Psychiatric Nursing Care Plan and Process Recording
use documents and just fill them in.
This is for a Psychiatric Nursing
DSM V Psychiatric Diagnosis:
Social Issues or Current Stressors:
Client’s understanding of the reason for hospitalization (Client’s words from interview or chart):
What precipitated the current hospitalization? (From the medical record)
List all prior psychiatric treatments and/or hospitalizations:
List what you consider to be the client’s current problems or needs in order of priority.
Description of the client (age, gender, physical appearance, and diagnosis)
Description of student’s stage of relationship with the client (prior interactions, developing trust, etc.)
Goals for the interaction (at least two). What you hope will occur for the patient as result.
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• BE SURE TO COMPLETE THE SELF-ANALYSIS AFTER THE PATIENT INTERACTION. (See last page of this assignment)
NURSE: Actual verbal and non-verbal communication CLIENT: Actual verbal and non-verbal communication INTROSPECTION
Student’s personal thoughts and feelings
ANALYSIS
1. Name of communication technique used
2. Is it therapeutic or non-therapeutic?
3. Was it effective? Why or why not?
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NURSE: Actual verbal and non-verbal communication CLIENT: Actual verbal and non-verbal communication INTROSPECTION
Student’s personal thoughts and feelings
ANALYSIS
1. Name of communication technique used
2. Is it therapeutic or non-therapeutic?
3. Was it effective? Why or why not?
1.
2.
3.
1.
2.
3.
Mental Status Examination
Mental Status From admission Psychiatric Assessment on ____________ (Provide date of initial assessment) Student assessment on ______ (Date)
Appearance – Describe overall impression, posture, clothes, grooming, apparent age
Motor Activity – Note mannerisms, gestures, combative, rigid, twitching, psychomotor retardation, alert, lethargic
Orientation – Ask name, where they are, the date, why they are here (person, place, time, situation)
Speech – Describe rate (rapid, pressured, slow), tone (soft, angry) volume, articulation (clear, slurred), language (aphasia); unusual style (rhyming, neologisms)
General Attitude – Note if cooperative, hostile, defensive, seductive, evasive, ingratiating
Mood – Ask “How would you describe your mood right now?”(emotional state: sad, happy, depressed, elated, anxious)
Affect – Describe apparent emotional state (sad, happy, full or restricted, flat, labile, appropriate or inappropriate)
Attention – Describe ability to concentrate and stay focused on the interview and answer questions; ask to spell WORLD backwards
Memory – Tell client you want to test memory: name 3 unrelated objects and ask the client to repeat them back (immediate memory); after 5 minutes, ask the client to again name the 3 objects (recent memory); remote (ability to recall early personal history)
Form of thought – Describe if thoughts are circumstantial, flight ideas, evasiveness, loosening associations, perseveration, blocking, etc.
Content of thoughts, suicidal or homicidal ideation – Note any preoccupations, phobias, obsessions, rituals. Ask if having thoughts that someone is trying to hurt them, or that people are against them, or talking about them; do they think they have special powers or abilities? Ask directly about thoughts to hurt self or others and, if yes, ask about a plan.
Perceptions – Ask if see or hear things that others do not see or hear; misperceptions, illusions, hallucinations.
Judgment – Ask what would do if found a sealed envelope that was addressed and stamped; or what would do if someone yelled “Fire” in a movie theatre
Insight – Ask how they think being in the hospital will be helpful, or what do they expect to gain from being in the hospital (ability to understand illness)
Intellectual Functioning- Fund of knowledge: Ask the client to name 5 countries in Europe; or name 5 cities in the U.S. Abstract thinking: Ask meaning of proverb: “People in glass houses shouldn’t throw stones”; or “How are an apple and a peach similar?”
Current Medications (Copy this page for each medication)
Medication, Classification, Dosage Action and target symptoms Nursing implications for assessment, observation and client teaching
Generic name
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