Description
This is 28 y old old male coming into the hospital unfortunately refusing to engage with me this afternoon. The patient apparently came in dishelved agitated using methamphetamine . disorganized unable to follow the conversation , not answering question.
client brought to the facility by mom after client mentioned suicidal thoughts. Client is not sleeping or eating . He will only drink water with strong encouragement . client has blank stare. he has blank stare. he can not communicate, his thoughts or advocate for his own needs. mom can not provide land of care needed at this time
chief complaint is “GO AWAY”
history: client has schizophrenia and has been non med compliant for at lease 1 month. client lives alone. he is agitated and appears to be responding if internal stimuli.
psychiatric history: multiple hospitalizations per documentation noted. Diagnoses of Schizophrenia, onset appear to be early 20’s. poor medication compliance for a month, worsening sign and symptoms over the last few weeks . Use of meth 1g to 2g daily , cocaine, erratic, alcohol .
he is not working, living alone
WBC 16.2h
RBC-5.33
Glucose 101
BUN 8
Medication: Zyprexia 10mg daily, Seroquel 200mg daily, Trazodone 50mg daily
Unformatted Attachment Preview
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Student
Date
Instructor
Patient Initials
Date of Admission
Patient DOB
Unit
Course
Legal Status
(Vol, 5150, 5250,
Conservatorship)
Chronological and
Apparent Age
Gender
Ethnicity
Allergies
Height/Weight
Temp (location)
Pulse (location)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure
(location)
Pain Scale 1-10
(location, character,
onset)
Psychiatric Diagnosis and DSM 5 Diagnostic Criterion
History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement
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
Page 1 of 8
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
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)
MENTAL STATUS EXAMINATION
Appearance
Gait and Motor Coordination
(awkward, staggering, shuffling, rigid, trembling
with intentional movement or at rest),
posture
(slouched, erect),
any noticeable mannerisms or gestures
Interpersonal Characteristics and
Approach to Evaluation
(oppositional/resistant, submissive, defensive,
open and friendly, candid and cooperative,
showed subdued mistrust and hostility, excessive
shyness)
Manner and Approach
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.
Recall and Memory
(recalls recent and past events in their personal
history). Recalls three words (e.g., Cadillac,
zebra, and purple)
Orientation
(person, place, time, presidents, your name)
Orientation, Alertness, and Thought Process
Alertness
(sleepy, alert, dull and uninterested, highly
distractible)
Coherence
(responses were coherent and easy to understand,
simplistic and concrete, lacking in necessary detail,
overly detailed and difficult to follow)
Thought Processes
(loose associations, confabulations, flight of ideas,
Hallucinations and Delusions
(presence, absence, denied visual but admitted
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Level of Participation in the Program/Activity
(Group attendance and milieu participation,
exercise)
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)
Concentration and Attention
(naming the days of the week or months of the year
in reverse order, spelling the word “world”, their
own last name, or the ABC’s backwards)
Judgment and Insight
(based on explanations of what they did, what
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
ideas of reference, illogical thinking, grandiosity,
magical thinking, obsessions, perseveration,
delusions, reports of experiences of
depersonalization).
Values and belief system
Mood or how they feel most days
(happy, sad, despondent, melancholic, euphoric,
elevated, depressed, irritable, anxious, angry).
Affect or how they felt at a given moment
(comments can include range of emotions such
as broad, restricted, blunted, flat, inappropriate,
labile, consistent with the content of the
conversation.
Risk Assessment:
Suicidal and Homicidal Ideation
(ideation but no plan or intent, clear/unclear
plan but no intent)
Self-Injurious Behavior
(cutting, burning)
Hypersexual, Elopement, Non-adherence to
treatment
Pertinent Lab Tests Results
(normal ranges in parentheses)
Valproic Acid (50 – 120 mcg/mL)
Lithium (0.5 – 1.2 mEq/L)
Carbamazepine (5 – 12 mcg/mL)
CBC (WBC with diff, ANC, RBC)
Page 3 of 8
olfactory and auditory, denied but showed signs of
them during testing, denied except for times
associated with the use of substances, denied while
taking medications)
Mood and Affect:
Rapport
(easy to establish, initially difficult but easier over
time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions
(relaxed, tense, smiled, laughed, became insulting,
yelled, happy, sad, alert, day-dreamy, angry, smiling,
distrustful/suspicious, tearful, pessimistic, optimistic)
Discharge Plans and Instruction:
Placement, outpatient treatment, partial
hospitalization, sober living, board and care, shelter,
long term care facility, 12 step program
happened, and if they expected the outcome, good,
poor, fair, strong)
Response to Failure on Test Items
(unaware, frustrated, anxious, obsessed, unaffected)
Impulsivity
(poor, effected by substance use)
Anxiety
(note level of anxiety, any behaviors that indicated
anxiety, ways they handled it)
Teaching Assessment and Client / Family
Education:
(Disease process, medication, coping, relaxation,
diet, exercise, hygiene)
Include barriers to learning and preferred learning
styles
Rationale for Abnormals
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Urine Drug Screen
Thyroid Panel
Liver Function (AST/ALT, LHD, Albumin, Bilirubin)
Kidney Function (BUN, creatinine)
Blood Alcohol Level
Diagnostic Test Results
(with dates)
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
Rationale for Abnormals
Substance Abuse and other Addictions
(gambling, sex, shopping, smoking)
Type:
Amount / Frequency:
Duration:
Last Used:
Withdrawal Symptoms:
C.A.G.E. Questionnaire
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
Abnormal Involuntary Movements
Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe
I: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,
grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and
out of mouth)
II: Extremity Movements:
Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous
athetoid movements.
Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of
foot
Page 4 of 8
Yes / No
Yes / No
Yes / No
Yes / No
0
1
2
3
4
0
1
2
3
4
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)
IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal
movements.)
V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)
Page 5 of 8
0
1
2
3
4
0
1
2
3
4
Yes
No
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
Diagnostic
Label
Diagnosis
Minimum of 2 NANDA actual and/or potential.
Include etiology and
signs and symptoms.
*Include
definition of the nursing
diagnoses with APA
citations
1.
Nursing Diagnosis
Definition:
2.
Planning
Outcome Criteria
Minimum of 2
measureable
goal per diagnosis related
to the nursing diagnosis
1.
1.
1.
2.
2.
3.
3.
4.
4.
1.
1.
2.
2.
3.
3.
4.
4.
2.
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2.
Signs and
Symptoms
As evidenced by
Implementation
Minimum of 4
independent and collaborative
nursing intervention include further
assessment, intervention, and
teaching that is related to the
outcome criteria
1.
Nursing Diagnosis
Definition:
Contributing
Factors
Related to
Rationales for interventions
(With APA citations )
Evaluation
Goal Met
Goal not Met
(If not met, what revisions
would you make?) How
did the patient respond to
your interventions
1.
2.
1.
2.
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
MEDICATION LIST
Medications
Generic / Trade
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Class/Rationale for the
patient
Dose/Route/
Time
(Frequency)
Range /
Therapeutic
Levels
Mechanism of action /
Onset of action
Common side
effects / Food and
drug interaction
Nursing considerations
specific to this patient
Course: NURS 223L
PSYCHIATRIC NURSING CARE PLAN TEMPLATE
REFERENCES
Page 8 of 8
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