per day for 1 month.
01/15/04
2.
Pt.’s Kennedy Axis V score on Psychological Impairment will
improve from current 30 to 40.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. apathy and poor motivation will diminish such that he is out
of bed for at least 2 hours per shift for 2 weeks.
04/15/03
2.
Pt. will use unsupervised privileges at least ½ hour per shift for
2 weeks without significant interference from his psychotic
symptoms.
04/15/03
3.
Pt. will participate in rehabilitation groups three times a week for
2 weeks.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.3
1–27
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ½ hour once a week to monitor pt. for any changes
in his depressive and psychotic symptoms. Antipsychotic and antidepressant meds as
prescribed. Labs as needed and AIMS Plus EPS exam q 6 months.
Virginia Coleman, MD
Social Work:
1.
Social worker will hold weekly meetings with pt. for 45 minutes (family to be included
monthly) to assess and address individual and family issues.
2.
Social worker will hold weekly meetings with pt. to assess readiness for discharge and
to determine obstacles to his discharge.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will hold weekly reality testing for ½ hour to determine obstacles to
improved level of functioning.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Nsg. staff will provide positive feedback to pt. for spontaneous attendance to his
appearance.
2.
Nsg. staff will engage pt. in one-to-one contact two to three times per day to encourage
interpersonal contact in on- and off-ward supervised activities.
3.
Nsg. staff will provide support and praise for appropriate, reality-based interactions.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–28
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.4 Psychotic Symptoms
Name: Kaplan, Carolyn
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
For more than 10 years, pt. has been almost constantly experiencing auditory hallucinations, persecutory
delusions, and bizarre behavior. Because of interference from her thought disorder, she currently is unable to
engage in meaningful conversation for more than 30 seconds. Pt. is becoming increasingly apathetic and does not
participate in any structured activities. Numerous treatment interventions have failed to bring about significant
improvement in her psychosis. These treatments have included trials of several different antipsychotics. Pt. has
recently been approved for a trial on clozapine. Pt. has a borderline abnormal ECG and tardive dyskinesia.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will improve to the extent that she can function on an
unlocked ward successfully for 3 months.
01/15/04
2.
Pt.’s Kennedy Axis V subscale score on Psychological Impairment
will improve from current 20 to 40.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt.’s thought disorder will improve to the extent that she is able
to participate in supervised groups for 1 hour, twice weekly for
1 month.
04/15/03
2.
Pt.’s hallucinations and disorganized thinking will diminish to
the extent that she is able to engage in a focused conversation for
5 minutes twice a week for 1 month.
04/15/03
3.
Pt. will participate in rehabilitation groups three times a week for
1 month.
04/15/03
4.
Pt.’s score on the BPRS will improve from current 61 to less than
40.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.4
1–29
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. to monitor any changes in pt.’s psychotic symptoms to
prescribe antipsychotic meds, such as clozapine.
2.
BPRS will be completed q 3 months. Kennedy Axis V to be completed q 6 months.
3.
Psychiatrist will order weekly WBC for first 6 months of treatment with clozapine,
then WBC twice a month.
4.
AIMS Plus EPS evaluation will be repeated as needed.
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor pt.’s pulse, BP, and temp weekly for the first month of clozapine
treatment, then monitor her as needed.
2.
Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a
conversation.
3.
Nsg. staff will provide one-to-one contact to encourage pt. to participate in program
activities two to three times per day.
4.
Nsg. staff will provide positive feedback to pt. for spontaneous participation in any
structured activity.
5.
Nsg. staff will monitor pt.’s weight monthly for possible excessive weight gain
secondary to clozapine.
Marilyn Davis, RN Å Nsg. Staff
Rehab:
1.
Rehab staff will meet one-to-one with pt. to refer pt. to appropriate groups to increase
her motivation and develop structure in her daily routine.
2.
Rehab staff will work with pt. to develop and update her weekly program schedule (see
attached weekly schedule).
Thomas Parker, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–30
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.5 Residual Psychosis
Name: Newman, Anne
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
Pt. thinking is often disorganized and she is easily overwhelmed by external stimuli. Pt. demonstrates moderate to
marked lethargy and frequently spends much of the day in bed. Pt. has a history of active psychosis; however,
currently she isn’t delusional and she does not appear to be hallucinating. Pt.’s insight and judgment are
moderately impaired. Care has to be taken when planning activities for pt. because she often, at a superficial level,
appears able to function higher than her actual skills will allow. Recently pt. has been able to function well several
days a week in a community day program.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will participate in full-time community day program 5 days a
week for 3 months.
01/15/04
2.
Pt.’s Kennedy Axis V score on Psychological Impairment will be
maintained at level 50 or better.
Ongoing
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will participate in full-time community day program 3 days
per week for 1 month.
04/15/03
2.
On days when not in community program, pt. will attend 2
hours of a ward- or hospital-based program per day for 1 month.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.5
1–31
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ½ hour once a month to monitor pt. for any return
of delusions or hallucinations and adjust pt.’s antipsychotic meds accordingly. Lab
work as needed and AIMS Plus EPS q 6 months.
Victor Dyson, MD
Social Work:
1.
Social worker will conduct weekly one-to-one meeting with pt. for 1 hour to discuss
methods of coping with and tolerating group interactions in daily ward and program
routine.
2.
Social worker will conduct weekly one-to-one meeting with pt. to evaluate pt.’s
readiness for discharge.
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will encourage pt. to participate in hospital and community programs.
2.
Rehab staff will make ongoing assessments of pt.’s actual abilities through observation
of her ability to perform specific ward and program tasks.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will encourage pt. to attend morning meeting and rehab groups.
2.
Nsg. staff will provide positive feedback to pt. for staying out of bed during the day for
periods of 2 hours or more.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–32
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.6 Apathy and Lack of Motivation
Name: King, Robert
ID #:
Area:
Nursing Diagnosis: Activity Intolerance
Date: 01/15/03
Problem Description:
Pt. has a lifelong history of noninvolvement in productive activities. He spends the bulk of the day lying in bed,
preoccupied with internal thoughts. Hospital staff has consistently been unsuccessful during previous hospitalizations in getting pt. involved in on- or off-ward activities. Recently pt. has expressed some interest in earning
money for extra cigarettes. Pt. has been tried on a number of antipsychotic meds, including typical and atypical
meds. Pt. has not had a trial on Clozaril.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will participate in 3 of 10 regularly scheduled program
activities.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will participate in 1 of 10 regularly scheduled program
activities.
03/15/03
2.
Pt. will participate in one structured work activity of 15 minutes
per day, such as washing windows on the ward.
03/15/03
3.
Kennedy NOSIE score in area of Motor Retardation will improve
from current score of –16 to –10.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.6
1–33
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will meet with pt. for ½ hour once a week to prescribe antipsychotics, such
as Clozaril, to help relieve the negative symptoms of pt.’s psychotic process. Lab as
needed, such as weekly WBC and periodic Clozaril blood levels.
Virginia Coleman, MD
Rehab:
1.
Rehab staff will arrange for pt. to participate in the Patient Wage Program.
2.
Rehab staff will schedule pt. for activities that he can complete successfully and that
lead to increased self-esteem and motivation to continue with the activities (see pt.’s
weekly schedule).
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will provide encouragement for pt. to participate in structured work
activities, such as washing windows or cleaning the dayroom.
2.
Nsg. staff will provide support and praise for pt.’s involvement in any program
activity.
Linda Larkin, RN Å Nsg. Staff
Social Work:
1.
When pt. is able to consistently participate in program activities, social worker will
begin meeting with pt. for ½ hour once weekly to evaluate his readiness for discharge
and to discuss discharge options.
Brenda St. Martin, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–34
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.7 Poor Focal Attention
Name: Brown, William
ID #:
Area:
Nursing Diagnosis: Disturbed Thought Process
Date: 01/15/03
Problem Description:
Pt. has a very short attention span; however, with frequent staff redirection, he is able to complete assigned
program tasks. This has been a long-standing problem for pt.; however, he does appear to respond to staff
member’s attention and verbal praise.
Implementation of treatment of Problem 1.1 Psychotic Symptoms to help relieve the contribution of pt.’s
psychotic symptoms to pt.’s poor focal attention.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt.’s focal attention will improve as measured by his ability to
maintain involvement in program 5 days a week with minimal
prompts.
01/15/04
2.
Score on the Kennedy Axis V Psychological Impairment will
improve from a current 40 to 60.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt.’s focal ability will improve such that he will be able to
maintain involvement in program 3 days per week.
07/15/03
2.
Pt. will be able to consistently maintain focus on topic beyond
the first two sentences of a conversation for 2 weeks.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.7
1–35
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Staff will increase focal attention through the use of graded activities designed to meet
his needs and interests.
2.
Staff will give verbal reinforcement for incremental increases in focal attention during
tasks.
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will give positive verbal reinforcement for staying focused on the topic of a
conversation.
2.
When nsg. staff members observe pt. wandering off task or off verbal focus, they will
immediately redirect pt. back to task, with immediate reinforcement for returning to
task, even though it requires guided redirection.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–36
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.8 Noncompliance With Treatment
Name: Krause, Cheryl
ID #:
Area:
Nursing Diagnosis: Noncompliance
Date: 01/15/03
Problem Description:
Pt. has a long history of noncompliance with her meds, despite being under a court order to take her psychotropic
meds. When she stops her meds, she gradually decompensates over a few weeks to a few months. Once
decompensated, she is very slow to recompensate after being restarted on her meds. There are concerns that after a
period of decompensation she never fully recovers back to her baseline. Currently she continues to be very resistant
to taking her meds. Pt. also refuses blood work and often refuses to go to program.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will demonstrate cooperation with all aspects of the treatment
plan, including meds and blood work for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will comply with blood work for 3 months.
04/15/03
2.
Pt. will attend assigned programs at least three times weekly for
3 months.
07/15/03
3.
Pt. will accept meds as prescribed for 3 months.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.8
1–37
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will maintain permission for forced treatments, including antipsychotic
meds, as outlined under Problem 7.1 Court Guardianship Plan.
Virginia Coleman, MD
Psychology:
1.
Psychologist will inventory reinforcing events, activities, and objects specific to this pt.
2.
Pt. will receive second-level reinforcement by accumulating one point for each
compliant action (e.g., allowing blood to be drawn or attending assigned group). When
pt. accumulates five points, she will receive a previously identified reinforcer (see
attached behavioral plan).
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Staff will discuss with pt. the importance of blood work and meds.
2.
Staff will give verbal reinforcement for all aspects of treatment compliance, such as
taking meds, complying with blood work, and going to program.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–38
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.9 Resists Independent Functioning
Name: Smith, Mary
ID #:
Area:
Nursing Diagnosis: Ineffective Role Performance
Date: 01/15/03
Problem Description:
Since adolescence, pt. has had difficulty functioning independently of her family or institutions. She is terrified of
growing up and separating from caregivers. However, she denies these fears and expresses a desire to leave the
hospital to live on her own. To avoid independence, she gets herself restricted by breaking the rules, assaulting
others, dressing inappropriately, making somatic complaints that have no physical basis, going AWA (away
without authorization), and refusing to go to programs or social activities that she has identified as interesting. Pt.’s
family often does things that increase pt.’s dependence, such as interrupting treatment despite their agreement to
schedule visits when she is not involved in program activities.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will demonstrate progress toward independent functioning
AEB at least ½ day involvement in off-ward program activities of
her choice 5 days per week for 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will be up, dressed appropriately, and have completed all
personal hygiene with no more than two verbal cues in time for
cafeteria at least 3 days per week for 1 month.
04/15/03
2.
Pt. will complete two ½-day sessions of off-ward programs per
week for 1 month.
07/15/03
3.
Pt.’s family will support pt. treatment plan.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.9
1–39
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will give pt. immediate verbal reinforcement for any significant independent
functioning, such as getting out of bed without cues, going to program with no more
than one cue, and independently preparing to go to program without any cues (see
attached behavioral plan).
2.
Nsg. staff will remind pt. to get ready for program activities with minimal verbal cues
(e.g., she will be reminded to get ready for her DBT group only once, 15 minutes before
the group).
Marilyn Davis, RN Å Nsg. Staff
Psychology:
1.
Psychologist will use DBT techniques to work with pt. one-to-one and in the DBT
group for 1 hour twice a week.
2.
Psychologist will inventory reinforcing events, activities, and objects specific to the pt.
and make modifications in the DBT plan as indicated by the results of the inventory.
Joseph LeBlanc, Psychologist
Social Work:
1.
Family education meetings will be held once weekly for ½ hour to engage parents in
pt. treatment, to help them identify and modify behaviors they contribute that slow
pt.’s improvement, and to teach them to identify and reward small improvements in
pt.’s independent functioning.
2.
Social worker will meet with pt. ½ hour once weekly to help pt. see the advantages of
living in the community and how her acting-out behaviors sabotage her transition into
the community.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–40
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.10 Escape Risk
Name: Jeneski, Raymond
ID #:
Area:
Nursing Diagnosis: Ineffective Coping
Date: 01/15/03
Problem Description:
Pt. has an extensive history of escaping from the hospital while on independent privileges. While on such
unauthorized passes, pt. has abused alcohol and attempted to break into houses. His escaping appears to be related
to his impulsivity and disorganized thinking. Pt. may put himself and others in dangerous situations while on
escape because of his poor judgment, especially when intoxicated.
Implementation of treatment of Problems 1.1 Psychotic Symptoms and 5.1 Alcohol Abuse to help lower pt.’s
escape risk.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will not attempt to escape for 6 months or more from
independent privileges and day passes.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will attend off-ward programs and supervised privileges
without attempting to escape for at least 1 month.
04/15/03
2.
Pt. will be able to go on independent privileges for ½ hour three
times daily for at least 1 month without attempting to escape.
04/15/03
3.
Pt. will be able to verbalize an understanding of the relationship
between his continued escaping and the increasing difficulty of
placing him in the community consistently for 1 month.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.10
1–41
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Pt.’s supervised privileges will be held for at least 1 week following his return from
escape. During this week, he will be assessed as to whether he is safe to restart
supervised privileges.
Virginia Coleman, MD
Social Work:
1.
Social worker will meet with pt. for 45 minutes once weekly to help pt. understand
how escaping from his treatment leads to increased loss of freedom and increased
difficulty with placing him in the community.
Brenda St. Martin, MSW
Rehab:
1.
Rehab staff will closely monitor pt.’s whereabouts while he is off-ward in scheduled
groups.
Thomas Parker, Rehab Å Rehab Staff
Psychology:
1.
Staff will provide one-to-one to assistance pt. to develop appropriate alternative means
of gaining freedom and independence.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Nsg. staff will monitor pt. for evidence that he is planning an escape (e.g., hoarding
money, wearing a coat while going to in-hospital activities).
2.
If suspicious behavior is noted, nsg. staff will discuss it with pt. to assess his rationale
for the behavior. If suspicions continue, staff will be very conscientious about
monitoring pt. and will notify psychiatrist of concerns.
3.
Prior to pt.’s going on privileges, nsg. staff will caution him against attempting to
escape. Upon his return from successful privileges, nsg. staff will praise pt. for his not
having attempted to escape.
4.
Nsg. staff will provide verbal praise and reinforcement for comments and behaviors
that suggest that he is working on alternatives to gain freedom, rather than escaping.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–42
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.11 Stealing
Name: Miller, Nancy
ID #:
Area:
Nursing Diagnosis: Ineffective Coping
Date: 01/15/03
Problem Description:
Pt. steals a wide variety of items, most frequently cosmetics. While on pass in the community, she has been
arrested twice during the last year. No charges were filed. Pt. could easily buy the items that she steals. Because of
her psychotic process, it is very difficult to understand why she steals; however, there does appear to be a
compulsive quality to her stealing. Her stealing makes it very difficult to give her unsupervised passes. Her family is
very interested in having pt. return home to live with them; however, her stealing makes it very difficult to allow
her to go unsupervised in the community. Rewarding her for not stealing with weekly trips to visit her family has
decreased the frequency of the stealing. Generally pt. does not steal when at home. Prozac has been helpful with
reducing pt.’s compulsion to steal.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will refrain from stealing and thus demonstrate behavioral
control such that she earns a pass home 3 weeks per month for
6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will refrain from stealing and thus demonstrate behavioral
control such that she earns a day pass for 2 weeks per month for
3 months.
04/15/03
2.
Pt. will be able to verbalize an understanding of why she steals.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.11
1–43
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
On each day there is an absence of conclusive evidence that she has stolen, staff will
take pt. to the canteen for a snack.
2.
In association with taking pt. on an earned trip to the canteen, staff will verbally
reinforce her appropriate (nonstealing) behavior. For example, saying, with smiling
approval, “You did such a good job controlling your impulse to steal that I want to
take you to the canteen.”
3.
Pt. will be rewarded with a day pass to home once weekly, if she is able to control her
urge to steal on the ward or in the community during the preceding week. This control
will be measured by the absence of conclusive evidence that she has stolen during the
last week.
Marilyn Davis, RN Å Nsg. Staff
Social Work:
1.
Social worker will arrange the schedule for passes with pt. family.
2.
Social worker will meet with pt.’s family for 1 hour once a month for supporting,
problem-solving family therapy.
Brenda St. Martin, MSW
Psychology:
1.
Psychologist will meet with pt. once a week for ½ hour to attempt to understand her
stealing and to develop strategies that will help decrease her stealing.
Joseph LeBlanc, Psychologist
Psychiatry:
1.
Psychiatrist will meet with pt. in treatment team for 1 hour once a month to monitor
any changes in pt.’s stealing and to prescribe treatments with SSRIs, such as Prozac
(fluoxetine).
Virginia Coleman, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–44
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.12 Psychosomatic Complaints
Name: Stone, David
ID #:
Area:
Nursing Diagnosis: Impaired Health-Seeking Behaviors
Date: 01/15/03
Problem Description:
Pt. has a long history of somatic complaints that are related to attention seeking and avoidance of involvement in
activities. Complaints include problems with stomach, bowel, broken bones, and headaches. Only rarely is there a
physical basis for the complaint.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Somatic complaints will be reduced such that these complaints
interfere with assigned program no more than 1 day per week.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Somatic complaints will reduce such that they interfere with
program attendance a maximum of 3 days per week.
Target Date
Date/Status*
01/15/04
Target Date
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.12
1–45
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will assess medical aspects of all somatic complaints and treat or arrange
for treatment of actual physical problems. Psychiatrist will give staff feedback
concerning the medical safety of pt.’s participation in various activities.
Victor Dyson, MD
Nursing Care Plan:
1.
Following medical assessment of complaints and reasonable assurance that pt. is not at
risk, nsg. staff will provide strong support and encouragement to patient for
functioning in program despite complaints.
2.
Nsg. staff will discuss health issues with pt. and teach healthy lifestyle changes for
½ hour once weekly.
3.
Nsg. staff will provide support and praise for any reductions in pt.’s seeking medical
attention for his psychosomatic complaints; for example, staff will praise pt. for being
able to go for a day without any significant attention obtained through the use of
psychosomatic complaints.
Linda Larkin, RN Å Nsg. Staff
Psychology:
1.
Psychologist will discuss stress reduction training with pt. and initiate if appropriate.
Susan Green, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–46
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.13 Work-Related Anxiety
Name: Pierce, Kenneth
ID #:
Area:
Nursing Diagnosis: Anxiety
Date: 01/15/03
Problem Description:
Two years ago, pt. developed temporal lobe epilepsy (TLE) syndrome. With treatment, he still has an episode about
once a month that is characterized by confused, disorganized thinking. The episodes are preceded by a “weird”
feeling and last only a few minutes. Since the development of TLE, pt. has not been involved in any productive
activity. Pt. states that his confidence is low and he is afraid of having an episode of TLE in front of customers in a
work setting. Pt. had been a very successful computer programmer before the onset of TLE, and the TLE should not
have significantly impaired his work performance.
Implementation of the medical treatment of Problem 6.1 Temporal Lobe Epilepsy.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will work 10 to 20 hours per week as a computer programmer
for a 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will be able to participate in scheduled exercise groups for
1 month.
03/15/03
2.
Pt. will able to participate in the sports and fitness club three
times weekly for 1 month.
04/15/03
3.
Pt. will be able to work in the hospital computer work program
5 hours per week for 1 month.
07/15/03
4.
Pt. will begin taking small programming jobs in the community
for 5 to 10 hours a week for 1 month.
10/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.13
1–47
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in exercise group three times weekly for 20 minutes to engage pt. in
a structured social activity to reduce anxiety in group activities.
2.
Pt. will participate in sports and fitness club three times weekly for 2 hours to engage
pt. in a structured social activity that will help reduce anxiety in group activities.
Albert Sanchez, RT
3.
Pt. will participate in vocational counseling for 1 hour once weekly to develop stepwise plan of engagement in vocational activities.
Thomas Parker, OT
4.
Pt. will participate in hospital industries program 5 hours weekly to assess and renew
his confidence in his work skills and to develop means of coping with the episodes of
TLE.
5.
Pt. will participate in vocational group for 1 hour once weekly to explore and
encourage vocational adjustment activities and to develop a means to cope with
occasional episodes of TLE while on the job.
Jane Hoover, OT
Psychology/Rehab:
1.
Pt. will participate in behavioral treatment to reduce anxiety correlated with the
initiation of structured activities (see Behavioral Plan).
Thomas Parker, OT, and Susan Green, Psychologist
Psychiatry:
1.
Pt. will take anxiolytics as prescribed for job-related anxiety and panic.
Victor Dyson, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
1–48
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.14 AIDS-Related Distress
Name: Diamond, Dennis
ID #:
Area:
Nursing Diagnosis: Disturbed Personal Identity
Date: 01/15/03
Problem Description:
Pt. is a 23-year-old gay male. He is HIV+ by history and appears to have a good understanding of being HIV+. He
presents with an adjustment disorder, which is apparently secondary to the stress of being labeled as an AIDS
patient. Despite no physical evidence of illness or any evidence of danger of transmitting the disease to others, he
has lost his job and his health insurance. He feels shunned by many of the people in his community. He is having
increasing financial difficulties and often wonders whether life is worth living; however, pt. is not believed to be
suicidal.
Implement treatment of medical aspects of being HIV+ and AIDS precautions as outlined under Problem 6.1 HIV+
(including an appointment with an infectious disease specialist).
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
The painful psychological and psychosocial impact of HIV
diagnosis will be minimized AEB pt. regaining a sense that his life
has meaning and that he is able to again enjoy living consistently
for a 2-month period.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will have fewer and milder psychological symptoms
(depression, anxiety, panic, and isolation) of AIDS-related distress
consistently for a 1-month period.
Target Date
Date/Status*
07/15/03
Target Date
Date/Status*
04/15/03
2.
Pt. will use legal and social supports consistently for a 1-month
period.
04/15/03
3.
Pt. will regain access to ongoing, optimal medical care
consistently for 1 month.
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Psychological Impairment (Problem Area 1)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.14
1–49
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will begin individual psychotherapy (being sure to include a discussion of
the limits of confidentiality) and pt. education with a plan to address the distress pt. is
feeling. This would include exploring pt.’s individual understanding of the meaning of
the infection, ostracism, and discrimination. Psychiatrist will reassure pt. that he is not
“losing his mind” and that this is a psychological reaction at present, not AIDS
dementia complex. Psychiatrist will explore possible solutions and sources of relief of
the pt.’s distress. Psychiatrist will caution pt. to be selective about informing others of
his infection, given the current social climate. However, psychiatrist will encourage pt.
to give appropriate warning at the appropriate time to anyone he could infect, such as
a potential sexual partner. Also, psychiatrist will address and monitor pt.’s feelings of
hopelessness and thoughts that life is not worth living. Consider antidepressant meds
and family therapy (including lover).
Victor Dyson, MD
Social Work:
1.
Social worker will discuss and introduce the pt. to the notion of group psychotherapy
and community support groups. These can lessen sense of being the “only one.” The
theme of the group is that some choices have been taken away by the nature of the
illness but that other choices remain and should be used and appreciated.
2.
Social worker will help pt. see how other gay men cope and ideally will stick with pt.
when healthy and when hospitalized.
Roger Sing, MSW, and Robert Weaver, Community Case Manager
3.
Social worker will explain to pt. that job and insurance discrimination is illegal and
refer pt. to community advocacy groups (both gay and HIV). Advise pt. that asserting
his rights can be psychologically therapeutic.
Roger Sing, MSW
Nursing Care Plan:
1.
Nsg. staff will conduct ongoing assessment of pt.’s sexual practices with regard to
encouraging safe ways to have physical intimacy. Staff will provide extensive teaching
of safer sex practices, as well as reassurance that the need for intimacy increases when
people are faced with the HIV diagnosis.
2.
Nsg. staff will provide support and reassurance and will verbally refocus pt. to positive
aspects of his life. Staff will support him in learning ways to cope with being HIV+.
Marilyn Davis, RN
Psychology:
1.
Psychologist will perform baseline neuropsychological testing.
Joseph LeBlanc, Psychologist
Rehab:
1.
Psychologist will perform detailed functional history.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
SOCIAL SKILLS
(Problem Area 2)
2–1
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Social Skills (Problem Area 2)
2–3
SOCIAL SKILLS
(Problem Area 2)
CONTENTS
Kennedy Axis V for Social Skills ................................................................................................................ 2–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Social Skills and can be helpful in composing a short description of each
problem.
Problem Names and Descriptions ............................................................................................................ 2–5
Examples of problem names and descriptions that may relate to Social Skills are listed here. These
examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 2–5
Examples of strengths that may be related to treatment and discharge in the area of Social Skills are
listed here.
Goals ......................................................................................................................................................... 2–6
Examples of treatment goals that may relate to problems in the area of Social Skills are listed here.
Treatment Modalities ............................................................................................................................... 2–8
Examples of treatment modalities that may relate to problems in the area of Social Skills are listed here.
Sample Individual Problem Plans ........................................................................................................... 2–13
A wide range of Individual Problem Plans relating to Social Skills are included here.
2–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Social Skills
100
Superior social skills, sought out by others because of his/her outstanding social/communication skills,
has many friends and no difficulty making new friends. No symptoms.
90 Good social skills, no difficulty being pleasant and engaging, good communication skills, socially
effective.
80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to
infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.
70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show
sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally
functioning fairly well, has some meaningful interpersonal relationships.
60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other
inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate
difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with
others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of
problems with social skills; communications are understandable but vague.
50 Serious impairment in social skills; has no friends because of clearly impaired social skills;
however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers
or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great
difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear
difficulty; frequently intrusive; inappropriate, nonsexual touching.
40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing
situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately
engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the
behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from
school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others;
great difficulty recognizing that his/her sexual advances are not welcome.
30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how
to share with others, and/or how to show sympathy toward others; conversations with others are grossly
inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual
touching, and the like.
20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short
phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as
smearing of feces or making sexual advances toward young children; however, may have some understanding that
such behavior is inappropriate.
10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent
awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others);
extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of
approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social
situations).
NR Not rated
Social Skills (Problem Area 2)
2–5
Problem Names and Descriptions
I.
II.
Poor Social Skills Problems
A.
Nonsexual
1.
Limited interpersonal skills
2.
Extremely impoverished social skills secondary to social isolation
3.
Socially inappropriate behavior due to lack of awareness of social norms
4.
Lack of consideration for others due to poor interpersonal skills
5.
Demanding, intrusive behavior
6.
Teasing, pestering, or agitation of peers due to poor social skills
7.
Poor communication skills
B.
Sexual
1.
Overly affectionate
2.
Inappropriate seductive dress and sexual actions with little or no understanding that these actions
are inappropriate
3.
Frequent, inappropriate masturbation without an understanding of the social and legal
consequences of such behavior
4.
Inappropriate sexual advances without awareness that the behavior is inappropriate
5.
Inappropriate hugging or inappropriate touching of other without an understanding of the
inappropriate nature of these acts
Other
A.
No examples given
Strengths (Brief List)
I.
Social Skills Strengths
A.
B.
C.
D.
E.
F.
Has fairly good social skills
Is able to be polite and pleasant
Is able to make and maintain friendships
Is able to communicate fairly well
Has good sense of humor
Other
2–6
Fundamentals of Psychiatric Treatment Planning
Goals
I.
II.
Expected Improvements in Skills and Symptoms
A.
Demonstration of socially appropriate behavior
1.
Pt. will initiate at least one socially appropriate interaction during each social activities group for
1 month.
2.
Pt. will make one clear, socially appropriate statement to a peer once a day for 1 week.
3.
Pt. will display appropriate social behavior for at least 30 minutes of each social skills group for
3 months.
4.
Pt. will make at least one comment that acknowledges the feelings or needs of the other person
once each waking shift in interactions with staff for 1 month.
5.
Pt. will develop an inventory of alternative, socially appropriate behaviors.
6.
Pt. will be able to consistently express an understanding of what is needed to assess prospective
relationships for 2 weeks.
7.
Pt. will consistently express an understanding of the effect on others of not attending to personal
hygiene for 1 month.
B.
Extinction of socially inappropriate behavior
1.
Pt. will not grab drinks or cigarettes from others for 2 out of 5 weekdays for 1 month.
2.
Pt.’s inappropriate attention-seeking behavior will decrease such that pt. requires no more than
two staff interactions for limit-setting during each social activities group for 1 month.
3.
Pt. will decrease inappropriate touching of others to less than one time per each 7-to-3 shift for
1 month.
4.
Pt. will not expose genitals to others for 6 months.
5.
Pt. will not make sexually provocative statements for 1 week.
6.
Pt. will be free of screaming episodes for at least 1 day per week for 1 month.
7.
Pt. will be able to consistently recognize inappropriate sexual impulses for 1 month.
8.
Pt.’s inappropriate teasing of others will decrease to one incident or less per week for 1 month.
Reporting of Symptoms
A.
Pt. will consistently discuss any problems that he or she is having in social interactions
for 1 month.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
D.
Pt. will participate in on-ward group activities for 5 minutes a day for 1 month.
Pt. will attend morning ward meeting twice per week for 1 month.
Pt. will attend one off-ward group activity per week for 1 month.
Pt. will engage in one independent off-ward social activity with a peer at least once a
week for 3 months.
IV. Understanding of and Compliance With Treatment Plans
A.
Medication and laboratory work
1.
Pt. will consistently acknowledge the importance of taking his or her meds for 1 month.
2.
Pt. will spontaneously express an understanding of the need to take psychotropic meds at least
once a week for 1 month.
B.
Program activities
1.
Pt. will consistently express the benefits of attending program activities focused on improving
social skills for 3 months.
2.
Pt.’s level of compliance will improve such that he or she will attend the group social activities
twice a week for 4 weeks.
Social Skills (Problem Area 2)
V.
2–7
C.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will be willing to participate in the evaluation process.
3.
Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and
blood work, for 2 weeks.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate a realistic orientation toward his or her progress such that pt. understands
and explains the connections between—
a.
Appropriate social interactions with others and positive responses and acceptance from
others, and
b.
Inappropriate social interactions and negative responses and avoidance by others.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it
can be completed.
2.
Pt. will cooperate so that an assessment can be made as to whether cultural factors significantly
interfere with the demonstration of pt.’s social skills.
B.
Evaluations to R/O various diagnoses
1.
Pt. will cooperate with testing to R/O mental retardation.
C.
Laboratory tests
1.
No examples given.
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V subscale score on Social Skills will improve from a current score of 30 to 40.
B.
Comprehensive Occupational Therapy Evaluation (COTE)
1.
Pt.’s COTE Rehabilitation score in the area of Interpersonal Behavior will improve from a current
score of ___ to ___.
VII. Miscellaneous
A.
No examples given
2–8
Fundamentals of Psychiatric Treatment Planning
Treatment Modalities
I.
II.
Verbal Treatment Modalities (emphasis on verbal interactions)
A.
Support and reassurance
1.
Staff will provide pt. with regular one-to-one support and reassurance, even when pt. is doing well
in the development of new social skills.
B.
Cognitive refocusing (redirection of focus toward reality and realistic self-appraisal)
1.
Staff will conduct one-to-one weekly meeting with pt. to discuss and assess pt.’s interpersonal
relationships with the opposite sex and to discuss appropriate alternatives to inappropriate
behavior.
2.
Staff will focus pt. away from plans based on psychotic thinking to realistic, achievable
relationship goals.
C.
Psychotherapy
1.
Staff will conduct weekly one-to-one interview to encourage and help increase social involvement
as a means of improving pt.’s social skills.
2.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand
how his or her behavior impacts others and how to modify behavior to more effectively meet pt.’s
needs.
3.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better understand
and cope with conflicts in pt.’s relationships.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Staff will praise pt. for improvements in social skills.
2.
Staff will give positive verbal feedback to pt. for appropriate social interactions, such as asking for
things wanted, rather than grabbing them.
3.
Staff will reinforce alternative, appropriate attention-seeking behaviors, such as pt. playing guitar.
4.
Nsg. staff will praise pt. when pt. makes appropriate statements and requests to peers.
5.
Nsg. staff will give pt. one extra cigarette, token, or quarter as a reward for appropriate social
interactions during community meeting.
6.
Staff will positively reinforce pt. with trips to the canteen for attending social skills group.
7.
Nsg. staff will give encouragement and praise when patient knows the daily schedule.
B.
Negative reinforcement (including discouragement, restriction, and
withholding of reinforcement)
1.
Staff will discourage inappropriate touching.
2.
Nsg. staff will confront pt. when he or she neglects personal hygiene to the point that pt. drives
others away with body odor, bad breath, or both.
3.
Staff will give pt. frequent reminders as to the offensiveness to others of unattended drooling and
nasal drainage.
4.
Staff will withhold privileges unless pt. is relatively free of sexually inappropriate behavior.
5.
Staff will limit pt. to supervised privileges for 24 hours when pt. fails to attend social skills group.
C.
Extinction
1.
All staff will ignore inappropriate social behavior, thus helping to extinguish it.
2.
Nsg. staff will interact with pt. as little as possible during screaming incidences in the hope of
extinguishing this behavior.
3.
Staff will ignore incoherent communications in an attempt to get pt. to try to communicate more
clearly.
Social Skills (Problem Area 2)
2–9
D.
Shaping and modeling
1.
Staff will use daily modeling of appropriate social behavior, such as addressing others by their first
name, maintaining eye contact, asking for things, and the like.
2.
Staff will consistently request pt. to articulate his or her speech more distinctly and more slowly.
3.
Nsg. staff will encourage pt. to restate incoherent communications in understandable terms.
4.
Staff will consistently reinforce incremental improvements in pt.’s ability to communicate.
5.
Rehab staff will assign social activities with gradually increasing levels of skill requirement as pt.’s
social skills improve.
6.
Staff will use group therapy to help pt. learn to model the behavior of others by observing
appropriate behaviors in relationships, such as dating or leisure activities group.
7.
Staff will assign a higher functioning pt. as a “buddy” for pt. to model during off-grounds outings.
8.
Pt.’s case manager will take pt. off the grounds once a week to model appropriate social behavior
in various off-grounds activities, such as eating in a restaurant or shopping in a store.
E.
Channeling of energies
1.
Staff will help pt. sublimate his or her sexual energies into more appropriate social activities.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
All staff will be as consistent as possible in redirecting pt. away from the inappropriate social
behavior.
2.
Nsg. staff will redirect pt. to go to his or her ward contact for all questions concerning appropriate
sexual behavior.
3.
Rehab staff will reduce the level of frustration and disorganization by breaking simple social
interactions into small, concrete, realistic steps.
4.
Staff will redirect pt. away from social interactions and relationships that are grossly unrealistic or
overly complicated for the pt.
5.
Nsg. staff will engage pt. during ward activities in relevant, appropriate conversations that will
help the pt. to understand how to communicate in a socially appropriate manner during various
activities.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will encourage family involvement in helping pt. to develop more effective social skills.
2.
Social worker will engage family members in psychoeducational counseling to help them model
appropriate social behaviors.
B.
Religious treatment modalities
1.
Staff will arrange small-group, supportive, religious outings to improve pt.’s ability to interact with
others and broaden his or her interests.
2.
Spiritual counselor will encourage members from pt.’s congregation to take pt. to services so that
pt. can interact with other members in a social environment.
C.
Other modalities
1.
Group therapy
a.
Staff will hold group therapy once weekly to facilitate discussions of problems with forming
relationships.
b.
Group leader will regularly attempt to engage pt. in topics being discussed.
2.
Psychodrama
a.
Psychologist will provide role playing to assist pt. in understanding and dealing with
complicated social interactions.
3.
Rehabilitation
a.
Rehab counselor will lead social skills building group for 1 hour once a week to help pt.
learn more appropriate social interactions.
2–10
Fundamentals of Psychiatric Treatment Planning
4.
Practicing social skills
a.
Staff will encourage pt. to practice social skills in various social settings, including
community meetings, dances, and leisure group activities.
b.
Staff will encourage pt. to participate in task-oriented groups that will allow pt. to socially
interact with peers.
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will redirect pt. to a quiet environment to allow pt. to practice appropriate social interaction
with fewer distractions.
2.
Staff will remove pt. from overwhelming social situations and place pt. in supportive,
nonthreatening social situations until his or her skills improve to allow pt. to interact in these
more demanding situations.
B.
Protective procedures (including special observations)
1.
Staff will provide a safe, secure environment so that the pt. is not victimized.
2.
Nsg. staff will observe pt. for signs that he or she is engaging in social activities that place him or
her at risk.
C.
Other milieu treatment modalities
1.
No examples given.
Medical Treatment Modalities
A.
Medication
1.
Meds will be taken as prescribed.
B.
Other medical treatment modalities
1.
Staff will provide a wheelchair to improve pt.’s social skills by allowing better access to social
outings.
VI. Patient and Family Education
A.
Social skills deficits
1.
Social worker will discuss with pt. and the family the effect of pt.’s inappropriate social
interactions on others and how pt.’s family can assist pt. to be more socially appropriate when
visiting at home.
B.
Medication
1.
Staff will discuss with the pt. the risks and benefits of meds.
2.
Staff will conduct one-to-one discussion for ½ hour once weekly about the need to take meds as
prescribed.
3.
Staff will show the concrete benefits of taking meds (e.g., “You seem more relaxed in social
situations,” “You act more appropriately toward others,” “You have more friends”).
C.
Benefits and consequences of behaviors
1.
Staff will discuss connections between improvements in pt.’s social skills and getting positive
responses from others, having friends, and going out on dates.
2.
Nsg. staff will provide recognition of pt.’s comment(s) and will praise to help the pt. understand
the consequences of his or her actions when pt. makes at least one socially appropriate comment
in the community meeting.
3.
Staff will demonstrate to pt. the benefits of being able to appropriately request something from
someone.
4.
Staff will work with pt. to help pt. to have a clearer understanding of the negative effects alcohol
has on pt.’s social skills.
5.
At least once weekly, staff will discuss the benefits of neatness and generally good personal
hygiene when trying to develop a relationship with someone.
Social Skills (Problem Area 2)
D.
2–11
Miscellaneous patient and family education
1.
Nsg. staff will provide one-to-one education to help pt. recognize inappropriate social behaviors
and to develop alternative behaviors.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Pt. will complete psychological testing for personality assessments.
2.
Pt. will complete psychological testing to determine pt.’s ability to engage in social interactions.
B.
Psychiatric evaluations
1.
Pt. will receive psychotropic medication evaluation to help determine whether psychotropic meds
will enhance his or her ability to participate in social skills training.
C.
Medical tests and evaluations
1.
See section on Psychological Impairment for examples of medical tests and evaluations for
psychological impairment that may apply to social skills.
D.
Other evaluations and assessments
1.
Pt. will complete speech evaluation at the Communication and Language Disorders Clinic at the
local university.
2.
Staff will refer pt. to rehab for standardized testing of social skills.
3.
Nsg. staff will make on-ward observations of pt.’s social interactions to assess pt.’s level of social
skills.
4.
Rehab staff will assess pt.’s areas of greatest interests and motivation to begin social activities
congruent with pt.’s interests.
VIII. Legal Treatment Modalities
A.
No examples given
IX. Miscellaneous Treatment Modalities
A.
Treatment of related problems (This is optional and can be included with the treatment modalities
or in the problem description.)
1.
Staff will treat pt.’s bizarre behavior as indicated under Problem 1.1 Psychotic Symptoms.
2.
Staff will treat pt.’s social withdrawal as indicated under Problem 1.1 Psychotic Symptoms.
3.
Staff will treat pt.’s sexually assaultive behavior as indicated under Problem 3.1 Sexually Assaultive
Behavior.
Notes
Social Skills (Problem Area 2)
2–13
Sample Individual Problem Plans
CONTENTS
Impoverished Social Skills....................................................................................................................... 2–14
Impaired Social Skills (Deferred) ............................................................................................................ 2–16
Sexually Inappropriate Behavior ............................................................................................................ 2–18
2–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.1 Impoverished Social Skills
Name: Snow, Karen
ID #:
Area:
Nursing Diagnosis: Impaired Social Interaction
Date: 01/15/03
Problem Description:
Pt. has a 15-year history of mental illness. Skills acquired before the onset of her illness have decreased
dramatically. Most of her interactions are with family members, and her skills demonstrated with her family are
often very awkward and ineffective. Her verbal responses are passive and monosyllabic. She generally avoids others
and has no close friends because of her impaired social skills. Pt. has only a minimal awareness of social norms;
however, she doesn’t act grossly inappropriately toward others, such as by initiating inappropriate sexual touching.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to follow the rules of a task group environment
(e.g., ask for things she needs about four out of five times
instead of taking things from others) for 3 months.
01/15/04
2.
Pt.’s Kennedy Axis V subscale score on Social Skills will improve
from a current score of 40 to 50.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
2.
3.
Pt. will ask for materials that she needs about 50% of the time
for 1 month.
Pt. will ask for things that she needs about four out of five times
for 1 month.
Pt. will be able to consistently interact with her peers in social
skills group without the interactions leading to very awkward
situations for 1 month.
Target Date
Date/Status*
Date/Status*
07/15/03
10/15/03
10/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Social Skills (Problem Area 2)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.1
2–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Staff will provide psychoeducational counseling of family with focus on helping the
family to model effective social interaction skills.
Brenda St. Martin, MSW
Rehab:
1.
Staff will focus on feedback of basic social skills, cooperative behavior, approximation
to the group, discrimination, and demand for minimal interaction with group leader
(e.g., asking for materials and instructions).
2.
Rehab programs will allow pt. to observe and practice social skills, including leisure
awareness, leisure exploration, recreational groups, and the like (see Program
Schedule).
3.
Staff will redirect her through modeling for more functional alternatives when pt.’s
social behaviors are ineffective.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Staff will interact with pt. one-to-one for at least 5 minutes for a minimum of three
times per shift to model effective social behaviors (e.g., addressing pt. by her first
name, maintaining eye contact, asking for things needed).
2.
Staff will provide pt. with daily encouragement and praise for keeping track of her
daily schedule of activities.
3.
Staff will provide support and praise for appropriate social interactions on the ward.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
2–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.2 Impoverished Social Skills (Deferred)
Name: Cosby, Laura
ID #:
Area:
Nursing Diagnosis: Impaired Social Interaction
Date: 01/15/03
Problem Description:
Pt. has markedly impaired social skills that prevent her from having any friends or peer relationships. Her skills are
not so impaired that she displays grossly inappropriate social acts. As indicated under Problem 1.1 Psychotic
Symptoms, pt. is withdrawn and has great difficulty trusting others.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
Date/Status*
Target Date
Date/Status*
Deferred: Due to the high level of psychotic symptoms, pt. is
currently not using the social skills she already possesses.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Social Skills (Problem Area 2)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.2
2–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
Social Work:
Psychology:
Rehab:
Nursing Care Plan:
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
2–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.3 Sexually Inappropriate Behavior
Name: Royal, Rebecca
ID #:
Area:
Nursing Diagnosis: Impaired Social Interaction
Date: 01/15/03
Problem Description:
Pt. is generally pleasant and engaging; however, she will often attempt to inappropriately kiss others. About once a
month, she will attempt to touch others in private areas. She does not appear to be aware of the inappropriateness
of her behaviors. She appears to be looking for love, affection, and acceptance. Her inappropriate advances
generally turn people off instead of meeting her needs for a caring, affectionate relationship. However, because of
her desperateness for affection, strangers could easily take advantage of her.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to develop a caring, appropriate relationship
with at least one person and maintain that relationship for at
least 3 months.
01/15/04
2.
Pt. will not inappropriately touch others on their private areas
for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will be free of inappropriate kissing and hugging for 1 week.
04/15/03
2.
Pt. will touch others on their private areas no more that once
during 3 months.
07/15/03
3.
Pt. will be able to appropriately participate in a social activity
for 1 hour three times a week for 1 month.
04/15/03
4.
Pt. will be able to recognize inappropriate sexual impulses and
avoid acting on them for 1 month.
05/15/03
5.
Pt. will develop an inventory of at least three alternative
behaviors to use when inappropriate impulses are recognized.
06/15/03
6.
Pt. will be able to identify criteria for evaluating prospective
relationships.
07/15/03
7.
Pt. will consistently demonstrate appropriate behavior related to
initiating prospective relationships for 2 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Social Skills (Problem Area 2)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.3
2–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in relationships group for 1 hour once weekly to review and learn
appropriate social interactions, especially with someone with whom she may develop
a relationship.
2.
Pt. will have one-to-one daily modeling of appropriate interactions with others,
including appropriate expressions of affection.
3.
Pt. will participate in leisure activity group for 1 hour three times weekly to help her
develop interests and skills in activities that would allow her to appropriately interact
with others at a social, affectionate, friendship level, such as going for a walk, meal,
or movie with a friend or playing board games or a physical sport with a friend.
Albert Sanchez, Rehab Å Program Staff
Nursing Care Plan:
1.
Pt. will participate in women’s group for 1 hour once weekly to explore the issues of
relationships and the skills related to these issues.
2.
Staff will provide stern one-to-one redirection when pt. inappropriately touches
others on private areas.
3.
Staff will redirect pt. with a minimum of attention to avoid reinforcing inappropriate
sexual behaviors that do not involve sexual touching.
4.
Staff will encourage and praise pt. for appropriate expression of affection.
5.
Staff will provide one-to-one skill teaching regarding the recognition of inappropriate
sexual impulses and development of alternative behaviors for 1 hour once weekly.
Linda Larkin, RN & Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
VIOLENCE
(Problem Area 3)
3–1
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Violence (Problem Area 3)
3–3
VIOLENCE
(Problem Area 3)
CONTENTS
Kennedy Axis V for Violence..................................................................................................................... 3–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Violence and can be helpful in composing a short description of each
problem.
Problem Names and Descriptions ............................................................................................................ 3–5
Examples of problem names and descriptions that may relate to Violence are listed here. These examples
can be used to develop the Problem List and to help compose a short description of each problem.
Strengths .................................................................................................................................................. 3–6
Examples of strengths that may be related to treatment and discharge in the area of Nonviolence are
listed here.
Goals ......................................................................................................................................................... 3–6
Examples of treatment goals that may relate to problems in the area of Violence are listed here.
Treatment Modalities ............................................................................................................................... 3–9
Examples of treatment modalities that may relate to problems in the area of Violence are listed here.
Individual Problem Plans (Frequent Entries).......................................................................................... 3–14
Two examples of information that is frequently entered into Individual Problem Plans relating to
Violence are listed here.
Sample Individual Problem Plans ........................................................................................................... 3–19
A wide range of Individual Problem Plans relating to Violence are included here.
3–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Violence
100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to
any inappropriate anger, frustration, or conflicts. No symptoms.
90 No significant evidence of violence to self or others; generally satisfied with life, no more than
everyday problems or conflicts (e.g., an occasional argument with family members).
80 No more than slight problems with anger and irritability; if symptoms are present, they are transient
and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild
anger after family argument); no suicidal ideation.
70 Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior;
thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning;
severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant
problems with violence or self-harm.
60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due
to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be
present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with
violence.
50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally
threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits
someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such
as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or
others; however, some precautions including close observation may be indicated.
40 Major problems with anger and irritability; some real danger of hurting self or others; violent
outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual;
occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single
suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others;
set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or
two minor fires.
30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met;
suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation;
actively following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close
observation or restraints may be necessary to prevent serious harm to self or others.
20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone;
attempted to very violently harm or violently rape someone within the last month; constant suicidal
preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal
attempts without clear expectation of death within the last month; close observation to prevent harm to self or
others may be required 1 or 2 days a week.
10 Persistent danger of severely hurting self or others; attempted to kill someone within the last
month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last
month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of
death; little or no control of impulses to hurt self or others; expressing loss of control of command
hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for
prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within
the last 2 years.
NR Not rated
Violence (Problem Area 3)
3–5
Problem Names and Descriptions
Note: This problem area relates to acts where one appears to be intentionally putting self or others at risk. Not all
dangerousness and risk factors are included here. Additional examples of dangerousness can be found in all of the
other problem areas.
I.
Assaultive and Threatening Behavior
A.
II.
Assaultive behavior (general)
1.
Assaultive, hostile, or combative behavior
2.
Assaultiveness associated with alcohol
3.
Periodic assaults against a particular person
4.
Retaliatory assaultiveness
5.
Agitated and explosive behavior
6.
Hostile, assaultive mood swings
7.
Episodes of bizarre behavior associated with violence
8.
Violent attention-seeking behavior
9.
Assaultiveness due to command hallucinations
10.
Teasing, pestering, or agitation of peers
11.
Disruptive behavior
12.
Unpredictable displays of hostility
13.
Overt hostility to any delay in immediate gratification
14.
Attempted murder or murder
B.
Threatening, irritable, and oppositional behavior
1.
Argumentative and threatening behavior
2.
Low frustration tolerance
3.
Oppositional attitude
4.
Anger and yelling in response to hallucinations
5.
Hostility in response to excessive stimulation (noise)
6.
Aggressive acts to get coffee or cigarettes
7.
Explosive outbursts (motivated by obvious secondary gains)
8.
Explosive outbursts (not motivated by obvious secondary gains)
C.
Sexually assaultive behavior
1.
Rape
2.
Sexual assault
3.
Overly or dangerously sexually aggressive
4.
Sexually disordered (e.g., sexual predator)
D.
Other violent acts or threats
1.
Stalking
2.
Kidnapping
3.
Potentially violent antisocial acts such as arson or armed robbery
Suicidal Ideation or Attempts
A.
Suicide (general)
1.
Suicidal ideation or attempts
2.
Self-abuse in response to hallucinations
3.
Self-abuse (due to obvious secondary gain)
4.
Noncontingent self-abuse
5.
Self-mutilation
III. Other
1.
No examples given
3–6
Fundamentals of Psychiatric Treatment Planning
Strengths (Brief List)
I.
Nonviolent Strengths
A.
B.
C.
D.
E.
F.
G.
No significant problems with being assaultive
No significant problems with being suicidal or self-abusive
Strong ethical and moral values against violent behavior
Strong ethical and moral values against suicidal and self-abusive behavior
Motivation to work on problems with violent behavior
Good response to past treatments for self-abusive behavior
Other
Goals
I.
Expected Improvements in Symptoms
A.
Assaultiveness
1.
General
a.
Pt. will be able to converse with staff for 1 minute once per shift without threatening or
attempting to assault staff.
b.
Pt.’s threatening behavior will decrease to no more than once per week for 1 month.
c.
Pt.’s frequency of explosive episodes (e.g., throwing chairs, ripping curtains) will be reduced
to no more than one time per week for 1 month.
d.
Pt. will be able to control his or her behavior such that other pts.’ complaints of his or her
aggression toward them will diminish to a maximum of one per week.
e.
Pt.’s assaultive behavior will decrease such that no incidences of assault occur for 2 months.
f.
Pt. will be able to demonstrate control of hostility by being able to apologize to anyone he or
she threatens.
g.
Pt. will maintain current status of no evidence of threatening or assaultive behavior.
h.
Pt. will be able to consistently express an understanding of the connection between his or
her paranoia and hostility and his or her assaultive behaviors for 1 month.
2.
Anger and frustration associated with having to perform
a.
Pt. will be able to tolerate the frustration of cooperating with the ward routine with a
maximum of one disruptive episode per waking shift for 1 week.
b.
Pt. will able to consistently complete two-step tasks without his or her performance being
impeded by angry, hostile behavior for 1 week.
c.
Pt.’s hostility will decrease to the point that pt. will be able to participate in one dayprogram activity each day for 2 weeks.
d.
Pt.’s irritability will decrease to the point that he or she can participate in community
meetings on a daily basis for 1 week.
3.
Tolerance of delays in gratification
a.
Pt.’s frequency of verbal outbursts when needs are not met will decrease to once per week or
less for 1 month.
b.
Pt. will be able to consistently tolerate delay of promised gratification for 2 hours without
irritable, demanding, intrusive behavior for 1 month.
c.
Pt. will be able to tolerate corrective feedback without becoming threatening once daily for
3 of 5 weekdays during the 7-to-3 shifts for 1 month.
4.
Alternative coping behaviors
a.
For 2 weeks, pt. will verbalize feelings of anger and frustration at least once per shift rather
than acting out on them.
b.
For 1 week, when feeling out of control pt. will demonstrate at least one alternative coping
skill per shift rather than losing control.
Violence (Problem Area 3)
B.
5.
Sexually assaultive behavior
a.
Pt. will be free of any inappropriate sexual touching for 6 months.
b.
Pt. will not show any inappropriate hostility toward the opposite sex for 6 months.
c.
Pt. will not have any interactions with children for 1 year.
d. Pt. will cooperate with taking meds to reduce his or her hostile, sexual impulses AEB a
reduction in pt.’s urge to masturbate from pt.’s current frequency of twice a day to no more
than twice a week for 3 months.
6.
Miscellaneous
a.
Pt. will be prevented from acting on aggressive, homicidal impulses directed at his or her
parent for 6 months.
Suicidal and self-abusive behavior
1.
General
a.
Pt.’s head slapping will decrease to once per week.
b.
Pt. will display no more than one incident of self-abuse or suicidal gesture per month for
3 months.
c.
Episodes of self-abuse or suicidal gesture will decrease to less than one every 3 months for
6 months.
d.
Pt. will be free of suicidal ideation for 3 months.
e.
Pt. will maintain his or her current status of showing no evidence of suicidal ideation or acts
of self-abuse.
f.
Pt. will be able to express an understanding of the connection between his or her feelings of
hopelessness and helplessness and pt.’s suicidal impulses.
2.
II.
3–7
Attention seeking and manipulative acts
a.
Pt. will not use threats of suicide to receive extra cigarettes or to avoid program attendance
for 1 week.
b.
Pt. will learn more appropriate methods of getting needed attention (such as verbalizing
feelings or asking for attention) other than cutting herself.
Reporting of Symptoms
A.
Suicidal and homicidal ideation and impulses
1.
Upon inquiry, pt. will accurately express either the presence or absence of homicidal threats
toward pt.’s parent.
2.
Upon inquiry, pt. will attempt to accurately express the degree of suicidal impulse.
3.
Pt. will make a verbal or written contract not to hurt self when he or she is suicidal.
4.
Pt. will spontaneously verbalize any thoughts of hurting self or others for 1 month.
5.
Pt. will consistently reveal to staff commands by voices to hurt self or others for 1 month.
6.
Pt. will consistently reveal to staff suicidal plans before attempting to act on them for 1 month.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
D.
E.
F.
G.
Pt. will remain in the group activity area with minimal redirection for 15 minutes per
day for 1 week.
Pt. will attend two program activities per week for 1 month.
Pt. will attend full-day programs 3 days a week for 1 month.
Pt. will start a Corps Services job.
Pt. will start a job in the community.
Pt. will participate in the anger management group once a week for 1 month.
Pt. will attend the self-abuse prevention group once weekly for 4 weeks.
IV. Understanding of and Compliance With Treatment Plans
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking his or her meds as prescribed twice weekly for 1 month.
2.
Pt. will be able to explain the reasons for taking his or her meds as prescribed.
3.
Pt. will take his or her antipsychotic or antidepressant meds as prescribed for 1 month.
4.
Pt. will comply with blood work for 3 months.
3–8
Fundamentals of Psychiatric Treatment Planning
B.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will demonstrate cooperation with all aspects of his or her treatment plan, including meds and
blood work, for 4 weeks.
3.
Pt. will express a willingness to participate in the evaluation process.
C.
Program activities
1.
Pt. will verbalize the reasons for attending program.
2.
Pt.’s level of compliance will improve such that pt. will attend art therapy class twice a week for
1 month.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate an understanding of his or her progress by being able to explain that—
a.
Having control of suicidal and homicidal ideation leads to privileges, passes, and ultimately
discharge; and
b.
Losing control of suicidal and homicidal ideation leads to restrictions and continued care at
the hospital.
2.
3.
4.
5.
6.
V.
Pt.’s statements will reflect a clear understanding of how others feel threatened and intimidated by
pt.’s aggressive, erotic attachments.
Pt. will express an understanding as to the association between pt.’s use of drugs and alcohol and
violent behavior.
Pt. will express an understanding as to the connection between pt.’s paranoia and his or her
violent behavior.
Pt. will express an understanding of the connection between possessing a gun and the pt. not
being allowed to live in the community.
Pt. will agree not to purchase a gun, despite his or her failure to understand that owning a gun
would pose a serious danger to pt. and others.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will allow needed psychological tests to be completed.
2.
Pt. will cooperate with rehabilitation assessment for appropriate day-program referral so that it
can be completed.
3.
Pt. will cooperate with psychological assessment to determine whether low self-esteem leads to an
expectation of failure to which pt. reacts with hostility and suicidal ideation.
4.
Pt. will cooperate with the assessment to determine whether pt.’s irritability reflects his or her
attempts to avoid communicating with anyone.
B.
Evaluations to R/O various diagnoses
1.
Pt. will allow the completion of an evaluation to R/O temporal lobe epilepsy.
2.
Pt. will allow the completion of an evaluation to R/O borderline personality disorder.
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V subscale score on Violence will improve from a current score of 40 to 60.
B.
Kennedy Nurses’ Observation Scale for Inpatient Evaluation
1.
Pt.’s K NOSIE score on Irritability will improve from a current score of –24 to –10.
2.
Pt.’s K NOSIE score on Social Competency will improve from a current score of +10 to +26.
VII. Miscellaneous
A.
No examples given
Violence (Problem Area 3)
3–9
Treatment Modalities
I. Verbal Treatment Modalities (emphasis on verbal interactions)
II.
A.
Support and reassurance
1.
To help pt. cope with delayed gratification (e.g., delay in privileges, coffee) and to reduce
frustration, staff will reassure pt. that gratification will occur.
2.
When pt. is agitated, nsg. staff will give pt. support and reassurance by expressing acceptance of
his or her emotional distress. Nsg. staff will avoid arguments with pt. over the justification of his
or her distress.
3.
Even when pt. is doing well, staff will provide pt. with regular one-to-one support and reassurance
at least once each shift (this should help reduce pt.’s inappropriate attention-seeking behaviors,
such as suicidal gestures).
B.
Cognitive refocusing (redirecting focus toward nonassaultive, nonsuicidal areas)
1.
Staff will reduce level of frustration by redirecting pt. toward alternative responses rather than
feelings of anger and frustration.
2.
Staff will ask pt. to apologize to anyone pt. threatens.
C.
Psychotherapy
1.
Staff will provide pt. with one-to-one insight-oriented psychotherapy once a week to help reduce
psychological conflicts that result in periods of uncontrollable anger and hostility.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help pt. better cope with
life’s day-to-day frustrations and thus lessen pt.’s anger.
3.
Social worker will provide one-to-one DBT counseling for pt. and lead DBT skills practice group to
help reduce pt.’s level of self-abusive behavior.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Nsg. staff members will verbally reinforce pt. for informing them of his or her suicidal feelings and
then suggest interventions
2.
Ward staff will provide positive feedback to pt. for appropriate control of pt.’s hostile impulses.
3.
Staff will praise pt. for completion of 1 hour of program without any evidence of anger or
hostility.
4.
Staff will positively reinforce pt. with canteen and cafeteria privileges for nonassaultive behaviors.
B.
Negative reinforcement (including discouragement, restriction, and
withholding of reinforcement)
1.
Staff will restrict pt. to supervised privileges for 1 week if pt. is self-abusive, such as by breaking a
window with his or her fist.
2.
To closer evaluate pt., staff will restrict pt. to the ward for 1 week following assaultive behaviors.
3.
Staff will restrict pt. to the ward for at least 1 week for reassessment if pt. is found bringing
weapons to the ward.
4.
Staff will restrict pt. from independent use of the phone for 1 week if pt. continues to call 911 for
frivolous reasons.
5.
After full review, staff will use aversive therapy to stop head banging (see court-approved plan).
C.
Extinction
1.
Following a suicidal gesture, staff will carry out all necessary medical procedures with minimal
dialogue and conversation with pt.
D.
Shaping and modeling
1.
Staff will provide primary and secondary positive reinforcers for incremental decreases in level of
hostility.
3–10
Fundamentals of Psychiatric Treatment Planning
E.
Channeling energies
1.
Pt. will participate in weekly group therapy to facilitate expression of anger in a more appropriate
manner.
2.
Pt. will talk with staff or go for a short walk with staff to reduce the level of frustration.
3.
Staff will increase structured periods to appropriately channel potentially aggressive behavior into
various activities; for example, maximize pt.’s involvement in structured day program, including
open workshop, patient wage program, leisure interest group, and community meeting.
4.
Staff will encourage pt. to verbalize his or her agitation rather than become oppositional or
unreasonable.
5.
Staff will divert pt. into acceptable channels to reduce chronic hypersexual arousal and associated
sexual assaults.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
Staff will break tasks down into small, concrete, realistic steps to reduce the level of frustration and
disorganization.
2.
Staff will break down the steps of dressing into small, understandable, reachable goals to reduce
pt.’s anger over failure.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will provide family therapy to explore conflicts within pt.’s family.
2.
Staff will provide family counseling to help pt.’s family learn means to cope with pt.’s hostile,
threatening episodes.
3.
Priest/rabbi/reverend will provide religious counseling to help pt. survive the loss of a child.
B.
Religious treatment modalities
1.
Spiritual advisor will counsel pt. concerning his or her reported voices from God demanding pt. to
kill others.
2.
Spiritual/religious advisor will counsel pt. concerning suicidal ideation.
C.
Other modalities
1.
Group therapy
a.
Pt. will participate in group therapy for 1 hour once weekly to facilitate discussions of
suicidal impulses.
b.
Pt. will participate in relapse prevention group to help pt. understand the importance of his
or her meds and of continuing DBT treatments.
2.
Psychodrama
a.
Pt. will participate in role playing to allow pt. to see alternative ways of responding to
frustrations and disappointments in life.
3.
Confrontations and pressures
a.
Staff will avoid pressuring pt. when pt. indicates that he or she wishes to be left alone
because pressuring pt. often simply leads to increased agitation and assaultiveness.
b.
Staff will avoid giving pt. ultimatums because ultimatums often lead to pt. striking out in
anger at a perceived authority figure.
4.
Empowerment
a.
Staff will empower pt. with the opportunity to make choices as to which activities to pursue
to reduce his or her anger and frustration of feeling unimportant and helpless.
IV. Milieu Treatment Modalities
A.
Stimulus reduction
1.
Staff will redirect pt. to a quiet environment if the pt. is agitated or expresses threats.
2.
Staff will redirect pt. to a quiet room when necessary to decrease stimulation and agitation.
Violence (Problem Area 3)
3.
4.
5.
B.
C.
V.
3–11
When pt. makes threats, staff will redirect him or her to the quiet room for 15 minutes or until pt.
is no longer threatening.
Staff will redirect pt. from triggering events or overstimulating areas.
Staff will remove pt. from overwhelming situations to reduce his or her level of frustration.
Protective procedures (including special observations)
1.
Staff will provide a safe, secure environment with special monitoring as necessary.
2.
Staff will continue to monitor the pt. for evidence of suicidal impulses. Pt. will be placed on
special precautions as necessary (strict suicidal precautions, suicidal precautions, or close
observation).
3.
If there appears to be a return of suicidal impulses, staff will ask pt. whether these are active
impulses or just isolated ideas, whether pt. has a plan, is future oriented on other matters, and the
like.
4.
If there appears to be a return of suicidal impulses, staff will ask pt. to provide a written or verbal
contract not to harm self.
5.
Nsg. staff will observe pt. for signs that pt. is becoming assaultive, such as agitation and internal
torment.
6.
Staff will consider transfer to the observation room for closer monitoring of sexual assaultiveness
and/or self-destructive behavior.
7.
Staff will refer pt. for screening for the Intensive Treatment Unit if pt.’s assaultive behavior
significantly worsens.
8.
When pt. becomes agitated, staff will place mitts on his or her hands to prevent self-abuse.
9.
Staff will employ escape precautions.
10.
If pt. brings weapons to the ward, staff will search pt. upon return to the ward for at least
1 month, in conjunction with continued counseling on the dangers of bringing weapons into the
hospital.
Other milieu treatment modalities
1.
No examples given.
Medical Treatment Modalities
A.
Medication
1.
Staff will prescribe antipsychotic meds to reduce the intensity of pt.’s anger and irritability.
2.
Psychiatrist will prescribe mood stabilizers, such Depakote, to help control pt.’s explosive
episodes.
3.
Prn meds, such as a combination of Haldol and Ativan, will be used to relieve acute explosive
episodes.
4.
Psychiatrist will prescribe an SSRI, such as Zoloft, or hormonal therapy, such as Depo-Provera, to
reduce pt.’s libido and associated hostile, sexual impulses.
B.
Other medical treatment modalities
1.
ECT
a.
Staff will give the pt. a course of ECT to help relieve intractable suicidal ideation.
VI. Patient and Family Education
A.
Mental illness
1.
Psychologist will discuss the association between the pt.’s paranoia and his or her assaultiveness.
2.
Social worker will discuss with the pt. and family the association between pt.’s feelings of
hopelessness and suicidal impulses.
B.
Medication
1.
Psychiatrist will discuss with pt. the risks and benefits of meds.
2.
Nsg. staff will meet one-to-one to educate pt. about the fact that the meds decrease pt.’s level of
anger and irritability.
3–12
Fundamentals of Psychiatric Treatment Planning
3.
Staff will show concrete benefits of taking meds (such as, “You are less angry and irritable,” “Your
suicidal impulses are decreased,” “You spend less time in restraints,” “People are less fearful of
you”).
C.
Benefits and consequences of behaviors
1.
Staff will discuss with pt. the fact that pt.’s paranoid, threatening behavior is running off all his or
her friends.
2.
Staff will discuss with pt. the fact that the effect of his or her threats is simply to cause others to
avoid pt. and that the threats do not result in getting what the pt. wants from other people.
3.
Psychologist will discuss with pt. the association between paranoia, drugs, alcohol, and violence.
4.
Social worker will discuss with the pt. and family the effect on pt.’s family of his or her
dependent, attention-seeking behaviors, including suicidal gestures.
5.
Staff will discuss connections between control of hostile, threatening behavior and realistic
progress toward pt.’s goals, including passes, shopping trips, and discharge planning.
6.
Nsg. staff will verbally outline for pt., three times per shift, the steps necessary to obtain
gratification (e.g., act civilly in community meeting and be in reasonable control of his or her
hostility before receiving coffee, privileges, and such) to help pt. understand the consequences of
his or her actions.
7.
Staff will work with pt. to help him or her have a clearer understanding of the effects alcohol has
on hostile, threatening behavior.
D.
Miscellaneous patient and family education
1.
No examples given.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Staff will conduct psychological tests to assess the potential lethality of pt.’s hostile impulses.
2.
Staff will conduct psychological tests to evaluate impulse control.
3.
Staff will conduct neuropsychological tests for evidence of organicity as the cause of pt.’s explosive
episodes.
4.
Staff will conduct neuropsychiatric tests for evidence of organicity as the cause of pt.’s assaultive
behavior.
B.
Psychiatric evaluations
1.
Psychopharmacology staff will consult for recommendations of meds that may reduce pt.’s
explosive behavior.
2.
Staff will conduct a psychiatric assessment of pt.’s violent behavior.
C.
Medical/laboratory tests and evaluations
1.
Staff will conduct an EEG to R/O TLE as the etiology of pt.’s explosive episodes.
2.
Staff will conduct a urine toxicology screen to R/O substance abuse as the etiology of pt.’s
explosive episodes.
3.
Staff will test pt.’s blood levels to help determine medication compliance.
4.
Staff will test pt.’s blood levels to determine whether the psychotropic meds are in the therapeutic
range.
D.
Monitoring for suicidal and homicidal ideation
1.
Staff will have one-to-one contact with pt. to assess suicidality.
2.
Nsg. staff will make on-ward observations to assess pt.’s level of irritability and potential for
assaultiveness.
3.
Staff will observe pt. for evidence of agitation and hostility and, if present, monitor pt. from a
distance to ensure reasonable safety to others.
4.
Psychologist will attempt to determine the nature of pt.’s frustration that leads to acts of selfabuse.
5.
Staff will conduct extended one-to-one evaluations to develop a working hypothesis as to the
source of the interactional hostility.
Violence (Problem Area 3)
E.
3–13
Other evaluations and assessments
1.
Rehab staff will assess pt.’s areas of greatest interests and motivation to begin structured activities
congruent with pt.’s interests.
VIII. Legal Treatment Modalities
A.
Court commitment
1.
Staff will seek court commitment for 6 months because of the dangers to self and others due to
mental illness.
B.
Guardianship
1.
Staff will seek court approval of the forced use of antipsychotics to control pt.’s assaultive
behavior.
C.
Other legal treatment modalities
1.
Psychiatrist will seek court approval for use of psychosurgery to control pt.’s unremitting
assaultive behavior.
IX. Miscellaneous Treatment Modalities
A.
Implementation of other treatment plans (This step is optional; instead, this information may
be included in the problem description.)
1.
Staff will implement treatment of Problem 1.1 Psychotic Symptoms to reduce the level of Bill’s
paranoia.
2.
Staff will implement treatment of Problem 1.1 Depressive Symptoms to relieve the depression that
is driving Angela’s suicidal impulses.
3–14
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plans (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Threatening and Assaultive
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Risk for Violence: Other-Directed Grieving;
Hopelessness; Powerlessness
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
Onset of symptoms and chronicity
•
•
•
•
•
•
Characteristics, frequency, intensity, and variance of threats and assaults
Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor
frustration tolerance)
Response to previous and current treatments and expected response to any proposed treatments
Current level of threats and assaults
Barriers to treatment, such as poor insight into the need for treatment, including meds
Presence or need for psychotropic medication guardianship, guardianship of person and/or estate
Current level of symptoms and activity level, including frequency of attendance at therapeutic activities
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any psychotic or depressive symptoms that may be driving pt.’s hostility
should be addressed in Problem Area 1 Psychological Impairment.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
Target Date
Date/Status*
1. Pt. will be free of assaults for a ___-week/-month period.
2. Pt. will be free of vicious assaults for a ___-week/month period.
3. Pt. will be free of threatening behavior at least ___ days a week for
___ month(s).
4. Pt. will not act in response to any paranoid delusions or
command hallucinations for a ___-week/month period.
5. Pt. will be free of command hallucinations telling him or her to
assault others for a ___-week/month period.
6. Pt. will not fail to accept redirection by staff when demonstrating
hostile or threatening behavior for a ____-week/month period.
7. Pt. will watch video(s) or read pamphlet(s) on anger management
entitled ______________________________________________.
8. Pt. will not allow the provocation or intrusiveness of other pts. to
escalate him or her to threatening or assaultive behavior for a
___-week/month period.
9. Pt. will be able to identify feelings of anger and frustration as
they occur, AEB pt. coming to staff for support rather than
threatening or assaulting for a ___-week/month period.
10. Pt.’s score on the Kennedy Axis V for Violence will improve from
the current score of ___ to ___.
11. Pt.’s score on the Kennedy NOSIE Irritability will improve from
the current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
3–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for ____ minutes at least ______ times weekly/monthly to
monitor any changes in intensity of agitation and out-of-control behavior. This will
allow the psychiatrist to assess the need for special precautions and level of privileges
and to prescribe treatment with antipsychotic meds such as __________________,
beta-blockers such as ____________________, anticonvulsants such as ____________,
lithium, or other meds such as __________________. Lab will be as ordered, including
blood levels.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. for ___ minutes at least ___ times weekly/monthly to
help pt. understand how his or her violent behavior acts as a barrier to discharge.
Brenda St. Martin, MSW
Psychology (or Social Work):
1. Psychologist (or social worker) will meet one-to-one with pt. for ___ minutes at least
___ time(s) monthly in supportive, problem-solving, cognitive therapy to reduce or
redirect pt.’s anger, impulsivity, and frustration.
2. Psychologist (or social worker) will lead group (e.g., anger management group) weekly
to help pt. recognize anger and learn methods for reducing and or more appropriately
expressing anger.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ times
weekly/monthly to review and revise his or her daily treatment schedule, will refer pt.
to appropriate groups, and will work to improve his or her frustration tolerance.
2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about
risk factors and how to avoid them. See weekly schedule for programs.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to pt.’s expressions of anger and frustration and will assist pt. in
dealing with these in an appropriate, nonthreatening manner.
2. Nsg. staff will immediately redirect pt. from hostile, angry, or threatening behavior and
will discuss appropriate alternatives to cope with anger and frustration.
3. Nsg. staff will question pt. directly at least ___ time(s) each shift/day/week to determine
whether pt. has any impulses to threaten or assault others.
4. If there are concerns about the pt.’s safe behavior, nsg. staff will have pt. verbally
contract for safety each time pt. goes off the ward. If needed, nsg. staff will escort pt. to
off-ward groups, programs, and other activities. If it is felt that pt. will threaten or
assault someone, nsg. staff may restrict pt. to the ward and place him or her on Special
Precautions until the psychiatrist can evaluate him or her.
5. Nsg. staff will meet with pt. for ___ minutes at least ___ weekly/monthly to educate pt.
about the consequences of violent behavior and about alternative methods to cope
with anger and frustration.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.2 Suicidal and Self-Abusive
Name: Smith, Jane
ID #:
Area:
Nursing Diagnosis: Risk for Violence: Self-Directed
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
•
•
•
Onset of symptoms and chronicity
Precipitants (e.g., depression, losses, substance abuse, command hallucinations)
Characteristics, frequency, intensity, and variance of suicidal threats, attempts, self-abusive behavior
Response to previous and current treatments and expected response to any proposed treatments
Current level of suicidal threats, attempts, self-abusive behavior
Barriers to treatment, such as hopelessness about outcome of treatment, poor self-esteem, poor motivation,
lethargy
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any psychotic or depressive symptoms that may be driving pt.’s hostility,
should be addressed in Problem Area 1 Psychological Impairment.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
Target Date
Date/Status*
1. Pt. will be free of suicidal attempts for a ___-week/month period.
2. Pt. will be free of suicidal ideation for a ___-week/month period.
3. Pt. will be free of suicidal ideation and self-abusive impulses at
least ___ day(s) a week for ___ month(s).
4. Pt. will be free of command hallucinations telling him or her to
commit suicide for a ___-week/month period.
5. Pt. will be able to identify feelings of hopelessness, helplessness,
and frustration as they occur, AEB pt. coming to staff for support
rather than attempting to hurt self for a ___-week/month period.
6. Pt. will be able to express an understanding of the connection
between his or her feelings of hopelessness and helplessness and
pt.’s suicidal impulses.
7. Pt. will learn more appropriate methods to get needed attention
(such as verbalizing feelings or asking for attention) other than
cutting self for a ___-week/month period.
8. Pt.’s score on the Kennedy Axis V for Violence will improve from
the current score of __ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.2
3–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
monitor any changes in intensity of suicidal/self-abusive impulses. This monitoring
will allow the psychiatrist to assess the need for special precautions and to prescribe
treatment with antidepressant meds such as _______________________ or other meds
such as _________________. Lab will be as ordered, including antidepressant levels.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. for __ minutes at least ___ time(s) weekly/monthly to
help pt. understand how his or her suicidal/self-abusive behaviors act as a barrier to
discharge.
Brenda St. Martin, MSW
Psychology (or Social Work):
1. Psychologist (or social worker) will meet one-to-one with pt. for ___ minutes at least
___ time(s) weekly/monthly in supportive, problem-solving, cognitive therapy to
reduce pt.’s suicidal/self-abusive impulses.
2. Psychologist (or social worker) will lead group (e.g., suicidal prevention group or DBT
group) weekly to help pt. reduce feelings of hopelessness and helplessness and/or more
effectively deal with stress, problems, and losses.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.’s daily treatment schedule and will refer pt. to
appropriate groups to work to improve his or her self-esteem/frustration tolerance.
2. Pt. will attend relapse prevention group ___ time(s) a week/month to learn more about
risk factors and how to avoid them. See weekly schedule for programs.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to pt.’s suicidal ideation and self-abusive impulses and will assist
pt. to deal with these in an appropriate, safe manner.
2. Nsg. staff will immediately redirect pt. from self-abusive behavior and discuss
appropriate alternative means to cope or get attention.
3. Nsg. staff will escort pt. to off-ward groups, programs, and other activities to ensure
that pt. does not attempt to harm self.
4. Nsg. staff will question pt. directly at least ___ time/s each shift/day/week to determine
whether pt. has any impulse to harm self.
5. If there are any concerns about pt. attempting to hurt self, at a minimum, nsg. staff
will have pt. verbally contract for safety each time he or she goes off the ward. For
safety reasons, pt. may be restricted to the ward and placed on special precautions until
psychiatrist can evaluate pt.
6. Nsg. staff will meet with pt. for ___ minutes at least ____ time/s weekly/monthly to
educate pt. about the consequences of self-abusive behavior and about alternative
means to cope or get attention.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Violence (Problem Area 3)
3–19
Sample Individual Problem Plans
CONTENTS
Suicidal Ideation and Attempts .............................................................................................................. 3–20
Suicidal Attempts.................................................................................................................................... 3–22
Anger and Explosiveness ........................................................................................................................ 3–24
Threatening and Assaultive Behavior..................................................................................................... 3–26
Homicidal Threat .................................................................................................................................... 3–28
Violence Secondary to Paranoia............................................................................................................. 3–30
Sexually Assaultive Behavior................................................................................................................... 3–32
Stalking Behavior.................................................................................................................................... 3–34
3–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Suicidal Ideation and Attempts
Name: Jones, Gerald
ID #:
Area:
Nursing Diagnosis: Risk for Self-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of attention-seeking suicidal ideation and dangerous suicidal attempts, including attempts to
hang himself, suffocate himself with a plastic bag, and, recently, to poison himself by drinking an insecticide.
Precipitants to suicidal attempts include 1) improvement with associated increased cognitive ability to appreciate
the tragedy of his illness and difficulties making real progress (“reality depression”) and 2) desire to escape
tormenting auditory hallucinations. Treatment should emphasize controlling hallucinations and helping pt. to
accept slow, gradual improvements in his progress toward goals. In the past, focusing on suicidal ideation has
increased pt.’s attention-seeking gestures.
Implement treatment of Problem 1.1 Psychotic and Depressive Symptoms, including regular and prn meds to
reduce the level of tormenting hallucinations.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will demonstrate behavioral control, such that there is no
evidence of suicidal ideation or attempts for 6 months.
01/15/04
2. Pt. will verbalize self-worth and express realistic hopes for his
future consistently for 6 months.
01/15/04
3. Pt. will be free of any suicidal ideation or attempts during 2 weeks
of overnight passes to a halfway house in the community.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will verbalize content of hallucinations,
particularly tormenting or self-destructive hallucinations,
consistently for 3 months.
07/15/03
2. Pt. will consistently approach staff to seek help when he feels
suicidal or when he is tormented by auditory hallucinations for
3 months.
07/15/03
3. Pt. will not use suicidal ideation to receive extra attention or to
avoid participation in treatment for 3 months.
07/15/03
4. Pt. will demonstrate a realistic orientation to his progress by
identifying practical steps toward his goal of discharge and acting
on them, consistently for 3 months.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
3–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1½ hours a month to assess pt.’s response to
treatment, including monitoring any changes in intensity of suicidal ideation, place pt. on
special precautions as needed, and allow increased privileges when pt. is assessed to be safe.
Victor Dyson, MD
Psychology:
1. Psychologist will meet with pt. for 45 minutes once weekly to discuss connections
between daily behavior (being out of bed, attending program) and progress toward pt.’s
goals, including discharge.
2. Staff will encourage pt. to inform staff of suicidal feelings when they occur and to help
pt. learn interventions, such as 1) focusing on his realistic goals (e.g., passes with
family, shopping trips, and discharge planning), 2) focusing on ward activities, and
3) focusing on his assets and accomplishments (e.g., hobbies, program attendance,
relatives who care for him, memories of happy experiences).
Susan Green, Psychologist
Social Work:
1. Social worker will meet with pt. for ½ hour once weekly to evaluate pt.’s readiness for
discharge.
2. Social worker will consistently offer pt. the opportunity for treatment planning
involvement.
Brenda St. Martin, MSW
Nursing Care Plan:
1. Nsg. staff will observe pt. for early signs of agitation and tormenting hallucinations.
If present, staff will inquire about reasons for distress, including content of
hallucinations. Nsg. staff will express understanding of pt.’s distress and suggest
interventions to reduce hallucinations, such as 1) redirecting into activity (e.g.,
program), 2) substituting stimulation (e.g., listening to the radio headset), or
3) requesting prn med.
2. On observing any signs of suicidal intent, nsg. staff will assess dangerousness and ask
pt. for verbal or written contract stating that he will be able to maintain control over
impulses to hurt himself.
3. Nsg. staff will continue to monitor pt. for changes in suicidal intent and will institute
special suicidal precautions as necessary.
4. Nsg. staff will notify psychiatrist as needed of any significant change in pt.’s level of
dangerousness.
5. Nsg. staff will encourage pt. to recognize and express self-worth (e.g., compliment him
when he improves his appearance).
Ronald Donahue, RN Å Nsg. Staff
Rehab:
1. Rehab staff will meet with pt. for at least ½ hour once a week to review and revise his
daily program schedule and refer him to appropriate groups to improve his self-esteem,
coping skills, and frustration tolerance.
2. Rehab staff will ensure that pt. is actively engaged in creative art therapy, an area of
strength for pt.
Albert Sanchez, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.2 Suicidal Attempts
Name: Brandt, Jennifer
ID #:
Area:
Nursing Diagnosis: Risk for Self-Directed Violence
Date: 01/15/03
Problem Description:
Two weeks following the loss of her job, pt. was found by neighbors with her wrist deeply cut. Pt. required 3 days
of medical hospitalization for treatment of blood loss and nerve injuries sustained during the suicidal attempt;
however, there appears to have been no permanent functional damage. She felt that she would not be able to get
another job. She felt that suicide was the only way to avoid her mounting bills and problems. Pt. now denies
suicidal ideation; however, she is felt to still be a serious risk of a suicidal attempt. In the past, pt. had attempted
suicide twice before by taking overdoses. The previous attempts were also associated with difficulty coping with
stress in her life.
Implement treatment of Problem 1.1 Depressive Symptoms, including meds to reduce the level of hopelessness and
helplessness.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will be free of suicidal ideation and self-destructive behavior
for 3 months.
04/15/03
2. K Axis score on Violence will improve from a current score of 40
to at least 60.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will attempt to accurately express the presence
or absence of suicidal impulses consistently for 3 weeks.
02/15/03
2. Pt. will be free of suicidal ideation or acts of self-abuse for
3 weeks.
02/15/03
3. Pt. will cooperate so that she completes the assessment of her
work skills and interests.
02/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.2
3–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1. Staff will provide family counseling to help pt.’s family understand her suicidal
attempts and help them to cope with fears that she will again attempt suicide.
Brenda St. Martin, MSW
Psychology:
1. Psychologist will meet with pt. for 1 hour once a week 1) to help pt. understand the
association between her hopelessness and helplessness and her suicidal attempts, 2) to
help pt. to verbalize her self-destructive thoughts rather than acting on them, 3) to
help her reduce feelings of hopelessness and helplessness, and 4) to help her more
effectively deal with stress in her life.
2. Staff will use psychological testing to help assess pt.’s level of dangerousness.
Susan Green, Psychologist
Rehab:
1. Staff will assess pt.’s skills and work interests to determine whether pt. has a problem
that would interfere with her getting and keeping a job.
2. Staff will assign pt. to appropriate groups to work to improve her self-esteem and selfconfidence, including suicidal prevention group.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will provide pt. with a safe, secure environment with special monitoring as
necessary.
2. Nsg. staff will observe pt. for signs that she is becoming self-destructive, such as
becoming withdrawn and verbalizing hopelessness.
3. Even when pt. is doing well, nsg. staff will provide pt. with regular one-to-one support
and reassurance at least once each shift.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.3 Anger and Explosiveness
Name: Parker, Janet
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of poor control over hostile impulses. Currently she is often angry, hostile, and threatening;
however, it has been more than 6 months since pt. was physically assaultive. Pt. is very likely to become angry
when demands are placed on her, especially concerning programs or her meds. She generally takes her anger out
on others; however, she has a history of breaking a window when angry, resulting in a serious laceration of her
hand. Pt. has been treated with a number of meds with some degree of success.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will demonstrate a maximum of one explosive, threatening
episode for 3 months.
07/15/03
2. Pt.’s Kennedy Axis V score for Violence will improve from a
current score of 50 to 60.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will show a maximum of one episode of inappropriate
expression of anger (e.g., verbal threats, screaming, demanding
behavior) per week for 1 month.
04/15/03
2. Pt. will continue to be free of physically aggressive and selfabusive behavior.
Ongoing
3. Pt. will learn appropriate alternative ways to express anger and
frustration, including seeking out staff to talk about situations
that cause her to get angry, consistently for 1 month.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.3
3–25
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will prescribe meds to help control anger and hostility, such as Clozaril,
Depakote, lithium, beta-blockers, and the like.
Victor Dyson, MD
Social Work:
1. Social worker will meet with pt. one-to-one weekly to give pt. the opportunity to
discuss personal issues.
Brenda St. Martin, MSW
Psychology:
1. Psychologist will encourage pt. to appropriately verbalize anger to staff.
2. Psychologist will lead pt. in relaxation exercises.
3. Psychologist will assess pt.’s appropriateness for referral to the DTB Program.
Joseph LeBlanc, Psychologist
Rehab:
1. Staff will train pt. to improve frustration tolerance via involvement in groups such as
anger management group.
2. Staff will provide pt. with opportunities to feel empowered (i.e., give her choices as to
the activities she would like to pursue).
Albert Sanchez, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to pt.’s expressions of anger and hostility and will assist her with
expressing these in an appropriate, nonthreatening manner.
2. Nsg. staff will provide positive verbal reinforcement for appropriate expression of
anger, frustration, and the like.
3. Nsg. staff will meet with pt. for 20 minutes twice weekly to educate her about the
consequences of her hostility toward others and about alternative methods to cope
with her hostility.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–26
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.4 Threatening and Assaultive Behavior
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of being assaultive and threatening. The assaultiveness has been reduced to about once a
month. Generally the assaults are no more than pushing someone or hitting someone on the arm; however, about
a year ago he attacked and injured an attendant. The assaultiveness is associated with periods of being angry and
irritable. Recently the pt. has been moderately angry and irritable because of conflicts with his family.
Implement treatment of Problem 1.1 Psychotic Symptoms to reduce paranoid feelings.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Assaultive behavior will decrease to no more than once during
6 months.
01/15/04
2. Kennedy Axis V score for Violence will improve from a current
score of 50 to 60.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will spontaneously verbalize any thoughts of hurting others
rather than assaulting anyone, consistently for 3 months.
07/15/03
2. Pt. will be able to converse with staff for 10 minutes each shift
without threatening or attempting to assault staff for 1 month.
04/15/03
3. Pt. will be able to tolerate the frustration of cooperating with
ward routine with a maximum of one disruptive episode per
waking shift for 3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.4
3–27
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will restrict pt. to supervised privileges for at least 1 week if he is assaultive
to others.
2. Psychiatrist will administer meds as prescribed to reduce pt.’s anger and irritability.
Victor Dyson, MD
Psychology:
1. Psychologist will discuss with pt. the association between pt.’s paranoia and
assaultiveness.
2. Psychologist will discuss with pt. Stress Reduction Training and will initiate it if
appropriate.
Susan Green, Psychologist
Nursing Care Plan:
1. Nsg. staff will observe pt. for signs that he is becoming assaultive, such as becoming
angry or irritable.
2. Nsg. staff will encourage pt. to verbalize his agitation rather than becoming
oppositional or threatening.
3. If needed, nsg. staff will offer pt. prn meds to relieve irritability and acute explosive
episodes.
4. Nsg. staff will redirect pt. to a quiet area if he becomes agitated or threatening.
5. Nsg. staff will provide positive feedback to pt. for appropriate control of his hostile
impulses.
6. Even when pt. is doing well, nsg. staff will provide him with regular one-to-one
support and reassurance at least once each shift.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–28
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.5 Homicidal Threat
Name: Stewart, Allen
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
In August 2001, pt. made an attempt to kill his mother. At that time, pt. had a knife at his mother’s throat, but was
pulled away by his brother. Since August 2001, patient has continued to make threats to kill his mother; however,
since the attempt in August 2001, he has not had the opportunity to harm his mother. Currently pt. is supervised
whenever he is off the ward; there is a restraining order to prevent him from going to the area where his mother
lives.
Implement treatment of Problem 1.1 Psychotic Symptoms and Problem 3.1 Anger and Explosiveness to help reduce
the danger toward pt.’s mother.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will accurately express the absence of
homicidal thoughts toward his mother for 6 months.
01/15/04
2. Pt. will be free of any homicidal impulses toward his mother for
6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Upon inquiry, pt. will accurately express either the presence or
absence of homicidal thoughts toward his mother consistently for
3 months.
07/15/03
2. Pt. will approach staff when he is having homicidal thoughts
toward his mother consistently for 3 months.
07/15/03
3. Pt. will not attempt to act on his impulses to hurt his mother for
3 months.
07/15/03
4. Pt. will be able to go on independent privileges for 3 months
without any evidence that he is having any impulses to hurt his
mother.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.5
3–29
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1. Nsg. staff will provide safe, secure environment using staff supervision and special
precautions as needed.
2. Nsg. staff will monitor pt. for signs of agitation and anger that may be directed toward
his mother.
3. Nsg. staff will ask pt. directly at least once each shift whether he is having any
impulses to hurt anyone, including his mother.
4. Nsg. staff will work with pt. and the rest of the team to protect pt.’s mother from pt.’s
homicidal impulses.
Linda Larkin, RN Å Nsg. Staff
Social Work:
1. Social worker will maintain contact with his mother to clarify any conflicts that she
may have with pt. and discuss possible resolution.
2. Social worker will keep pt.’s mother informed of any potential danger from pt. as
indicated under the hospital duty-to-warn policy.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–30
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.6 Violence Secondary to Paranoia
Name: Bell, Howard
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of assaultive, threatening behavior in association with paranoid thoughts. Pt. has had an
ongoing fascination with weapons and police work. Prior to the current hospitalization, pt. threatened his father
with a knife because he felt that his father was conspiring with the Mafia to have him assassinated.
Implement treatment of Problem 1.1 Psychotic Symptoms to reduce pt.’s level of paranoia.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will be free of threatening and assaultive behavior for
3 months.
10/15/03
2. Pt.’s Kennedy Axis V score for Violence will improve from a
current score of 40 to 60.
10/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt.’s home will be free of any weapons for at least 3 months.
07/15/03
2. Pt. will be free of threatening and assaultive behavior for
3 months.
07/15/03
3. Pt. will express an understanding of the connection between his
paranoia and his assaultiveness consistently for 3 months.
07/15/03
4. Pt. will agree not to attempt to purchase weapons consistently for
3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.6
3–31
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1½ hours a month to monitor any changes in
his violent impulses to make decisions concerning the need for special precautions and
level of privileges and to prescribe prn meds to help control angry impulses.
Victor Dyson, MD
Social Work:
1. Social worker will provide family counseling for 1 hour twice monthly to help pt.’s
family understand and learn to cope with pt.’s hostile, threatening episodes.
2. Social worker will encourage family members to remove all weapons from their home.
Roger Sing, MSW
Psychology:
1. Psychologist will provide one-to-one therapy for 1 hour once weekly to help pt.
understand the association between his paranoia, hostility, weapons, and
dangerousness.
2. Psychologist will encourage pt. to verbalize his hostile impulses rather than assaulting
others.
3. Psychologist will use psychological testing to help assess pt.’s level of dangerousness.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1. Nsg. staff will provide a safe, secure environment with special monitoring as necessary.
2. Nsg. staff will observe pt. for signs that he is becoming hostile, paranoid, or agitated.
3. When pt. is becoming hostile, paranoid, or agitated, nsg. staff should give him support
and reassurance by expressing acceptance of his emotional distress.
4. Nsg. staff should avoid arguments with pt. about his paranoid thinking.
5. Nsg. staff should administer prn meds as needed for agitation.
6. Nsg. staff should administer regular meds as outlined under Problem 1.1 Psychotic
Symptoms.
7. Even when pt. is doing well, nsg. staff will provide him with regular one-to-one
support and reassurance at least once each shift.
Ronald Donahue, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–32
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.7 Sexually Assaultive Behavior
Name: Jones, Stanley
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Pt. has a long history of inappropriate sexual behaviors, including public nudity, sexually inappropriate touching
of females, and masturbating in public. Pt.’s sexually assaultive behavior appeared to be under fairly good control;
however, recently pt. began openly masturbating in front of the social worker while having an individual therapy
session in her office. Pt. barred her from leaving the room until he had reached a climax. This attack was felt to
have been more of an inappropriate attempt at sexual gratification, rather than an act of hostility. Pt. appears to
have very little insight into the hostile, frightening nature of his acts toward females. Pt. has been resistive to
taking meds to help control his sexual impulses.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1. Pt. will be free of sexually assaultive episodes for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1. Pt. will be free of sexually assaultive episodes for 3 months.
07/15/03
2. Pt. will express a willingness to explore the possibility of a trial
on meds to help control his sexual impulses consistently for
3 months.
07/15/03
3. Pt. will cooperate with treatments to lower his libido AEB his
frequency of masturbating decreasing from twice a day to no
more than twice a week for 3 months.
10/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.7
3–33
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will activate an assessment process for transfer to the Intensive Treatment
Unit in the event of further sexually assaultive behavior.
2. Psychiatrist will encourage pt. to consider a trial on an SSRI, such as Paxil, or hormonal
treatment, such as Depo-Provera, to help pt. maintain better control over his sexual
impulses.
Virginia Coleman, MD
Rehab/Psychology:
1. Staff will initiate cognitive-behavioral training for socially appropriate responses to
women in a variety of heterosexual situations, using modeling and role-playing.
2. Psychologist will help pt. to understand the legal consequences of sexually assaultive
behavior.
Joseph LeBlanc, Psychologist
Albert Sanchez, Rehab
Nursing Care Plan:
1. Nsg. staff will closely observe pt. for signs of inappropriate sexual or assaultive
behavior.
2. Nsg. staff will educate pt. concerning the risks and benefits of various meds that might
be considered to help him to better control his sexual impulses.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
3–34
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.8 Stalking Behavior
Name: Drago, Charles
ID #:
Area:
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
Patient has been obsessed with one of the social workers at the hospital (Anne Stevens) since 12/01. He has been
making threatening comments to her by letter, calling her at home, and waiting for her outside her office and by
her car. Patient appears to have no insight into the threatening nature of his acts. Currently, he seems less
preoccupied by this social worker and less convinced that they share something special; however, these thoughts
do occur at times. In the past, pt. has not been able to have any significant relationship with a member of the
opposite sex.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will not harm anyone, including Anne Stevens, for 6 months.
01/15/04
2. Pt. will not demonstrate stalking behavior for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will not harm anyone, including Anne Stevens, for 3 months.
07/15/03
2. Pt. will not demonstrate stalking behavior for 3 months.
07/15/03
3. Pt. will not make any threats toward anyone for 3 months.
07/15/03
4. Pt. will be able to demonstrate a focus away from Anne Stevens
AEB his not making any plans to attempt to contact Anne or send
her a gift for 3 months.
07/15/03
5. Pt. will be able to pass by Anne when on privileges without
making an attempt to get Anne’s attention for 3 months.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Violence (Problem Area 3)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.8
3–35
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1. Nsg. staff will notify Anne Stevens of any changes in pt.’s privilege status or passes.
2. Nsg. staff will notify Anne Stevens, Department of Mental Health Police, police
department from his area, state police, District Attorney’s office, pt.’s next of kin, and
the hospital’s chief operating officer (Virginia Day) if pt. escapes.
3. Nsg. staff will place duty-to-warn label on the cover of pt.’s chart so all staff will be
aware of the need to warn.
Marilyn Davis, RN Å Nsg. Staff
Psychology:
1. Psychologist will meet one-to-one with pt. for 1 hour weekly in cognitive therapy to
help pt. resolve his obsession with Anne Stevens.
2. Psychologist will lead the sex offenders group once weekly to help pt. gain insight into
the inappropriateness of his behaviors through the group process, as well as to help
him understand the legal consequences of his stalking behaviors.
Joseph LeBlanc, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
ADL–OCCUPATIONAL SKILLS
(Problem Area 4)
4–1
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ADL–Occupational Skills (Problem Area 4)
4–3
ADL–OCCUPATIONAL SKILLS
(Problem Area 4)
CONTENTS
Kennedy Axis V for ADL–Occupational Skills............................................................................................ 4–4
This rating scale can be used to measure the outcome of treatment. It also helps to define which
problems fit into the category of ADL–Occupational Skills and can be helpful in composing a short
description of each problem.
Problem Names and Descriptions ............................................................................................................ 4–5
Examples of problem names and descriptions that may relate to ADL–Occupational Skills are listed here.
These examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 4–6
Examples of strengths that may be related to treatment and discharge in the area of ADL–Occupational
Skills are listed here.
Goals ......................................................................................................................................................... 4–6
Examples of treatment goals that may relate to problems in the area of ADL–Occupational Skills are listed
here.
Treatment Modalities ............................................................................................................................... 4–8
Examples of treatment modalities that may relate to problems in the area of ADL–Occupational Skills are
listed here.
Sample Individual Problem Plans ........................................................................................................... 4–13
A wide range of Individual Problem Plans relating to ADL–Occupational Skills are included here.
4–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—ADL–Occupational Skills
100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a
homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of
hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those
expected of a successful college graduate.
90 Good skills in all ADL–occupational activities; no more than average difficulties with any work
assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school
graduate.
80 No more than slight impairment in occupational skills or skills in school; has slight difficulty
performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork
assignments; slight impairment in workmanship.
70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following
instructions, workmanship is somewhat sloppy), but generally functioning fairly well.
60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed; however,
has trouble carrying through assignments; some difficulty problem solving or following instructions; some
difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home or
apartment).
50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more
than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following
instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using
public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating
properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call.
40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any
significant period or do routine housework due to poor work skills; failing in school due to poor academic skills);
needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food
restaurant; poor understanding of how to budget money.
30 No job and unable to independently maintain a home due to serious impairment in skills needed
to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare
simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call,
follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs
(e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire
alarm; difficulty finding way back from short errands.
20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some
supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs
supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most
simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from
short errands).
10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete
most tasks even with constant supervision; may even have to be physically assisted to complete a task, including
eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support
(e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering
into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately
respond to a fire alarm.
NR Not rated
ADL–Occupational Skills (Problem Area 4)
Problem Names and Descriptions
I.
II.
ADL–Occupational Skill Deficits Problems
A.
Broad skill deficits
1.
Skill deficits secondary to mental retardation
2.
Skill deficits secondary to dementia
3.
Inability to deal with abstract thoughts or ideas
4.
Confusion and disorientation due to organic impairment
5.
Poor memory
6.
Poor insight and judgment due to organic factors
7.
Poor insight due to limited intellect
8.
Institutionalized
B.
Specific skill deficits
1. Needs to improve money management skills
2. Has difficulty completing tasks
3. Requires frequent prompts to complete tasks
4. Has poor personal hygiene due to a lack of personal hygiene skills
5. Lacks adequate nutritional skills
6. Needs to take better care of personal clothing
7. Needs to take better care of immediate living space
8. Has sloppy workmanship due to lack of skills
9. Is unable to find way back from short errands
10. Has difficulty feeding or dressing self
11. Wets or soils clothes or bedding due to lack of ability to use the toilet
C.
Other
1.
No examples given
Poor ADL Skills Often Associated With Dangerousness
A.
General
1.
Lacks ability to perform self-preservation skills
2.
Lacks basic life survival skills
3.
Is unable to care for self
4.
Has dependent patient status
5.
Appears incapable of recognizing dangers
B.
Specific
1.
Eats in a manner that would lead to choking
2.
Has hazardous smoking habits
3.
Walks in front of cars due to a lack of understanding of the danger
4.
Wanders away
4–5
4–6
Fundamentals of Psychiatric Treatment Planning
Strengths (Brief List)
I.
ADL–Occupational Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
Has average or above average intellectual ability
Is able to read and write
Is a high school or college graduate
Is capable of independent living
Is independent in personal care
Has a job to return to
Is able to successfully work in full-time competitive employment for more than 1 year
Has technical or vocational skills for a job
Other strengths
Goals
I.
Expected Improvements in Skills and Symptoms
A.
II.
Skills that pt. will learn
1.
Pt. will learn to make his or her bed AEB making the bed without supervision for 2 weeks.
2.
Pt. will be able to complete his or her daily personal hygiene without guidance or instructions for
2 weeks.
3.
Pt. will learn to use the ashtray three out of five times he or she smokes for 1 month.
4.
Pt. will be able to consistently dress self without having to be told what to put on for 1 month.
5.
Pt. will learn to do simple tasks around the ward AEB mopping the floor without supervision for
1 month.
6.
Pt. will be able to consistently carry out three-step tasks without guidance or instructions for
1 month.
7.
Pt. will learn to do complicated multistep tasks AEB preparing a meal without supervision at least
3 days a week for 1 month.
8.
Pt. will learn to handle his or her own funds such that pt. retains sufficient money (when
working) to meet daily purchasing needs for 2 months.
9.
Pt. will demonstrate sufficient ability to function in areas of ADLs to warrant discharge home with
parent for 3 months.
Reporting of Symptoms
A.
Pt. will become more aware of ADL limitations AEB asking for help in areas where
needed for 1 month.
III. Participation in Groups, Program Activities, and Such
A.
B.
C.
Pt. will participate in on-ward group activities for 5 minutes a day for 1 month.
Pt. will attend morning ward meetings twice per week for 1 month.
Pt. will attend one off-ward group activity per week for 4 weeks.
IV. Understanding of and Compliance With Treatment Plans
A.
Medication and laboratory work
1.
Pt. will consistently discuss the benefits of taking his or her psychotropic meds as prescribed for
1 month.
2.
Pt. will express the benefits of taking meds as prescribed consistently for 1 month.
3.
Pt. will take psychotropic meds as prescribed for 3 months.
ADL–Occupational Skills (Problem Area 4)
V.
4–7
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process for
1 month.
2.
Pt. will cooperate with treatment plans, such as IQ testing and vocational evaluations.
3.
Pt. will consistently accept realistic plans for employment for 3 months.
C.
Program activities
1.
Pt. will gain insight into the need to attend program, AEB being able to consistently explain the
reasons for attending, for 1 month.
2.
Pt.’s level of compliance will improve such that pt. will attend art therapy class twice a week for
1 month.
3.
Pt. will attend the programs recommended by the treatment plan on a regular basis for 1 month.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate an understanding of his or her progress by being able to consistently explain,
for 1 month, the connections among—
a.
Dressing and attending to personal hygiene and being able to go to activities off the ward,
b.
Working in a prevocational program and getting a job in the community,
c.
Failing to learn basic ADL skills and receiving continued care at the hospital, and
d.
Failing to learn basic occupational skills and being unable to get a job.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Staff will complete rehabilitation assessment for appropriate day-program referral.
2.
Pt. will cooperate so that rehab staff can assess the degree to which apathy, lack of motivation, or
poor focal attention obscure ADL skills.
3.
Pt. will cooperate so that psychological testing can be completed.
B.
Evaluations to R/O various diagnoses
1.
Staff will complete evaluation to R/O mental retardation.
2.
Staff will complete evaluation to R/O thought disorder.
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V score for ADL–Occupational Skills will improve from a current score of 30 to
40.
B.
Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)
1.
Pt.’s K NOSIE score on Social Competency will improve from a current score of +10 to +28.
2.
Pt.’s K NOSIE score on Personal Neatness will improve from a current score of +10 to +18.
C.
Comprehensive Occupational Therapy Evaluation (COTE)
1.
Pt.’s COTE score will improve from a current score of _____ to _____.
VII. Miscellaneous
A.
Staff will maintain a safe, secure environment for (dependent) pt. while attempting to
maximize his or her functional ability.
4–8
Fundamentals of Psychiatric Treatment Planning
Treatment Modalities
I.
II.
Verbal Treatment Modalities (emphasize verbal interactions)
A.
Support and reassurance
1.
Even when pt. is doing well in the development of his or her occupational skills, staff will provide
pt. with regular one-to-one support and reassurance.
B.
Cognitive refocusing (redirect focus toward reality and realistic self-appraisal)
1.
When pt. is able to handle increased periods of pt. wage program and maintain reasonable periods
of focused activity, staff will refer pt. to day program to continue work on focused, purposeful
activity.
2.
Staff will focus pt. away from plans based on his or her psychotic thinking to realistic, achievable
occupational goals.
C.
Psychotherapy
1.
Rehab staff will provide supportive, problem-solving psychotherapy to help pt. better cope with
problems on the job.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Nsg. staff will encourage pt. and provide verbal praise for performing on-ward work activities.
2.
Staff will reinforce with positive verbal praise pt.’s positive behaviors, such as following through
with daily ADL requirements.
3.
Staff will give pt. encouragement for completion of multistep tasks in the absence of ritualistic or
other bizarre behavior.
4.
Staff will spend one-to-one time daily to encourage pt.’s participation in vocational groups.
5.
Nsg. staff will accompany pt. into the bathroom to encourage and reinforce appropriate personal
hygiene habits.
6.
Staff will give pt. one extra cigarette as a reward for learning the steps of a fairly complicated
multistep task.
7.
Staff will positively reinforce pt. with canteen and cafeteria privileges for regular attendance at the
vocational training group.
B.
Negative reinforcement (including discouragement, restriction, and withholding of
reinforcement)
1.
Pt. will be restricted to supervised privileges for 24 hours when pt. fails to attend the vocational
training group.
2.
Independent privileges will be held if pt. has sloppy inappropriate dress, has not taken care of his
or her dorm area, or has not attended to personal hygiene.
C.
Extinction
1.
Nsg. staff will limit their interactions with pt. when he or she fails to work on learning how to do
multistep tasks, such as making the bed and washing clothes.
D.
Shaping and modeling
1.
Staff will provide daily modeling of ADL tasks, such as making the bed, choosing clothes, setting
the table, and such.
2.
Work supervisor and co-workers will provide modeling to improve desired work skills, such as
filing and using the copier.
3.
Staff will provide primary and secondary positive reinforcers for incremental increases in level of
vocational skills.
4.
Staff will refer pt. to day programming for involvement in tasks that require gradually increasing
skill levels.
5.
Nsg. staff will engage pt. in joint tasks around the ward with some of the higher-functioning pts.
ADL–Occupational Skills (Problem Area 4)
4–9
E.
Channeling energies
1.
Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help pt.
channel potentially aggressive behavior into work.
2.
Rehab staff will assist pt. to learn vocational skills so that pt. can get a job that will help divert
pt.’s energies into acceptable channels to reduce chronic hypersexual arousal and associated sexual
assaults.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
Staff will offer verbal prompts and physical assistance needed to enable pt. to complete basic
ADLs.
2.
Staff will use the same person as consistently as possible for redirection.
3.
All staff will redirect pt. to go to his or her contact for all general questions and requests.
4.
Contact will instruct pt. to write down the job steps, and, when appropriate, contact will direct pt.
to those written steps.
5.
Staff will have clothes and self-care items set up and ready before it is time for the ADL activities.
6.
Staff will break tasks down into small, concrete, realistic steps to reduce the level of frustration and
disorganization.
7.
Staff will break down the steps of treatment into small, understandable goals reachable by pt.
8.
Staff will redirect pt. away from decisions, plans, and actions that are grossly unrealistic or overly
complicated for pt.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will encourage family involvement in support of pt.’s job plans.
2.
Staff will provide family therapy to explore reasons within pt.’s family members for their desire for
pt. to fail at independent employment.
B.
Religious treatment modalities
1.
Provide religious counseling to help pt. learn how to use religious resources to get a volunteer job
where pt. can practice and improve work skills.
2.
Pt. will do volunteer work for 2 hours 5 days weekly at the church lunch program to improve pt.’s
work skills.
C.
Other modalities
1.
Group therapy
a.
Group therapy will facilitate discussions of job-related problems.
2.
Psychodrama
a.
Role-playing for 1 hour once weekly will assist pt. in dealing with situational conflicts on the
job.
b.
Role-playing for 1 hour once weekly will teach pt. how to act during a job interview.
3.
Rehabilitation
a.
Staff will provide weekly counseling to identify work goals, to identify deficits in work skills,
and to develop plans for education and training needed to meet goals.
b.
Staff will involve pt. in the on-ward rehabilitation group at least once weekly.
c.
Staff will involve pt. in money management group for 1 hour once weekly, including
community banking.
d.
Assigned staff will redirect this dependent pt. away from decisions, plans, and actions that
place pt. in danger.
4–10
Fundamentals of Psychiatric Treatment Planning
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Rehab training should be in a quiet area because of pt.’s easy distractibility.
B.
Protective procedures (including special observations)
1.
Staff will provide safe, secure environment with special monitoring as necessary.
2.
Staff will confine pt. to Privilege Level IV (cafeteria and supervised privileges) because of pt.’s very
impaired ADL skills, including difficulty crossing streets.
3.
Staff will follow hospital procedures for dependent pt. status.
4.
Pt. will not be allowed access to cigarettes or matches because of hazardous smoking habits.
C.
Other milieu treatment modalities
1.
No examples given.
Medical Treatment Modalities
A.
Medication
1.
Staff will administer meds as prescribed.
2.
Staff will use prn meds to relieve pt. from acute episodes of tormenting hallucinations so pt. can
participate in prevocational training.
B.
Other medical treatment modalities
1.
Staff will provide a wheelchair to increase pt.’s ability to participate in prevocational training.
VI. Patient and Family Education
A.
Mental illness
1.
Staff will discuss with pt. ways of coping with mental illness while working.
B.
Medication
1.
Staff will discuss the risks and benefits of meds with the pt. and family.
2.
Staff will discuss one-to-one the need to take meds as prescribed, including how meds can
facilitate pt.’s ability to participate in vocational programs.
3.
Staff will show concrete benefits of taking meds (e.g., “You are able to stay focused and, therefore,
better able to benefit from vocational training,” “You are less paranoid on the job; therefore, you
are able to participate in on-the-job training”).
C.
Benefits and consequences of behaviors
1.
Staff will discuss connections between daily appropriate behavior (e.g., being out of bed, attending
job training) and realistic progress toward pt.’s goals (full-time competitive employment).
2.
To help pt. understand the consequences of his or her actions, staff will verbally outline for pt.,
once each morning, the steps necessary to obtain gratification (e.g., pt. must get dressed and
attend to personal hygiene to go to prevocational training; next, pt. must graduate from
prevocational training before he or she can get a part-time job in the hospital canteen).
3.
Staff will demonstrate to pt. benefits of being able to count money.
4.
At least once weekly, staff will discuss the benefits of neatness and generally good personal
hygiene.
D.
Miscellaneous patient and family education
1.
No examples given.
ADL–Occupational Skills (Problem Area 4)
4–11
VII. Evaluations and Assessments
A.
Rehabilitation assessment
1.
Staff will assess pt.’s work preferences and work skills.
2.
Staff will assess pt.’s areas of greatest interests and motivation to begin occupational training
congruent with pt.’s interests.
3.
Rehab staff will assess the degree that apathy, lack of motivation, and poor focal attention obscure
ADL skills.
4.
Staff will refer pt. to occupational therapist for formal assessment of ADL skills and interests.
5.
Pt. will participate in trial job period to assess pt.’s job skills.
6.
Staff will use work hardening (slowly increasing hours and difficulty of task) to determine
endurance and skill level.
B.
Psychological tests (and other formal verbal tests)
1.
Staff will conduct psychological testing to determine pt.’s ability to engage in treatment, including
job training.
C.
Psychiatric evaluations
1.
Staff will conduct psychotropic medication evaluation to assess the potential for medication to
facilitate pt.’s ability to learn new ADL skills.
2.
Staff will conduct psychiatric evaluation to assess the degree that side effects of pt.’s psychotropic
medication might be impairing pt.’s ADL skills.
3.
Staff will provide neuropsychiatric consultation to assess the degree that factors related to pt.’s
abnormal EEG might impair job performance.
D.
Medical tests and evaluations
1.
Staff will conduct medical tests and evaluations as needed to R/O factors that might impair pt.’s
ADL skills or ability to gain new skills.
E.
Other evaluations and assessments
1.
Nsg. staff will observe pt. doing on-ward tasks to assess pt.’s level of ADL skills.
2.
Staff will test pt.’s ability to find his or her way around the hospital.
3.
Nsg. staff will test pt.’s ability to respond to a fire alarm.
4.
Nsg. staff will complete “emergency fact sheet” on this dependent pt.
VIII. Legal Treatment Modalities
A.
Commitment
1.
Psychiatrist will seek court commitment under Sections 7 and 8 for a period up to 6 months
because of pt.’s inability to care for self because of limited ADL skills.
B.
Guardianship
1.
Psychiatrist will seek permanent legal guardian to make decisions for pt. related to his or her
medical and psychiatric condition and estate.
IX. Miscellaneous Treatment Modalities
A.
Treatment of problems affecting ADL–occupational skills (This step is optional; instead, this
information may be included in the problem description.)
1.
Staff will treat pt.’s lack of motivation to get out of bed and attend to personal hygiene, as
indicated under Problem 1.1 Psychotic Symptoms.
2.
Staff, as indicated, will treat pt.’s marked lack of motivation and apathy under Problem 1.2 Lack of
Motivation.
3.
Staff will treat pt.’s problems with interpersonal relations on the job as indicated under Problem
2.1 Poor Social Skills.
Notes
ADL–Occupational Skills (Problem Area 4)
4–13
Sample Individual Problem Plans
CONTENTS
Impaired ADL Skills ................................................................................................................................. 4–14
Impaired ADL Skills (Deferred)............................................................................................................... 4–16
Poor Work Skills ...................................................................................................................................... 4–18
Dependent Patient ................................................................................................................................. 4–20
Hazardous Smoking Habits .................................................................................................................... 4–22
4–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.1 Impaired ADL Skills
Name: Jackson, Kenneth
ID #:
Area:
Nursing Diagnosis: Self-Care Deficit
Date: 01/15/03
Problem Description:
Pt. has a history of many years of severe impairment of ADL skills due to long stays in institutions. Pt. needs
constant supervision to complete almost any task (e.g., dressing, preparing a simple meal, and returning from short
errands).
Implement treatment of withdrawn apathetic behavior and poor focal attention under Problem 1.1 Psychotic
Symptoms and Problem 1.2 Poor Focal Attention.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to perform basic ADLs without supervision four of
five mornings (i.e., dressing, grooming, showering, and morning
housekeeping activities).
01/15/04
2.
Pt.’s Kennedy Axis V score for ADL–Occupational Skills will
improve from a current score of 20 to 30.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will ask for things that he needs for his morning routine about
50% of the time for 1 month.
07/15/03
2.
Pt. will be able to independently dress himself four mornings a
week for 1 month.
10/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.1
4–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab/Nursing Care Plan:
1.
Staff will prepare the environment before the time of the ADL activities (e.g., have
clothes and self-care utensils ready).
2.
Staff will provide one-to-one modeling of ADL tasks (e.g., making his bed, choosing
clothes, and looking for utensils).
3.
Staff will encourage and praise pt. for successful completion of various ADL tasks.
Albert Sanchez, Rehab
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.2 Impaired ADL Skills
Name: Raphael, Linda
ID #:
Area:
Nursing Diagnosis: Impaired Home Maintenance
Date: 01/15/03
Problem Description:
Pt. has marked impaired ADL skills and needs supervision to perform even basic self-care skills; however, the
impairment appears to be mostly due to her apathy and disorganized thinking. With encouragement, she is able to
perform basic ADLs in self-care and housekeeping, such as preparing a small, simple meal, sewing on buttons, or
mending a tear.
Implement treatment of apathy and disorganized thinking under Problem 1.1 Psychotic Symptoms.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
Date/Status*
Target Date
Date/Status*
Deferred: Due to a high level of psychotic symptoms, pt. is currently
not using the ADL skills she already possesses. This problem plan will
be activated when pt.’s psychotic process is under better control.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.2
4–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
Social Work:
Psychology:
Rehab:
Nursing Care Plan:
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.3 Poor Work Skills
Name: Titus, Kevin
ID #:
Area:
Nursing Diagnosis: Deficient Knowledge
Date: 01/15/03
Problem Description:
Pt. has held three jobs in the past 6 years; however, he was unable to keep any of the jobs for more than 1 month.
He was fired from one job for poor performance and quit the other two jobs because he “didn’t like them.” Pt.
appears to lack many of the basic skills necessary to keep a job. Pt. has difficulty following instructions and
difficulty performing somewhat complicated tasks, such as running the copier, filing, and stocking shelves. Pt. also
has difficulty taking public transportation and is unable to drive a car.
Implement treatment of Problems 1.2 Lack of Motivation and 1.3 Poor Focal Attention.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will get and keep a part-time job (l6 to 20 hours per week) in a
competitive work environment for at least 6 months.
01/15/04
2.
Pt.’s Kennedy Axis V score for ADL–Occupational Skills will
improve from a current score of 50 to 60.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Staff will identify areas of deficits in work skills.
02/15/03
2.
Pt. will be able to file 50 letters with no more than one misfile.
04/15/03
3.
Pt. will be able to copy standard size, single-sided letters with no
significant difficulty for 2 weeks.
04/15/03
4.
Pt. will work 10 hours per week in a work program of his choice
and will keep the job for at least 1 month.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.3
4–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Rehab:
1.
Pt. will participate in weekly individual and group counseling to identify deficits in
work adjustment in order to—
a. Address deficits in work skills
b. Identify and plan for vocational goals
c. Determine education and training needed to meet goals
2.
Staff will identify job interests to help pt. choose an appropriate work program to
increase the probability of pt. keeping a job and developing needed work skills.
a. Pt. will complete interest testing to aid in vocational decision making.
b. Pt. will participate in a 2-week trial in a job of his choice for situational
assessment.
c. Individual vocational rehab counselor will assign work according to pt.’s choice.
d. Vocational rehab counselor will monitor, address, and document work adjustment
issues on a daily basis.
3.
Work supervisor and peers will use role modeling and verbal praise to increase desired
work behaviors, such as using the copier and filing correspondence.
4.
Staff will use work hardening (slowly increasing hours and difficulty of task) to
determine pt.’s endurance and skill level.
Jane Hoover, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.4 Dependent Patient
Name: Dodge, Patricia
ID #:
Area:
Nursing Diagnosis: Deficient Knowledge
Date: 01/15/03
Problem Description:
Pt. is generally unable to find her way around the hospital. If lost, it is felt that she may not be able to identify
herself or tell where she is from. It is feared that if given the opportunity she may wander away from the hospital.
Pt. appears to be able to safely cross streets; however, it is believed she is vulnerable to advances of strangers.
Without supervision, pt. does not respond to emergencies, such as fire alarms.
Implement treatment of Problem 2.1 Poor Social Skills.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to function so that she will no longer require a
dependent patient status.
01/15/05
2.
Pt. will be able to identify herself and her ward location
consistently once per day for 3 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will be able to identify herself and her location once per day
for 1 month.
07/15/03
2.
Pt. will be able to lead staff to the hospital store and back to the
ward three times weekly for 1 month.
07/15/03
3.
Pt. will be able to go to and return from the hospital store
independently and consistently for 3 months.
01/15/04
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.4
4–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will maintain a safe, secure environment while attempting to maximize pt.’s
functional ability.
2.
Nsg. staff will follow hospital procedure for dependent patients, including labeling the
outside of pt.’s chart, notifying the proper authorities if pt. is missing, and the like.
3.
Nsg. staff will ensure that pt. wears an identification bracelet or tag at all times.
4.
Pt. contact will conduct off-ward training trips twice daily to teach pt. the route to the
hospital store and back.
5.
Pt. contact will spend 5 to 10 minutes per shift working with pt. to self-identify and to
give correct ward address.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
4–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 4.5 Hazardous Smoking Habits
Name: Saxon, Howard
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has been a careless smoker for years. He often burns holes in his clothes, thus posing a health hazard.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt.’s smoking will improve such that he will be able to go for
6 months without burning holes in his clothes.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1.
Pt. will use ashtray three out of five times he smokes without staff
cues for 1 month.
04/15/03
2.
Pt.’s smoking will improve such that he will be able to wear one
set of clothes each day for 1 month without burning holes in
them.
04/15/03
3.
Pt.’s smoking will improve such that he will be able to go for
3 months without burning holes in his clothes.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
ADL–Occupational Skills (Problem Area 4)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 4.5
4–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will reinforce the need for and use of an ashtray each time a cigarette is
given.
2.
Nsg. staff will remind patient not to burn holes in his clothes.
3.
If patient does not use an ashtray or if he reports for the next scheduled cigarette with
a hole in his clothes, his cigarettes will be withheld for 1 hour.
4.
If cigarettes are withheld, nsg. staff will explain why they are being held and will
remind pt. what smoking behaviors are necessary to continue hourly cigarette
schedule.
5.
Nsg. staff will educate pt. for ½ hour once weekly to help pt. understand the dangers
associated with his careless use of cigarettes.
Linda Larkin, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
SUBSTANCE ABUSE
(Problem Area 5)
5–1
This page intentionally left blank
Substance Abuse (Problem Area 5)
5–3
SUBSTANCE ABUSE
(Problem Area 5)
CONTENTS
Kennedy Axis V for Substance Abuse ....................................................................................................... 5–4
This rating scale can be used to measure the outcome of treatment. It also helps to define which
problems fit into the category of Substance Abuse and can be helpful in composing a short description
of each problem.
Problem Names and Descriptions ............................................................................................................ 5–5
Examples of problem names and descriptions that may relate to Substance Abuse are listed here.
These examples can be used to develop the Problem List and to help compose a short description of
each problem.
Strengths .................................................................................................................................................. 5–5
Examples of strengths that may be related to treatment and discharge in the area of Sobriety are listed
here.
Goals ......................................................................................................................................................... 5–5
Examples of treatment goals that may relate to problems in the area of Substance Abuse are listed here.
Treatment Modalities ............................................................................................................................... 5–7
Examples of treatment modalities that may relate to problems in the area of Substance Abuse are listed
here.
Individual Problem Plan (Frequent Entries) ........................................................................................... 5–12
An Individual Problem Plan that contains examples of information that is frequently entered into
Individual Problem Plans relating to Substance Abuse is included here.
Sample Individual Problem Plans ........................................................................................................... 5–15
A wide range of Individual Problem Plans relating to Substance Abuse are included here.
5–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Substance Abuse
100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no
use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone
who is totally free of problems with substance abuse. No symptoms.
90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social
drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and
minimal, if any, treatment needed to maintain sobriety.
80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes
daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or
caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse
(e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety
with minimal treatment needed to maintain sobriety.
70 Mild impairment in social, occupational, or school functioning due to substance abuse, but
generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription
drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy
smoker; unable to quit cigarettes despite numerous attempts.
60 Moderate difficulty in social, occupational, or school functioning because of substance
abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or
co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week;
occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust),
Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes
despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.
50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance abuse;
moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing substances
despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol or
marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions;
moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or
muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular
basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than
cigarettes) is beginning to cause some medical complications.
40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids
friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his
family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally
has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety.
30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably
impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances
without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical
hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious
neglect of children due to substance abuse.
20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin,
or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving
for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very
serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs
into his/her veins more than twice a day.
10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or
withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking
drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to
severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in
frequent medical hospitalizations; life-threatening neglect of children due to substance abuse.
NR Not rated
Substance Abuse (Problem Area 5)
5–5
Problem Names and Descriptions
I.
II.
Substance Abuse Problems (alcohol, drugs, or both)
A.
Examples
1.
Abuse of drugs, cigarettes, or alcohol
2.
Lack of insight into acute and chronic alcoholism
3.
Inability to quit the use of drugs, cigarettes, or alcohol despite desire to do so
4.
Addiction to caffeine
B.
Other
1.
Addiction to drinking excessive fluids (this problem is often included under Problem 1.1
Polydipsia, Problem 6.1 Hyponatremia Secondary to Polydipsia, or both)
Problems Associated With Substance Abuse (substance abuse often leads to other acute
or chronic problems that might be addressed under their particular problem area[s])
A.
Examples
1.
Continued abuse of drugs, cigarettes, or alcohol despite acute or chronic medical problems caused
by them
2.
Inability to quit cigarettes despite physical damage from cigarettes
3.
Multiple accidental overdoses of drugs or alcohol
4.
Hypomania triggered by excessive caffeine intake
5.
Depression and suicidal ideation secondary to chronic alcohol abuse
Strengths (Brief List)
I.
Substance Abuse Strengths (sobriety)
A.
B.
C.
D.
No significant problem with drugs or alcohol
Recently able to attain 10 years of sobriety
Has strong moral and ethical beliefs against use of drugs or alcohol
Other strengths
Goals
I.
Expected Improvements in Symptoms
A.
Evidence of increasing control over substance abuse
1.
Pt. will attend one off-ward independent activity per week for 1 month without abusing drugs or
alcohol.
2.
Pt. will engage in one independent off-ward social activity with a peer once per week for 1 month
without abusing drugs or alcohol.
3.
Pt. will use his or her independent privileges for 1 month without abusing drugs or alcohol.
4.
Pt. will not abuse drugs or alcohol for 3 months when pt. is on pass or AWA (away without
authorization) from the hospital.
5.
Pt. will be free of abuse of drugs or alcohol for 3 months despite the opportunity to use them.
6.
Pt. will continue to avoid use of drugs or alcohol.
7.
Pt. will stop smoking for 1 month.
8.
Pt. will consistently eat meals and snacks that are less likely to be associated with past patterns of
use of cigarettes or alcohol for 3 months.
5–6
II.
Fundamentals of Psychiatric Treatment Planning
Reporting of Symptoms
A.
B.
C.
Pt. will consistently discuss with staff his or her impulse to use drugs or alcohol for
1 month.
Pt. will consistently disclose to staff occasions on which pt. broke his or her agreement
not to abuse drugs or alcohol for 3 months.
Pt. will agree to sign a contract that pt. will not abuse alcohol when on pass.
III. Participation in Groups, Program Activities, and the Like
A.
B.
Pt. will attend the programs recommended by the treatment plan, including AA
meetings, 4 out of 5 weekdays for 3 months.
Pt. will participate in weekly AA and substance abuse discussion groups within the
hospital for 1 month.
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking psychotropic meds as prescribed.
2.
Pt. will express an understanding of the benefits of taking psychotropic meds as a means of
decreasing his or her impulses to use narcotics.
3.
Pt. will take psychotropic meds as prescribed for 3 months.
4.
Pt. will cooperate with spot checks of urine for toxicology screen, if substance abuse is suspected,
for 3 months.
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process
consistently for 1 month.
2.
Pt. will be willing to participate in the evaluation process.
3.
Pt. will explore potential resources and support systems available in the community.
4.
Pt. will verbalize that participation in the work program will help to improve self-esteem, reduce
boredom, and channel excess energy away from alcohol.
C.
Program activities
1.
Pt. will verbalize the benefits of attending program activities.
D.
Consequences of actions
1.
Pt. will be able to verbalize an understanding of the connections among the following:
a.
Continued drug or alcohol abuse and continued deterioration of one’s lifestyle and rejection
by family and friends;
b.
Continued abuse of illegal drugs and continued conflicts with the law;
c.
Continued abuse and neglect of basic health needs and reoccurring physical illnesses;
d.
Substance abuse, AIDS, and other serious health problems;
e.
Substance abuse and inability to retain a job; and
f.
Alcohol abuse and worsening of depression.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate with the evaluation process.
2.
Pt. will consistently cooperate with urine toxicology screens when substance abuse is suspected for
3 months.
3.
Pt. will complete rehabilitation assessment for appropriate day-program referral.
B.
Evaluations to R/O that psychiatric illnesses are self-medicated or caused by substance
abuse
1.
Pt. will cooperate with complete evaluation to R/O depression secondary to alcoholism.
2.
Pt. will cooperate with the assessment to help R/O pt.’s self-medicating an anxiety disorder with
street drugs.
Substance Abuse (Problem Area 5)
5–7
VI. Standardized Outcome Measures
A.
Kennedy Axis V
1.
Pt.’s Kennedy Axis V score for Substance Abuse will improve from a current score of 50 to 70.
VII. Miscellaneous
A.
B.
Pt. will seek a discharge environment free of street drugs and alcohol.
Pt. will work for a company that stresses employee health, including smoking cessation
and abstinence of alcohol for those with an alcohol problem.
Treatment Modalities
I.
Verbal Treatment Modalities (emphasize verbal interactions)
A.
Support and reassurance
1.
Staff will provide one-to-one supportive, problem-solving therapy to help pt. learn to cope with
life without resorting to drug abuse.
2.
Staff will provide one-to-one support when pt. presents as calm and clear but despairing.
3.
Staff will provide one-to-one contact with pt. with needed support and reassurance to give pt.
a sense that people care for pt.
4.
Nsg. staff will provide episodic one-to-one contact to give a sense that pt. is receiving attention.
5.
Staff will provide one-to-one interactions to help build a trusting relationship between pt. and
staff.
6.
Staff will express understanding of pt.’s distress and suggest interventions when pt. is suffering
from severe anxiety and depression.
7.
Nsg. staff will provide pt. with regular one-to-one support and reassurance at least once each shift,
even when pt. is doing well.
B.
Cognitive refocusing (redirect focus away from things that support substance abuse and
toward things that support sobriety)
1.
Psychologist will meet with pt. once a week to direct pt. toward considering methods other than
drinking for dealing with depression and anxiety.
2.
Staff will help pt. recognize and express self-worth (e.g., compliment pt. when his or her
appearance improves to bolster self-esteem and engage pt. in activities that pt. can succeed in and
feel comfortable doing without needing alcohol).
3.
Staff will maximize structured activities to minimize preoccupation with drugs and to help pt. stay
focused on alternative behaviors. This refocusing can be done by maximizing pt.’s involvement in
structured day programs, including open workshop, patient wage program, leisure interest group,
and community meeting.
C.
Psychotherapy
1.
Staff will provide pt. with one-to-one, insight-oriented psychotherapy once a week to help pt.
uncover the reasons why he or she turns to alcohol to cope with problems.
2.
Psychologist will provide supportive, problem-solving psychotherapy to help pt. find alternatives
to substance abuse for coping with life’s problems.
5–8
II.
Fundamentals of Psychiatric Treatment Planning
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Ward staff will encourage and give verbal praise for pt.’s involvement in non-drug-related social
activities.
2.
Staff will provide ongoing verbal reinforcement for pt.’s decision to stop drinking.
3.
Staff will reinforce with positive verbal praise pt.’s positive behaviors, such as taking on
responsibilities and attempting self-discipline.
4.
Staff will positively reinforce pt. with trips to the canteen for involvement in the treatment
planning process.
5.
Nsg. staff will provide frequent encouragement for pt. to attend to personal hygiene and
appearance.
B.
Negative reinforcement (including discouragement, restriction, and withholding of
reinforcers)
1.
Staff will restrict pt. to supervised privileges for 1 week if pt. returns from AWA intoxicated.
Restriction will be only 3 days if there is no evidence of intoxication.
2.
Staff will discourage pt. from talking about “war stories” from his or her life of drug use on the
streets.
3.
Staff will restrict pt. to supervised privileges for at least 1 week while his or her commitment to
abstinence is assessed when pt. is found to be abusing drugs or alcohol.
C.
Extinction
1.
Nsg. staff members will limit their interactions with pt. when pt. fails to work on means of
controlling impulses to abuse drugs and alcohol.
D.
Shaping and modeling
1.
Pt. will use the “buddy” system to provide a model of non–drug use for pt. to follow.
E.
Channeling energies
1.
Pt. will be placed in a job as a salesperson at a retail store to divert pt.’s hyperactivity and high
level of energy from drug dealing to more socially acceptable behaviors.
2.
Staff will encourage pt. to spontaneously report urges to drink and will discuss alternatives to help
manage these urges.
F.
Task simplification (reduce confusion and frustration by simplifying tasks and
providing consistency and assistance)
1.
Staff will use the same person as consistently as possible for redirection and support.
2.
Substance abuse counselor will break down the steps of reaching and maintaining sobriety into
small, understandable goals reachable by pt.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Staff will provide family therapy to explore family’s continued financial support of pt.’s drug use.
B.
Substance abuse groups, agencies, and help programs
1.
Staff will encourage pt. to attend a substance abuse treatment program once per week.
2.
Staff will encourage pt. to attend a relapse prevention group once weekly.
3.
Staff will refer pt. to the AA meeting in the hospital.
4.
Staff will refer pt. to the Narcotics Anonymous group in town.
5.
Staff will refer pt.’s spouse to an Al-Anon family group.
6.
Staff will give pt. an appointment with a community self-help group to help pt. with his or her
commitment to stay off cigarettes.
C.
Religious treatment modalities
1.
Provide religious services to enhance pt.’s self-esteem and feelings of meaning and community.
2.
Provide religious counseling to help pt. explore moral issues related to abusing his or her body
through the use of drugs and alcohol.
Substance Abuse (Problem Area 5)
D.
5–9
Other modalities
1.
Psychodrama
a.
Staff will use psychodrama to assist pt. to be able to say “No” when pressured by peers to use
drugs.
2.
Termination
a.
Pt. will be terminated from the program if, after 1 week, pt. shows no significant motivation
for change.
b.
Pt will be readmitted when his or her drug lifestyle is painful enough for pt. to want to
change.
3.
Significant other
a.
Staff will explore whether a significant other, such as pt.’s fiancé(e), will help pt. follow
through with a commitment to stopping drinking.
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will restrict pt. from associates and areas that have triggered drug use in the past.
2.
Staff will work at identifying and reducing triggering cues.
3.
Dietitian will work with pt. to identify eating habits that trigger smoking (or drinking).
4.
Staff will work with pt. for 1 hour once weekly to reduce cues that trigger substance abuse.
B.
Protective procedures (including special observations)
1.
Staff will provide a safe, secure, drug-free environment with special monitoring as necessary.
2.
Staff will provide a drug-free environment by—
a.
Having the pt. remain on the locked section of the Detox Unit until pt. has better control of
his or her urges to abuse drugs and alcohol;
b.
Supervising visits and searching pt. for drugs and drug utensils when pt. returns from any
unsupervised, off-ward activity;
c.
Monitoring pt.’s phone calls and screening the pt.’s letters to ensure that pt. does not
attempt to get someone to bring drugs onto the ward;
d.
Performing unannounced drug toxicology screens, randomly and when substance abuse is
suspected.
C.
Other milieu treatment modalities
1.
No examples given.
Medical Treatments
A.
Medication
1.
Staff will gradually reduce medication doses as prescribed to detox pt. off drugs and alcohol.
2.
Staff will administer vitamin supplement as prescribed.
3.
Staff will place pt. on methadone maintenance.
4.
Staff will place pt. on Antabuse (disulfiram) to help prevent relapse back into alcohol use.
5.
Staff will place pt. on nicotine gum or nicotine patch to reduce craving for cigarettes.
B.
Other medical treatments
1.
Pt. will get a physical exam and an individualized program of physical fitness to help improve
health awareness and self-esteem.
5–10
Fundamentals of Psychiatric Treatment Planning
VI. Patient and Family Education
A.
Mental illness
1.
Staff will discuss with pt. his or her addiction to drugs and alcohol.
2.
Staff will discuss with pt.’s family the nature of pt.’s addiction and the fact that pt. will not be able
to stop the abuse of drugs by himself or herself.
B.
Medication
1.
Staff will discuss with pt. the process of detoxification using methadone.
2.
Staff will discuss with the pt. and family the use of drugs like methadone and Antabuse
(disulfiram) in an aftercare program.
C.
Benefits and consequences of behaviors
1.
Staff will discuss with pt. the association between substance abuse and worsening of
hallucinations and assaultiveness.
2.
Staff will give pt. concrete examples of the effects of continued drug abuse (e.g., “Your probation
officer will revoke your probation if he or she learns of your continued drug abuse,” “You are
starting to show evidence of liver and brain damage secondary to alcohol abuse that will worsen if
abuse of alcohol is continued,” “Your depression is worsened by your chronic use of alcohol,” and
the like).
3.
Staff will work with pt. to help pt. have a clearer understanding of the effects alcohol has on
behavior.
D.
Miscellaneous patient and family education
1.
No examples given.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Staff will conduct psychological testing for addictive profile.
2.
Staff will conduct neuropsychological testing to R/O organic brain damage secondary to alcohol
and drug abuse.
B.
Psychiatric evaluations
1.
Staff will conduct a psychiatric diagnostic evaluation to R/O an underlying psychiatric illness that
pt. is self-medicating with drug abuse.
2.
Staff will conduct a psychiatric evaluation to help determine whether pt. would be better treated
in a psychiatric facility or in a drug treatment program.
C.
Medical tests and evaluations
1.
Urine toxicology screen
2.
Blood screen for liver disease
3.
Blood screen for venereal disease
a.
Blood screen for syphilis
b.
Blood screen for AIDS
4.
D.
GC (gonococcus) smear to rule out gonorrhea
Other evaluations and assessments
1.
Staff will conduct a one-to-one weekly interview to identify stimuli of substance abuse.
2.
Staff will conduct a one-to-one weekly interview to determine the nature of pt.’s anxiety about
going into a drug treatment facility.
3.
Social worker will investigate the availability and appropriateness of drug treatment programs in
the area.
4.
Staff will assess pt.’s areas of greatest interests and motivation to begin structured activities
congruent with pt.’s interests.
5.
Social worker will interview family members to assess their ability to communicate with each
other and to identify family interactions that may contribute to pt.’s alcoholism.
Substance Abuse (Problem Area 5)
5–11
VIII. Legal Treatment Modalities
A.
Court commitment
1.
Staff will initiate petition for mandatory substance abuse treatment.
IX. Miscellaneous Treatment Modalities
A.
Treatment of related problems (This is optional and can be included with the treatment
modalities or in the problem description.)
1.
Staff will treat the hopelessness and despair associated with pt.’s alcoholism as indicated under
Problem 1.1 Depressive Symptoms.
2.
Staff will treat pt.’s chronic hepatitis as outlined under Problem 6.1 Chronic Hepatitis.
5–12
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plan (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.1 Substance Abuse
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Ineffective Coping, Related to Substance
Abuse
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
Onset of symptoms and chronicity
•
•
•
Response to previous and current treatments and expected response to any proposed treatments
Precipitants (e.g., lifestyle, peer pressure, depression, anxiety, losses, other stress, boredom)
Characteristics, frequency, intensity, and variance of substance abuse behavior, including types, quantities,
and frequency of use of drugs or alcohol
Current level of substance abuse, urges to abuse substances, preoccupation with substance abuse
Barriers to treatment, such as minimizing one’s problem with substance abuse, poor motivation
2.
Make sure that the above relate to goals and treatment modalities.
3.
The description and treatment of any depressive or anxious symptoms that may be driving pt.’s impulses to
abuse drugs or alcohol should be addressed in Problem Area 1 Psychological Impairment and violence
secondary to substance abuse in Problem Area 3 Violence.
Goal(s) (Discharge Criteria and Objectives)
(Please number all goals.)
Target Date
Date/Status*
1. Pt. will be free of substance abuse for ___ week(s)/month(s).
2. Pt. will be able to go on off-grounds privileges on a regular basis
without using/abusing drugs/alcohol for ___ week(s)/month(s).
3. Pt. will participate in substance abuse meetings ___ time(s) a
week/month for ___ week(s)/month(s).
4. Pt. will complete steps _____ of the 12-step AA program.
5. Pt. will exhibit diminished denial and minimization AEB being
able to admit that drugs or alcohol are a problem in pt.’s life
consistently for a ___ -week/-month period.
6. Pt. will watch video(s) or read pamphlet(s) on substance abuse
titled __________________________________________________.
7. In substance abuse groups, pt. will be able to express an
understanding as to how substance abuse can 1) interfere with job
and functioning, 2) lead to assaultive or suicidal behavior, 3) force
one into criminal activity, and 4) adversely affect one’s mental
and/or physical health.
8. Pt. will work with a significant other for at least ___
week(s)/month(s) to help ensure that pt. will follow through with
treatment and abstinence.
9. Pt. will consistently agree to spot checks of urine for toxicology
screen if substance abuse is suspected for ___ week(s)/month(s).
10. Pt. will be able to express an understanding of the connection
between his or her depression, stress, or losses and substance abuse.
11. Pt.’s score on the Kennedy Axis V for Substance Abuse will
improve from a current score of ___ to ___.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.1
5–13
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
monitor any changes in intensity of impulses to abuse drugs/alcohol and to prescribe
treatments that may help reduce the craving or sense of need for drugs/alcohol such as
___________________________. Labs as ordered, including urine toxicology screens.
Virginia Coleman, MD
Social Work:
1. Social worker will meet with pt. for ___ minutes at least ___ time(s) weekly/monthly to
help pt. understand how his or her impulses to abuse drugs or alcohol act as a barrier
to pt.’s discharge.
Brenda St. Martin, MSW
Psychology (or Social Work):
1. Psychologist (social worker) will meet one-to-one with pt. for ___ minutes at least ___
time(s) weekly/monthly in alcohol counseling to reduce pt.’s craving or sense of need
for drugs/alcohol.
2. Psychologist (social worker) will lead group (e.g., substance abuse relapse prevention
group) weekly to help reduce pt.’s craving or sense of need for drugs or alcohol and
more effectively deal with pt.’s stress, problems, and losses.
Susan Green, Psychologist
Brenda St. Martin, MSW
Rehab:
1. Rehab staff will meet one-to-one with pt. for ___ minutes at least ____ time(s)
weekly/monthly to review and revise pt.’s daily treatment schedule and will refer pt.
to appropriate groups working to improve his or her problem with drugs/alcohol.
2. Pt. will attend AA/Narcotics Anonymous meetings ___ time(s) a week/month to learn
more about substance abuse risk factors and how to avoid them. See weekly schedule
for substance abuse programs.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will be alert to any evidence of intoxication or withdrawal and report any
significant findings to the psychiatrist or physician.
2. Nsg. staff will obtain urine toxicology screen or do Breathalyzer test if substance abuse
is suspected.
3. Nsg. staff will be alert to pt.’s impulses to abuse drugs or alcohol and med-seeking
behavior and will assist pt. in dealing with these in an appropriate, sober manner.
4. Nsg. staff will give encouragement and verbal praise for pt.’s involvement in non-drugrelated social activities.
5. Nsg. staff will escort pt. to off-ward groups, programs, and other activities to ensure pt.
does not attempt to abuse drugs or alcohol.
6. Nsg. staff will question pt. directly at least ____ time(s) each shift/day/week to
determine whether pt. has any impulses to abuse drugs/alcohol.
7. Nsg. staff will meet with pt. for ___ minutes at least ____ time(s) weekly/monthly to
educate pt. about the consequences of substance abuse and about alternative means of
relating to others, coping, or dealing with stress.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Substance Abuse (Problem Area 5)
5–15
Sample Individual Problem Plans
CONTENTS
Polysubstance Abuse .............................................................................................................................. 5–16
Substance Abuse, Mixed......................................................................................................................... 5–18
Nicotine Dependence ............................................................................................................................. 5–20
5–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.1 Polysubstance Abuse
Name: Graves, Gail
ID #:
Area:
Nursing Diagnosis: Risk for Injury
Date: 01/15/03
Problem Description:
Pt. has a history of several years of abusing substances, including alcohol, marijuana, and cocaine. At first, patient
denied abuse of drugs and alcohol; however, her extensive substance abuse problem quickly became apparent.
Abuse of drugs and alcohol appears to pervade her thinking and behavior. When given privileges, pt. would
frequently go AWA to get alcohol. During these periods, pt. places herself in potentially dangerous situations. Staff
feels that if given the opportunity, pt. would abuse drugs and alcohol on a daily basis. Pt.’s driver’s license was
revoked last year because of driving under the influence. In part, pt.’s substance abuse is seen as a method of
blocking out her feelings of low self-esteem. She has not used any drugs IV.
Pt.’s low self-esteem, which appears to be a factor in her substance abuse, will be treated as indicated under
Problem Area 1.1 Depressive Symptoms.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1. Pt. will be able to go on off-grounds privileges on a regular basis
without abusing drugs or alcohol for 3 months.
07/15/03
2. The pt.’s Kennedy Axis V score for Substance Abuse will improve
from a current score of 35 to 55.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1. Pt. will accurately discuss with staff her impulses to use drugs and
alcohol for 1 month.
04/15/03
2. Pt. will participate twice weekly in AA and substance abuse
discussion groups within the hospital for 1 month.
04/15/03
3. Pt. will be able to go on independent privileges on the hospital
grounds for 1 month without going AWA to get drugs or alcohol.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.1
5–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for at least 1½ hours each month to monitor any
changes in intensity of impulses to abuse drugs and alcohol.
2. Staff will consider prescribing medication to reduce craving for substance abuse, such
as naltrexone.
3. Psychiatrist will order urine toxicology screens to help ensure that pt. is not abusing
substances.
4. Pt. will be restricted to supervised privileges for 1 week if she returns to the ward
intoxicated or if she has a positive urine toxicology screen. During that period, staff
will reassess pt.’s commitment to sobriety, the treatment plan, and her level of
dangerousness in the community.
Victor Dyson, MD
Psychology:
1. Psychologist will meet one-to-one with pt. to direct her toward methods other than
substance abuse for relieving her depression and anxiety.
2. Staff will refer pt. to and encourage her to attend AA meetings and substance abuse
disorders group at least twice weekly in the hospital.
Joseph LeBlanc, Psychologist
Rehab:
1. Pt. will work in hospital cafe 4 hours each workday to help pt. stay focused on
alternatives to substance abuse and to improve her self-esteem.
2. Rehab staff will lead the relapse prevention group for 1 hour weekly to help pt. learn
about substance abuse risk factors and how to avoid them.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will provide encouragement and verbal praise for pt.’s involvement in nondrug-related social activities.
2. Nsg. staff will be alert to any evidence of intoxication, obtain urine toxicology screens
if substance abuse is suspected, and report any significant finding to the attending
psychiatrist.
3. Nsg. staff will meet with pt. for ½ hour once weekly to educate her about the
consequences of substance abuse and about alternative means of coping with stress
and her low self-esteem.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
5–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.2 Substance Abuse, Mixed
Name: Zachary, Maurice
ID #:
Area:
Nursing Diagnosis: Risk for Injury
Date: 01/15/03
Problem Description:
Pt. was recently transferred from our Psychiatric Acute Treatment Unit to our Substance Abuse Treatment Unit. Pt.
began abusing alcohol and marijuana around age 15. His episodic but persistent abuse of alcohol and marijuana
invariably leads to a worsening of his psychiatric symptoms. This abuse clearly impairs his functioning in his
community residence and his day treatment program. This abuse has led to multiple psychiatric hospitalizations,
including the present.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1. Patient will not abuse drugs or alcohol for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
01/15/04
Target Date
1. Pt. will acquire a willingness to examine substance abuse as a
problem in his life as demonstrated by independent participation
in a multifaceted educational and treatment program for
1 month.
04/15/03
2. Pt. will be able to consistently verbalize an understanding of
how substance abuse interferes with his daily functioning for
3 months.
07/15/03
3. Pt. will be free of drugs and alcohol for 3 months.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.2
5–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will lead medication and mental illness education group weekly to help pt.
to learn about the interaction between mental illness and substance abuse disorder.
2. Psychiatrist will monitor and document episodes of substance abuse and provide
medical/detox interventions as ordered.
Victor Dyson, MD
Social Work:
1. Social worker will lead weekly community transition group to help pt. develop plans
around living in the community and to identify support systems and resources that he
can use when he is out of the hospital.
Brenda St. Martin, MSW
Psychology/Social Work:
1. Psychologist and social worker will lead twice-weekly on-ward substance abuse group
to help pt. learn about problems created by substance abuse and to develop supports,
strategies, and alternatives to substance abuse.
2. Psychologist and social worker will lead weekly relapse prevention group for pt. to
learn ways of preventing relapse of both mental illness and substance abuse.
Joseph LeBlanc, Psychologist
Brenda St. Martin, MSW
Nursing Care Plan:
1. Nsg. staff will offer ongoing feedback and support for pt.’s decision to attain and
maintain abstinence.
2. Nsg. staff will encourage pt.’s attendance at substance abuse groups, including AA
meetings, twice weekly in the hospital and once weekly in the community.
3. Contact person will keep track of pt.’s attendance at program activities.
4. Nsg. staff will escort pt. as needed to off-ward groups to ensure that he does not
attempt to use marijuana or alcohol.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
5–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 5.3 Nicotine Dependence
Name: Drake, Dawn
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has been smoking one to two packs of cigarettes per day for the past 10 years. Pt. has recently begun to
experience shortness of breath. Pt. has also begun to experience a persistent, dry cough, and she occasionally
experiences upset stomach and chest tightness on days when her smoking is especially heavy (two packs per day).
Pt. has expressed a strong desire to cut down or stop smoking, but past attempts have been unsuccessful.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1. Pt. will cease cigarette smoking AEB continuous abstinence from
all tobacco products for 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1. Pt. will begin eating meals and snacks that are less likely to be
connected with previous patterns of smoking for 1 month.
04/15/03
2. Pt. will increase her interest in and awareness of health issues AEB
her participation in an exercise group three times a week for
1 month.
04/15/03
3. Pt. will work with a significant other for at least 1 month to help
ensure that she will follow through with stopping smoking.
04/15/03
4. Pt. will stop smoking for 1 month.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Substance Abuse (Problem Area 5)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 5.3
5–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1. Psychiatrist will meet with pt. for 15 minutes once weekly to assess any changes in
pt.’s craving for cigarettes and to prescribe treatments, such as nicotine gum or
nicotine patch, that will help to reduce episodes of cigarette craving.
Victor Dyson, MD
Psychology:
1. Psychologist will meet with pt. for ½ hour once a week to identify sources of potential
relapse (e.g., cues and triggers for smoking) and to develop coping strategies to reduce
risks of returning to smoking.
2. Psychologist will run the clinic self-help group, where pt. can obtain further
information regarding the problems associated with cigarette smoking and also obtain
peer reinforcement around the decision to stop smoking and to not restart.
Joseph LeBlanc, Psychologist
Social Work:
1. Staff will explore whether a significant other, such as her fiancé, will help pt. follow
through with her commitment to stop smoking.
Brenda St. Martin, MSW
Rehab:
1. Staff will work with pt. to plan and implement an individualized program to focus on
good health maintenance, including physical fitness exercises and smoking cessation.
Jane Hoover, Rehab
Nursing Care Plan:
1. Nsg. staff will encourage pt. to participate in the clinic self-help group.
2. Nsg. staff will give encouragement and verbal praise for pt.’s involvement in nonsmoking-related social activities.
3. Nsg. staff will question pt. directly every day to determine whether she is losing
control of cravings to smoke and report any significant worsening to the psychiatrist.
4. Nsg. staff will lead the on-ward smoking cessation group for ½ hour once weekly to
educate pt. about the health consequences of smoking and to help pt. develop
strategies for avoiding smoking.
Marilyn Davis, RN
Dietitian:
1. Dietitian will work with pt. to identify eating habits that trigger smoking. As the
triggers are identified, the dietitian will help pt. develop eating habits that are less
connected with previous patterns of cigarette smoking.
Louise Tallo, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
MEDICAL IMPAIRMENT
(Problem Area 6)
6–1
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Medical Impairment (Problem Area 6)
6–3
MEDICAL IMPAIRMENT
(Problem Area 6)
CONTENTS
Kennedy Axis V for Medical Impairment.................................................................................................. 6–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Medical Impairment and can be helpful in composing a short description of
each problem.
Problem Names and Descriptions ............................................................................................................ 6–5
Examples of problem names and descriptions that may relate to Medical Impairment are listed here.
These examples can be used to develop the Problem List and to help compose a short description of each
problem.
Strengths .................................................................................................................................................. 6–6
Examples of strengths that may be related to treatment and discharge in the area of Medical Strengths
are listed here.
Goals ......................................................................................................................................................... 6–6
Examples of treatment goals that may relate to problems in the area of Medical Impairment are
listed here.
Treatment Modalities ............................................................................................................................... 6–8
Examples of treatment modalities that may relate to problems in the area of Medical Impairment are
listed here.
Individual Problem Plan (Frequent Entries) ........................................................................................... 6–12
An Individual Problem Plan, containing examples of information frequently entered into Individual
Problem Plans relating to Medical Impairment, is included here.
Sample Individual Problem Plans ........................................................................................................... 6–15
A wide range of individual problem plans relating to Medical Impairment are included here.
6–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Medical Impairment
100 Superior medical health; physical exam and laboratory tests are normal, including no significant weight
problem; illnesses never seem to affect him/her; few if any problems with even common medical problems (e.g.,
colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to medical
problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a
multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms.
90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more
than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical
problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor
visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally
needs over-the-counter medication.
80 If medical problems are present, they are transient and cause minimal impairment in
social, occupational, or school functioning; somewhat more than average missing of work or school due to
medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a
prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to
organic problems.
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
60 Moderate difficulty in social, occupational, or school functioning due to medical problems;
missing no more than about 1 month a year from work or school due to medical problems (e.g., moderate asthma,
moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia secondary to
polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia, mild angina
on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po medications (e.g.,
injections, blood levels, nebulizer, physical therapy); needs bladder bag.
50 Serious impairment in social, occupational, or school functioning due to medical problems;
serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses, hearing
aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment is needed for
mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a car.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR Not rated
Medical Impairment (Problem Area 6)
6–5
Problem Names and Descriptions
I.
II.
Medical Problems Often Seen in Psychiatric Patients
A.
General medical problems
1. Angina
2. Hypertension
3. Endocarditis
4. Duodenal ulcer
5. Diabetes mellitus
6. Hypoglycemia
7. Asthma
8. Seizure disorder
9. Temporal lobe epilepsy
10. AIDS
11. Positive TB skin test
12. Migraine headaches
13. Acne
14. Allergy to penicillin
B.
Psychiatric illness sequelae (secondary to overdoses, self-inflicted cuts, gunshot wounds,
jumping from high places, substance abuse, and the like)
1. Organic brain dysfunction
2. Atonic bladder with associated incontinence
3. Paralysis
4. Laceration of wrist
5. Fracture
6. Malnutrition secondary to anorexia
7. Fluid and electrolyte problems secondary to polydipsia
8. Chronic obstructive pulmonary disease
9. Cirrhosis
10. Hepatitis
11. Chronic pancreatitis
12. Frostbite
13. Bed sores
14. Poor health maintenance
C.
Psychotropic medication side effects
1. Tardive dyskinesia
2. EPS (extrapyramidal side effects)
3. Akathisia
4. Hypothyroidism secondary to lithium
5. Constipation
6. Renal dysfunction secondary to lithium
7. Agranulocytosis secondary to Clozaril (clozapine)
8. Postural hypotension
9. Tachycardia
10. Dysphagia
11. Marked weight gain
12. Diabetes mellitus associated with use of Zyprexa (olanzapine)
Special Medical Status
A.
B.
C.
D.
E.
Pt.
Pt.
Pt.
Pt.
Pt.
is pregnant.
uses birth control.
has a single kidney.
is a carrier of an unexpressed genetic disease.
has mitral valve prolapse.
6–6
Fundamentals of Psychiatric Treatment Planning
III. Dental Problems
A.
B.
C.
D.
Multiple caries
Abscessed tooth
Gingivitis
Poor dental maintenance
Strengths (Brief List)
I.
Medical Strengths
A.
B.
C.
D.
E.
F.
G.
H.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
Pt.
has good physical health.
has no more than minor medical problems.
exercises on a regular basis.
is health-conscious.
sticks to a very healthy diet.
practices a healthy lifestyle.
practices safe sex.
has other medical strengths.
Goals
I.
Expected Improvements in Symptoms
A.
Medical problems secondary to psychotropic medications
1.
Pt.’s akathisia will improve so that pt. will be able to consistently sit through ½-hour groups for
1 month.
2.
Pt. will show no worsening or some remission of tardive dyskinesia for 6 months.
3.
Pt. will cooperate with the reduction of antipsychotic medication to the lowest reasonable dose to
minimize danger of tardive dyskinesia for 3 months.
4.
Pt. will return to euthyroid state (hypothyroidism secondary to lithium).
5.
Malignant neuroleptic syndrome will resolve.
B.
General medical problems
1. Pt.’s cholesterol will be reduced to below 200.
2. Pt.’s incidence of acne eruptions will reduce AEB pt.’s face appearing significantly clearer for
1 month.
3. Pt.’s blood pressure will be maintained at a safe level for 3 months.
4. Pt. FBS will be maintained within the normal range for 6 months.
5. Pt. will have a realistic goal of no further weight gain for 3 months, even though pt. is
significantly obese because of a lack of insight and a lack of motivation.
6. Pt. will maintain present optimal bladder function (considering the organic impairment of pt.’s
bladder).
7. Pt. will have no episodes of shortness of breath for 3 months.
8. Pt. will have no further deterioration in respiratory function AEB no deterioration in pt.’s
pulmonary function studies for 6 months.
9. Pt. will be free from poor skin integrity for 6 months.
10. Pt’s infections will heal without complications.
11. Pt.’s right foot will be free from infection for 6 months.
12. Pt. will continue to be free of seizures with treatment for 6 months.
13. Pt. will be free of pain and complications of hemorrhoids for 3 months.
14. Pt. will consistently report any incidences of falling for 3 months.
Medical Impairment (Problem Area 6)
II.
6–7
Reporting of Symptoms
A.
B.
C.
Pt. will report headaches or changes in symptoms consistently for 1 month.
Pt. will report any change or discomfort for 1 month.
Pt. will report any reoccurrence of bleeding for 3 months.
III. Participation in Groups, Program Activities, and the Like
A.
B.
C.
Pt. will participate in the physical therapy program once weekly for 1 month.
Pt. will attend speech therapy sessions twice weekly for 1 month.
Pt. will cooperate with dental work for the next three scheduled appointments.
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking psychotropic meds as prescribed.
2.
Pt. will express the benefits of taking meds as prescribed.
3.
Pt. will take meds as prescribed for 3 months.
4.
Pt. will comply with blood work for 3 months.
B.
Treatment planning
1.
Pt. will consistently cooperate with at least one treatment team member in the treatment
planning process for 1 month.
2.
Pt. will cooperate with the treatment plan to restrict fluid intake for 1 week.
3.
Pt. will demonstrate cooperation with all aspects of the treatment plan for 1 month.
C.
Program activities
1.
Pt. will express the benefits of attending the physical therapy program.
Diagnostic Tests and Evaluations
A.
Assessments
1.
Pt. will cooperate with the evaluation process for 2 weeks.
2.
Pt. will cooperate to complete the physical therapy assessment.
3.
Pt. will cooperate so that staff can determine the level of nursing care required for placement in
the community.
B.
Evaluations to R/O various diagnoses
1.
Pt. will cooperate with the complete evaluation to R/O seizure disorder.
C.
Laboratory tests
1.
Pt. will cooperate to complete the comprehensive laboratory screen.
2.
Pt. will cooperate to complete the EEG and CT scan.
3.
Pt. will cooperate to complete the ECG.
VI. Standardized Outcome Measures
A.
AIMS and AIMS Plus EPS exams
1.
Pt. will show no deterioration in tardive dyskinesia as measured by monthly AIMS Plus EPS exam
for 6 months.
2.
Pt.’s akathisia will improve as demonstrated in next month’s AIMS Plus EPS exam.
B.
Mini-Mental State
1.
Pt.’s score on the Mini-Mental State will improve from a current score of 12 to 18.
C.
Laboratory tests
1.
Pt.’s FBS will remain WNL for 3 months.
2.
Pt.’s thyroid function will remain WNL for 6 months.
6–8
Fundamentals of Psychiatric Treatment Planning
VII. Miscellaneous
A.
B.
Pt. will cooperate so that he or she can remain in an environment that protects the pt.
during the healing process.
Pt. will cooperate with the competency assessment to determine whether pt. is able to
make competent decisions about medical treatments.
Treatment Modalities
Because of the extremely broad range of the category Medical Impairment, only a brief outline of treatment
modalities is presented here. This outline focuses on the psychiatric aspects of the medical treatments. Additional
examples of treatment modalities for Medical Impairment are included on the sample Individual Problem Plans for
Medical Impairment.
I.
Verbal Treatment Modalities (emphasis on verbal interactions)
A.
II.
Support and reassurance
1.
Medical staff will work on a one-to-one relationship with pt. to increase trust.
2.
Nsg. staff will provide pt. with needed one-to-one support and reassurance that people are
concerned about pt.’s health and well-being.
3.
Rehab staff will work with pt. one-to-one to help pt. accept the significant residual impairment
following pt.’s stroke.
4.
Psychologist will meet with pt. one-to-one to enhance pt.’s self-esteem and feelings of meaning
and community to offset pt.’s despair following a diagnosis of late-stage ovarian cancer.
Behavioral Treatment Modalities
A.
Positive reinforcement
1.
Nsg. staff will give pt. positive feedback and encouragement for appropriate statements and
decisions concerning pt.’s physical health.
2.
Staff will encourage pt.’s independence by giving pt. as much decision-making power as possible.
3.
Psychologist will encourage pt. to be involved in the treatment planning process.
III. Miscellaneous Verbal and Behavioral Treatment Modalities
A.
Family treatment modalities
1.
Social worker will provide family therapy to help improve family’s willingness to help pt. follow
through with medical treatments.
B.
Religious treatment modalities
1.
Pt. will receive religious counseling for support and hope concerning pt.’s left-sided paralysis.
2.
Pt. will receive religious counseling to provide a religious perspective on the prognosis that pt. is
likely to die from cancer within 3 months.
3.
Pt. will receive religious counseling to help pt. objectively examine belief that his or her medical
illness is a punishment for sins.
C.
Other modalities
1.
Group therapy
a.
Group therapy will be used to facilitate discussion of pt.’s medical problems.
2.
Psychodrama
a.
Role-playing will be used to help reduce pt.’s anxiety about talking about his or her illness,
including the prognosis.
Medical Impairment (Problem Area 6)
6–9
IV. Milieu Treatment Modalities
V.
A.
Stimulus reduction
1.
Staff will redirect pt. from triggering events or overstimulating areas to reduce stress that may
worsen pt.’s physical symptoms.
2.
Sound-absorbing material will be added to pt.’s dorm area to help reduce noise.
3.
Nsg. staff will redirect other pts. from yelling, talking loudly, or playing their radios too loudly
near patient, to help pt. relax while healing.
B.
Protective procedures (including special observations)
1.
Staff will provide an environment that protects pt. during the healing process.
2.
Staff will keep pt. away from street drugs and alcohol to prevent further physical damage. At the
same time, pt. will be treated for substance abuse in the hope that pt. will abstain from substance
abuse once there is an opportunity to use drugs.
3.
Staff will employ escape precautions.
4.
Staff will monitor pt. closely to ensure that he doesn’t pick at sutures or wander off the ward.
C.
Other milieu treatment modalities
1.
Pt. will be placed in an environment in which pt.’s physical handicap will not be a significant
barrier to functioning.
Medical Treatment Modalities
A.
Medication
1.
Internist will prescribe meds as indicated for pt.’s physical illness.
2.
Nsg. staff will give pt. prn meds to relieve acute exacerbations of illness.
3.
Psychiatrist will reduce antipsychotic meds to the lowest reasonable dose to minimize danger of
tardive dyskinesia.
B.
Other medical treatment modalities
1.
Surgery
2.
Radiation therapy
3.
Physical therapy
4.
Chiropractic treatments
5.
Miscellaneous
a.
Acupuncture
b.
Exercise as tolerated
VI. Patient and Family Education
A.
Medical illness
1.
Nsg. staff will educate pt. about ways to cope with medical illness.
2.
Nsg. staff will meet with the pt. and family once weekly for ½ hour to teach them ways to
recognize signs of deterioration and other medical dangers.
3.
Internist will discuss with the pt. and family the nature of pt.’s medical illness and the prognosis.
B.
Medication
1.
Nsg. staff will educate pt. about the risks and benefits of meds.
2.
Nsg. staff will show pt. concrete benefits of taking meds (e.g., “The infection is clearing,” “You are
looking less pale,” “Your breathing is a lot less labored”).
3.
Pt.’s nurse or internist will discuss with pt.’s family the reasons pt. needs to take meds.
6–10
Fundamentals of Psychiatric Treatment Planning
C.
Benefits and consequences of behaviors
1.
Nsg. staff will discuss connections between daily appropriate attention to pt.’s medical care and
progress toward recovery from medical illness.
2.
Social worker will discuss with pt.’s family members the benefits of their visits and support.
D.
Miscellaneous patient and family education
1.
Nsg. staff will involve pt.’s family members in a psychoeducational program to improve their
ability to cope with pt.’s medical illness.
2.
Pt. will receive education to help pt. understand and deal with the long-term aspects of the illness.
3.
Nsg. staff will provide education to help pt. understand, recognize, and reduce some of the
underlying causes of the illness.
4.
Staff will schedule pt. for an appointment for counseling in family planning.
5.
Staff will encourage pt. to become involved in a sex education program that addresses pt.’s needs.
6.
Nsg. staff will educate pt. about pregnancy and delivery, including prenatal care and signs and
symptoms of labor.
VII. Evaluations and Assessments
A.
Psychological tests (and other formal verbal tests)
1.
Psychologist will perform psychological testing to determine pt.’s ability to engage in treatment
and to cope with serious illness.
2.
Staff will conduct neuropsychological testing to monitor for further deterioration in pt.’s mental
functioning.
B.
Psychiatric evaluations
1.
Staff will conduct a psychiatric diagnostic evaluation.
2.
Psychiatrist will perform a psychopharmacological assessment.
3.
Psychiatrist will perform an AIMS or AIMS Plus EPS exam every 6 months.
4.
Staff will measure EPS weekly using the AIMS Plus EPS to observe for reductions in pt.’s EPS as
Risperdal is decreased.
C.
Medical/laboratory tests and evaluations
1.
Internist will order needed urine tests and blood work.
2.
Psychiatrist will order blood levels to help determine medication compliance.
3.
Staff will monitor blood levels to determine whether meds are in the therapeutic range.
4.
Pt. will have EEG to R/O temporal lobe epilepsy.
5.
Pt. will have chest X ray to R/O pneumonia.
6.
Pt. will have CT scan to R/O organic etiology.
7.
Nsg. staff will record pt.’s seizures on the seizure flow chart.
D.
Religious evaluations and assessments
1.
Pt. will receive a religious assessment to determine whether religion will be an asset to pt.’s
recovery from illness.
2.
Pt. will receive an assessment to determine whether pt. sees self as being punished by getting this
illness and, if so, how religious/spiritual counseling can help reduce the guilt and improve pt.’s
compliance with treatment.
E.
Other evaluations and assessments
1.
Rehab staff will assess pt.’s areas of interests and motivation to begin structured activities
congruent with pt.’s interests.
2.
Social worker will interview family members to assess their ability to communicate with each
other and to give needed support to pt. during cancer treatments.
3.
Psychiatrist will refer pt. to Movement Disorder Clinic to further assess and treat pt.’s tardive
dyskinesia.
Medical Impairment (Problem Area 6)
VIII. Legal Treatment Modalities
A.
Medical guardianship
1.
Psychiatrist will seek a medical guardianship to obtain permission for the needed surgery.
IX. Miscellaneous Treatment Modalities
A.
No examples given
6–11
6–12
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plan (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.0 Health Maintenance
Name: Smith, John
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
1.
Enter any significant medical history, unless it is addressed under a separate problem.
2.
List any active or significant medical problems and any meds or treatment the pt. is taking, such as
prophylactic meds, multivitamins, aspirin, and such.
3.
List minor problems (such as acne, constipation, indigestion, mild obesity, mild hyperlipidemia, mild
dysphagia, mild hyponatremia, mild dehydration, mild hypertension).
4.
List any special treatments needed to maintain pt.’s health.
5.
List any dietary requirements.
6.
List any allergies.
7.
If the treatment of a particular medical problem is very complicated, use a separate problem plan to address
that problem, such as an active breast cancer, severe diabetes, severe obesity, severe dysphagia, severe chronic
obstructive pulmonary disease (COPD), or difficult-to-manage seizure disorder.
Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will continue to maintain an optimal level of health while
hospitalized, AEB compliance with all prescribed meds, lab work,
and treatments for pt.’s medical problems.
2.
Pt. will maintain an optimal level of wellness, AEB compliance
with all prescribed meds, lab work, and treatments for pt.’s
medical problems for ____ month(s).
3.
Pt. will comply with meds, treatments, and diagnostic tests for
pt.’s medical problems for ____ month(s).
4.
Pt. will perform good basic facial cleansing daily with one verbal
prompt for ____ month(s).
5.
Pt.’s [cholesterol, weight, sodium, BP] will improve from a
current ____ to ____.
6.
Pt. will have no more than one seizure per year.
7.
Pt.’s fasting blood glucose level will be maintained for ____
week(s)/month(s) in the following range: ________________
8.
Pt. will comply with a [whole, chopped, ground] diet with no
choking episodes for ____ month(s).
9.
Pt.’s score on the Kennedy Axis V for Medical Impairment will
improve from the current score of ____ to ____.
10.
Pt.’s score on the Kennedy Axis V for Medical Impairment will be
maintained at ____.
Target Date
Date/Status*
Ongoing
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.0
6–13
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
Physician will assess [acne, constipation, indigestion, mild hyperlipidemia, mild
obesity, mild dysphagia, mild hyponatremia, mild dehydration, mild hypertension,
mild diabetes, mild ___________________] and make appropriate treatment
recommendations.
2.
Physician will order and/or perform the following health measures:
a.
Annual physical exam
b.
Annual Mantoux test
c.
Baseline ECG and chest X ray and follow-up as needed
d.
Routine screen for hepatitis
e.
Routine dental checks
f.
Podiatry consults
g.
Follow-up exams with dermatology as needed
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor pt. daily and follow up on any signs and symptoms of illness.
2.
Nsg. staff will administer all prescribed meds and treatments as ordered and will
document pt.’s compliance.
3.
Nsg. staff will assess and document pt.’s level of understanding of prescribed
treatment and provide necessary teaching at pt.’s level of understanding.
4.
Nsg. staff will prompt pt. to comply with treatments, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany pt. to
procedures. Staff will offer praise for compliance and will document compliance.
5.
Nsg. staff will prompt pt. to attend to basic daily personal hygiene, including bathing,
facial cleansing, shaving, combing hair, brushing teeth, and putting on clean clothes.
Staff will offer praise for compliance.
6.
Nsg. staff will weigh pt. q____________, take BP and pulse q_______________, and
report any significant changes to physician.
7.
Nsg. staff will monitor pt.’s fluid and food intake and urine output and will report
any significant changes to physician.
8.
Nsg. staff will encourage pt. to eat a [healthy-heart, low-fat, low-cholesterol, low-salt,
high-fiber, low- or high-calorie], [whole, chopped, ground] diet and increase or
decrease fluid intake to prevent [constipation, hyponatremia, dehydration], promote
a healthy heart, reduce or gain weight, or maintain good health.
9.
Nsg. staff will indicate in the record pt.’s allergies to ________________________.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Medical Impairment (Problem Area 6)
6–15
Sample Individual Problem Plans
CONTENTS
Hypertension .......................................................................................................................................... 6–16
Chronic Obstructive Pulmonary Disease ................................................................................................ 6–18
Diabetes Mellitus .................................................................................................................................... 6–20
Elevated Cholesterol ............................................................................................................................... 6–22
Hypothyroidism Secondary to Lithium................................................................................................... 6–24
Seizure Disorder ..................................................................................................................................... 6–26
Hyponatremia Secondary to Polydipsia ................................................................................................. 6–28
Kidney Dysfunction Secondary to Lithium . ........................................................................................... 6–30
Dysphagia ............................................................................................................................................... 6–32
EPS (Extrapyramidal Side Effects) .......................................................................................................... 6–34
Akathisia ................................................................................................................................................. 6–36
Tardive Dyskinesia .................................................................................................................................. 6–38
Family Planning ...................................................................................................................................... 6–40
Family Planning ...................................................................................................................................... 6–42
Pregnancy ............................................................................................................................................... 6–44
6–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.1 Hypertension
Name: Scott, Daniel
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has had hypertension for the last several years. His hypertension has been well controlled with a combination
of diet, exercise, and meds. This has led to a resolution of pt.’s mild obesity. There is no history of alcohol abuse or
cigarette use. Pt.’s family history is strongly positive for hypertension and heart disease. Pt.’s cholesterol and
triglycerides are WNL.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Maintain blood pressure WNL.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will be able to verbalize a reasonable understanding of
hypertension and its treatment.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Ongoing
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.1
6–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe antihypertensives and diuretics.
2.
Internist will order blood work, including potassium and cholesterol levels.
3.
Internist will order a low-cholesterol, low-salt diet and weight control.
4.
Internist will determine level of exercise pt. can safely tolerate.
5.
Internist will order aspirin 1 po daily as a prophylactic against an MI.
Donald Mason, MD
Dietitian:
1.
Dietitian will meet with pt. once a week to help pt. continue with his healthy-heart,
low-sodium diet.
2.
Dietitian will help pt. monitor calories to help ensure that pt. maintains his weight
loss.
Sandra Anderson, Dietitian
Rehab:
1.
Rehab counselor will arrange a regular exercise program for pt. that he can safely
tolerate.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will monitor vital signs monthly.
2.
Nsg. staff will make ongoing observations of skin color, swelling, and temp. for
evidence of edema or peripheral vascular disease.
3.
Nsg. staff will continue to educate pt. to help him understand, recognize, and
continue to reduce some of the underlying risk factors, such as lack of exercise, poor
diet, and psychological stress.
4.
Nsg. staff will ensure that pt. has routine follow-ups with the internist.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.2 Chronic Obstructive Pulmonary
Disease
Nursing Diagnosis: Impaired Gas Exchange
Name: Johnson, Tiffany
ID #:
Area:
Date: 01/15/03
Problem Description:
Pt. has long-standing history of cigarette use (one to two packs a day). Six months ago, she was diagnosed as
having COPD secondary to cigarette smoking. To prevent further deterioration in her respiratory status, she
stopped smoking at that time; however, at times, pt. appears to have difficulty maintaining her abstinence from
cigarettes. At present, pt. walks freely about the ward with no significant evidence of shortness of breath; however,
pt. has great difficulty walking up a flight of stairs. Over the last few months, pt.’s pulse ox has been around 94%.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain patency of bronchial airways and facilitate
reasonable exchange of C02/02, AEB no deterioration in her
pulmonary function studies for 6 months.
01/15/04
2.
Pt.’s pulse ox will be maintained at 94% or greater for 3 months.
Ongoing
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will be able to verbalize a reasonable understanding of her
illness and the long-term importance of treatment, including
continued abstinence from smoking.
Target Date
Date/Status*
Date/Status*
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.2
6–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe bronchodilators, such as albuterol, and other respiratory meds
as ordered.
Margaret Patel, MD
Rehab:
1.
Rehab staff will provide activities as tolerated and provide an opportunity for rest as
needed.
Albert Sanchez, Rehab
Nursing Care Plan:
1.
Nsg. staff will make ongoing observations for evidence of respiratory distress,
including changes in pt.’s skin color.
2.
Nsg. staff will assess pt.’s breath sounds weekly, as well as when she is showing any
respiratory distress.
3.
Nsg. staff will use the pulse oximeter to measure pt.’s blood oxygenation (pulse ox)
once daily.
4.
Nsg. staff will notify pt.’s internist of any significant change in pt.’s pulmonary
function.
5.
Nsg. staff will schedule pt. for routine follow-up at Pulmonary Clinic.
6.
Nsg. staff will encourage pt. to breathe deeply and to have a reasonable fluid intake.
7.
Nsg. staff will educate pt. to help her understand, recognize, and attempt to reduce
some of the underlying risk factors, such as smoking, air pollution, allergies
(including high pollen count), lack of exercise, and dehydration.
8.
Nsg. staff will educate pt. to help her understand and deal with the long-term aspects
of her COPD.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–20
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.3 Diabetes Mellitus
Name: Costello, Roger
ID #:
Area:
Nursing Diagnosis: Risk for Elevated Blood Sugar
Date: 01/15/03
Problem Description:
Pt. is a 48-year-old man who has had diabetes for the last 10 years. There is no known etiology of his diabetes,
other than having a family history that is strongly positive for adult-onset diabetes. When first diagnosed, his
diabetes was controlled with diet and low doses of oral hypoglycemics. However, for the last few years, pt. has
required insulin to control his blood sugar. Currently, pt.’s diabetes is well controlled with diet and insulin;
however, pt. does not appear to have a good understanding of his diabetes and its possible complications.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain good control of his diabetes, AEB normal blood
sugars, including absence of hyperglycemic and hypoglycemic
episodes, for 6 months.
Ongoing
2.
Pt. will consistently verbalize an understanding that treatment
of his diabetes will help prevent the development of diabetic
complications, such as recurrent cellulitis of his feet, diabetic
retinopathy, cataracts, and diabetic nephropathy, for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will consistently verbalize an understanding of the risk
factors associated with diabetes mellitus and an understanding
of the treatment modalities for 3 months.
Target Date
Date/Status*
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.3
6–21
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order blood sugar levels, including finger-stick blood sugar levels.
2.
Based on pt.’s blood sugar levels, internist will make needed adjustments in pt.’s
regular insulin dosage and adjust pt.’s Insulin Sliding Scale as needed.
3.
Internist will order periodic complete blood workup; urinalysis, including sugar and
acetone levels; ECG; and chest X ray.
4.
Internist will treat any diabetic complications as they occur.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will monitor pt. for evidence that he is developing diabetic complications.
2.
Nsg. staff will monitor pt.’s finger-stick blood sugars and make adjustments in his
insulin according to pt.’s Insulin Sliding Scale.
3.
Nsg. staff will monitor pt.’s weight and BP once a month.
4.
Nsg. staff will monitor pt.’s physical activity.
5.
Nsg. staff will run diabetic group 45 minutes per week for pt. education with regard
to the diabetic condition, nutrition, insulin, and risk factors and complications
associated with diabetes and insulin.
6.
Nsg. staff will ensure that pt. is seen in Podiatry Clinic at least once q 3 months.
Marilyn Davis, RN Å Nsg. Staff
Dietitian:
1.
Dietitian will provide dietary consultation as needed to maintain pt. on an
antidiabetic diet with enough calories to meet daily demands as per physical activity,
height, and weight.
Sandra Anderson, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–22
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.4 Elevated Cholesterol
Name: Schwartz, Ronald
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has a history of elevated cholesterol that was first detected in 07/02. Pt.’s cholesterol level at that time was 276.
Pt.’s diet was very high in cholesterol and saturated fats. Nursing attempts to get pt. to stick to a low-cholesterol
diet led to a reduction of pt.’s cholesterol level to around 240. Currently it is felt that pt. could benefit from
cholesterol-lowering meds, in addition to continuing his diet. Pt. does not have a good understanding of the
relationship between cholesterol and heart disease. Pt.’s family history is strongly positive for cardiovascular
disease. Pt.’s mother also has elevated cholesterol.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will achieve and maintain normal blood cholesterol level for
at least 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will be able to consistently verbalize a reasonable
understanding of the relationship between blood cholesterol
and heart disease for 1 month.
04/15/03
2.
Pt. will be able to consistently identify and avoid foods high in
cholesterol and saturated fats for 1 month.
04/15/03
3.
Pt.’s blood cholesterol will be decreased to less than 200 for
1 month.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.4
6–23
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order periodic blood cholesterol levels and lipid profiles.
2.
Internist will order a dietary consult for follow-up of pt.’s low-fat, low-cholesterol
diet.
3.
Internist will prescribe cholesterol-lowering meds, such as niacin (vitamin B3), Lipitor
(atorvastatin calcium), or Zocor (simvastatin).
Donald Mason, MD
Dietitian:
1.
Dietitian will educate pt. on how to identify and avoid foods that are high in
cholesterol and saturated fats, as well as how to identify foods that are a part of a
low-fat, low-cholesterol diet.
Sandra Anderson, Dietitian
Nursing Care Plan:
1.
Nsg. staff will educate pt. as to the importance of dietary compliance and help him
limit his intake of foods that are high in cholesterol and saturated fats.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.5 Hypothyroidism Secondary to
Lithium
Nursing Diagnosis: Risk for Endocrine Imbalance
Name: Russell, Maria
ID #:
Area:
Date: 01/15/03
Problem Description:
Pt. has been on lithium for many years with associated hypothyroidism. Endocrinology workup diagnosed the
problem as hypothyroidism secondary to lithium. Pt. is on thyroid replacement meds (Synthroid) and is currently
euthyroid. She does not have a goiter. Pt.’s psychiatric symptoms are clearly improved by lithium, and alternatives
to lithium are less effective. At times, pt. is reluctant to take her Synthroid because she has experienced very few
symptoms of hypothyroidism; therefore, she often argues that she does not have any problems with her thyroid
function.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will remain in a euthyroid state for 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
Ongoing
Target Date
1.
Pt. will cooperate with treatment so that complications
associated with hypothyroidism will be prevented.
Ongoing
2.
Pt. will consistently verbalize an understanding of her need to
take her meds for 3 months.
07/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.5
6–25
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order periodic follow-up by the Endocrine Clinic as needed.
2.
Internist will order blood thyroid function studies as needed.
3.
Internist will prescribe thyroid replacement medication, such as Synthroid, and adjust
the dose based on pt.’s thyroid function studies.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will educate pt. for ½ hour once weekly to help pt. understand the need to
take her thyroid replacement meds.
2.
Nsg. staff will monitor pt. for evidence of hyperthyroidism and inform pt.’s internist
of any significant findings.
Ronald Donahue, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–26
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.6 Seizure Disorder
Name: Harrison, Henry
ID #:
Area:
Nursing Diagnosis: Risk for Seizures
Date: 01/15/03
Problem Description:
Pt. has had seizures since age 12, including grand mal seizures that occurred 1 to 2 times a month. The seizure
activity was present at the same frequency for years despite various attempts to reduce the frequency. EEGs
revealed multiple epileptic foci. Over the last few years, using a combination of anticonvulsants, the frequency of
seizures has stabilized at the current level of less than once every 6 months. At times in the past, pt. was reluctant
to take his anticonvulsants; however, currently he appears to have a fairly good understanding of the need to
continue his anticonvulsants.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will have no more than 1 seizure q 6 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
Ongoing
Target Date
1.
Pt. will have no more than 1 seizure q 3 months.
Ongoing
2.
Pt. will be compliant with his taking his anticonvulsants for
3 months.
Ongoing
3.
Pt. will consistently verbalize an understanding of his seizure
disorder and the need to take his meds for 3 months.
Ongoing
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.6
6–27
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will prescribe anticonvulsants, such as Depakote (divalproex sodium) and
Neurontin (gabapentin).
2.
Internist will order periodic serum blood levels, such as Depakote (divalproex sodium)
levels.
3.
Internist will refer pt. for follow-up appointments as needed with a neurologist.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will lead seizure group once per week to help pt. maintain an
understanding of his seizure disorder and the need to take his meds.
2.
Nsg. staff will keep a flow sheet on the frequency of pt.’s seizures and will inform the
internist of any increase in the frequency of pt.’s seizures.
Linda Larkin, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–28
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.7 Hyponatremia Secondary to
Polydipsia
Nursing Diagnosis: Excess Fluid Volume
Name: Drago, Evelyn
ID #:
Area:
Date: 01/15/03
Problem Description:
Pt. has a long history of drinking water and other fluids to a dangerous excess, which results in electrolyte
imbalances. There appears to be no organic basis for the polydipsia. Two years ago, this resulted in seizures when
her blood Na+ dropped to 124 (pt. has a seizure disorder that is well controlled by anticonvulsants when pt.’s Na+
is above 130). Through monitoring and encouraging pt. to limit her fluid intake, pt. has not had seizures for years.
With monitoring, including twice-weekly Na+ levels, her Na+ is generally 134 or greater. Because of drops in her
Na+ below 130, she requires one-to-one monitoring once or twice every 6 months. Pt. appears to have a reasonable
understanding of the risk factors associated with polydipsia and the treatment modalities; however, she constantly
complains of being thirsty.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain a Na+ of 130 or greater so that she will not
require one-to-one monitoring for 6 months.
01/15/04
2.
Pt.’s Na+ levels will be maintained at an “acceptable” level
(134 or greater) for 6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt.’s Na+ levels will be maintained at an “acceptable” level
(134 or greater) for 3 months.
07/15/03
2.
Pt. will not gain 8 pounds or more during a 24-hour period for
3 months.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.7
6–29
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will order electrolytes twice weekly—daily if Na+ falls below 130.
2.
Internist will restrict pt. to the ward and place pt. on one-to-one monitoring if Na+
falls below 130.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will encourage pt. to limit her fluid intake and to eat solid foods and foods
high in Na+.
2.
Nsg. staff will weigh pt. bid.
3.
Nsg. staff will restrict pt. to the ward if pt. gains 8 pounds during a 12-hour period
and will have a blood Na+ drawn immediately.
4.
Nsg. staff will restrict pt. to the ward, place pt. on one-to-one monitoring, and restrict
pt.’s fluid intake to 2000 cc/24 hrs if Na+ falls below 130.
5.
When pt. is restricted to the ward, nsg. staff will maintain intake/output records and
pt.’s Na+ level will be drawn q day.
6.
Nsg. staff will provide positive reenforcement when pt. is able to maintain her blood
Na+ level at 134 or greater.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–30
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.8 Kidney Dysfunction Secondary to
Lithium
Nursing Diagnosis: Impaired Urinary Elimination
Name: Bryant, Harriet
ID #:
Area:
Date: 01/15/03
Problem Description:
During a period of dehydration in association with a weight reduction diet, pt. developed lithium toxicity. Pt. had
been toxic once before in the past, in association with skipping blood lithium levels. During the toxic episode, pt.
was immediately taken off the lithium. Following the toxic episode, it was noted that pt. had developed diabetes
insipidus secondary to lithium toxicity. Pt. is currently off lithium, and fortunately her diabetes insipidus is
expected to resolve. Pt.’s manic, aggressive behavior is being reasonably well controlled with a mood stabilizer,
Depakote. There are no plans at present to restart lithium because of pt.’s difficulty following up with her diet and
blood tests required for lithium.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt.’s kidney function will return to normal AEB normal blood
Na+, BUN, and creatinine levels and normal urine specific
gravity for 6 months.
01/15/04
2.
Pt.’s manic and aggressive behaviors will be reasonably well
controlled without having to restart pt. on lithium for
6 months.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will have a normal blood Na+, BUN, and creatinine for
3 months.
Target Date
Date/Status*
Date/Status*
07/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.8
6–31
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Internist:
1.
Internist will get nephrology consults as needed.
2.
Internist will monitor progress of diabetes insipidus and check for evidence of renal
failure with monthly electrolytes, BUN, and creatinine.
3.
Internist will order weekly urine specific gravity checks.
4.
Internist will order meds such as hydrochlorothiazide to assist kidney function.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will ensure that pt. has adequate fluid intake to keep up with fluid loss.
2.
Nsg. staff will use an intake and output chart to monitor pt.’s fluid intake.
Marilyn Davis, RN Å Nsg. Staff
Dietitian:
1.
Dietitian will provide dietary consult if pt. decides to go on another weight-reduction
diet.
Sandra Anderson, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–32
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.9 Dysphagia
Name: Frantz, Marshall
ID #:
Area:
Nursing Diagnosis: Impaired Swallowing
Date: 01/15/03
Problem Description:
Pt. has been noted to have difficulty swallowing, which appears to have been worsened by the use of neuroleptic
meds. Pt. eats very rapidly, and his chewing is very inefficient. Yesterday he choked on a meatball. The nurse had
to perform the Heimlich maneuver to open his airway. AIMS Plus EPS exam reveals a significant amount of EPS.
Pt.’s mental status has clearly benefited from the use of neuroleptic meds.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will maintain normal nutrition through efficient chewing
and swallowing of a regular diet as measured by his maintaining
his present weight for 6 months.
01/15/04
2.
Pt. will be free of any further choking episodes for 1 year.
01/15/04
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will be free of any further choking episodes for 3 months.
07/15/03
2.
Pt. will be able to experience a reduction in EPS AEB a reduction
in the tightness in his neck and the stiffness in his arms for
3 months.
07/15/03
3.
Pt. will demonstrate a slowing in his eating and an increased
efficiency in chewing of his food for 3 months.
07/15/03
4.
Pt. will be switched from a chopped diet back to a regular diet
when he is determined to be able to safely eat a regular diet.
07/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.9
6–33
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatrist:
1.
Psychiatrist will treat pt.’s EPS with a reduction in pt.’s neuroleptic meds; a change to
another neuroleptic, such as Zyprexa; or a prescription for an antidyskinetic, such as
Cogentin.
2.
Psychiatrist will do an AIMS Plus EPS evaluation in 2 weeks following the above med
changes.
3.
Psychiatrist will refer pt. to Dysphagia Clinic for possible modified barium swallow to
more fully assess pt.’s dysphagia.
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will provide one-to-one monitoring during meals by staff trained in
Heimlich maneuver.
2.
Nsg. staff will educate pt. on avoiding hard or dry foods and alternating bites of food
with fluids.
Marilyn Davis, RN Å Nsg. Staff
Dietitian:
1.
Dietitian will provide pt. with a chopped diet.
2.
Dietitian will evaluate and educate pt. in weekly one-to-one meetings concerning his
eating habits and the relationship to choking.
Sandra Anderson, Dietitian
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–34
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.10 EPS (Extrapyramidal Side Effects)
Name: Walsh, Ruth
ID #:
Area:
Nursing Diagnosis: Impaired Physical Mobility
Date: 01/15/03
Problem Description:
Pt. complains of stiffness of extremities. Exam reveals bradykinesia, left greater than right, cogwheel rigidity of
wrists and elbows, left greater than right 4 to 6 Hz hand tremor, shuffling gait, diminished arm swing, and foreflexed posture consistent with neuroleptic-induced extrapyramidal side effects (pseudo-Parkinsonism). These
findings were not present before reinitiation of neuroleptic treatment 6 months ago. Parkinsonism may be
associated with increased falling risk in this pt. Pt. is currently on Risperdal (risperidone) 6 mg bid. Maintenance
dose in the community had been 4 mg bid. The pt.’s psychotic symptoms have responded well to Risperdal, but
she is known to decompensate rapidly when off neuroleptics.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will have control of psychotic symptoms with least possible
extrapyramidal side effects for 3 months.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will continue to be free from episodes of falling.
Ongoing
2.
Pt. will express a feeling of a reduction in the sensation of
stiffness without a worsening of her psychotic symptoms for
1 month.
04/15/03
3.
Pt.’s score on the AIMS Plus EPS (EPS Section) will decrease from
current 12 to 6 or less, without a worsening of her psychotic
symptoms (i.e., without a decrease in her Kennedy Axis V score
for Psychological Impairment).
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.10
6–35
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will reduce Risperdal from 6 mg bid to 4 mg bid and begin Cogentin 1 mg
po bid. Increase Cogentin by 1 mg/day every 3 days until rigidity and shuffling
improve or until 6 mg/day is reached. Further changes in meds as ordered.
2.
If above interventions fail to reduce EPS in 1 month, psychiatrist will consider
changing pt. to a neuroleptic less likely to cause EPS, such as Zyprexa (olanzapine).
Virginia Coleman, MD
Psychology:
1.
Kennedy Axis V rating prior to Risperdal reduction and then monthly to capture any
deterioration in pt.’s mental status in association with the medication adjustment.
Joseph LeBlanc, Psychologist
Nursing Care Plan:
1.
Nsg. staff will make ongoing mental status evaluations to observe for any
deterioration with decrement in Risperdal dosage.
2.
Nsg. staff will make weekly measurements using the AIMS Plus EPS exam to observe
for reductions in pt.’s EPS during the period of Risperdal reduction.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–36
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.11 Akathisia
Name: Gumble, Vincent
ID #:
Area:
Nursing Diagnosis: Impaired Physical Mobility
Date: 01/15/03
Problem Description:
Pt. complains of restlessness with difficulty sitting through 30-minute groups, sitting through meals, watching TV,
or calming down to go to sleep. Examination reveals no evidence of Parkinsonism or dystonia, but there is ongoing
motor restlessness with leg rubbing and rocking when seated, shifting from foot to foot when asked to stand still,
and a tendency to pace rapidly in the hallways. Low-potency antipsychotics and atypical antipsychotics have not
been as effective as Haldol (haloperidol) in controlling pt.’s psychotic symptoms. It is felt that reasonable control
may be maintained on a lower dose of Haldol. Also, pt.’s akathisia is suspected to be contributing to the appearance
of greater severity of his psychosis.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will be able to maintain good control of his psychotic
symptoms with minimal akathisia for 1 month.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will be able to sit through meals and 30-minute groups
consistently for 2 weeks.
Target Date
Date/Status*
04/15/03
Target Date
Date/Status*
03/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.11
6–37
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will rate the Kennedy Axis V before Haldol reduction and then weekly to
observe for any deterioration in pt.’s mental status in association with the medication
adjustment.
2.
Psychiatrist will slowly reduce Haldol and give entire dose at HS.
3.
Psychiatrist will make ongoing observations for changes in pt.’s akathisia during the
period of Haldol reduction.
4.
Psychiatrist will make weekly measurements of akathisia using the AIMS Plus EPS to
observe for reductions in pt.’s akathisia during the period of Haldol reduction.
5.
Psychiatrist will make ongoing mental status evaluations to observe for any
deterioration with the medication adjustments.
6.
Once pt. is medically cleared and if akathisia continues, psychiatrist will consider
starting pt. on a trial of beta-blockers, such as Inderal.
Virginia Coleman, MD
Internist:
1.
Internist will medically clear pt. for possible use of beta-blockers.
Margaret Patel, MD
Nursing Care Plan:
1.
Nsg. staff will make ongoing assessments of pt.’s akathisia and mental status,
especially when administering his meds.
2.
Nsg. staff will report to the psychiatrist any significant changes in pt.’s akathisia or
mental status.
Marilyn Davis, RN Å Nsg. Staff
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–38
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.12 Tardive Dyskinesia (TD)
Name: Danavich, Debra
ID #:
Area:
Nursing Diagnosis: Impaired Physical Mobility
Date: 01/15/03
Problem Description:
AIMS exam about 2 weeks ago revealed moderate choreoathetoid movement of tongue and distal extremities
consistent with TD. Previous AIMS exams did not meet the criteria for TD. Several weeks before the current AIMS
exam, pt.’s Haldol was decreased; therefore, the current increase in the AIMS score may represent a withdrawal
emergent syndrome. In the past, pt. has decompensated when Haldol was decreased to levels significantly lower
than she is currently on. Pt. has a general understanding of the risks associated with tardive dyskinesia and
continued use of Haldol. She agrees to continue Haldol at a reduced dose, despite the risks. She is also willing to
supplement the Haldol with Zyprexa (olanzapine), which may be less likely to worsen her TD. It is hoped that the
Zyprexa can be used to replace the Haldol.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to demonstrate control of her psychotic
symptoms with the lowest reasonable neuroleptic dosage and, if
possible, use neuroleptics that are less likely to cause TD for
3 months.
07/15/03
2.
Pt. will show no worsening of her dyskinetic movements for
3 months.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Pt. will show no worsening of her dyskinetic movements for
1 month.
Target Date
Date/Status*
Date/Status*
04/15/03
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.12
6–39
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will decrease Haldol as Zyprexa is added to pt.’s treatment regimen.
2.
To R/O TD versus withdrawal emergent syndrome, psychiatrist will repeat AIMS exam
q month to determine whether pt.’s dyskinetic movements resolve consistent with
withdrawal emergent syndrome or persist consistent with TD.
3.
If pt. continues to meet AIMS criteria for TD more than 3 months after the reduction
of Haldol dosage, psychiatrist will refer pt. to Movement Disorder Clinic for
consideration of alternative drug treatment strategies aimed at a reduction of
dyskinesia.
4.
If pt.’s AIMS scores worsen after 3 months, psychiatrist will consider a trial of
clozapine.
5.
Pt. will be prescribed vitamin E to help minimize tardive dyskinesia.
Virginia Coleman, MD
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–40
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.13 Family Planning
Name: Lampson, Angela
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. is a 32-year-old, twice-divorced mother of three children. All her children are in foster care. She remains sexually
active with various partners of the opposite sex and is requesting birth control. She does not want any more
children at this time. She has never practiced birth control and is not sure which method is right for her lifestyle.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will faithfully adhere to her birth control program for
3 months.
07/15/03
2.
Pt. will consistently express an understanding of the need to
immediately contact her physician with any symptoms of
sexually transmitted diseases (STDs) for 3 months.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will cooperate with a gynecological exam.
02/15/03
2.
Pt. will be able to express a reasonable understanding of birth
control, including risks and benefits, for 1 month.
03/15/03
3.
Pt. will have an awareness of the risks associated with multiple
sexual partners for 1 month.
03/15/03
4.
Pt. will express an awareness of STDs, including symptoms that
require medical attention.
03/15/03
5.
Pt. will choose a contraceptive method that fits her lifestyle and
meets her needs.
03/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.13
6–41
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Nursing Care Plan:
1.
Nsg. staff will schedule appointment for gynecological exam.
2.
Family planning counselor will provide pt. with literature on family planning and
meet weekly with pt. for ½ hour for at least 2 weeks to educate pt. about the
following:
a.
The available birth control methods, including risks and benefits
b.
STDs and symptoms and when to seek help from her physician
3.
At the end of the educational program, counselor will schedule an appointment for
an additional ½ hour to assist pt. in choosing a suitable birth control method.
4.
Nsg. staff will schedule pt. for follow-up appointments at the family planning clinic
in the hospital. At discharge, a follow-up appointment will be scheduled at her local
family planning clinic.
Ronald Donahue, RN
Linda Larkin, RN (Family Planning Counselor)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–42
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.14 Family Planning
Name: Lang, Dorothy
ID #:
Area:
Nursing Diagnosis: Ineffective Health Maintenance
Date: 01/15/03
Problem Description:
Pt. is a 26-year-old, twice-divorced mother of three children. One of her children has been adopted and two are in
foster care. She has had two abortions. She remains sexually active with various partners of the opposite sex. She is
refusing birth control and is anxious to have more children. Pt. appears to have a lot of fantasies and misunderstandings concerning sexual relationships and having children. Pt.’s sexual behavior appears to be related to her
loneliness and dependency needs. Also, she does not understand the risks of STDs.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will be able to express a reasonably informed understanding
of her sexual behavior consistently for 3 months.
07/15/03
2.
Pt. will recognize her loneliness and dependency needs and
identify more appropriate ways of dealing with them
consistently for 3 months.
07/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will begin to develop a trusting relationship with her
counselor.
02/15/03
2.
Pt. will begin verbalizing in one-to-one therapy her thoughts,
feelings, and fantasies about having children consistently for
1 month.
04/15/03
3.
In one-to-one therapy, Pt. will explore positive and negative
aspects of her relationships with men, including identification
of needs satisfied, consistently for 1 month.
04/15/03
4.
Pt. will accept family planning counseling, including counseling
on the risk of STDs.
04/15/03
5.
Pt. will begin to participate in a sex education program.
04/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.14
6–43
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychology:
1.
Psychologist will schedule meetings with pt. initially for 15 minutes twice a week;
meetings will be increased to ½ hour as psychologist develops a therapeutic
relationship with pt.
2.
Psychologist will gradually explore pt.’s fantasies around pregnancy and child rearing
and assist pt. in understanding the realities of pregnancy and child rearing.
3.
Psychologist will assist pt. with identifying needs met by her sexual behavior and
help pt. explore alternative means of meeting her needs.
4.
Psychologist will encourage pt. to enroll in the weekly women’s group.
5.
Psychologist will encourage pt. to become involved in a sex education program that
addresses her needs and encourage pt. to work with the Family Planning Counselor.
Susan Green, Psychologist
Rehab:
1.
Rehab counselor will lead the weekly women’s group to help pt. explore positive and
negative aspects of her relationships with men.
Jane Hoover, Rehab
Nursing Care Plan:
1.
Family planning counselor will make pt. aware that family planning counseling is
available and encourage pt.’s participation.
2.
Family planning counselor will provide family planning counseling for ½ hour once
weekly when pt. is agreeable.
Linda Larkin, RN (Family Planning Counselor)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
6–44
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.15 Pregnancy
Name: Duncan, Helen
ID #:
Area:
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. is a 28-year-old single female who is here in the hospital in her last trimester of her first pregnancy. She carries a
diagnosis of schizophrenia and has a history of multiple psychiatric admissions. She has not been going for
prenatal care, is not taking her antipsychotic meds, and is floridly psychotic. She denies that she is pregnant. The
paternity of the child is unknown. Pt.’s mother is her legal guardian, and her mother wishes to care for the baby
once it is born. Staff feels that pt.’s mother can provide a healthy, nurturing environment for the baby, as well as
allow pt., when she is doing well, to have an ongoing relationship with her baby.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
Pt. will safely deliver a full-term, healthy baby.
04/15/03
2.
Pt. will concur with the need to place her baby in the care of her
mother until she can safely care for her baby.
04/15/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
Pt. will see an obstetrician as soon as possible.
01/29/03
2.
Pt. will cooperate with and will receive adequate nutrition, rest,
and exercise.
02/15/03
3.
Pt. will acknowledge her pregnancy.
02/15/03
4.
Pt. will verbalize an understanding of the need for prenatal care
and verbalize an awareness of the signs and symptoms of labor.
02/15/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Medical Impairment (Problem Area 6)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.15
6–45
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work/Nursing:
1.
Staff will discuss with pt. and her mother the placement of pt.’s infant with pt.’s
mother.
Brenda St. Martin, MSW, and Linda Larkin, OBS Primary Nurse
Nursing Care Plan:
1.
Nsg. staff will maintain pt. in an environment that is safe for her and her unborn
child.
2.
Nsg. staff will develop a trusting relationship with pt. to get pt. to cooperate with
prenatal care.
3.
Nsg. staff will monitor nutrition, elimination, rest, and activity; staff will report any
difficulties to the obstetrician.
Ronald Donahue, RN Å Nsg. Staff
4.
Nsg. staff will meet with pt. for ½ hour once weekly to provide education about
pregnancy and delivery, including signs and symptoms of labor.
Linda Larkin, RN, OBS Primary Nurse
5.
Nsg. staff will be educated to the signs and symptoms of labor so they can monitor
these signs and symptoms on a daily basis, as well as review them with pt.
Linda Larkin, OBS Primary Nurse Å Nsg. Staff
6.
Staff will collaborate to determine when pt. will be transferred to the Maternity Ward.
Ronald Donahue, RN
Linda Larkin, OBS Primary Nurse
7.
As pt.’s due date approaches, check pt. every 15 minutes for evidence of labor.
Ronald Donahue, RN Å Nsg. Staff
Other:
1.
Treatment outlined in Problem 1.1 Psychotic Symptoms, including a low-dose
antipsychotic med that is medically cleared and recommended by pt.’s psychiatrist
and obstetrician following a discussion of the risks and benefits with pt. and her
guardian.
Staff as indicated
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
ANCILLARY IMPAIRMENT
(Problem Area 7)
7–1
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Ancillary Impairment (Problem Area 7)
7–3
ANCILLARY IMPAIRMENT
(Problem Area 7)
CONTENTS
Kennedy Axis V for Ancillary Impairment ................................................................................................ 7–4
This rating scale can be used to measure the outcome of treatment. It also helps to define the problems
that fit into the category of Ancillary Impairment and can be helpful in composing a short description
of each problem.
Problem Names and Descriptions ............................................................................................................ 7–5
Examples of problem names and descriptions that may relate to Ancillary Impairment are listed here.
These examples can be used to develop the Problem List and to help compose a short description of
each problem.
Strengths .................................................................................................................................................. 7–5
Examples of strengths that may be related to treatment and discharge in the area of Ancillary Strengths
are listed here.
Goals ......................................................................................................................................................... 7–6
Examples of treatment goals that may relate to problems in the area of Ancillary Impairment are listed
here.
Treatment Modalities ............................................................................................................................... 7–7
Examples of treatment modalities that may relate to problems in the area of Ancillary Impairment are
listed here.
Individual Problem Plan (Frequent Entries) ............................................................................................. 7–8
An Individual Problem Plan containing examples of information relating to Ancillary Impairment is
included here.
Sample Individual Problem Plans ........................................................................................................... 7–11
A wide range of Individual Problem Plans relating to Ancillary Impairment are included here.
7–4
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Ancillary Impairment
100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood,
home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe
environment. No significant ancillary problems or symptoms.
90 Good life situation; has few if any ancillary problems; no more than minor problems with living
environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet
his/her needs, rare late payment on a bill, rare parking or traffic ticket.
80 If ancillary problems are present, they are transient and cause no more than minimal
difficulty with his/her living situation, financial resources, or the law; somewhat more than average
problems with his/her living environment, financial resources, or legal problems.
70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the
law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal
violence in his/her environment; however, generally safe living situation.
60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous
homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or
income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards;
evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing,
defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for
competency to make decisions concerning person, estate, and/or treatment.
50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of
moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor
but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under
the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for
placement.
40 Major problems with living situation, finances, and/or the law; some real danger of being
physically injured in his/her environment; evaluation and/or disposition is being made for very violent
criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).
30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless
or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate
physical injuries from violence in his/her environment.
20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all
of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing
or because of high level of violence in his/her environment; evaluation and/or disposition is being made for
extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).
10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack
of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment;
evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone,
very viciously harming or very viciously raping a child, arson with intent of hurting others).
NR Not rated
Ancillary Impairment (Problem Area 7)
Problem Names and Descriptions
I.
Ancillary Problems
A.
Placement difficulties
1.
Homelessness
2.
Alienation of halfway house staff members
3.
Ambivalence about leaving the hospital
4.
Appropriate placement not available
5.
Placement blocked by unresolved legal difficulties
B.
Financial problems
1.
No means of support
2.
Debts beyond ability to pay
3.
Overwhelming credit card debt
4.
Social Security Disability Income (SSDI) benefits needed
C.
Legal difficulties
1.
Court report
2.
Court assessment of competency
3.
Court permission for forcing medication
4.
Court review of use of antipsychotic meds
5.
Court review of use of an experimental drug
6.
Court review of psychosurgery
7.
Criminal charges
8.
Guardian is not properly handling pt.’s money
9.
Divorce
D.
Data collection
1.
Insufficient database
2.
No information available on pt.’s psychiatric history
3.
No information available on pt.’s current housing or legal status
E.
Other ancillary problems
1.
Dangerous homeless situation
2.
High level of violence in pt.’s environment
3.
No stable residence
4.
Abusive spouse
5.
Target of a stalker
Strengths (Brief List)
I.
Ancillary Strengths
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Community placement to return to
Safe environment to return to
Supportive family or friend who is actively involved in pt.’s care
Good community support network
Good religious support system
Economic security
Financial resources for basic needs
Private insurance
SSDI in place
Guardianship in place for psychotropic meds
Guardianship in place for person and estate
Other ancillary strengths
7–5
7–6
Fundamentals of Psychiatric Treatment Planning
Goals
I.
II.
Expected Improvements
A.
Placement
1. Pt. will be able to demonstrate basic community living skills, including the ability to use public
transportation, budget money, shop for food, and prepare a meal, for 3 months.
2. Pt. will be able to verbalize fears and ambivalence about moving into a community residence.
3. Pt. will go on a “no-strings-attached” tour of prospective halfway houses.
4. Pt. will be able to consistently express an understanding of the benefits of going into a halfway
house for 1 month.
5. Pt. will be able to begin the process of slow transition to a community setting without serious
regression.
6. Pt. will be able to successfully go to the community day program two times a week for 1 month.
7. Pt. will be placed in a structured residential setting without serious regression during the
transition.
8. Pt. will be able to transition from a locked ward to an unlocked, open ward.
9. Pt. will reduce dependency on his or her mother to the point that pt. will begin to discuss
community residential alternatives to being discharged to live with mother.
10. Pt. will express an understanding of the fact that pt. can benefit from discharge to a halfway house
rather than return to mother’s home.
11. Pt. will be discharged to the appropriately supervised residential setting.
12. Pt. will improve so that court approval can be obtained for discharge to a halfway house.
B.
Financial
1.
Pt. will begin getting SSDI benefits as a step toward being able to move out of the homeless
shelter.
2.
Pt. will be able to get a job that will provide the income necessary to stabilize pt.’s life to live
outside of the hospital.
3.
Pt. will cooperate with social worker on ways to get credit card debt under control.
C.
Legal
1.
Pt. will cooperate so that the information needed to complete the mandated court evaluation can
be gathered.
2.
Pt. will show up for the court hearing.
3.
Pt. will have a permanent legal guardian appointed by the court for financial, medical, and
psychiatric concerns.
4.
Pt. will consistently maintain communication with the guardian for 3 months.
5.
Pt. will consistently cooperate with the lawyer in gathering the necessary information for pt.’s
upcoming divorce, for 1 month.
6.
Pt. will consistently cooperate with the lawyer in pt.’s defense against the charge of attempted
murder for 3 months.
D.
Other
1.
No examples given.
Reporting of Symptoms
A.
Pt. will discuss fears about leaving the hospital.
III. Participation in Groups, Program Activities, and the Like
A.
B.
Pt. will participate in discharge transition group.
Pt. will participate in the abused spouses group.
Ancillary Impairment (Problem Area 7)
7–7
IV. Understanding of and Compliance With Treatment Plans
V.
A.
Medication and laboratory work
1.
Pt. will discuss the benefits of taking meds.
2.
Pt. will express the benefits of taking meds.
3.
Pt. will take meds as prescribed.
4.
Pt. will go for follow-up lab tests in the community.
B.
Treatment planning
1.
Pt. will cooperate with at least one treatment team member in the treatment planning process.
2.
Pt. will be willing to participate in the court evaluation process as laid out in pt.’s treatment plan.
C.
Program activities
1.
Pt. will express the benefits of attending community transition group meetings.
2.
Pt. will consistently agree to go for follow-up at the community clinic.
D.
Consequences of pt.’s actions
1.
Pt. will demonstrate a realistic orientation toward progress such that pt. understands and explains
the connections among—
a.
Failure to work with the lawyer and legal setbacks
b.
Alienation of community staff and difficulty transitioning into the community
c.
Inconsistent program attendance, recurring setbacks, and continued care at the hospital
d.
Failure to follow through with the terms of pt.’s probation and a return to jail
Diagnostic Tests and Evaluations
A.
B.
C.
Pt. will cooperate with the evaluation of the nature of pt.’s anxiety about discharge.
Pt. will cooperate with the competency exam.
Pt. will cooperate with the treatment team to gather the information necessary to
complete mandated court evaluation.
VI. Standardized Outcome Measures
A.
Kennedy Axis V subscale for Ancillary Impairment will improve from a current score of
40 to 60.
VII. Miscellaneous
A.
B.
C.
D.
Once level of care has been determined, pt. will give staff permission to determine the
availability of appropriate discharge placement.
Pt. will allow the community case manager to be involved in the discharge planning
process.
Pt. will cooperate with determining who would be best to act as pt.’s guardian.
Pt. will demonstrate motivation for discharge by advocating for self with case
management about the fact that an appropriate placement is lacking, despite pt.’s
readiness to function in a community residence.
Treatment Modalities
Because of the extremely diverse nature of the category of Ancillary Impairment, no listing of treatment modality
examples is included. However, some examples of treatment modalities for Ancillary Impairment are included in
the samples of Individual Problem Plans at the end of this section on Ancillary Impairment. Also, the categories of
treatment modalities presented in previous sections should generally apply to the treatment of Ancillary
Impairment.
7–8
Fundamentals of Psychiatric Treatment Planning
Individual Problem Plan (Frequent Entries)
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.1 Court Evaluation (for criminal
behavior)
Nursing Diagnosis: Ineffective Community Coping
Name: Smith, John
ID #:
Area:
Date: 01/15/03
Problem Description:
1.
The problem description should include the following:
•
•
•
Description and date of alleged crime
•
•
•
•
•
Motive (e.g., anger, jealousy, revenge, monetary gain, sexual gratification)
Type of court evaluation (e.g., competency to stand trial, criminal responsibility)
Precipitants (e.g., noncompliance with meds, substance abuse, command hallucinations, stress, poor
frustration tolerance, poor impulse control, antisocial personality characteristics, pedophilia)
Brief description of criminal history (e.g., frequency and characteristics of crimes)
Outcome of previous court evaluations
Current potential for repeating the alleged crime
Barriers to the evaluation (e.g., unwillingness to cooperate, poor or distorted memory for the event, lack
of witnesses or other corroborating information)
2.
Make sure that the description relates to goals and treatment modalities.
3.
Address the description and treatment of associated problems that may have led to pt.’s alleged crime in the
appropriate problem area, such as Problem Area 1 Psychological Impairment, Problem Area 3 Violence, or
Problem Area 5 Substance Abuse.
Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will consistently cooperate with the assessment process for ___
week(s).
2.
Pt. will provide the necessary information to complete the court
evaluation.
3.
Pt. will cooperate with the forensic evaluation so that it can be
completed by the target date.
4.
Pt. will consistently provide necessary information to complete
the Forensic Evaluation for ____ week(s).
5.
Pt. will be able to express some understanding that he or she has
committed a crime and needs to act to defend self in court for
____ week(s).
6.
Pt. will cooperate with efforts to regain competency to stand trial
for ____ week(s).
7.
Pt. will regain competency to stand trial AEB working with the
attorney and demonstrate an understanding of the charges and
the role of court members for ____ week(s).
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.1
7–9
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Psychiatrist will discuss case with the forensic team, including diagnosis, medication,
laboratory findings, physical findings, and follow-up psychiatric treatment
recommendations.
Victor Dyson, MD
Social Work:
1.
Social worker will discuss with the forensic team issues related to environmental or
social precipitants of the alleged crime and aftercare treatment services.
Brenda St. Martin, MSW
Psychology (or Social Work):
1.
Psychologist will discuss psychological testing with the forensic team.
Susan Green, Psychologist
Rehab:
1.
Rehab staff will discuss with the forensic team issues relating to how pt. is doing in
scheduled program groups.
Jane Hoover, Rehab
Nursing Care Plan:
1.
Nsg. staff will discuss with the forensic team issues relating to pt.’s behavior on the
ward and any medical issues.
Marilyn Davis, RN
Forensic Team:
1.
Forensic team will gather the necessary information from the pt. and treatment team
members to complete the court-ordered forensic report.
Madison Yu, PhD, Forensic Team Leader
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
Ancillary Impairment (Problem Area 7)
7–11
Sample Individual Problem Plans
CONTENTS
Placement ............................................................................................................................................... 7–12
Homelessness.......................................................................................................................................... 7–14
Court Evaluation ..................................................................................................................................... 7–16
Court Assessment of Competency.......................................................................................................... 7–18
7–12
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.1 Placement
Name: Marco, Anne
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
In the past, pt. has resided in single rooms and shelters. Historically, she abuses alcohol and behaves
inappropriately in the community. With the assistance of friends, she has been able to function fairly well in the
community; however, these friends are unable to provide pt. with regular support and care. When they are not
available, she places herself in dangerous situations. Her friends are encouraging her to consider living in a
community residential program. She has historically rejected community residential programs.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will be discharged to a safe, appropriate setting.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
07/15/03
Target Date
1.
Pt. will go on a tour of residential placements with “no strings
attached.”
03/15/03
2.
Pt. will be able to carry on a reasonable discussion concerning
possible community residential placement consistently for
1 month.
04/15/03
3.
If pt. decides to live in a community residential program, she will
be tentatively accepted by a community residential program that
is acceptable to her.
05/15/03
4.
If agreeable to pt., she will begin transitioning into a residential
program, including going for overnight visits.
06/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.1
7–13
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Hold one-to-one session twice weekly to discuss and address placement issues with
the pt.
2.
Continue to explore supervised community residential placement, as well as
alternatives to supervised community residential placement.
3.
Coordinate with pt. and community resources, including significant others, if a
reasonable placement plan can be agreed on.
4.
Arrange for residential tours, interviews, and the like.
5.
Plan for community day-program involvement.
Roger Sing, MSW
Rehab:
1.
Assess pt.’s ability to live outside of the hospital.
John Loudon, Rehab
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
7–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.2 Homelessness
Name: Wolfe, Nicholas
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
Pt. has a long history of homelessness, which began sometime before his first psychiatric hospitalization in his late
teens. He has no family support and has used alcohol and drugs when living on the streets. When not living on the
streets, he is in a shelter, a psychiatric hospital, or jail for minor legal offenses. He has refused previous attempts to
refer him to a community residence. Last winter, pt. had to be treated for medical problems suffered after exposure
to the severe weather conditions. Pt.’s judgment is increasingly impaired and he is increasingly making irrational
plans to continue living on the streets. If brought to the court, it is very unlikely that the court would honor pt.’s
request to be discharged to the streets.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will be discharged to a community residential setting after
successfully completing 1 week of overnights.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
05/15/03
Target Date
1.
Pt. will agree to work with his social worker and community case
manager concerning discharge plans.
02/15/03
2.
Pt. will agree to visit the community residences available in his
placement area.
03/15/03
3.
Pt. will be able to express at least three advantages to living in a
community residence.
03/15/03
4.
Pt. will agree to be referred to a community residence of his
choice in his placement area.
04/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.2
7–15
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Social worker will meet with pt. at least 1 hour weekly to discuss discharge plans,
including the advantages of moving from the streets into a community residence.
2.
Social worker will arrange visits with pt. to appropriate community residences.
Brenda St. Martin, MSW
Social Work/Case Management:
1.
Social worker will assist pt. in establishing relationships in the community (e.g., staff
and residents in the community day program and the community residential
program).
2.
Case manager will arrange for residential tours, interviews, and the like.
Brenda St. Martin, MSW
Richard Sullivan, Community Case Manager
Other:
1.
Continue treatment of pt.’s mental illness as outlined in other sections of this
treatment plan.
Staff as indicated
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
7–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.3 Court Evaluation
Name: Robinson, James
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
Pt. faces criminal charges, including assault and battery, attempt to commit murder, and assault and battery with a
dangerous weapon. Pt. was committed for evaluation of competency to stand trial and criminal responsibility at
the time of the alleged crime. Commitment expires on 02/15/03.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt. will return to court with completed court-mandated
evaluation.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/15/03
Target Date
1.
Pt. will cooperate so that the treatment team can begin to gather
the information necessary to complete the court evaluation.
01/22/03
2.
Pt. will cooperate so that the forensic team can complete the first
draft of the court report.
02/07/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.3
7–17
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Social Work:
1.
Staff will obtain community records, including police report and report from
community psychiatrist.
Brenda St. Martin, MSW
Treatment Team Evaluators:
1.
Staff will give pt. Lambe warning that information obtained in the course of this
evaluation will be used as part of the evaluation to be sent to court.
2.
Staff will complete psychosocial, psychological, psychiatric, and nursing databases.
Discipline-Specific Evaluating Staff
Nursing Care Plan:
1.
Nsg. staff will discuss with the forensic team issues related to pt.’s behavior on the
ward, including any medical issues.
Marilyn Davis, RN Å Nsg. Staff
Forensic Team:
1.
Staff will gather the necessary information from the pt. and treatment team members
to complete the court-ordered forensic report.
2.
Forensic team will present the report to the court and testify, if necessary.
Madison Yu, PhD, Forensic Team Leader
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
7–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.4 Court Assessment of Competency
Name: Ball, Paula
ID #:
Area:
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
Pt. appears to be incompetent. She needs to have the courts declare her incompetent and appoint a guardian. Pt.
has a long history of being unable to care for herself. Her insight and judgment are markedly impaired. She appears
unable to make competent decisions concerning her money and medical care. She is also unable to make rational
statements as to why she needs to be in the hospital. Pt.’s mother appears to be a good candidate for pt.’s legal
guardian.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
Pt.’s mother will be appointed permanent legal guardian,
including having the right to consent to pt.’s medical treatment
and the right to commit pt. to a mental institution.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
04/15/03
Target Date
1.
Pt. will cooperate so that the competency report can be
completed for court.
02/15/03
2.
Pt. will cooperate so that everything is ready for the court
hearing, including a court date.
03/15/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
Ancillary Impairment (Problem Area 7)
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.4
7–19
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Psychiatry:
1.
Staff will complete report on pt.’s competency to care for herself, her ability to make
decisions concerning medical treatment, and her ability to make decisions concerning
committing herself to a mental institution.
2.
Staff will testify in court as to pt.’s competency.
Victor Dyson, MD
Psychology:
1.
Psychologist will perform psychological testing to assess depressive cognition.
2.
Psychologist will meet one-to-one with pt. for 45 minutes once weekly in supportive,
problem-solving therapy to improve pt.’s mood and help her function, even if
depressive symptoms persist.
Joseph LeBlanc, Psychologist
Social Work:
1.
Staff will discuss with pt.’s mother the issues surrounding her seeking legal
guardianship of pt. and the responsibilities associated with being assigned legal
guardianship of the pt.
2.
Staff will assist the legal office in obtaining necessary paperwork from pt.’s mother and
from pt.’s record.
Roger Sing, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Notes
BLANK FORMS
BF–1
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Blank Forms
BF–3
BLANK FORMS
CONTENTS
Master Treatment Plan........................................................................................................................... BF–5
Problem List .................................................................................................................................................. BF–5
Strengths/Discharge Plan/Diagnosis ............................................................................................................. BF–6
Individual Problem Plan................................................................................................................................ BF–7
Signature Page ............................................................................................................................................... BF–9
Treatment Plan Review......................................................................................................................... BF–11
Notes
Blank Forms
BF–5
Name:
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Problem List
ID #:
Area:
Name of Facility
Date:
Date of Admission:
Problem
Number
Problem Name
Discharge
Barrier*
Date Estab. &
Status**
Date Changed
& New Status***
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
BF–6
Fundamentals of Psychiatric Treatment Planning
Name:
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #:
Strengths/Discharge Plan/Diagnosis
Area:
Date:
Patient’s Strengths (related to treatment and discharge):
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
SOC =
GAF Equivalent =
VIO =
ADL =
SAb =
MED =
Dangerousness Level =
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /___
Blank Forms
INDIVIDUAL PROBLEM PLAN
Problem # and Name:
BF–7
Name:
ID #:
Area:
Nursing Diagnosis:
Date:
Problem Description:
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
Target Date
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
BF–8
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: ________
Date: ________
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Blank Forms
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Signature Page
BF–9
Name:
ID #:
Area:
Name of Facility
Date:
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
(Patient’s or guardian’s signature and date)
(If guardian, relation to patient)
Patient’s Comments (optional):
Staff Members’ Comments (optional):
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Date:
Print Name:
Nurse:
Date:
Print Name:
Social worker:
Date:
Print Name:
Psychologist:
Date:
Print Name:
Rehabilitation:
Date:
Print Name:
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.”
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
Notes
Blank Forms
Treatment Plan Review
Including Review of
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Name of Facility
BF–11
Name:
ID #:
Area:
Date:
1. Changes in Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
AXIS II:
AXIS III:
2. Changes in Problem List:
3. Evaluation of Progress and Plan’s Effectiveness in Achieving Goals for Active Problems:
Check if review is continued on reverse [ ]
BF–12
Fundamentals of Psychiatric Treatment Planning
MASTER TREATMENT PLAN AND NURSING CARE PLAN REVIEW Continued
4. Changes in Treatment Plan Goals and/or Modalities:
5. Reasons for Continued Hospitalization:
6. Discharge Planning Update:
7. Continuation/Comments:
8. Level of Care: Active Treatment [ ] Extended [ ]
Awaiting SNF [ ]
9. Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Date:
Print Name:
Nurse:
Date:
Print Name:
Social worker:
Date:
Print Name:
Psychologist:
Date:
Print Name:
Rehabilitation:
Date:
Print Name:
Other:
Date:
Print Name:
Patient: I participated in the review:
Date:
Note: Changes in the plan should also be entered directly on the Master Treatment Plan, then dated and initialed.
QUESTIONNAIRES
Q–1
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Questionnaires
Q–3
QUESTIONNAIRES
CONTENTS
Overview and Use of Questionnaires ...................................................................................................... Q–4
References and Acknowledgments ......................................................................................................... Q–4
Kennedy Axis V ........................................................................................................................................ Q–5
Kennedy Nurses’ Observation Scale for Inpatient Evaluation (K NOSIE)............................................. Q–17
AIMS Plus EPS (Abnormal Involuntary Movement Scale Plus Extrapyramidal Side Effects)................ Q–19
Q–4
Fundamentals of Psychiatric Treatment Planning
Overview and Use of Questionnaires
The questionnaires in this manual have been developed to make them useful and practical in clinical,
nonresearch settings. Many questionnaires are developed for research purposes and are only
tangentially useful in nonresearch settings. Complex administration, scoring, and interpretation
methods may be necessary for research purposes; however, this often makes such questionnaires of little
use to the harried clinician.
Details on the Kennedy Axis V (K Axis) and the Kennedy Nurses’ Observation Scale for Inpatient
Evaluation (K NOSIE) are included in the companion book Mastering the Kennedy Axis V: A New
Psychiatric Assessment of Patient Functioning. This companion book also acts as a training manual for
both the Kennedy Axis V and the Kennedy NOSIE.
Progress notes are often the standard for measuring outcome in clinical practice, not formal
research instruments. The use of questionnaires should be based on whether they can improve on or
add to the information manageability of progress notes. These improvements have to be gained without
unduly taxing staff time and resources.
The major difference between the Abnormal Involuntary Movement Scale Plus EPS (AIMS Plus EPS)
and the original AIMS is that in addition to measuring evidence of tardive dyskinesia, the AIMS Plus EPS
also measures extrapyramidal side effects (EPS). There is tremendous overlap between the physical exam
used to assess involuntary movements and that used to assess EPS. Therefore, for clinical purposes and
ease of documentation, both are included on the AIMS Plus EPS.
If questionnaires are used to follow up treatment, predicted scores should be included on the
treatment plan as goals. However, these scores should be used along with other measurable clinical
outcomes. As shown earlier in this manual, these questionnaires can easily be integrated into the
format of a goal. For example,
The score on the K Axis subscale for Psychological Impairment will improve from a current score of
40 to 60.
The score on the K NOSIE for Irritability will improve from the current score of –12 to –6.
References and Acknowledgments
Dr. Kennedy is the author of the Kennedy Axis V and Kennedy NOSIE. These instruments are
introduced in
Kennedy JA: Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning.
Washington, DC, American Psychiatric Publishing, 2003
The Kennedy Axis V and the Kennedy NOSIE are not in the public domain. For details on how to
obtain a licensing agreement to use the Kennedy Axis V or the Kennedy NOSIE questionnaires, please
contact James A. Kennedy, MD, or go online to www.kennedymd.com.
Dr. Kennedy, in conjunction with the Massachusetts State Medical Record Committee, developed
the AIMS Plus EPS. It was introduced in
Kennedy JA: Fundamentals of Psychiatric Treatment Planning. Washington, DC, American Psychiatric
Press, 1992
The AIMS and the AIMS Plus EPS are both in the public domain. The AIMS was developed at the
National Institute of Mental Health:
National Institute of Mental Health, Alcohol Drug Abuse and Mental Health Administration: Abnormal
Involuntary Movement Scale. Washington, DC, U.S. Department of Health, Education and Welfare,
1974
Questionnaires
Q–5
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Questionnaires
Q–7
Instruction Sheet
What Is the Kennedy Axis V (K Axis)?
The K Axis consists of seven subscales for Axis V: Psychological Impairment, Social Skills, Violence, ADL–
Occupational Skills, Substance Abuse, Medical Impairment, and Ancillary Impairment. These subscales capture the
clinician’s impression of the individual’s overall level of functioning during the previous week (longer if significant,
e.g., suicidal attempts).
In addition to an individual score for each of the subscales, clinicians can generate a patient profile using the
K Axis, as well as a score equivalent to the GAF. The K Axis is useful for developing Problem Lists, planning
treatment, measuring its impact, and predicting outcome. Note: If needed, each subscale can stand alone and act as
an individual questionnaire.
Using the Kennedy Axis V to Create Equivalents to the GAF Scale
•
•
GAF Equivalent (GAF Eq): Add the first four subscales and divide by four to give a score that is roughly
equivalent to a score from the GAF Scale. This score should ensure that the major areas of functioning are
not overlooked when rating the patient.
Dangerousness Level (DL): The DL is roughly equivalent to the GAF’s measure of dangerousness. The
numbers used to derive the DL are on the scoring sheet directly below each subscale score. The lowest of
these numbers becomes the DL. If the DL is 50 or less, it is often associated with the need for very high
intensity outpatient care, residential care, or even hospitalization.
Choosing Current, Discharge, and Highest Level of Functioning Ratings
•
•
•
The current rating should be based on the level of functioning at the time of the evaluation and is most
reflective of the current need for treatment or care.
The discharge rating should be based on the level of functioning at the time of discharge and, when
compared with the admission rating, is most reflective of the impact of treatment.
The highest level of functioning should be based on the highest level of functioning that lasted for at least a
few months during the last year. This score may be very predictive of outcome.
Using “Best Fit” to Capture the Clinical Impression
The rating choice should be guided by the best fit for the client, even though some of the thinking or behaviors at
that level may not be characteristic of the client. The anchor points only serve as aids and are not required for a
specific rating. Ultimately, the clinical impression is the determinant of the score, and the best fit should guide one
to that score rather than a particular anchor point.
Using Each Subscale to Measure Multiple Factors
In each subscale, rate the factor that causes the most impairment. On the Violence subscale, the best fit should be
based on suicidal factors for the suicidal client and on factors related to assaultiveness for the assaultive client. On
the Substance Abuse subscale, the best fit should be based on use of alcohol for the alcoholic patient and use of
drugs for the patient who abuses drugs. Impairments in multiple factors should help confirm a lower rating.
Factors that relate to being withdrawn or showing lack of interest or poor motivation should be rated under
Psychological Impairment rather than under Social Skills or ADL–Occupational Skills.
Measuring the Effects of Treatment, Stress, Physical Limitations, and the Like
•
•
The presence or absence of support, medication, other treatments, or even severe stress generally should not affect
the rating, unless it is covering up skills. The rating should be based on the level of functioning, and no
adjustment should be made for the presence or absence of these factors. Do not factor out the effects of
treatment, even if the patient may drop out of treatment.
The effect of physical/environmental limitations generally should be factored out of the rating. For example, factor
out not abusing drugs or not assaulting others due to being incarcerated or physically restrained; factor out
not being socially active or employed due to physical constraints of being in a wheelchair or confined to
bed. Rate how functional or dysfunctional a client would be if given reasonable opportunity—that is, do
not let physical barriers cover up skills or violence.
Q–8
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Psychological Impairment
(Problem Area 1)
100 Superior psychological functioning/coping, no psychological impairment; life’s everyday problems
never seem to lead to any significant anxiety or depression. No symptoms.
90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good psychological functioning in all
areas; interested and involved in a wide range of activities; generally satisfied with life; no more than everyday
problems or concerns.
80 If symptoms are present, they are transient and expected reaction to psychosocial
stressors (e.g., upset by breakup with girlfriend; difficulty concentrating after a family argument; mild
preoccupation with problems; a woman has many friends, functions extremely well at a difficult job, but says “The
stress is too much”); not considered to have mental problems by those who know him/her.
70
Some mild symptoms (e.g., depressed mood with mild insomnia, occasional truancy, theft within the
household, difficulty trusting others, mild insensitivity to the feelings and needs of others), but generally
functioning fairly well; however, those who know him/her well might express some concerns about his/her mental
state.
60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks; frequently
preoccupied; moderate impairment in attention span); moderate insensitivity to the feelings and needs of others;
to those who know him/her well it is clear that he/she has mental problems.
50 Serious symptoms (e.g., moderately depressed mood, moderate lethargy, severe obsessional rituals, severe
phobia, severe sexual perversion, moderate problems with anorexia/bulimia, frequent shoplifting, frequent anxiety
attacks, moderately guarded, mild but definite manic syndrome).
40 Major psychological impairment; some impairment in reality testing or communication (e.g., speech is
at times illogical, obscure, or irrelevant; moderate paranoia; may have hallucinations or delusions; however,
probably realizes they are not a part of reality); major impairment in several areas, such as judgment, thinking, or
mood (e.g., depressed man avoids friends, neglects family, and is not motivated to work; or, moderate negative
symptoms of schizophrenia); even those who do not know him/her well would likely consider him/her to have
mental problems.
30 Behavior is considerably influenced by delusions or hallucinations; appears to be responding to
hallucinations; serious impairment in communication or judgment (e.g., sometimes incoherent, thinking is
occasionally grossly inappropriate); severely depressed mood; withdrawn, with few spontaneous communications;
inability to function in almost all areas (e.g., stays in bed all day and does not care for own living space; no job,
home, or friends due to paranoia, poor motivation, social withdrawal, extremely poor insight, or being almost
totally insensitive to the feelings and needs of others); at times attention span is markedly impaired; severe
sociopathic behaviors have led to multiple arrests; severe sexual perversion toward prepubescent children.
20 Thinking and communication are generally grossly impaired; manic excitement or catatonia;
largely incoherent or mute; generally markedly impaired attention span; occasionally fails to maintain minimal
personal hygiene due to severe lethargy or very disorganized, bizarre thinking (e.g., too lethargic to attempt to wipe
food off shirt; smears feces for bizarre, delusional reasons).
10 Thinking is totally disorganized; totally insensitive to the feelings and needs of others; completely
incoherent; completely mute, extremely catatonic; persistent inability to maintain minimal personal hygiene or
minimal safety due to totally disorganized thinking or very severe lethargy; unable to focus attention for even a
few seconds; chronic, self-induced vomiting has led to a very life-threatening situation.
NR
Not rated
Questionnaires
Kennedy Axis V—Social Skills
Q–9
(Problem Area 2)
100 Superior social skills, sought out by others because of his/her outstanding social/communication skills,
has many friends and no difficulty making new friends. No symptoms.
90
Good social skills, no difficulty being pleasant and engaging, good communication skills, socially
effective.
80 No more than slight impairment in social skills, slightly inappropriate social behavior leads to
infrequent interpersonal conflicts, no more than slight difficulty maintaining several friendships.
70 Some difficulty with social skills (e.g., mild difficulty knowing how to share with others, show
sympathy for others, and/or understand feelings of others), social skills are not obviously impaired, generally
functioning fairly well, has some meaningful interpersonal relationships.
60 Moderate difficulty with social skills (e.g., conflicts with peers due to inappropriate teasing or other
inappropriate social behavior; attempts to be pleasant and engaging are usually moderately awkward; moderate
difficulty knowing what to say even when talking with friends; moderate difficulty knowing how to share with
others, show sympathy toward others, and/or understand feelings of others); hardly any friends because of
problems with social skills; communications are understandable but vague.
50 Serious impairment in social skills; has no friends because of clearly impaired social skills;
however, has some peer relationships, despite social skills being clearly impaired; frequent conflicts with peers
or co-workers because of inappropriate social behavior; conversations are often socially inappropriate; great
difficulty communicating thoughts and feelings; unable to introduce self and a second person without clear
difficulty; frequently intrusive; inappropriate, nonsexual touching.
40 Major impairment in social skills; attempts to approach others quickly lead to embarrassing
situations; no friends and virtually no peer relationships because of poor social skills; unable to appropriately
engage in almost any social activity; continually intrusive with little understanding of the inappropriateness of the
behavior; major acts of socially inappropriate behavior lead to being assaulted, fired from work, or expelled from
school; great difficulty recognizing or coping with inappropriate sexual or aggressive advances by others;
great difficulty recognizing that his/her sexual advances are not welcome.
30 Acts grossly inappropriately toward others; virtually no understanding of the feelings of others, how
to share with others, and/or how to show sympathy toward others; conversations with others are grossly
inappropriate; unaware of or ignores most social norms as manifested by open masturbation, inappropriate sexual
touching, and the like.
20 Very few social skills; generally unable to communicate in an organized, understandable way; uses short
phrases or gestures to get basic needs met; acts with shocking inappropriateness in front of others, such as smearing
of feces or making sexual advances toward young children; however, may have some understanding that such
behavior is inappropriate.
10 Few if any social skills; unable to communicate in an organized, understandable way; shows no apparent
awareness of social norms (e.g., doesn’t realize that it is inappropriate to grab food or cigarettes from others);
extremely vulnerable to victimization (e.g., has no understanding of the inappropriateness and/or dangers of
approaching strangers or assaulting others, needs constant care and supervision to not get into dangerous social
situations).
NR
Not rated
Q–10
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Violence
(Problem Area 3)
100 No evidence of violence to self or others; very satisfied with life; life’s problems never seem to lead to
any inappropriate anger, frustration, or conflicts. No symptoms.
90 No significant evidence of violence to self or others; generally satisfied with life, no more than
everyday problems or conflicts (e.g., an occasional argument with family members).
80 No more than slight problems with anger and irritability; if symptoms are present, they are transient
and expectable reactions to psychosocial stressors (e.g., occasional “blow up” with family members or friends; mild
anger after family argument); no suicidal ideation.
70
Mild symptoms (e.g., mild problems with anger and irritability; occasional thoughts of violent behavior;
thoughts that life may not be worth living); symptoms are not interfering significantly with his/her functioning;
severely assaulted others or serious suicidal attempt over 5 years ago; however, for years, has had no significant
problems with violence or self-harm.
60 Moderate difficulty with anger and irritability (e.g., moderate conflicts with peers or co-workers due
to anger and hostility; occasional threats of violent behavior); some evidence that self-destructive thoughts may be
present. Murdered someone over 10 years ago; however, for many years, has had no significant problems with
violence.
50 Serious problems with anger and irritability; moderate threats of violence; becomes verbally
threatening when needs/demands are not immediately met or when pushed to do something; occasionally hits
someone; occasional, relatively minor, sexual assault; occasional suicidal ideation; nonsuicidal self-abuse, such
as burning self with cigarettes or cutting self superficially; not felt to be in real danger of seriously hurting self or
others; however, some precautions including close observation may be indicated.
40 Major problems with anger and irritability; some real danger of hurting self or others; violent
outbursts toward family and neighbors; frequent threats of violence; hitting or biting someone is not unusual;
occasionally difficult to redirect from aggressive behavior; induces much fear of physical assault in others; single
suicidal gesture within the last month; moderate suicidal ideation; actively making plans to hurt self or others;
set a relatively minor fire within the last 3 months or is having fire-setting impulses with history of setting one or
two minor fires.
30 Often hitting or biting others; becomes physically aggressive when needs are not immediately met;
suicidal attempt without clear expectation of death during the last month; frequent suicidal preoccupation; actively
following through with plans to hurt self or others (e.g., obtaining a gun, pills, rope); at times close observation or
restraints may be necessary to prevent serious harm to self or others.
20 Frequently violent; very real danger of hurting self or others; serious thoughts of killing someone;
attempted to very violently harm or violently rape someone within the last month; constant suicidal
preoccupation; however, he/she is felt to have some control of the suicidal impulses; two or more suicidal
attempts without clear expectation of death within the last month; close observation to prevent harm to self or
others may be required 1 or 2 days a week.
10 Persistent danger of severely hurting self or others; attempted to kill someone within the last
month; attempted to very violently harm or violently rape a child within the last month; set a fire within the last
month with intent of hurting others; serious suicidal attempt within the last month with clear expectation of
death; little or no control of impulses to hurt self or others; expressing loss of control of command
hallucinations to hurt self or others; one-to-one, at-arms-length observation and/or physical restraint for
prevention of serious harm to self or others may be required 3 or more days a week; murdered someone within
the last 2 years.
NR
Not rated
Questionnaires
Kennedy Axis V—ADL–Occupational Skills
Q–11
(Problem Area 4)
100 Superior ADL–occupational skills in a wide range of activities (e.g., in school, on the job, as a
homemaker, pursuing a complicated hobby); superior workmanship; work challenges never seen to get out of
hand; is sought out by others because of his/her work skills. No symptoms. Skills are consistent with those
expected of a successful college graduate.
90 Good skills in all ADL–occupational activities; no more than average difficulties with any work
assignment. Absent or minimal symptoms. Skills are consistent with those expected of a successful high school
graduate.
80 No more than slight impairment in occupational skills or skills in school; has slight difficulty
performing at an average level; slight difficulties with routine chores, work assignments, or schoolwork
assignments; slight impairment in workmanship.
70 Mild difficulty with occupational skills or skills in school (e.g., minor difficulty following
instructions, workmanship is somewhat sloppy), but generally functioning fairly well.
60 Moderate difficulty with occupational skills or skills in school (e.g., probably employed;
however, has trouble carrying through assignments; some difficulty problem solving or following instructions;
some difficulty driving a car; some difficulty knowing how to budget money; some difficulty maintaining a home
or apartment).
50 Serious impairment in occupational skills or skills in school (e.g., unable to keep a job for more
than a few weeks due to poor occupational skills; almost failing in school; moderate difficulty following
instructions; moderately sloppy workmanship); needs supervision when shopping for food; some difficulty using
public transportation; some difficulty preparing self a reasonable, family-style meal; some difficulty ordering, eating
properly, tipping, etc., in a regular restaurant; some difficulty making a long-distance phone call.
40 Major impairment in occupational skills or skills in school (e.g., unable to work at a job for any
significant period or do routine housework due to poor work skills; failing in school due to poor academic skills);
needs supervision to use public transportation; mild to moderate difficulty ordering and eating in a fast-food
restaurant; poor understanding of how to budget money.
30 No job and unable to independently maintain a home due to serious impairment in skills needed
to perform ADLs and tasks at home; serious difficulty following instructions; needs some supervision to prepare
simple meals for self, such as a sandwich and beverage; needs supervision to dress self, make a local phone call,
follow a very simple self-medication procedure; needs constant supervision to complete more complicated ADLs
(e.g., operating a washer and dryer); very sloppy workmanship; some difficulty responding appropriately to a fire
alarm; difficulty finding way back from short errands.
20 Gross impairment in skills needed to perform ADLs and tasks at home (e.g., needs some
supervision to maintain minimal personal hygiene; is almost totally unable to follow simple instructions; needs
supervision to feed self; unable to function independently (e.g., needs constant supervision to complete most
simple tasks; does not know the value of money; unable to dial 911 in an emergency; unable to find way back from
short errands).
10 Demonstrates almost no ADL skills (e.g., is totally unable to follow instructions; unable to complete
most tasks even with constant supervision; may even have to be physically assisted to complete a task, including
eating or dressing); persistent inability to maintain minimal personal hygiene; considerable external support
(e.g., nursing care and supervision) is needed to prevent him/her from accidentally harming self (e.g., wandering
into traffic, danger of seriously burning self when attempting to cook or when smoking); unable to appropriately
respond to a fire alarm.
NR
Not rated
Q–12
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Substance Abuse
(Problem Area 5)
100 No significant problems with drugs or alcohol; no use or almost no use of alcohol; nonsmoker; no
use of street drugs; never abuses substances, even when life’s problems get out of hand; is an example of someone
who is totally free of problems with substance abuse. No symptoms.
90 No more than the average problems and concerns with alcohol; minimal use of alcohol; social
drinker; no use of illegal drugs; history of serious alcohol or drug abuse with over 10 years of sobriety and
minimal, if any, treatment needed to maintain sobriety.
80 No more than slight impairment; drinks to mild intoxication about once a month; smokes cigarettes
daily; experiments with marijuana less than once a year; some mild abuse of over-the-counter medications and/or
caffeine; no more than slight impairment in social, occupational, or school functioning due to substance abuse
(e.g., temporarily falling behind in schoolwork); serious alcohol or drug abuser with over 5 years of sobriety
with minimal treatment needed to maintain sobriety.
70 Mild impairment in social, occupational, or school functioning due to substance abuse, but
generally functioning fairly well; drinks to mild or moderate intoxication 1 or 2 days a week; excessive prescription
drug seeking; experiments with drugs such as marijuana, Valium, Ativan, or Librium once or twice a year; heavy
smoker; unable to quit cigarettes despite numerous attempts.
60 Moderate difficulty in social, occupational, or school functioning because of substance
abuse (e.g., substance abuse results in moderate impairment in job performance and/or conflicts with peers or
co-workers); drinks on a regular basis, often to excess; drinks to moderate intoxication more than 2 days a week;
occasionally experiments with drugs such as cocaine, Quaaludes, amphetamines (speed), LSD, PCP (angel dust),
Ecstasy, inhalants; moderate abuse of over-the-counter medications and/or caffeine; unable to quit cigarettes
despite chronic medical complications; serious alcohol or drug abuser with less than 2 years of sobriety.
50 Serious symptoms; behavior and/or lifestyle is considerably influenced by substance
abuse; moderate drug-/alcohol-seeking behavior; often intoxicated when driving or when working; abusing
substances despite being pregnant; unable to keep a job; marriage failing or failing school due to abuse of alcohol
or marijuana; one alcohol- or drug-related arrest; stealing prescription pads and/or altering or forging prescriptions;
moderate daily use of drugs such as marijuana, Valium, Ativan, Librium; occasionally injects drugs into skin or
muscle; has a morning drug or drink to get going; uses narcotics other than heroin or cocaine on a fairly regular
basis; frequently abuses over-the-counter medications and/or caffeine; use of alcohol or drugs (other than
cigarettes) is beginning to cause some medical complications.
40 Major impairment in several areas because of substance abuse (e.g., alcoholic man avoids
friends, neglects family, and is unable to get a job; student is failing in school and having serious conflicts with his
family or roommate due to substance abuse); occasionally injects heroin or cocaine into his/her veins; occasionally
has an accidental drug overdose; severe alcohol or drug abuser with less than 1 month of sobriety.
30 Drugs or alcohol pervade his/her thinking and behavior; his/her behavior is considerably
impaired by substance abuse; injects heroin or cocaine into his/her veins once or twice a day; abuses substances
without regard for personal safety (e.g., some accidental overdoses and/or auto accidents resulting in medical
hospitalizations); blackout spells; prostitutes self for drugs/alcohol; multiple alcohol- or drug-related arrests; serious
neglect of children due to substance abuse.
20 Functioning is extremely impaired by daily use of drugs such as LSD, PCP, cocaine, heroin,
or inhalants; unable to go for more than a few hours without significant physical and/or psychological craving
for drugs or alcohol; continued use of alcohol or drugs (other than cigarettes) is beginning to cause very
serious medical complications (e.g., liver failure, overt brain damage, AIDS or high risk for AIDS); injects drugs
into his/her veins more than twice a day.
10 His/her life is totally controlled by drugs or alcohol; continually in a state of intoxication or
withdrawal; at extremely high risk of seizures or DTs (delirium tremens) due to withdrawal; continually seeking
drugs or alcohol; numerous alcohol- or drug-related arrests; clear evidence that drugs or alcohol will lead to
severe physical harm or death; numerous instances of drug-related accidents or accidental overdoses resulting in
frequent medical hospitalizations; life-threatening neglect of children due to substance abuse.
NR
Not rated
Questionnaires
Kennedy Axis V—Medical Impairment
Q–13
(Problem Area 6)
100 Superior medical health; physical exam and laboratory tests are normal, including no significant
weight problem; illnesses never seem to affect him/her; few if any problems with even common medical problems
(e.g., colds, headaches, indigestion, constipation, diarrhea); virtually never has to miss work or school due to
medical problems; exercises regularly; on no medication, except may take a prophylactic medication, such as a
multivitamin; doesn’t wear glasses/contacts. No significant medical problems or symptoms.
90 Good medical health; has few if any medical problems; physical exam and laboratory test reveal no more
than minor abnormalities; illnesses seldom seem to affect him/her; average difficulties with common medical
problems (e.g., colds, headaches, indigestion, constipation, diarrhea); wears glasses/contacts that correct minor
visual problems; wears dentures; only occasionally misses work or school due to medical problems; occasionally
needs over-the-counter medication.
80 If medical problems are present, they are transient and cause minimal impairment in
social, occupational, or school functioning; somewhat more than average missing of work or school due to
medical problems; impairment in mobility or use of hands or hearing that is totally corrected by the use of a
prosthesis, hearing aids, and the like; mild obesity or mild emaciation; occasional urinary incontinence due to
organic problems.
70 Mild medical problems which may cause some difficulty in social, occupational, or school
functioning; however, generally functioning fairly well; missing no more than about 1 to 2 weeks a year from
work or school due to medical problems; mild impairment in mobility, speech, use of hands, vision, or hearing
despite use of prosthesis, glasses, hearing aids, and the like; has chronic illness but has few if any overt signs or
symptoms of the illness (e.g., mild asthma, mild hypertension, mild diabetes, mild arthritis; mild dysphagia;
epilepsy easily controlled with medication; mild tardive dyskinesia); requires medical follow-up several times a
year; takes prescription medication on a daily basis.
60 Moderate difficulty in social, occupational, or school functioning due to medical
problems; missing no more than about 1 month a year from work or school due to medical problems (e.g.,
moderate asthma, moderate hypertension, moderate diabetes, moderate COPD, mild to moderate hyponatremia
secondary to polydipsia, HIV positive, chronic hepatitis, mild cerebral palsy, mild cystic fibrosis, mild hemophilia,
mild angina on exertion); medical problems requiring daily or weekly monitoring and treatments beyond po
medications (e.g., injections, blood levels, nebulizer, physical therapy); needs bladder bag.
50 Serious impairment in social, occupational, or school functioning due to medical
problems; serious impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis,
glasses, hearing aids, and the like; considered a serious risk for falling; only partially controlled epilepsy; equipment
is needed for mobility (e.g., wheelchair, portable oxygen). Medical problems prevent him/her from driving a
car.
40 Major impairment in several areas (such as work or school or family relations) because of medical
problems; missing about 2 months a year or more from work or school due to medical problems; medical problems
result in major impairment in mobility, speech, use of hands, vision, or hearing despite use of prosthesis, glasses,
hearing aids, and the like; frequently confined to bed or wheelchair because of chronic medical problems.
30 Behavior and/or lifestyle is considerably impaired by medical problems; very serious medical
problems confine him/her to bed or wheelchair most of the time (e.g., very symptomatic cases of diseases such as
metastatic cancer, multiple sclerosis, cerebral palsy, or AIDS); chronic failure of a major body system (e.g., heart,
lung, kidney, liver); on dialysis for kidney failure.
20 Major medical problems confine him/her to bed all of the time and intensive, continuous
medical treatment is required without which he/she would rapidly progress to death (e.g., late stages of metastatic
cancer, multiple sclerosis, AIDS, and the like); chronic, near terminal failure of a major body system (e.g., heart,
lung, kidney, liver); quadriplegic.
10 Chronic medical incapacity requiring basic life support (e.g., ventilator); removal of life support
would rapidly lead to death; he/she is in chronic vegetative or near vegetative state; persistent delirium or coma.
NR
Not rated
Q–14
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V—Ancillary Impairment
(Problem Area 7)
100 Superior life situation; currently in or has ready access to ideal living environment (neighborhood,
home, school, work, etc.); superior financial resources for his/her needs; no legal problems; extremely safe
environment. No significant ancillary problems or symptoms.
90 Good life situation; has few if any ancillary problems; no more than minor problems with living
environment, financial resources, and/or legal problems, e.g., occasionally living environment doesn’t fully meet
his/her needs, rare late payment on a bill, rare parking or traffic ticket.
80 If ancillary problems are present, they are transient and cause no more than minimal
difficulty with his/her living situation, financial resources, or the law; somewhat more than average
problems with his/her living environment, financial resources, or legal problems.
70 Mild ancillary problems, e.g., some difficulty with his/her living environment, financial resources, or the
law; mild difficulty paying bills/credit cards; mild difficulty with parking or traffic tickets; occasional mild verbal
violence in his/her environment; however, generally safe living situation.
60 Moderate difficulty with living situation, finances, or the law; high risk for being in a dangerous
homeless or jail situation; criminal charges place him/her at high risk of incarceration; no stable residence and/or
income, often having to move from one living situation to another; moderate difficulty paying bills/credit cards;
evaluation and/or disposition is being made for nonviolent criminal activity (e.g., trespassing, stealing,
defacing/destruction of property, or lewd behavior); evaluation and/or disposition is being made for
competency to make decisions concerning person, estate, and/or treatment.
50 Serious problems with living situation, finances, and/or the law; frequent risks or threats of
moderate violence in his/her environment; evaluation and/or disposition is being made for relatively minor
but violent or dangerous criminal activity (e.g., minor assault, threats to do physical harm, driving while under
the influence, sexually touching someone or exposing self); serious placement difficulties, even when ready for
placement.
40 Major problems with living situation, finances, and/or the law; some real danger of being
physically injured in his/her environment; evaluation and/or disposition is being made for very violent
criminal activity (e.g., vicious assault, attempted rape, attempting to molest a child, arson).
30 Lifestyle is considerably influenced by ancillary problems; he/she is in a very dangerous homeless
or jail situation most of the time; unable to obtain basic food, shelter and/or clothing; frequent, mild to moderate
physical injuries from violence in his/her environment.
20 Major ancillary problems (e.g., he/she is in a very dangerous homeless or jail situation all
of the time); at times, his/her life is at serious risk due to lack of resources for basic food, shelter, and/or clothing
or because of high level of violence in his/her environment; evaluation and/or disposition is being made for
extremely serious criminal charges (e.g., attempted murder, vicious rape, viciously molesting a child).
10 Living/financial situation is totally inadequate; his/her life is continually at serious risk due to lack
of basic food, shelter, and/or clothing or because of extremely high level of violence in his/her environment;
evaluation and/or disposition is being made for the most extreme charges of violence (e.g., murdering anyone,
very viciously harming or very viciously raping a child, arson with intent of hurting others).
NR
Not rated
Questionnaires
Q–15
Kennedy Axis V: Scoring Sheet
Name:
© 1986–2003
#:
Age:
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
ÄÄ FUNCTIONAL
DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
Primarily (check one):
Not Impaired___
Antisocially Impaired___
Other Impairment___
Both___
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
Primarily (check one):
Nonviolent___
Violent to Self___
Violent to Others___
Violent to Self and Others___
4. ADL–Occupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
45
40
35
30
25
20
15
10
5
100
95
90
85
80
75
70
65
60
55
50
Primarily (check one):
Nonabuser___
Alcohol Abuser___
Drug Abuser___
Both___
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
50
40
35
25
15
5
7. Ancillary Impairment (optional)
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
GAF Equivalent:
#1
+ #2
+ #3
+ #4
=
/
4
=
Dangerousness Level (indicate only the most dangerous rating):
Signature:
Date:
Notes
Questionnaires
Q–17
Kennedy Nurses’ Observation Scale for Inpatient Evaluation
Kennedy NOSIE or K NOSIE
Copyright © 1985–2003 James A. Kennedy, MD
Patient’s Name: _______________________________________________ #: ______________________ Date: ____/____/____
Name and Title of Rater: _______________________________________________________________________________________
Note: Closely follow The Guide to the Kennedy NOSIE by James A. Kennedy, MD (available at www.kennedymd.com), to
significantly improve the reliability and validity of your ratings.
1.
Social Competence
Never
Sometimes
Often
Usually
Always
A.
Refuses to do the ordinary things expected of him/her
–0
–1
–2
–3
–4
B.
Has trouble remembering
–0
–1
–2
–3
–4
C.
Has to be reminded what to do
–0
–1
–2
–3
–4
D.
Has to be told to follow hospital routine
–0
–1
–2
–3
–4
E.
Has difficulty completing even simple tasks on
his/her own
–0
–1
–2
–3
–4
Never
Sometimes
Often
Usually
Always
Sec. #1: –______
2.
Social Interest
A.
Shows interest in activities around him/her
+0
+1
+2
+3
+4
B.
Tries to be friendly with others
+0
+1
+2
+3
+4
C.
Laughs or smiles at funny comments or events
+0
+1
+2
+3
+4
D.
Starts up a conversation with others
+0
+1
+2
+3
+4
E.
Talks about his/her interests
+0
+1
+2
+3
+4
Never
Sometimes
Often
Usually
Always
Sec. #2: +______
3.
Personal Neatness
A.
Is sloppy
–0
–1
–2
–3
–4
B.
Keeps clothes neat
+0
+1
+2
+3
+4
C.
Is messy in eating habits
–0
–1
–2
–3
–4
D.
Keeps self clean
+0
+1
+2
+3
+4
Sec. #3: ______
Subtotal: ______
Transfer subtotal to the back
Å
Enter Licensing Agreement Number Here:
Based on NOSIE–30 (Gilbert Honigfeld, Roderic D. Gillis, and C. James Klett: “NOSIE-30: A Treatment-Sensitive
Ward Behavior Scale.” Psychological Reports 19:180–182, 1966).
Q–18
Fundamentals of Psychiatric Treatment Planning
Kennedy NOSIE
(Page 2 of 2)
4.
Irritability
Never
Sometimes
Often
Usually
Always
A.
Is impatient
–0
–1
–2
–3
–4
B.
Gets angry or annoyed easily
–0
–1
–2
–3
–4
C.
Becomes easily upset if something doesn’t suit him/her
–0
–1
–2
–3
–4
D.
Is irritable and grouchy
–0
–1
–2
–3
–4
E.
Is quick to fly off the handle
–0
–1
–2
–3
–4
Never
Sometimes
Often
Usually
Always
–1
–2
–3
–4
Sec. #4: –______
5.
Manifest Psychosis
A.
Hears things that are not there
–0
B.
Sees things that are not there
–0
–1
–2
–3
–4
C.
Talks, mutters, or mumbles to self
–0
–1
–2
–3
–4
D.
Giggles or smiles to self without any apparent reason
–0
–1
–2
–3
–4
Never
Sometimes
Often
Usually
Always
Sec. #5: –______
6.
Motor Retardation
A.
Sits, unless directed into activity
–0
–1
–2
–3
–4
B.
Sleeps, unless directed into activity
–0
–1
–2
–3
–4
C.
Is slow moving and sluggish
–0
–1
–2
–3
–4
Sec. #6: –______
Final Scoring Section
I. Subtotal from front:
II. Subtotal from back:
III. Kennedy NOSIE total:
–
(Range –76 to +28)
(–76 ÄDysfunctional –––– FunctionalÅ +28)
Rating for last 3 days ________ or typical 3-day period during the last 2 weeks ________
Questionnaires
AIMS Plus EPS
Abnormal Involuntary Movement Scale
Plus Extrapyramidal Side Effects Scale
Q–19
Name:
Hosp #:
Ward:
Date:
Instructions: Rate highest severity observed. Rate movements that occur upon activation one less than those
observed spontaneously.
Code:
0 = None; 1 = Minimal, may be extreme normal; 2 = Mild; 3 = Moderate; 4 = Severe
(circle the appropriate rating below).
Tardive Dyskinesia (Do not include tremors.)
1.
Muscles of facial expression _________________________________________________________ 0
1
2
3
4
1
2
3
4
1
2
3
4
e.g., movements of forehead, eyebrows, periorbital area, cheeks; include frowning, blinking, smiling,
grimacing
2.
Lips and perioral area _______________________________________________________________ 0
e.g., puckering, pouting, smacking
3.
Jaw _________________________________________________________________________________ 0
e.g., biting, clenching, chewing, mouth opening, lateral movement
4.
Tongue______________________________________________________________________________ 0
1
2
3
4
5.
Upper extremities (arms, wrists, hands, fingers)________________________________________ 0
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
include choreic movements (e.g., rapid, objectively purposeless, irregular, spontaneous), athetoid movements
(e.g., slow, irregular, complex, serpentine)
6.
Lower extremities (legs, knees, ankles, toes) ___________________________________________ 0
e.g., irregular lateral knee movement, irregular foot or heel movements
7.
Trunk movements (neck, shoulders, hips) _____________________________________________ 0
e.g., irregular rocking, twisting, or squirming or pelvic gyrations
TD Total:
Extrapyramidal Side Effects
1.
Dystonia ____________________________________________________________________________ 0
e.g., persistent spasm usually of the eyes, face, neck, or back muscles (this results in persistent abnormal
positioning of one or more extremities or of the face, neck, or trunk)
2.
Parkinsonism _______________________________________________________________________ 0
e.g., bradykinesia (decreased movement), shuffling gait, masklike facies, resting tremor, drooling
3.
Akathisia ____________________________________________________________________________ 0
e.g., restlessness, pacing, rocking, inability to sit still
4.
Rigidity _____________________________________________________________________________ 0
e.g., increased muscle tone with continuous passive resistance to movement, cogwheel rigidity
5.
Parkinsonian tremor ________________________________________________________________ 0
e.g., slow, rhythmic, present at rest (pill rolling)
6.
Akinesia_____________________________________________________________________________ 0
decreased motor movements often associated with weakness, decreased spontaneous
movements, and paresthesias
EPS Total:
Comments:
Examiner: _________________________________________________________________
Date: ___________
Q–20
Fundamentals of Psychiatric Treatment Planning
Examination Procedure
Either before or after completing the examination procedure, observe the patient unobtrusively, at rest (e.g., in
waiting room). The chair to be used in this examination should be a hard, firm one without arms.
1.
Ask patient whether there is anything in his or her mouth (such as gum or candy) and if there is, to
remove it.
2.
Ask patient about the current condition of his or her teeth. Ask if patient wears dentures. Do teeth or
dentures bother patient now?
3.
Ask patient whether he or she notices any movements in mouth, face, hands, or feet. If yes, ask patient
to describe and to what extent they currently bother patient or interfere with activities.
4.
Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor. (Look at entire
body for movements while in this position.)
5.
Ask patient to sit with hands hanging unsupported. If male, between legs, if female and wearing a dress,
hanging over knees. (Observe hands and other body areas.)
6.
Ask patient to open mouth. (Observe abnormalities of tongue movement.)
7.
Ask patient to protrude tongue. (Observe abnormalities of tongue movement.) Do this twice.
8.
Ask patient to top thumb with each finger, as rapidly as possible for 10 to 15 seconds; separately with
right hand, then with left hand. (Observe facial and leg movements.)*
9.
Flex and extend patient’s left and right arms, one at a time.
10.
11.
Ask patient to stand up. (Observe in profile. Observe all body areas again, hips included.)
Ask patient to extend both arms outstretched in front with palms down. (Observe trunk, legs, and
mouth.)*
12.
Have patient walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice.
*Activated movements.
APPENDIX
A–1
This page intentionally left blank
Appendix
A–3
APPENDIX
CONTENTS
Focused Master Treatment Plans .............................................................................................................A–5
Rating Master Treatment Plans..............................................................................................................A–20
Rating Master Treatment Plans (Spreadsheet) ......................................................................................A–27
Nursing Diagnoses..................................................................................................................................A–28
Notes
Appendix
A–5
Focused Master Treatment Plans
Joseph L. Black, MD ,∗ suggests using focused Master Treatment Plans when there is a fairly specific
comprehensive rehabilitation goal (long-term goal) that is the focus of hospitalization. That
comprehensive rehabilitation goal should also be associated with a target date that the patient can
realistically attain in 30 days or less. Such focused treatment plans may be useful in a wide range of
treatment and evaluation settings, such as the following:
•
•
•
•
Treatment for acute detoxification
Treatment for acute psychotic decompensation
Treatment to restore competency to stand trial
Evaluation of criminal responsibility
In such cases, Dr. Black recommends having one comprehensive rehabilitation goal for most, if
not all, of the active problems. For example, when a patient has been admitted from the courts for
restoration of competency to stand trial, the comprehensive rehabilitation goal might be as follows:
Patient will return to the 15th Judicial District Court of Parker County upon demonstrating a
rational and factual understanding of the proceedings against him and sufficient ability to
consult with a reasonable degree of rational understanding.
In these focused Master Treatment Plans, Dr. Black suggests that one should attempt to defer most,
if not all, active problems that are not directly related to the comprehensive rehabilitation goal. These
deferred problems would be addressed after the comprehensive rehabilitation goal has been attained
and the patient has been discharged, transferred, or returned to court.
In these focused Master Treatment Plans, the patient should be expected to respond to treatment
for the active problems in a relatively short period of time, usually less than 30 days. Generally, the
longer the treatment that is needed, the more difficult it becomes to defer other active problems and to
focus on the comprehensive rehabilitation goal. Clearly, treatment for some active problems, especially
a medical problem such as diabetes or seizures, cannot be deferred.
On the following pages, Dr. Black presents a Kennedy Axis V rating and a focused Master
Treatment Plan for a patient, John Lightfoot, who was committed for treatment to restore competency
to stand trial.
∗
Joseph L. Black, MD: “Inpatient Treatment Plan Based on Functional Outcomes Measurement” (Session 6, #18),
American Psychiatric Association Institute on Psychiatric Services, Innovative Programs, Orlando, FL, October 12,
2001.
A–6
Fundamentals of Psychiatric Treatment Planning
Kennedy Axis V: Scoring Sheet
Name: John Lightfoot
© 1986–2003
#: F02845
Age:
24
Instructions: For each subscale, enter the rating followed by a brief description of the relevant symptoms and behaviors. Round off
intermediate codes, e.g., 43, 62, 78, to the nearest multiple of 5, e.g., 45, 60, 80. Enter NR if Not Rated. The numbers for deriving the
Dangerousness Level are located directly below the subscale scores and are automatically indicated as one checks each subscale score.
ÄÄ FUNCTIONAL
DYSFUNCTIONAL ÅÅ
1. Psychological Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Not Impaired___
Antisocially Impaired___
Other Impairment X
Both___
Primarily (check one):
Major psychological impairment AEB auditory and visual hallucinations, delusions of grandeur, and impaired judgment and
insight.
2. Social Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
70
65
65
60
55
45
40
30
25
20
15
5
50
Major impairment in social relationships as evidenced by insensitivity to the feelings and needs of others and aggressive,
intrusive behaviors.
3. Violence
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 X 15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Nonviolent___
Violent to Self___
Violent to Others X
Primarily (check one):
Frequently violent. Pt. is in real danger of hurting others and destroying property.
Violent to Self and Others___
4. ADL–Occupational Skills
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 X 55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Moderate difficulty in occupational and school functioning.
5. Substance Abuse
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 X 25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Nonabuser___
Alcohol Abuser___
Drug Abuser X
Both___
Primarily (check one):
Pt.’s behavior is considerably influenced by substance abuse, namely his frequent use of Peyote.
6. Medical Impairment
100 ___95 ___90 ___85 ___80 ___75 ___70 X 65 ___60 ___55 ___50 ___45 ___40 ___35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
90
85
80
75
75
70
70
65
60
55
55
40
35
25
15
5
50
Mild medical problems that may cause some difficulty in social, occupational, or school functioning, including his need to
take prescription meds on a daily basis and his need for periodic medical follow-up.
7. Ancillary Impairment (Optional)
100 ___95 ___90 ___85 ___80 ___75 ___70 ___65 ___60 ___55 ___50 ___45 ___40 X 35 ___30 ___25 ___20 ___15 ___10 ___5 ___
100
95
90
85
80
75
70
65
60
55
45
40
35
30
25
20
15
10
5
50
Major problems with the law AEB his having been found incompetent to stand trial on a charge of aggravated assault with a
deadly weapon and a charge of theft greater than $20,000.
GAF Equivalent:
#1
40
+ #2
40
+ #3
20
+ #4
60
Dangerousness Level (indicate only the most dangerous rating):
Signature:
Joseph Black, M.D.
= 160 /
4
=
40
20
Date:
01/05/03
Appendix
A–7
Name: Lightfoot, John
MASTER TREATMENT PLAN
& NURSING CARE PLAN
Problem List
ID #: F02845
North Texas State Hospital
Area: Spruce Unit
Name of Facility
Date: 01/15/03
Date of Admission: 01/03/03
Problem
Number
Problem Name
Discharge
Barrier*
Date Estab. &
Status**
1.1
Psychotic Symptoms
Yes
01/15/03
Active
2.1
Impaired Social Skills
Yes
01/15/03
Active
3.1
Assaultive Behavior
Yes
01/15/03
Active
4.1
Impaired Occupational Skills
No
01/15/03
Deferred
5.1
Peyote Abuse
No
01/15/03
Deferred
6.0
Health Maintenance
No
01/15/03
Active
6.0a
Rule Out Seizure Disorder
No
01/15/03
Active
7.0
Court Evaluation
Yes
01/15/03
Active
Date Changed
& New Status***
*DISCHARGE BARRIER: YES = Significant barrier to discharge; NO = Not a significant barrier to discharge
**ESTAB. STATUS: Active, Inactive, Inactive With Tx, Deferred, Noted
***CHANGED STATUS: Resolved, Active, Inactive With Tx, Revised, Canceled, Noted
Check if list is continued [ ]
A–8
Fundamentals of Psychiatric Treatment Planning
Name: Lightfoot, John
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: F02845
Strengths/Discharge Plan/Diagnosis
Area: Spruce Unit
Date: 01/15/03
Patient’s Strengths (related to treatment and discharge):
•
•
•
•
•
•
•
•
•
Interests: horseback riding and Native American cultures and ceremonies
Good verbal skills
Fluent in both English and Comanche languages; also speaks Spanish and Cheyenne
No self-abusive or suicidal thoughts or behaviors
Average intelligence
Has a driver’s license, though currently suspended due to driving while intoxicated
Has worked in competitive employment as a laborer for up to 6 months
Fairly good physical health
Supportive family when he is not abusing drugs
Discharge Criteria/Planning (Include anticipated placement environment, criteria for discharge, long-term goals
needed for discharge, and anticipated target date. If a problem exists with placement, complete an Individual Problem Plan on
Placement.):
John Lightfoot will return to the 15th Judicial District Court of Parker County upon demonstrating a rational and
factual understanding of the proceedings against him and sufficient ability to consult with a reasonable degree of
rational understanding.
Discharge Coordinated By: Juan Sanchez, MSW
Anticipated Discharge Date: 02/05/03
Psychiatric Diagnosis (DSM-IV-TR):
AXIS I:
Substance-induced mood disorder with manic features
Substance-induced psychotic disorder with delusions and hallucinations
Hallucinogen dependence (peyote) in a controlled environment
Adult antisocial behavior
AXIS II:
No diagnosis
AXIS III:
No diagnosis
AXIS IV:
Ancillary Impairment =
AXIS V:
PSY =
40
SOC =
GAF Equivalent =
40
40
40
VIO =
20
ADL =
60
SAb =
Dangerousness Level =
30
MED =
70
20
Significant changes have been made in the diagnosis and those changes have been documented on the
Treatment Plan Review dated:
/ /
/ /
/ /
/ /__
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 1.1 Psychotic Symptoms
A–9
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Disturbed Thought Processes
Date: 01/15/03
Problem Description:
Off and on since 2000, John has had major psychological impairment AEB auditory and visual hallucinations,
delusions of grandeur, and poor judgment and insight. Recently he has reported that he had a vision in which the
Great Spirit appointed him as the leader of his people. Pt. has also made statements to the effect that local laws do
not apply to him. He has been observed by staff to sit motionless for 12 or more hours as if he were in a trance.
John’s poor focal attention, poor judgment, and poor insight impair his taking medication as prescribed.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/05/03
Target Date
1.
John will learn to communicate in a rational, coherent, and
logical manner, AEB being able to engage in a 10-minute
conversation with staff five times a week for 1 week.
01/29/03
2.
John will seek out his unit advisor to get his needs met and to
discuss issues regarding his treatment daily for 1 week.
01/22/03
3.
John will be able to name pertinent information regarding his
medication, including its effect on psychotic symptoms,
consistently for 1 week.
01/22/03
4.
John will accept prescribed medication and necessary lab work for
2 weeks.
01/29/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–10
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 1.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Psychoactive meds per Dr. Black’s order by licensed vocational nurse (LVN) supervised
by the RN under the direction of the Nurse Manager.
Joseph Black, MD
Marilyn Davis, RN
2.
Unit advisor will talk with John for 2 hours per week.
Jane Hoover, Rehab
3.
Medication education group with LVN will meet with pt. 2 hours per week.
Marilyn Davis, RN
4.
The case coordinator will correspond with mental health assistant and primary
correspondent, once John signs consent, in order to facilitate aftercare planning.
Juan Sanchez, MSW (Case Coordinator)
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 2.1 Impaired Social Skills
A–11
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Impaired Social Interactions
Date: 01/15/03
Problem Description:
John has major impairment in social relations AEB his insensitivity to the feelings and needs of others and his
aggressive, intrusive behaviors.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/05/03
Target Date
1.
John will learn to interact with others in a socially appropriate
manner, AEB not demonstrating any aggressive, intrusive
behaviors toward others for 2 weeks.
01/29/03
2.
John will be able to learn to consistently identify for 1 week at
least three socially inappropriate behaviors that have led to
conflicts with others and placed him at risk of losing self-control.
01/29/03
3.
John will be able to verbalize an adequate understanding of the
positive aspects, values, beliefs, cultural links, attitudes,
similarities, and differences in both North American and his own
culture and will be able to apply these concepts to increase selfesteem and identity.
01/29/03
4.
John will be able to engage in empathetic conversations with his
family consistently for 2 weeks.
02/05/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–12
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 2.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Pt. will participate in on-unit psychosocial rehab group (Social Skills Group) 2 hours
per week.
Jane Hoover, Rehab
2.
Pt. will participate in on-unit psychosocial rehab group (Relating Alternatives Group)
2 hours per week.
Jane Hoover, Rehab
3.
Pt. will participate in on-unit psychosocial rehab group (Cultural Awareness Group)
1 hour twice per week.
Juan Sanchez, MSW Å Roger Sing, MSW
4.
Pt. will participate in Problem-Solving Group with his family 1 hour per week.
Juan Sanchez, MSW
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 3.1 Assaultive Behavior
A–13
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Risk for Other-Directed Violence
Date: 01/15/03
Problem Description:
John has a history of aggressive and assaultive behavior. He is a known gang member; he is reputed to be a gang
leader. Currently he is frequently violent. He is felt to be in real danger of hurting others and destroying property.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
Target Date
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
02/05/03
2.
John’s K Axis score for Violence will improve from his current
score of 20 to a score of 60.
02/05/03
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
1.
John will demonstrate the ability to resolve conflicts and respond
to stressors in a proper manner by using clinical time-out and
discussions with staff consistently for 1 week.
01/29/03
2.
John will learn alternative coping mechanisms to relieve stress,
rather than acting out against others, AEB not being threatening
or assaultive for 2 weeks.
01/29/03
Date/Status*
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–14
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 3.1
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
Psychoactive meds will be administered per Dr. Black’s order by the LVN/RN
supervised by the RN under the direction of the nurse manager.
Joseph Black, MD
Marilyn Davis, RN
2.
Pt. will participate in on-unit psychosocial rehab group (Stress and Anger Management
Group) 2 hours per week.
Joseph LeBlanc, Psychologist
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 6.0 Health Maintenance
A–15
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Health Maintenance
Date: 01/15/03
Problem Description:
Pt. has mild medical problems, including his need to take prescription meds on a daily basis and his need for
periodic medical follow-up. Pt. may have impairment of conscious awareness due to a seizure disorder.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John will continue to maintain an optimal level of health while
hospitalized, AEB compliance with all prescribed meds, lab work,
and treatments for his medical problems.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
1.
Target Date
Date/Status*
Ongoing
Target Date
Date/Status*
Same as long-term goal.
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–16
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 6.0
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
Date/Status*
Medical:
1.
Doctor will work up John for the possibility of a seizure disorder, including EEG and
referral to Neurology Clinic, and will make appropriate treatment recommendations.
Joseph Black, MD
Virginia Coleman, MD
Nursing Care Plan:
1.
Nsg. staff will monitor John daily and follow up on any signs and symptoms of illness.
2.
Nsg. staff will administer all prescribed medication and treatments as ordered and will
document John’s compliance.
3.
Nsg. staff will assess and document pt.’s level of understanding of prescribed treatment
and provide necessary teaching at John’s level of understanding.
4.
Nsg. staff will prompt John to comply with treatments, lab work, and any other
medical procedures. If needed, nsg. staff will support and accompany John to
procedures. Staff will offer praise for compliance and will document compliance.
Marilyn Davis, RN
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
INDIVIDUAL PROBLEM PLAN
Problem # and Name: 7.0 Court Evaluation
A–17
Name: Lightfoot, John
ID #: F02845
Area: Spruce Unit
Nursing Diagnosis: Ineffective Community Coping
Date: 01/15/03
Problem Description:
John was referred to North Texas State Hospital–Vernon pursuant to Article 46.02 Section 5(a) of the Texas Code of
Criminal Procedure after he was found incompetent to stand trial on charges of aggravated assault with a deadly
weapon (to wit: lance, revolver, and scalping knife) and of theft greater than $20,000 (horses and cattle) out of the
15th District Court of Parker County, Texas.
When local examiners evaluated him, pt. sat motionless, stared straight ahead, and refused to speak. He was
subsequently found incompetent to stand trial.
Long-Term Goal(s) (Discharge Criteria)
(Please number all goals.)
1.
John Lightfoot will return to the 15th Judicial District Court of
Parker County upon demonstrating a rational and factual
understanding of the proceedings against him and sufficient
ability to consult with a reasonable degree of rational
understanding.
Short-Term Goal(s) (Objectives)
(Please number all goals.)
Target Date
Date/Status*
02/05/03
Target Date
1.
John will demonstrate an ability to work with his attorney in
preparation of his defense and will display a factual knowledge of
the court system.
02/05/03
2.
John will be able to assist in his defense as determined by no
observations or self-reported statements that reflect poor reality
contact or lack of knowledge of the court processes.
02/05/03
Date/Status*
*Status: Attained, Canceled, Revised (Also strike through the goal when it is Attained, Canceled, or Revised.)
A–18
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLAN
Continued on Problem #: 7.0
Date: 01/15/03
TREATMENT MODALITIES (Include the modality, time period, and frequency. Also
include the individual responsible and discipline. Please number all modalities.)
1.
Date/Status*
The treatment team will meet with John as a part of the competency training group for
2 hours per week.
Joseph Black, MD, Team Leader
2.
Pt. will receive counseling with case coordinator 1 hour per week to reinforce realitybased statements that promote competency and discourage those that do not.
Juan Sanchez, MSW, Case Coordinator
*Status: Completed, Canceled, Revised (Also strike through the modality when it is Completed, Canceled, or Revised.)
Appendix
A–19
Name: Lightfoot, John
MASTER TREATMENT PLAN
& NURSING CARE PLAN
ID #: F02845
Signature Page
Area: Spruce Unit
Name of Facility
Date: 01/15/03
Patient Participation in Treatment Planning (check as appropriate):
Contributed to goals and plan
Aware of plan content
Present at team meeting
Refused to participate
Unable to participate
Refused to sign plan
(Patient’s or guardian’s signature and date)
X
X
(If guardian, relation to patient)
Patient’s Comments (optional):
Staff Members’ Comments (optional):
John is very resistive to treatment. At times he sits motionless for 12 or more hours, as if he were in a trance.
Treatment Team Members (all participants in the treatment planning must sign below):
Psychiatrist:
Joseph Black, MD
Date:
01/15/03
Print Name:
Joseph Black, MD
Nurse:
Marilyn Davis, RN
Date:
01/15/03
Print Name:
Marilyn Davis, RN
Social worker:
-XDQ6DQFKH]06:
Date:
01/15/03
Print Name:
Juan Sanchez, MSW
Psychologist:
Joseph LeBlanc, PhD
Date:
01/15/03
Print Name:
Joseph LeBlanc, PhD
Rehabilitation:
Jane Hoover, Rehab
Date:
01/15/03
Print Name:
Jane Hoover, Rehab
Other:
Date:
Print Name:
Note: The above signatures document that the participants have reviewed the Master Treatment Plan on the date
signed and that they agree with the plan, unless indicated otherwise under “Staff Members’ Comments.”
ALL SUBSEQUENT CHANGES ON THIS PLAN SHOULD BE DATED, INITIALED, and supported by associated progress
note(s) and/or Treatment Plan Review(s).
A–20
Fundamentals of Psychiatric Treatment Planning
Rating Master Treatment Plans Based on the
Kennedy Treatment Planning System
Instructions
This system for rating Master Treatment Plans uses the following rating scale:
NA
0
1
2
3
=
=
=
=
=
Not applicable
Absent
Unacceptable
Mild to moderate problems
Acceptable to excellent
Rate the 10 sections of a Master Treatment Plan:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Problem List
Strengths
Discharge plan
Psychiatric diagnosis
Problem description
Long-term goals
Short-term goals
Treatment modalities
Changes in goal status and treatment modalities
Signature page
Determine the score for each section:
1.
2.
3.
4.
Rate each applicable component in that section.
Add the scores of each component that was rated.
Divide that total score by the number of rated components.
Round off this number to the nearest whole number.
Record the score for each section on the summary sheet. Determine the plan rating as follows:
1.
2.
3.
Add the scores for each section rated.
Divide that total score by the number of sections rated.
Round off this number to the first decimal place.
A set of blank Master Treatment Plan Rating Forms follows.
Appendix
A–21
SUMMARY SHEET
Master Treatment Plan Rating Form
© 2003 James A. Kennedy, MD
Patient’s Name:
ID#:
Rater’s Name:
Date of Plan:
Section
Rating
Date of Rating:
Comments
1. Problem List
2. Strengths
3. Discharge plan
4. Psychiatric diagnosis
5. Problem description
6. Long-term goals
7. Short-term goals
8. Tx modalities
9. Signature page
10. Goals and Tx modalities
status changes
Total
Comments:
________ ÷ (# of Items Rated) = Plan Rating:
A–22
Fundamentals of Psychiatric Treatment Planning
Master Treatment Plan Rating Form
© 1998–2003 James A. Kennedy, MD
Patient’s Name:
ID#:
Rater’s Name:
Date of Plan:
NA
0
1
2
3
=
=
=
=
=
Date of Rating:
Not applicable
Absent
Unacceptable
Mild to moderate problems
Acceptable to excellent
Start Rating Here (Enter section rating on summary sheet.)
PROBLEM LIST
1. Problem List
Rating
Comments
Problem number
Problem name
Discharge barrier
Date established and status
Date changed and status
Missing problems or placed
in wrong problem area
Missing Individual Problem
Plans
Total
________ ÷ (# of Items Rated) = Section Rating:
Appendix
STRENGTHS/DISCHARGE CRITERIA/DIAGNOSIS
2. Strengths
Rating
Comments
Related to treatment and
discharge
Covers Kennedy strength
areas
Includes interests
Total
3. Discharge Plan
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Discharge environment
Criteria for discharge
Target discharge date
Discharge coordinator
Total
4. Psychiatric Diagnosis
(DSM-IV-TR)
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Axis I
Axis II
Axis III
Axis IV (ancillary impairment)
Axis V (GAF-Eq)
Total
_____ ÷ (# of Items Rated) = Section Rating:
A–23
A–24
Fundamentals of Psychiatric Treatment Planning
INDIVIDUAL PROBLEM PLANS
5. Problem Description
Rating
Comments
Onset of problem indicated
Description of symptoms
Current severity of symptoms
indicated
Measurability of current
severity of symptoms
Total
6. Long-Term Goals
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Target behaviors indicated
Behaviors observable/
measurable
Frequency and time interval
indicated
Goals relate to problem
description, short-term goals,
and Tx modalities
Target dates present and
reasonable
Dated and numbered
Total
_____ ÷ (# of Items Rated) = Section Rating:
Appendix
INDIVIDUAL PROBLEM PLANS
7. Short-Term Goals
Continued
Rating
Comments
Target behaviors indicated
Behaviors observable/
measurable
Frequency and time interval
indicated
Goals relate to problem
description, long-term goals,
and Tx modalities
Target dates present and
reasonable
Dated and numbered
Total
8. Treatment Modalities
_____ ÷ (# of Items Rated) = Section Rating:
Rating
Comments
Relevant disciplines are
included
Modality, time period, and
frequency are included
Related to problem
description and goals
Individual responsible is
identified
Dated and numbered
Total
_____ ÷ (# of Items Rated) = Section Rating:
A–25
A–26
Fundamentals of Psychiatric Treatment Planning
SIGNATURE PAGE
9. Signature Page
Rating
Comments
Plan signed by team members
Patient involvement indicated
Patient/guardian signed plan
or absence explained
Sources of new entries are
identifiable
Total
_____ ÷ (# of Items Rated) = Section Rating:
PLAN GOALS AND TREATMENT MODALITIES STATUS CHANGES
10. Goals and Tx
Modalities Status
Changes
Rating
Comments
If goal changed, new status
and date are indicated
Line drawn through changed
goals
New goals added as needed
Expired target dates are
updated
Modalities are updated as
needed
New modalities are added as
needed
Total
_____ ÷ (# of Items Rated) = Section Rating:
Appendix
A–27
Rating Master Treatment Plans
Example of a Summary of Results Using a Spreadsheet
Inpt./
Outpt.
P. List
Stgths.
D/C Crit.
Dx.
Albert Smith
Inpt.
3
3
3
3
3
3
David Jones
Outpt.
3
3
1
3
3
George Jones
Outpt.
3
3
3
3
Inpt.
2
3
2
3
Michael Jones
Outpt.
3
3
1
Linda Jones
Outpt.
1
3
2
Robert Jones
Outpt.
3
3
1
Name
Mary Jones
Prob.
D.
Ltg. Stg.
Tx.
Mod.
Sig.
Total
Plan
Rating
3
3
3
27
3.0
3
3
3
3
25
2.7
2
3
2
2
2
3
3
25
2.7
2
3
3
22
2.4
3
3
2
3
3
2
3
1
22
2.4
3
2
3
2
21
2.3
3
2
2
2
2
3
21
2.3
Chgs.*
Janet Jones
Inpt.
2
3
0
2
2
2
2
3
1
17
1.8
Alice Jones
Inpt.
1
3
1
3
1
1
1
1
3
15
1.7
William Jones
Inpt.
1
0
1
3
0
3
2
2
2
14
1.6
Brenda Jones
Inpt.
AVERAGE =
1
0
0
0
0
3
2
3
3
12
1.3
2.1
2.5
1.4
2.5
1.9
2.5
2.1
2.6
2.5
20.1
2.2
*This spreadsheet represents ratings of just-completed Master Treatment Plans and, therefore, does not include ratings of subsequent
changes (Chgs.) in Goals and Modalities.
A–28
Fundamentals of Psychiatric Treatment Planning
Nursing Diagnoses
The following pages list nursing diagnoses from Nursing Diagnoses: Definitions and Classifications∗ that
have been categorized according to the Kennedy Axis V subscale areas. This reference should help
nurses to locate the appropriate nursing diagnosis when incorporating the Nursing Care Plan into the
Master Treatment Plan.
This categorization system has been reviewed by Rose Mary Carroll-Johnson, MN, RN, editor,
Nursing Diagnosis: The International Journal of Nursing Language and Classification. Many of the nursing
diagnoses fit into more than one subscale area; therefore, notes in italics help to separate many of the
nursing diagnoses into two or more subscale areas. For example, Activity Intolerance is included under
the subscale areas of Psychological Impairment and Medical Impairment. Its inclusion under
Psychological Impairment is clarified as “Activity Intolerance (related to Psy. Factors)” and its inclusion
under Medical Impairment is clarified as “Activity Intolerance (related to Medical Factors).”
When using the nursing diagnosis, it is not necessary to include the additions to the nursing
diagnoses. Also, some nursing diagnoses may extend into subscale areas that have not been indicated.
This categorization includes only what is felt to be the most likely area or areas that pertain. This is a
guideline; you must use your own clinical judgment when choosing a particular nursing diagnosis, that
is, when pairing a nursing diagnosis to a particular problem name in the Individual Problem Plan
section of the Master Treatment Plan or Nursing Care Plan.
“Health Maintenance” is commonly used as a problem name in treatment planning to allow
clinicians to list treatments that are intended to maintain good or optimal physical health, even when
the patient does not have any significant medical problems. There was no equivalent nursing diagnosis
to pair with Health Maintenance; therefore, it was added to NANDA’s list. As described earlier, it is set
in italics to indicate that it is not an official NANDA-approved nursing diagnosis.
∗
Nursing Diagnoses: Definitions and Classifications 2001–2002. Philadelphia, PA, North American Nursing Diagnosis
Association, 2001.
Appendix
NANDA’S Nursing Diagnoses Categorized by the
Kennedy Axis V
1. Psychological Impairment
Activity Intolerance (related to Psy. Factors)
Activity Intolerance, Risk for (related to Psy. Factors)
Adaptive Capacity, Decreased Intracranial
Adjustment, Impaired
Anxiety
Anxiety, Death
Body Image, Disturbed
Confusion, Acute (related to Psy. Factors)
Constipation, Perceived
Coping, Defensive
Coping, Ineffective (related to Psy. Factors)
Decisional Conflict
Denial, Ineffective
Development, Risk for Delayed (related to Psy. Factors)
Diversional Activity, Deficient
Failure to Thrive, Adult
Falls, Risk for (related to Psy. Factors)
Fatigue
Fear
Fluid Volume, Deficient (related to Psy. Factors)
Fluid Volume, Deficient, Risk for (related to Psy. Factors)
Fluid Volume, Excess (related to Psy. Factors)
Fluid Volume, Imbalance, Risk for (related to Psy. Factors)
Grieving, Anticipatory
Grieving, Dysfunctional
Growth and Development, Delayed (related to Psy. Factors)
Growth, Disproportionate, Risk for Altered (related to Psy. Factors)
Health-Seeking Behaviors, Impaired (related to Psy. Factors)
Hopelessness
Incontinence, Urinary, Functional
Injury, Risk for (related to Psy. Factors)
Loneliness, Risk for
Memory, Impaired (related to Psy. Factors)
Noncompliance
Nutrition, Imbalanced: Less Than Body Requirements (related to Psy. Factors)
Nutrition, Imbalanced: More Than Body Requirements (related to Psy. Factors)
Nutrition, Imbalanced: Risk for More Than Body Requirements (related to Psy. Factors)
Pain, Acute (related to Psy. Factors)
Pain, Chronic (related to Psy. Factors)
Personal Identity, Disturbed
Post-Trauma Syndrome
Post-Trauma Syndrome, Risk for
Powerlessness
Powerlessness, Risk for
Rape-Trauma Syndrome
Rape-Trauma Syndrome, Compound Reaction
Rape-Trauma Syndrome, Silent Reaction
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Performance, Ineffective
Additions to NANDA’s nursing diagnoses are in italics.
A–29
A–30
Fundamentals of Psychiatric Treatment Planning
Self-Care Deficit, Bathing/Hygiene (related to Psy. Factors)
Self-Care Deficit, Dressing/Grooming (related to Psy. Factors)
Self-Care Deficit, Feeding (related to Psy. Factors)
Self-Care Deficit, Toileting (related to Psy. Factors)
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Situational Low, Risk for
Sensory Perception, Disturbed (related to Psy. Factors)
Sexual Dysfunction (related to Psy. Factors)
Sexuality Patterns, Ineffective
Sleep Deprivation
Sleep Pattern, Disturbed
Social Interaction, Impaired (related to Psy. Factors)
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Suffocation, Risk for (related to Psy. Factors)
Thought Processes, Disturbed (related to Psy. Factors)
Ventilatory Weaning Response, Dysfunctional (related to Psy. Factors)
Wandering (related to Psy. Factors)
2. Social Skills
Communication, Verbal, Impaired
Injury, Risk for (related to Social Skills Deficits)
Social Interaction, Impaired (related to Social Skills Deficits)
3. Violence
Falls, Risk for (related to Violence to Self)
Injury, Risk for (related to Violence to Self)
Self-Mutilation
Self-Mutilation, Risk for
Suicide, Risk for
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
4. ADL–Occupational Skills
Breastfeeding, Ineffective (related to ADL Skills Deficits)
Breastfeeding, Interrupted (related to ADL Skills Deficits)
Confusion, Chronic (related to Retardation/Dementia)
Environmental Interpretation Syndrome, Impaired
Falls, Risk for (related to ADL Skills Deficits)
Health Maintenance, Ineffective
Health-Seeking Behavior, Impaired (related to ADL Skills Deficits)
Home Maintenance, Impaired
Injury, Risk for (related to ADL Skills Deficits)
Knowledge, Deficient
Memory, Impaired (related to Retardation/Dementia)
Poisoning, Risk for (related to ADL Skills Deficits)
Self-Care Deficit, Bathing/Hygiene (related to ADL Skills Deficits)
Self-Care Deficit, Dressing/Grooming (related to ADL Skills Deficits)
Self-Care Deficit, Feeding (related to ADL Skills Deficits)
Self-Care Deficit, Toileting (related to ADL Skills Deficits)
Suffocation, Risk for (related to ADL Skills Deficits)
Therapeutic Regimen Management, Effective
Additions to NANDA’s nursing diagnoses are in italics.
Appendix
Therapeutic Regimen Management, Ineffective
Thought Processes, Disturbed (related to Retardation/Dementia)
Trauma, Risk for (related to ADL Skills Deficits)
Wandering (related to Retardation/Dementia)
5. Substance Abuse
Confusion, Acute (related to Substance Abuse)
Confusion, Chronic (related to Substance Abuse)
Coping, Ineffective (related to Substance Abuse)
Development, Risk for Delayed (related to Substance Abuse)
Falls, Risk for (related to Substance Abuse)
Family Processes, Dysfunctional: Alcoholism
Health Maintenance, Ineffective (related to Substance Abuse)
Injury, Risk for (related to Substance Abuse)
Protection, Ineffective (related to Substance Abuse)
Sensory Perception, Disturbed (related to Substance Abuse)
Thought Processes, Disturbed (related to Substance Abuse)
6. Medical Impairment
Activity Intolerance (related to Medical Factors)
Activity Intolerance, Risk for (related to Medical Factors)
Airway Clearance, Ineffective
Aspiration, Risk for
Body Temperature, Risk for Imbalanced
Breathing Pattern, Ineffective
Breastfeeding, Effective
Breastfeeding, Ineffective (related to Medical Factors)
Breastfeeding, Interrupted (related to Medical Factors)
Cardiac Output, Decreased
Confusion, Acute (related to Medical Factors)
Confusion, Chronic (related to Medical Factors)
Constipation
Constipation, Risk of
Dentition, Impaired
Development, Risk for Delayed (related to Medical Factors)
Diarrhea
Disuse Syndrome, Risk for
Dysreflexia, Autonomic
Dysreflexia, Risk for Autonomic
Falls, Risk for (related to Medical Factors)
Fluid Volume, Deficient (related to Medical Factors)
Fluid Volume, Deficient, Risk for (related to Medical Factors)
Fluid Volume, Excess (related to Medical Factors)
Fluid Volume, Imbalanced, Risk for (related to Medical Factors)
Gas Exchange, Impaired
Growth and Development, Delayed (related to Medical Factors)
Health Maintenance
Health Maintenance, Enhanced
Health Seeking Behaviors (enhanced)
Hyperthermia
Hypothermia
Incontinence, Bowel
Incontinence, Urinary, Reflex
Incontinence, Urinary, Risk for Urge
Incontinence, Urinary, Stress
Incontinence, Urinary, Total
Additions to NANDA’s nursing diagnoses are in italics.
A–31
A–32
Fundamentals of Psychiatric Treatment Planning
Incontinence, Urinary, Urge
Infant Behavior, Disorganized
Infant Behavior, Disorganized, Risk for
Infant Behavior, Readiness for Enhanced Organized
Infant Feeding Pattern, Ineffective
Infection, Risk for (related to Medical Factors)
Latex Allergy Response
Latex Allergy Response, Risk for (related to Medical Factors)
Mobility, Impaired, Bed
Mobility, Impaired, Physical
Mobility, Impaired, Wheelchair
Nausea
Neglect, Unilateral
Nutrition, Imbalanced: Less Than Body Requirements (related to Medical Factors)
Nutrition, Imbalanced: More Than Body Requirements (related to Medical Factors)
Nutrition, Imbalanced: Risk for More Than Body Requirements (related to Medical Factors)
Oral Mucous Membrane, Impaired
Pain, Chronic (related to Medical Factors)
Peripheral Neurovascular Dysfunction, Risk for
Protection, Ineffective (related to Medical Factors)
Sensory Perception, Disturbed (related to Medical Factors)
Sexual Dysfunction (related to Medical Factors)
Skin Integrity, Impaired
Skin Integrity, Impaired, Risk for
Suffocation, Risk for (related to Medical Factors)
Surgical Recovery, Delayed
Swallowing, Impaired
Thermoregulation, Ineffective
Thought Processes, Disturbed (related to Medical Factors)
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective
Transfer Ability, Impaired
Urinary Elimination, Impaired
Urinary Retention
Ventilation, Impaired Spontaneous
Ventilatory Weaning Response, Dysfunctional (related to Medical Factors)
Walking, Impaired
7. Ancillary Impairment
Breastfeeding, Interrupted (related to Environmental Factors)
Caregiver Role Strain
Caregiver Role Strain, Risk of
Conflict, Parental Role
Coping, Community, Ineffective
Coping, Community, Readiness for Enhanced
Coping, Compromised Family
Coping, Disabled Family
Coping, Readiness for Enhanced Family
Development, Risk for Delayed (related to Environmental Factors)
Energy Field, Disturbed
Falls, Risk for (related to Environmental Factors)
Family Process, Interrupted
Growth and Development, Delayed (related to Environmental Factors)
Growth, Disproportionate, Risk for Altered (related to Environmental Factors)
Infection, Risk for (related to Environmental Factors)
Injury, Risk for (related to Environmental Factors)
Injury, Risk for, Perioperative Positioning
Additions to NANDA’s nursing diagnoses are in italics.
Appendix
Latex Allergy Response, Risk for (related to Environmental Factors)
Therapeutic Regimen Management, Community, Ineffective
Therapeutic Regimen Management, Family, Ineffective
Parent/Infant/Child Attachment, Risk for Impaired
Parenting, Impaired
Parenting, Impaired, Risk for
Poisoning, Risk for (related to Environmental Factors)
Suffocation, Risk for (related to Environmental Factors)
Trauma, Risk for (related to Environmental Factors)
Ventilatory Weaning Response, Dysfunctional (related to Environmental Factors)
Additions to NANDA’s nursing diagnoses are in italics.
A–33
Notes
