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Hello,Please fill this out with the patients information listed. i will send both pdf’s thank you. just fill out and try to fill out as much and long information as possible about this patient. use initials for this patient like i provided.
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Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 1
Psychiatric Mental Health Nursing
NURS 223L
Student Name:
Date:
Patient Identification:
Name (initials):______ Age: _____ Gender: _____ Unit: _____
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con):
Description of Hold:
Psychiatric Diagnosis:
Medical Diagnosis (If any):
AllergiesVital Signs Presenting Problem
Chief Compliant: (Patient’s own words):
Past Psychiatric History:
Prior Hospitalizations:
Prior Suicide Attempts:
Family History:
Substance Use
Substance
Amount /
Frequency
Duration
Last Used
ETOH:
Tobacco:
Illicit Drugs:
Other:
Psychosocial and Environmental Problems:
(problems with primary support group, education, occupational, housing, economic, access to health care)
Page 1 of 5
Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 2
Mental Status Examination
Appearance (grooming, hygiene, disheveled etc.):
Motor Activity: (balance, coordination, gait, tremors, tics etc.):
Cognition (orientation, memory recall):
Speech (normal rate, rhythm & tone, delayed, vague, clanging, rapid, pressured, loud, spontaneous, slurred,
other):
Affect (flat, guarded, blunted, labile, restricted, other):
Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, etc. ):
Mood (Irritable, euthymic, anxious, expansive, euphoric, apathetic, depressed, elevated, other):
Thought Content:
Suicide Ideation (plan and/or intent):
Homicidal Ideation (plan and/or intent):
Hallucinations (auditory, visual, olfactory, gustatory, tactile):
Delusions (bizarre, somatic, paranoid, grandiose, religious):
Perception (ideas of reference, thought insertion, thought broadcasting, depersonalization, phobias, illusions,
other):
Thought Process (flight of ideas, logical, coherent, goal directed, circumstantial, tangential, loose association,
preservation, rumination, confabulations, other):
Insight/Judgement:
Goals (Long/short term):
Nursing Interventions (Patient education):
Example: Provided patient education on the importance of medication compliance
Page 2 of 5
Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 3
MEDICATION LIST
Medication
(Generic / Trade)
Dose / Route / Frequency /
Range
Side Effects
Food and Drug Interaction
Purpose / Rationale for the
Patient
Medication
(Generic / Trade)
Dose / Route / Frequency /
Range
Side Effects
Food and Drug Interaction
Purpose / Rationale for the
Patient
Medication
(Generic / Trade)
Dose / Route / Frequency /
Range
Side Effects
Food and Drug Interaction
Purpose / Rationale for the
Patient
Complete charts below using two disorders that patient has been diagnosed with. If patient only has one
diagnosis, choose a disorder that interests you.
Disorder:
Risk Factor:
Etiology:
Page 3 of 5
Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 4
Expected Findings:
Patient Education:
Disorder:
Risk Factor:
Etiology:
Expected Findings:
Page 4 of 5
Course: NURS 223L
PSYCHIATRIC NURSING PROCESS WORKSHEET: Daily Charting 5
Patient Education:
Page 5 of 5
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