NURS 223L - Psychiatric Nursing Process Worksheet.

Student Name: NAME HERE Date: 04/08/20 Client History: Name (initials only): _M.M _ Age: _31 Gender: F Unit: _Psych_ Date of Admission: 01/27/20. Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): Not know, Mother care for patient 5150 Advisement (quote): “Here mother usually comes by on Tuesdays to bring clean clothes for patient” Psychiatric Diagnosis: Suicidal ideation, Depression, Anxiety, Post- traumatic stress disorder. Medical and (or) physical problems: Diabetes, Hypertension, Renal Disease which leads to kidney failure, infection, and Substance abuse, Psychosocial and Environmental Problems: Access to health care, Problem with primary care support, Lack of education. (problems with primary support group, education, occupational, housing, economic, access to health care) Presenting Problem: Reason for hospitalization (Client’s own words): Recent suicide attempt Current stressors: Depression, Anxiety, Post traumatic stress disorder and Infection. Mental Status Examination Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy makeup): Patient wearing dirty clothes, her hair tangled and lots of black eyeliner. Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other): Angry, refused eye contact by facing away and starring at the wall Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Angry, guarded and later cooperative