NURS 3381 Nursing Care Plan Psychiatric Diagnoses & Medical Problems Worksheet.

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NURS 3381 Nursing Care Plan Psychiatric Diagnoses & Medical Problems Worksheet.

NURS 3381 Nursing Care Plan Psychiatric Diagnoses & Medical Problems Worksheet.


A patient had problems with the wife about thier household (children), the wife felt negleted and threaten to go on divorce, because of these, the husband pulled gun on himself but mixed. complete the form with refrences


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Student Name__________________________________           Client Initials: ________       Age________

S:SituationPsychiatric Diagnoses Medical ProblemsCurrent issues (Chief Complaint, Precipitating Factors)
B:BackgroundPsychosocial/Environmental History (Predisposing Factors):  Neurological / Genetic History (Predisposing Factors): 
A:AssessmentMental Status Assessment• Appearance:• Behavior:• Speech:• Mood• Affect:• Cognition:• Thought Process:• Thought Content:• Perceptual Disturbances:• Insight/Judgment:• Suicide ideation:• Homicide ideation:• Aggression:• Psychosis:• Falls:• Substance use: Maslow Hierarchy of Needs/Rational (top 2 priorities)1.2. Current Medications (Include Therapeutic & Side Effects)1.2.3.Current Psychiatric Therapies
R: Recommended Actions1.Priority Problem Statement/Nursing DiagnosisSmart Goals:S/TL/TNursing InterventionsS/T1.2.L/T1.2.2. Problem Statement /Nursing DiagnosisSmart Goals:S/TL/TNursing InterventionsS/T1.2.L/T1.2.
Patient Teaching:Resources and/or Referrals needed:


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