Nursing care plan for homicidal ideation

Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Student Date Instructor Patient Initials Date of Admission Patient DOB Unit Course Legal Status (Vol, 5150, 5250, Conservatorship) Chronological and Apparent Age Gender Ethnicity Allergies Height/Weight Temp (location) Pulse (location) Respiration Pulse Ox (O2 Sat) Blood Pressure (location) Pain Scale 1-10 (location, character, onset) Psychiatric Diagnosis and DSM 5 Diagnostic Criterion History of Present Psychiatric Illness: Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement Psychopathology of admitting and/or related psychiatric diagnosis Biophysical and/or related medical diagnosis Description of how this diagnosis relates to your patient With APA citations Erickson’s Developmental Stage Include Rationale Based on the Patient With APA citations Page 1 of 8 Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE Presenting Appearance (nutritional status, physical deformities, hearing impaired, glasses, injuries, cane) Basic Grooming and Hygiene (clean, disheveled and whether it is appropriate attire for the weather) Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness) Recall and Memory (recalls recent and past events in their personal history). Recalls three words (e.g., Cadillac, zebra, and purple) Orientation (person, place, time, presidents, your name) Thought Processes (loose associations, confabulations, flight of ideas, Page 2 of 8 MENTAL STATUS EXAMINATION Appearance Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), any noticeable mannerisms or gestures Manner and Approach Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing). Coping and stress tolerance. Orientation, Alertness, and Thought Process Alertness (sleepy, alert, dull and uninterested, highly distractible) Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow) Hallucinations and Delusions (presence, absence, denied visual but admitted Level of Participation in the Program/Activity (Group attendance and milieu participation, exercise) Speech (normal rate and volume, pressured, slow, loud, quiet, impoverished) Expressive Language (no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling) Receptive Language (normal, able to comprehend questions, difficulty understanding questions) Concentration and Attention (naming the days of the week or months of the year in reverse order, spelling the word "world", their own last name, or the ABC's backwards) Judgment and Insight (based on explanations of what they did, what Course: NURS 223L PSYCHIATRIC NURSING CARE PLAN TEMPLATE ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization). Values and belief system Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry). Affect or how they felt at a given moment (comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation. Risk Assessment: Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent) Self-Injurious Behavior (cutting, burning) Hypersexual, Elopement, Non-adherence to treatment Pertinent Lab Tests Results (normal ranges in parentheses) Valproic Acid (50 – 120 mcg/mL) Lithium (0.5 – 1.2 mEq/L) Carbamazepine (5 – 12 mcg/mL) CBC (WBC with diff, ANC, RBC) Page 3 of 8 olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications) Mood and Affect: Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset) Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry,