NURS 223L - Psychiatric Nursing Process Worksheet.

NURS 223L - Psychiatric Nursing Process Worksheet. PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 1 Student Name: NAME HERE Date: 04/08/20 Client History: Name (initials only): _M.M _ Age: _31 Gender: F Unit: _Psych_ Date of Admission: 01/27/20. Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Not know, Mother care for patient 5150 Advisement (quote): “Here mother usually comes by on Tuesdays to bring clean clothes for patient” Psychiatric Diagnosis: Suicidal ideation, Depression, Anxiety, Post- traumatic stress disorder. Medical and (or) physical problems: Diabetes, Hypertension, Renal Disease which leads to kidney failure, infection, and Substance abuse, Psychosocial and Environmental Problems: Access to health care, Problem with primary care support, Lack of education. (problems with primary support group, education, occupational, housing, economic, access to health care) Presenting Problem: Reason for hospitalization (Client’s own words): Recent suicide attempt Current stressors: Depression, Anxiety, Post traumatic stress disorder and Infection. Mental Status Examination Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): Patient wearing dirty clothes, her hair tangled and lots of black eyeliner. Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): Angry, refused eye contact by facing away and starring at the wall Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Angry, guarded and later cooperative Affect (blunted, flat, guarded, labile, expansive, sad, or other): Blunted and later become verbal that was when she requested for some sheet and pain medication. Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Angry, Anxious and Apathetic Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other): Very low tone Thought Content: Suicide Ideation (plan and/or intent): Attempt Homicidal Ideation (plan and/or intent): Unknown Hallucinations (auditory, visual, olfactory, gustatory, tactile): Unknown Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania): N/A Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other): Withdrawn patient does not like to participate in group therapy Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other): Logical, Coherent. AEB patient asking for Ambien, that she does not want, to make the nurse understand how her feeling. Cognition (orientation, memory recall, concentration, attention span): Oriented and have good concentration/attention span Insight: Knows little about present illness Judgment: does not have good Judgment. Coordination/gait/notable movement: Unknown