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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Pain (Numeric 1-10): Location:
Character:
How would you describe your health:
Excellent
Average
Good Poor
Medical and/or physical problems:
Nutritional Status:
Diet:
Feeding supplement: Swallowing difficulty:
Chewing
difficulty
Physical Assessment:
Substance Abuse:
Substance
Amount/Frequency
Duration
Last Used
Signs of withdrawal symptoms:
Additional data:
Based on the nursing assessment, list three identified nursing diagnoses according to priorities:
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Psychiatric Nursing Care Plan
Nursing Diagnosis (NANDA):
Nursing Diagnosis Priority #1
RATIONALE FOR
PRIORITY DX:
Nursing Diagnosis Priority # 2:
Nursing Diagnosis Priority#3:
Definition of the
Diagnosed
Psychiatric
Disorder(s):
(Cite APA format)
Related to:
(Etiology)
As Evidenced by:
(Signs and
Symptoms)
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Developmental
Stage:
Psychopathology:
Please Describe the
Mental Pathology of the
Disease Process.
Assessment
1. Subjective Data:
2. Objective Data:
Nursing Outcome
The patient will:
Criteria (NOC): Be
Realistic with
Measurable Timeline.
Please Provide a
Minimum of Three
Patient Centered
Nursing Care
Outcomes
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Discharge
Planning:
Intervention (NIC)
Interventions (NIC):
Rationale:
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Evaluation
interventions?
Was the desired outcome
achieved?
Yes ( ) No ( )
If no, what revisions (either to
desired
outcomes
and/or
interventions would you make?
Additional Re-Assessments:
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