Student:
Date:
Psychiatric Nursing Care Plan
Patient Initials: HIPPA
Age:
Admit Date:
Marital Status:
Gender:
Children/ Ages:
Legal Status:
Occupational:
Socioeconomic/ Cultural Affiliation:
History of Psychiatric Illness:
Medical History:
Previous Psychiatric Admission/Outpatient Mental Health Services: Living
Arrangements:
Support System:
Reason for Psychiatric Care Admission: Current
Stressors:
Substance Abuse:
Level of Participation in the unit:
Teaching Needs: Discharge Plans:
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Mental Status Examination
Appearance:
Behavior:
Psychotic symptoms:
Affect:
Mood:
Speech:
Thought Content:
Risk Potential Suicide Ideation
Homicidal Ideation: Hypersexual:
Fall Risk:
Elopement risk:
Thought Process:
Cognition:
Insight:
Judgment
Psychomotor activity: Coordination/gait/notable
movement:
Cultural Issues and Religious Affiliation: Familial
Concerns:
Current Health (Axis III)
Vital Signs T:
P:
R:
BP:
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