NURS 223L - Psychiatric Nursing Process
Worksheet week 3.
Student Name: NAME HERE Date 04/24/20
Client History:
Name (initials only): _VR_ Age: _57_ Gender: _F_ Unit: _PSYCH Date of Admission: 04/24/20
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Suspected voluntary admission, Family still
care for patient. “Grandson and niece that is her support system and Power of Attorney”
Psychiatric Diagnosis: Dementia, Depression and Anxiety
Medical and (or) physical problems: CHF, DVT, Stage IV Ovarian Cancer with multiple Lymph node
involvement and possible liver metastasis.
Psychosocial and Environmental Problems: Lack of education only went to high school; Patient does not
attend group activities. Thinking that everyone is trying to hold her hostage.
(problems with primary support group, education, occupational, housing, economic, access to health care)
Presenting Problem
Reason for hospitalization (Client’s own words): Attempted elopement from her Memory Care Unit. patient
Wanders
Current stressors: Stage IV Ovarian Cancer with multiple lymph node involvement and possible liver
metastasis, Anxiety, Depression.
Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy
makeup): Patient mental statue is inappropriate due to “terminal condition that has metastasized to the
brain causing an alteration in mental status”
Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor
retardation, restlessness, repetitive behavior, other): Retardation, Restlessness “Wandering into other
patients’ rooms, slapping them in the face and stealing cups off the medication cart”
, Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Patient attitude is
guarded and uncooperative with care
Affect (blunted, flat, guarded, labile, expansive, sad, or other): Patient is very Sad,
Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Patient is Irritable
and anxious
Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred,
pressured, or other): Patient is very soft spoken with a low tone
Thought Content:
Suicide Ideation (plan and/or intent): NO
Homicidal Ideation (plan and/or intent): NO
Hallucinations (auditory, visual, olfactory, gustatory, tactile): NO
Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose,
religious, erotomania): Sometimes patient is Delusional
Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought
broadcasting, depersonalization, phobias, illusions, other): Ideal of influence has the perception
that everyone is trying to hold her hostage.
Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose
association, preservation, rumination, confabulations, confusion, other): Patient is confused, thought
process is illogical
Cognition (orientation, memory recall, concentration, attention span): Patient is Alert and oriented x 1
Insight: Poor Judgment: Poor
Coordination/gait/notable movement: Patient is independently Ambulatory
Cultural issues, familial concerns and religious affiliation that may affect his/her care: Patient is a Catholic,
Has a good relationship with her family.
Worksheet week 3.
Student Name: NAME HERE Date 04/24/20
Client History:
Name (initials only): _VR_ Age: _57_ Gender: _F_ Unit: _PSYCH Date of Admission: 04/24/20
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Suspected voluntary admission, Family still
care for patient. “Grandson and niece that is her support system and Power of Attorney”
Psychiatric Diagnosis: Dementia, Depression and Anxiety
Medical and (or) physical problems: CHF, DVT, Stage IV Ovarian Cancer with multiple Lymph node
involvement and possible liver metastasis.
Psychosocial and Environmental Problems: Lack of education only went to high school; Patient does not
attend group activities. Thinking that everyone is trying to hold her hostage.
(problems with primary support group, education, occupational, housing, economic, access to health care)
Presenting Problem
Reason for hospitalization (Client’s own words): Attempted elopement from her Memory Care Unit. patient
Wanders
Current stressors: Stage IV Ovarian Cancer with multiple lymph node involvement and possible liver
metastasis, Anxiety, Depression.
Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy
makeup): Patient mental statue is inappropriate due to “terminal condition that has metastasized to the
brain causing an alteration in mental status”
Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor
retardation, restlessness, repetitive behavior, other): Retardation, Restlessness “Wandering into other
patients’ rooms, slapping them in the face and stealing cups off the medication cart”
, Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Patient attitude is
guarded and uncooperative with care
Affect (blunted, flat, guarded, labile, expansive, sad, or other): Patient is very Sad,
Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): Patient is Irritable
and anxious
Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred,
pressured, or other): Patient is very soft spoken with a low tone
Thought Content:
Suicide Ideation (plan and/or intent): NO
Homicidal Ideation (plan and/or intent): NO
Hallucinations (auditory, visual, olfactory, gustatory, tactile): NO
Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose,
religious, erotomania): Sometimes patient is Delusional
Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought
broadcasting, depersonalization, phobias, illusions, other): Ideal of influence has the perception
that everyone is trying to hold her hostage.
Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose
association, preservation, rumination, confabulations, confusion, other): Patient is confused, thought
process is illogical
Cognition (orientation, memory recall, concentration, attention span): Patient is Alert and oriented x 1
Insight: Poor Judgment: Poor
Coordination/gait/notable movement: Patient is independently Ambulatory
Cultural issues, familial concerns and religious affiliation that may affect his/her care: Patient is a Catholic,
Has a good relationship with her family.
