(Vol, 5150, 5250, Conservatorship)

Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement

Biophysical and/or related medical diagnosis

Description of how this diagnosis relates to your patient

With APA citations

Include Rationale Based on the Patient

With APA citations

(nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)

Basic Grooming and Hygiene

(clean, disheveled and whether it is appropriate attire for the weather)

(awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),

posture

(slouched, erect),

any noticeable  mannerisms or gestures

(Group attendance and milieu participation, exercise)

Approach to Evaluation

(oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)

(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.

(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)

(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)

(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)

(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)

(loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).

Values and belief system

(presence, absence, denied visual but admitted 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)

(based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

(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.

(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, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)

(unaware, frustrated, anxious, obsessed, unaffected)

Impulsivity

(poor, effected by substance use)

Anxiety

(note level of anxiety, any behaviors that indicated anxiety, ways they handled it)

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

Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program

(Disease process, medication, coping, relaxation, diet, exercise, hygiene)

Include barriers to learning and preferred learning styles

(normal ranges in parentheses)

(with dates)

(gambling, sex, shopping, smoking)

Amount / Frequency:

Duration:

Last Used:

Withdrawal Symptoms:

Amount / Frequency:

Duration:

Last Used:

Withdrawal Symptoms:

Code:  0 = None   1 = Minimal   2 =  Mild   3 = Moderate   4 = Severe

grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)

     Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.

     Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot

Minimum of 2 NANDA – actual and/or potential.

Include etiology and signs and symptoms.

*Include

definition of the nursing diagnoses with APA citations

Outcome Criteria

Minimum of 2 measureable

goal per diagnosis related to the nursing diagnosis

Minimum of 4

independent and collaborative nursing intervention include further assessment, intervention, and teaching that is related to the outcome criteria

(With APA citations )

Goal Met

Goal not Met

(If not met, what revisions would you make?) How did the patient respond to your interventions

Nursing Diagnosis Definition:

2.

2.

3.

4.

2.

3.

4.

2.

Nursing Diagnosis Definition:

2.

2.

3.

4.

2.

3.

4.

2.

Generic / Trade

(Vol, 5150, 5250, Conservatorship)

Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement

Biophysical and/or related medical diagnosis

Description of how this diagnosis relates to your patient

With APA citations

Include Rationale Based on the Patient

With APA citations

(nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)

Basic Grooming and Hygiene

(clean, disheveled and whether it is appropriate attire for the weather)

(awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),

posture

(slouched, erect),

any noticeable  mannerisms or gestures

(Group attendance and milieu participation, exercise)

Approach to Evaluation

(oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)

(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.

(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)

(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)

(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)

(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)

(loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).

Values and belief system

(presence, absence, denied visual but admitted 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)

(based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

(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.

(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, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)

(unaware, frustrated, anxious, obsessed, unaffected)</p

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.

All Rights Reserved Terms and Conditions
College pals.com Privacy Policy 2010-2018