Course: NURS 223L
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
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, starring at the wall
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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
This study source was downloaded by 100000815376421 from CourseHero.com on 06-29-2021 00:24:43 GMT -05:00
Page 1 of 8
https://www.coursehero.com/file/64649548/NURS-223L-Psychiatric-Nursing-Process-Worksheetdocx/
, starring at the wall
This study source was downloaded by 100000815376421 from CourseHero.com on 06-29-2021 00:24:43 GMT -05:00
Page 2 of 8
https://www.coursehero.com/file/64649548/NURS-223L-Psychiatric-Nursing-Process-Worksheetdocx/
