The CAAR will provide documented evidence of the learning experience and the attainment of clinical objectives for the clinical affiliation at the
assigned facility. There will be no resubmissions of CAAR assignments. It is essential that you
follow the CAAR Grading Rubric when completing these assignments.
GUIDELINES
1. Choose one patient for your in-depth focus on your first day on the unit.( Male patient J.M. 57 year old, from North Texas state diagnosis =Schizophrenia , Bipolar Disorder and Psychosis, homicidal, Severe Anxiety, PTSD.)( pt is from Somali, language barrier plays apart of being incompetent, pt murdered mom for money because she told him no..pt has been in mental hospital for 20 years since the murder happened, came to USA when he was 22, wife and kids back home and pt family doesn’t want anything to do with him and have told case worker to not contact them. facility unit is all male unit two story, downstairs is the cafeteria where individuals are called by name to receive trays as well as chairs and tables being bolted down and nursing office, also chart room. upstairs unit had to dorm halls one end had single beds the other had double beds. both have locked doors to the dorms. beds are bolted to floor. And laundry baskets with names in front of the bed. one staff walks around the unit and checks to make sure door is locked. nurse stations is glassed in with door locked. locked wooden window opens to use for giving snacks and water. there is a patio wrap around where clients can go out and in a fenced unit. play music with staff, cards etc.. outside has a basketball court fenced in. )
2. Read the medical record for pertinent data on your specific patients. Note the diagnosis,
symptoms, medications and therapy. Note any specific problems which have been identified
for the one patient. Students are allotted only one hour with a patient’s chart in which to
obtain the appropriate data for CAAR completion.
3. CAAR Guidelines:
PART I: An introduction which includes a brief client history and present condition.
Identify the DSM-V categories of medical and psychological diagnoses.
Describe the client and the setting (ie:. Grooming, degree of privacy noise level,
description of facility). Briefly discuss the medical plan and nursing plan. The
medical plan of care includes pharmacological information. Nursing plan of care
includes treatment plan/care plan and group therapies (in mental health setting).
Identify one (1) primary nursing diagnosis and at least one (1) patient goal
(outcome) with three (3) nursing interventions.
PART II: Identify and describe the type of communication used with the client. Discern if
the communication is therapeutic or non-therapeutic. Evaluate the client’s
responses for appropriateness and evidence of client values and coping
mechanisms. Label defense mechanisms (denial, etc.), and any abnormal
communication such as (loose association, delusions, etc.).
PART III: Analyze the student/client interaction including the following:
a. Client factors that influenced the interaction (i.e. values, coping mechanisms,
developmental state, physical problems, etc.)
b. Factors in your own background that contribute to your responses (i.e. values,
expectations, coping mechanisms, etc.)
c. Evaluate the communication techniques used in the interaction according to
how effectively they helped you explore the client’s feelings
d. Student’s thoughts and feelings about the experience
e. Give suggestions for improvement and/or altered technique to attain more
therapeutic conversations.
PART IV: Select an Evidenced Based Nursing Journal article that relates to your client’s
mental health diagnosis, signs and symptoms, therapies, or medications. Correlate
the information from the journal to your clinical experiences and patient
observations. Journal publication must be within 5 years.
CAAR Rubric
Criteria Ratings Pts
Client history
DSM-V, categorization of medical diagnoses OR ICD-10 equivalent
Medical plan of care
Client setting: Description of setting, including therapeutic and safety elements
Primary nursing diagnosis identified
Nursing goals identified(1 Short and 1 Long term goal)
Nursing interventions identified
Type of communication student utilized, to include caring elements
Evaluation of client responses
Defense mechanisms which client demonstrated
Client interaction factors, to include cultural elements
Student background in mental health
Students thought and feelings, to include caring elements
Evaluation and suggestions for improvement of student/client interaction
Journal within 5 years
Overview of the chosen topic
Relevance of topic to the client problem
Grammar, sentence structure and paragraph formation
APA formatting and use of APA 7th ed guidelines
Reference page
This area is where you will find the specific guidelines for your CAAR Assignment. This is to be completed during your rotation at North Texas State Hospital. The CAAR will provide documented evidence of the learning experience and the attainment of clinical objectives for the clinical affiliation at the assigned facility.
CAAR Part I: The Client: Examine and analyze the complex pathophysiological concepts of a client in the mental health setting and integrate data in prioritizing and planning care; employ the nursing process to identify evidence-based clinically competent nursing care within the mental health system (Learning and clinical outcomes 2.3, 1.1, 1.4, and 1.5).
CAAR Part II: Therapeutic Communication: Demonstrate a caring behavior toward the client in the mental health setting; communicate and collaborate as a member of the healthcare team in providing continuity of care and achievement of positive outcomes for the client in the mental health setting; demonstrate effective communication techniques and determine the effects of therapeutic and non-therapeutic communication (Learning and clinical outcomes 3.0, 4.0, and 4.2).
CAAR Part III: The Nurse/Client Interaction: Demonstrate a caring behavior toward the client in the mental health setting; identify ways to modify nursing care to meet client needs; examine multiculturalism and its impact on clients in mental health; examine professional issues encountered within the mental health setting; summarize behaviors important in the development of the professional nurse role within the mental health setting (Learning and clinical outcomes 3.0, 3.1, 5.0, 6.1, and 9.1).
CAAR Part IV: Review of Journal Article: Utilizing evidenced based practice, examine the interrelationship of physiological, psychological, social, and spiritual development in a client’s response to dysfunctional health patterns in the mental health patient; analyze the complex pathophysiological and integrate critical thinking to the client care situations and plans of care (Learning objectives: 1.1, 2.3, and 2.4).
