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Psychiatric Nursing Care Plan and
Process Recording
Use documents and just fill them in.This is for a Psychiatric
Nursing
DSM V Psychiatric Diagnosis:
Social Issues or Current Stressors:
Client’s understanding of the reason for hospitalization
(Client’s words from interview or chart):
What precipitated the current hospitalization? (From the
medical record)
List all prior psychiatric treatments and/or
hospitalizations:
List what you consider to be the client’s current problems or
needs in order of priority.
Description of the client (age, gender, physical appearance,
and diagnosis)
Description of student’s stage of relationship with the
client (prior interactions, developing trust, etc.)
Goals for the interaction (at least two). What you hope will
occur for the patient as result.1.2.
• BE SURE TO COMPLETE THE SELF-ANALYSIS AFTER THE PATIENT
INTERACTION. (See last page of this assignment)NURSE: Actual verbal
and non-verbal communication CLIENT: Actual verbal and non-verbal
communication INTROSPECTIONStudent’s personal thoughts and
feelingsANALYSIS1. Name of communication technique used2. Is it
therapeutic or non-therapeutic?3. Was it effective? Why or why not?
NURSE: Actual verbal and non-verbal communication CLIENT:
Actual verbal and non-verbal communication INTROSPECTIONStudent’s
personal thoughts and feelingsANALYSIS1. Name of communication
technique used2. Is it therapeutic or non-therapeutic?3. Was it
effective? Why or why not?
Mental Status ExaminationMental Status From admission
Psychiatric Assessment on ____________ (Provide date of initial
assessment) Student assessment on ______ (Date)Appearance –
Describe overall impression, posture, clothes, grooming, apparent
ageMotor Activity – Note mannerisms, gestures, combative, rigid,
twitching, psychomotor retardation, alert, lethargicOrientation –
Ask name, where they are, the date, why they are here (person,
place, time, situation)Speech – Describe rate (rapid, pressured,
slow), tone (soft, angry) volume, articulation (clear, slurred),
language (aphasia); unusual style (rhyming, neologisms)General
Attitude – Note if cooperative, hostile, defensive, seductive,
evasive, ingratiatingMood – Ask “How would you describe your mood
right now?”(emotional state: sad, happy, depressed, elated,
anxious)Affect – Describe apparent emotional state (sad, happy,
full or restricted, flat, labile, appropriate or
inappropriate)Attention – Describe ability to concentrate and stay
focused on the interview and answer questions; ask to spell WORLD
backwards
Memory – Tell client you want to test memory: name 3
unrelated objects and ask the client to repeat them back (immediate
memory); after 5 minutes, ask the client to again name the 3
objects (recent memory); remote (ability to recall early personal
history)Form of thought – Describe if thoughts are circumstantial,
flight ideas, evasiveness, loosening associations, perseveration,
blocking, etc.Content of thoughts, suicidal or homicidal ideation –
Note any preoccupations, phobias, obsessions, rituals. Ask if
having thoughts that someone is trying to hurt them, or that people
are against them, or talking about them; do they think they have
special powers or abilities? Ask directly about thoughts to hurt
self or others and, if yes, ask about a plan.Perceptions – Ask if
see or hear things that others do not see or hear; misperceptions,
illusions, hallucinations.Judgment – Ask what would do if found a
sealed envelope that was addressed and stamped; or what would do if
someone yelled “Fire” in a movie theatre
Insight – Ask how they think being in the hospital will be
helpful, or what do they expect to gain from being in the hospital
(ability to understand illness)Intellectual Functioning- Fund of
knowledge: Ask the client to name 5 countries in Europe; or name 5
cities in the U.S. Abstract thinking: Ask meaning of proverb:
“People in glass houses shouldn’t throw stones”; or “How are an
apple and a peach similar?”Current Medications (Copy this page for
each medication)Medication, Classification, Dosage Action and
target symptoms Nursing implications for assessment, observation
and client teachingGeneric name
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