NURSING ASSESSMENT & NOTES
9123 Neuro/Cognitive: Alert, orientedx 4. Speech clear, pressured
1710
Integumentary: Numerous superficial cuts to the bilateral thighs
Bleeding controlled
Psychosocial: iad breakup with boyfriend last night. *He says I'm too
clingy.” Clean, non-disheveled. Reports that she made a statement that
she would take all of her psych medications on social media to "end it
all" Client now states she is not suicidal.
, Nursing Other
9/23 1700 Client Inform:
Medical History:
« Depression
« Generalized anxiety disorder
« Borderline personality disorder
« Pehic inflammatory disease
« Gonorrhea
« Anorexia nervosa
Mental Health History:
« Two suicide attempts
« Two admissions to local mental health facilty
Social History:
+ Smoke 1 pack/day cigarettes
+ Occasional mariuana use
« History of IV drug abuse
Medication:
« Topiramate 75 mg by mouth twice daily
« Haloperidol 3 mg by mouth three times daily
9/23 1700 Personal Preferences:
« Relationship: multiple partners — male and female
« Cultural: none
« Spirtual: none
« Identified Gender: Female
9123 Neuro/Cognitive: Alert, orientedx 4. Speech clear, pressured
1710
Integumentary: Numerous superficial cuts to the bilateral thighs
Bleeding controlled
Psychosocial: iad breakup with boyfriend last night. *He says I'm too
clingy.” Clean, non-disheveled. Reports that she made a statement that
she would take all of her psych medications on social media to "end it
all" Client now states she is not suicidal.
, Nursing Other
9/23 1700 Client Inform:
Medical History:
« Depression
« Generalized anxiety disorder
« Borderline personality disorder
« Pehic inflammatory disease
« Gonorrhea
« Anorexia nervosa
Mental Health History:
« Two suicide attempts
« Two admissions to local mental health facilty
Social History:
+ Smoke 1 pack/day cigarettes
+ Occasional mariuana use
« History of IV drug abuse
Medication:
« Topiramate 75 mg by mouth twice daily
« Haloperidol 3 mg by mouth three times daily
9/23 1700 Personal Preferences:
« Relationship: multiple partners — male and female
« Cultural: none
« Spirtual: none
« Identified Gender: Female
