Nursing Assessment and Care Plans

Key Points

• Psychiatric care planning starts with comprehensive physical and mental health assessment.
• Prioritization centers on safety, risk, and client-defined goals.
• Plans should be evidence-based, culturally informed, and recovery-oriented.
• Ongoing evaluation determines whether to continue, adapt, or replace interventions.

Pathophysiology

Incomplete assessment can misidentify priority problems and delay effective intervention, increasing harm risk in psychiatric settings. Structured nursing-process workflows improve reliability and continuity.

Dynamic symptom patterns require continual reassessment and iterative care-plan updates.

Classification

• Assessment phase: Data collection via interview, observation, mental status exam, and tools.
• Planning phase: Problem prioritization, outcomes definition, and intervention design.
• Execution-evaluation phase: Action implementation, documentation, and outcome reassessment.

Nursing Assessment

NCLEX Focus

Prioritize safety threats first, then functional and psychosocial drivers.

• Collect comprehensive mental, physical, social, and cultural data.
• Use validated tools (for example PHQ-9, GAD-7) when clinically appropriate.
• Identify actual and potential nursing problems from assessment cues.
• Prioritize hypotheses by risk severity and immediacy.
• Co-define expected outcomes in language meaningful to the client.

Nursing Interventions

• Build individualized care plans aligned with client goals and evidence.
• Implement trauma-informed, culturally humble, least-restrictive interventions.
• Coordinate interdisciplinary actions and referrals as needed.
• Document objectively, including response to each intervention.
• Modify plan promptly when outcomes are unmet or risks change.

Static Plan Failure

Leaving care plans unchanged despite new cues can worsen risk and delay recovery.

Pharmacology

Medication interventions should be integrated with psychosocial and behavioral strategies; nursing assessment tracks benefits, side effects, adherence, and impact on care-plan goals.

Clinical Judgment Application

Clinical Scenario

A client with severe anxiety and depression reports passive suicidal thoughts, poor sleep, social withdrawal, and missed medications.

Recognize Cues: Multi-domain risk and function impairment are present. Analyze Cues: Safety and adherence concerns are immediate priorities. Prioritize Hypotheses: Highest priority is suicide-risk mitigation and stabilization. Generate Solutions: Create integrated plan with safety steps, medication support, and psychotherapy linkage. Take Action: Implement interventions, coordinate team communication, and document response. Evaluate Outcomes: Reassess risk, symptom burden, and goal progression; revise plan accordingly.

Related Concepts

• dsm-5-criteria-and-use - Supports standardized diagnostic framing in assessment.
• clinical-guidelines-and-standards - Anchors care-plan quality in professional standards.
• clinical-judgment-measurement-model - Structures cue interpretation and action selection.
• promoting-recovery-in-psychiatric-nursing - Aligns care plans with recovery orientation.
• communication-within-the-health-care-team - Ensures coordinated implementation and reevaluation.