lOMoARcPSD|3013804
NURS 223L - Psychiatric Nursing Process
Worksheet 8
Mental Health (West Coast University)
, lOMoARcPSD|3013804
Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 1
Student Name: Astrid Hernandez
Date: 1/8/2021
Client History: Patient is 24-year-old male. Patient has been admitted to the psychiatric hospital after
attempting suicide. Patient has had a hard time accepting the death of younger sibling. Family members
state patient has been having a difficult time dealing with grief. Patient states feeling hopelessness and no
desire to live.
Name (initials only): H.H. Age: 29 Gender: M Unit: _Psychiatric Unit Date of Admission:
1/6/2021
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con):
5150 Advisement (quote):
N/A
Psychiatric Diagnosis:
Major Depressive Disorder
Medical and (or) physical problems:
N/A
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): Patient was brought in by family members after attempting
suicide. Family members found patient unconscious after patient ingested half of a bottle of Xanax in attempt
to end life. Patient states feeling like life was no longer worth living after his younger brother passed away.
The patient states guilt because brother passed away in a tragic car accident after they had an argument.
Patient’s family members have tried having the patient go to therapy and have been trying to stand by the
patient through the difficult times. The patient has had panic attacks related to the brother’s death. In the
panic attacks the patient states getting erratic and usually throw things , yelling uncontrollably, and
screaming. Patient states not being able to get the death. Patient states feeling hopelessness and despair,
patient states not being able to sleep at night for the past two months and a lack of appetite.
Current stressors: Major depression and anxiety due to recent death in family.
Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy
makeup): Patient appears worn out. Patient looks underweight. Patient is ungroomed. Patient looks frail and
sick.
Page 1 of 7
NURS 223L - Psychiatric Nursing Process
Worksheet 8
Mental Health (West Coast University)
, lOMoARcPSD|3013804
Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 1
Student Name: Astrid Hernandez
Date: 1/8/2021
Client History: Patient is 24-year-old male. Patient has been admitted to the psychiatric hospital after
attempting suicide. Patient has had a hard time accepting the death of younger sibling. Family members
state patient has been having a difficult time dealing with grief. Patient states feeling hopelessness and no
desire to live.
Name (initials only): H.H. Age: 29 Gender: M Unit: _Psychiatric Unit Date of Admission:
1/6/2021
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con):
5150 Advisement (quote):
N/A
Psychiatric Diagnosis:
Major Depressive Disorder
Medical and (or) physical problems:
N/A
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): Patient was brought in by family members after attempting
suicide. Family members found patient unconscious after patient ingested half of a bottle of Xanax in attempt
to end life. Patient states feeling like life was no longer worth living after his younger brother passed away.
The patient states guilt because brother passed away in a tragic car accident after they had an argument.
Patient’s family members have tried having the patient go to therapy and have been trying to stand by the
patient through the difficult times. The patient has had panic attacks related to the brother’s death. In the
panic attacks the patient states getting erratic and usually throw things , yelling uncontrollably, and
screaming. Patient states not being able to get the death. Patient states feeling hopelessness and despair,
patient states not being able to sleep at night for the past two months and a lack of appetite.
Current stressors: Major depression and anxiety due to recent death in family.
Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy
makeup): Patient appears worn out. Patient looks underweight. Patient is ungroomed. Patient looks frail and
sick.
Page 1 of 7
