Nursing Process and Mental Health Discussion

Please fill out the nursing process sheet; Please use the narrator’s talk of his symptoms to answer the process sheet questions. I understand you are not going to have all the information in the clip to answer all of the questions. Where the question is not applicable, please indicate N/A; where you’re unable to assess (substance use, maybe medications, pt’s mood) please indicate UTA (unable to assess). Typed submissions only. You should have at least 1-2 nursing dxs (can be at-risk or actual). Anticipate you’re the nurse assessing/caring for this pt. You do not have to do the D-A-R portion. Thank you!

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Student Name: ___________ Date:

Client History:

Name (initials only):______ Age: _____ Gender: _____ Unit: _____ Date of Admission: _________________

Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con):

5150 Advisement (quote):

Psychiatric Diagnosis:

Medical and (or) physical problems:

Psychosocial and Environmental Problems:

(problems with primary support group, education, occupational, housing, economic, access to health care)

Presenting Problem

Reason for hospitalization (Client’s own words):

Current stressors:

Mental Status Examination

Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup):

Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other):

Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent):

Affect (blunted, flat, guarded, labile, expansive, sad, or other):

Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other):

Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, or other):

Thought Content:

Suicide Ideation (plan and/or intent):

Homicidal Ideation (plan and/or intent):

Hallucinations (auditory, visual, olfactory, gustatory, tactile):

Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania):

Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other):

Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other):

Cognition (orientation, memory recall, concentration, attention span):

Insight: Judgment:

Coordination/gait/notable movement:

Cultural issues, familial concerns and religious affiliation that may affect his/her care:

Support System:

Current Physical Health:

Vital Signs – T: P: R: BP: / Pulse Oximeter reading:

Pain (Numeric 1-10): Location: Character:

How would you describe your health: Excellent Average Good Poor

Nutritional Status:

Diet: Feeding supplement: Swallowing / Chewing difficulty:

Elimination Pattern:

Activity-Exercise-Sleep-Rest Pattern:

Group Attendance and Level of Participation:

Substance Abuse:

Substance	Amount / Frequency	Duration	Last Used

Withdrawal symptoms:

Other Addictions (gambling, sex, internet, shopping, internet, etc.):

Discharge Plans:

Potential Nursing Diagnosis (Risk / Actual):

Planning (patient goals):

Nursing Interventions (include patient education):

Evaluation (patient response to interventions and teachings):

MEDICATION LIST

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Medication

(Generic / Trade)

Dose / Route / Frequency / Range

Side Effects

Food and Drug Interaction

Purpose / Rationale for the Patient

Laboratory Report:

LAB	DATE	RESULTS	REERENCE RANGE
DEPAKOTE
LITHIUM
TEGRETOL
DILANTIN
WBC

Date:

Hour	Focus / Nursing Diagnosis	D – Data A – Action R – Response

West Coast

University

Patient Care Notes

Patient Identification

Student Daily Journal

Personal goals for the day:

Experience and activities of the day:

Thoughts about your experience today: (How did you meet your goal?)

Your feelings about today: (How can you utilize your experience in the future?)