Nurs 223L Psychiatric Nursing Care Plan Template 2023.

NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE 2023. Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Student Date 2020 Instructor Course N223L Patient Initials Date of Admission Legal Status (Vol, 5150, 5250, Patient DOB Conservatorship) UTA Unit MH Chronological and Apparent Age Gender Male Ethnicity UTA Allergies NKDA Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure (location) Pain Scale 1-10 (location, character, onset) UTA 98.9 F (Temporal) 98 beats per minute (Left radial) 20 breaths per minute 98% (O2 Sat) 140/80 (Left forearm) N/A Psychiatric Diagnosis and DSM 5 Diagnostic Criterion History of Present Psychiatric Illness: Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement Anxiety. Excessive anxiety and worry occurring more days than not for at least 6 months. Individual finds it more difficult to control the worry. The anxiety and worry are associated with three or more of the following six symptoms: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance (Varcarolis, 2018). J.G. was admitted to Swift River hospital voluntarily. Patient reports he gets restless, starts breathing rapidly, and has trouble concentrating on homework. Psychopathology of admitting and/or related psychiatric diagnosis Biophysical and/or related medical diagnosis Description of how this diagnosis relates to your patient With APA citations Erickson’s Developmental Stage Include Rationale Based on the Patient With APA citations Anxiety causes a feeling of apprehension, uneasiness, , or dread that results from a real or perceived threat. Anxiety invades the central core of the personality and it diminishes feelings of self-esteem and personal worth. Different levels of anxiety can occur. Mild anxiety allows an individual to perceive reality in sharp focus and typically experience a slight discomfort, restlessness, and irritability. Moderate anxiety an individual may experience a pounding heart, increased pulse, and increase respiratory rate. Severe anxiety a person can have difficulty noticing what is going on in the environment and may experience trembling, pounding heart, and a sense of J.G. is at stage 6 of Erickson’s Developmental Stage, intimacy versus isolation. At stage 6, young adults are beginning to develop relationships with people on a more intimate level where each person shares different parts about themselves and develop deep connections. They also begin making commitments to each other. If a young adult fears making commitments when developing relationships, it can lead to a feeling of isolation. Isolation can lead to loneliness and can affect their mental health. (Taylor, 2019). Page 1 of 9 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE impending doom. Panic is the most extreme level and individuals are unable to process what is going on and lose touch with reality (Varcarolis, 2018). MENTAL STATUS EXAMINATION Appearance Presenting Appearance (nutritional status, physical deformities, hearing impaired, glasses, injuries, cane) Basic Grooming and Hygiene (clean, disheveled and whether it is appropriate attire for the weather) Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), any noticeable mannerisms or gestures Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise) J.G. has no hearing impairments. Patient is clean and dressed appropriately Gait is steady. Posture is erect. Patient is mentally stable to participate in group activities Manner and Approach Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing). Coping and stress tolerance. Speech (normal rate and volume, pressured, slow, loud, quiet, impoverished) Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling) Receptive Language (normal, able to comprehend questions, difficulty understanding questions) J.G is open and friendly, and cooperative. J.G. appears to be anxious , but alert. Speech is clear and normal rate and rhythm. J.G. has no problems expressing self. He is able to comprehend questions.