Psychiatric Clinical Nursing Assessment and Care Plan Essay

2454 Words Aug 10th, 2013 10 Pages
Psychiatric Clinical Nursing Assessment
Jennifer Stokes
Daytona State College

Directions: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom. Patient Initials | EM | Physician | Dr. Singh | Date | 08/07/2013 | | Not Present | Very Mild | Mild | Moderate | Moderately Severe | Severe | Extremely Severe | SOMATIC CONCERNS – preoccupation with physical health, fear of physical illness, hypochondriasis | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | ANXIETY------worry, fear, overconcern for present or future, uneasiness | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | EMOTIONAL WIYHDRAWAL---------lack of spontaneous interaction,isolation,deficiency in relating to others. | ☐ | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ |
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| CONTENT OF THOUGHTNormal for Age/Culture ☐Suicidal Thoughts ☐Suicidal Plans ☐Assaultive Ideas ☐Homicidal Plans ☐Antisocial Attitudes ☐Suspiciousness ☒Poverty of Content ☐Phobias ☐Obsessions/Compulsions ☐Feelings of Unreality ☐Feels Persecuted ☐Thoughts of Running Away ☐Somatic Complaints ☐Ideas of Guilt ☐Ideas of Hopelessness ☐Ideas of Worthlessness ☐Excessive Religiosity ☒Sexual Preoccupation ☐Blames Others ☒Ideas of Reference ☐Magical Thinking ☐Illogical Thinking ☒Illlusions ☐Present ☐Mood –Incongruent ☐Auditory ☒Visual ☒Gustatory ☐Olfactory ☐Somatic ☐Tactile ☐DELUSIONSMood-Congruent ☒Mood-Incongruent ☐Of Persecution ☐of Grandeur ☐of Reference ☐Somatic ☐Systematized ☐Of Being Controlled ☐Bizarre ☒Nihilistic ☐Of Poverty ☐Jealousy ☐INSIGHTAND JUDGMENTNormal for Age/Culture ☐Poor Insight ☒Poor Judgment ☒Unrealistic Regarding ☒Degree of Illness ☒Doesn’t Know Why He is Here ☐Unmotivated for Treatment |

Daytona State College Nursing Care Plan Nursing IV
Name: Jennifer Stokes Date: 08/07/2013
Client Initials: EM Date of Admission: 07/23/2013 Allergies: NKDA Care Plans (list according to priority) | Nursing Diagnosis: Risk for injury (self-directed or to others) R/T hallucinatory or delusionary experience and suicide ideation.Goal Statement:Patient will remain free from any self-harm and harm directed towards others during hospitalization

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