NURS 223L
NURS 223L: PSYCHIATRIC MENTAL HEALTH NURSING CARE PLAN
Student Date
Instructor
Patient Initials H.E Date of Admission 05/04/24 Legal Status Patient consent for
(Vol, 5150, 5250,
Unit Mental Health Conservatorship)
treatment
Allergies None
Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
(location) (location, character,
onset)
T: 36.2 HR: 91 12-18 breaths O2SAT98% BP: 111/60, Pain: 0
per minute
Psychiatric Diagnosis and DSM 5 Diagnostic Criterion History of Present Psychiatric Illness:
Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient
Mental Health Services/5150 Advisement
1. Physical examination and interview to identify symptoms The patient is 14 years old, lives with his aunt and attending high
increased anger, restlessness, high impulsivity, use of school. Previous diagnosis record shows that he is suffering from
psychotic substances, becoming detached or isolation from major depression Lorazepam/ativan 2 mg PO once a day and
family. Fluoxetine/Prozac 20 mg PO every evening. The patient is a
2. Blood tests to identify underlying conditions like transgender man, but transitioned from female to male. He has
hypothyroidism severally tried to commit suicide by cutting his wrist, using sharp
3. The Beck Depression Inventory (BDI). This is a psychological objects, claiming that he feels that he is not accepted in the society
evaluation carried out to record behavioral manifestations. and with most family members, relatives and friends. He often does
It also measures the severity of depression. not want to be checked on his private parts, or be touched, unless it is
for necessary health reasons.
Psychopathology of admitting and/or related psychiatric diagnosis Erickson’s Developmental Stage
Biophysical and/or related medical diagnosis Include Rationale Based on the Patient
Description of how this diagnosis relates to your patient With APA citations
With APA citations
West Coast University Care Plan Template Page 1
Revision Date: March 2024
Revision Date: Month, Year December 2021 Page 1
,NURS 223L
West Coast University Care Plan Template Page 2
Revision Date: March 2024
Revision Date: Month, Year December 2021 Page 2
, NURS 223L
MENTAL STATUS EXAMINATION
Appearance
Presenting Appearance Gait and Motor Coordination Level of Participation in the Program/Activity
(nutritional status, physical deformities, hearing (awkward, staggering, shuffling, rigid, trembling (Group attendance and milieu participation,
impaired, glasses, injuries, cane) with intentional movement or at rest), exercise)
Basic Grooming and Hygiene posture
(clean, disheveled and whether it is appropriate (slouched, erect),
attire for the weather) any noticeable mannerisms or gestures
Manner and Approach
Interpersonal Characteristics and Behavioral Approach Speech
Approach to Evaluation (distant, indifferent, unconcerned, evasive, (normal rate and volume, pressured, slow, loud,
(oppositional/resistant, submissive, defensive, negative, irritable, depressive, anxious, sullen, quiet, impoverished)
open and friendly, candid and cooperative, angry, assaultive, exhibitionistic, seductive, Expressive Language
showed subdued mistrust and hostility, frightened, alert, agitated, lethargic, needed (no problems expressing self, circumstantial and
excessive shyness) minor/considerable reinforcement and soothing). tangential responses, difficulties finding words,
Coping and stress tolerance. echolalia, mumbling)
Receptive Language
(normal, able to comprehend questions,
difficulty understanding questions)
Orientation, Alertness, and Thought Process
Recall and Memory Alertness Concentration and Attention
(recalls recent and past events in their (sleepy, alert, dull and uninterested, highly (naming the days of the week or months of the
personal history). Recalls three words (e.g., distractible) year in reverse order, spelling the word "world",
Cadillac, zebra, and purple) Coherence their own last name, or the ABC's backwards)
Orientation (responses were coherent and easy to understand,
(person, place, time, presidents, your name) simplistic and concrete, lacking in necessary detail,
overly detailed and difficult to follow)
West Coast University Care Plan Template Page 3
Revision Date: March 2024
Revision Date: Month, Year December 2021 Page 3
