NURSING 340 Process Worksheet

NURSING 340 Process Worksheet

Student:                                                                                                                        Date:

 

Client History

Name (initials only):           Age:              Gender:                Unit:                                          Date of Admission:

Current Legal Status (Vol, 5150, 5250, Conservatorship, T-Con):

 

5150 Advisement (quote):

 

 

Psychiatric Diagnosis:

 

 

Medical and (or) physical problems:

 

 

Psychosocial and Environmental Problems:

(problems with primary support group, education, occupational, housing, economic, access to heath care)

 

Presenting Problem

Reason for hospitalization (Client’s own words):

 

 

Current stressors:

 

Mental Status Examination

Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy make up):

 

 

Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor retardation, restlessness, repetitive behavior, other):

 

Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent):

 

 

Affect (blunted, flat, guarded, labile, expansive, sad, other):

 

 

Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, other):

 

 

Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred, pressured, other):

 

 

Thought Content:

Suicide Ideation (plan and/or intent):

 

Homicidal Ideation (plan and/or intent):

 

Hallucinations (auditory, visual, olfactory, gustatory, tactile):

 

Delusions ( bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious, erotomania):  ­­

 

 

Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought broadcasting, depersonalization, phobias, illusions, other):

 

 

Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose association, preservation, rumination, confabulations, confusion, other):

 

 

Cognition (orientation, memory recall, concentration, attention span):

 

 

Insight:                                                            Judgment:

 

 

Coordination/gait/notable movement:

 

 

Cultural issues, familial concerns and religious affiliation that may affect his/her care:

 

 

Support System:

 

Current Physical Health:

Vital Signs – T:          P:             R:              BP:            /                Pulse Oximeter reading:

 

 

Pain (Numeric 1-10):                 Location:                                  Character:

 

 

How would you describe your health:     Excellent                 Average                Good                     Poor

 

Nutritional Status:

Diet:                            Feeding supplement:                           Swallowing / Chewing difficulty:

 

 

Elimination Pattern:

 

 

Activity-Exercise-Sleep-Rest Pattern:

 

 

Group Attendance and Level of Participation:

 

Substance Abuse:

Substance	Amount / Frequency	Duration	Last Used

 

Withdrawal symptoms:

 

 

Other Addictions (gambling, sex, internet, shopping, internet, etc.):

 

 

Discharge Plans:

 

Potential Nursing Diagnosis (Risk / Actual):

 

 

Planning (patient goals):

 

Nursing Interventions (include patient education):

 

Evaluation (patient response to interventions and teachings):

 

 

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

 

Medication (Generic / Trade) Dose / Route / Frequency / Range
Side Effects Food and Drug Interaction
Purpose / Rationale for the Patient

 

Laboratory Report:

LAB	DATE	RESULTS	REERENCE  RANGE
DEPAKOTE
LITHIUM
TEGRETOL
DILANTIN
WBC

Hour	Focus / Nursing Diagnosis	D – Data          A – Action         R – Response

Personal goals for the day:

Experience and activities of the day:

Thoughts about your experience today: (How did you meet your goal?)

Your feelings about today: (How can you utilize your experience in the future?)

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