Ms. Janet Steel is a 26-year-old female with a History of HTN, Anxiety, Asthma, Hypochondria and PCOS. She was admitted to Millwood Hospital due to a Panic Attack she experienced 1 month ago. She was initially admitted to JPS psych unit, was discharged home but she is still unstable at this time. The patient has been complaining of having a wound and pain (level 6) under her left foot, but there is no wound under her left foot. The patient’s mother is her support system and Responsible Party. When the charge nurse entered the room to ask the reason for admission, the patient stated “I have severe anxiety and I had a panic attack last month. I am having pain under my left foot because I have a wound”. The charge nurse did a head to toe assessment, but there is no wound under her left foot. The family indicated that the patient will often complain of having something wrong with her all the time. She has been going to the hospital every week for the last 6 months and the physicians diagnosed her with Hypochondria. The patient has been very restless and anxious. She has been very uncooperative with care because she thinks everyone is going to hurt the wound on her left foot, that does not exist. She has a flat affect and is very anxious. She has very soft speech and a medium tone. She denies having any homicidal, suicidal, visual or auditory hallucinations. She is having delusions about the wound on her left foot, that does not exist. Her perception is that she is in lots of pain due to a wound that does not exist per the charge nurse assessment. Her thought processes are illogical. She is alert and oriented x 2, has moderate insight and judgement, is independently ambulatory and is able to toilet herself. She is continent of bowel and bladder. She is non-denominational and does not attend church regularly. She is on a Regular diet with thin liquids. She has good dentition. She has good health and sleeps for 6 hours every night. She does not attend group activities; she has abused marijuana in the past 3 months. She finished Highschool. She plans to go home with her mother upon discharge.

Medication List:

Seroquel 25mg 1 tab PO BID

Xanax 1 mg 1 tab PO q12 hours PRN

Lisinopril 10mg 1 tab PO QD

Acetaminophen 325mg 1 tab PO q4 hours PRN

Metformin 500mg 1 tab PO QD

Vital signs:

VS: 98.6°, 110/74, 72, 18, 99% ra

Objective Data

Alert and Oriented X 2

Normal Dentition

Height 5ft 10in; Weight 135lb.

Cardiovascular: S1, S2, S3 present; all peripheral pulses palpable

Respiratory: Normal lung sounds in all lobes

Gastrointestinal: BS present in all 4 quadrants.


Test Results Ref. Range Units

Sodium 139 137-145 mmol/L

Potassium 3.7 3.5-5.3 mmol/L

Chloride 101 98-107 mmol/L

Carbon dioxide 24 22-30 mmol/L

Anion gap 13.0 7.0-16.0 mmol/L

Creatinine 1.20 0.66-1.25 mg/dL

Estimated GFR Non AFR American 100 >60 ml/min/1.73m2

Anion gap 12 7.0- 16.0 mmol/L

Blood Urea Nitrogen (BUN) 28 9-20 mg/dL

WBC: 8.0 3.4 -10.8 x10E3/ul





Patient Initials

Date of Admission

Legal Status

(Vol, 5150, 5250, Conservatorship)

Patient DOB


Chronological and Apparent Age





Temp (location)

Pulse (location)


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



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)

Gait and Motor Coordination

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


(slouched, erect),

any noticeable mannerisms or gestures

Level of Participation in the Program/Activity

(Group attendance and milieu participation, exercise)

Manner and Approach

Interpersonal Characteristics and

Approach to Evaluation

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

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.


(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)

Orientation, Alertness, and Thought Process

Recall and Memory

(recalls recent and past events in their personal history). Recalls three words (e.g., Cadillac, zebra, and purple)


(person, place, time, presidents, your name)


(sleepy, alert, dull and uninterested, highly distractible)


(responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)

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)

Thought Processes

(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

Hallucinations and Delusions

(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)

Judgment and Insight

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

Mood and Affect:

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.


(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)

Response to Failure on Test Items

(unaware, frustrated, anxious, obsessed, unaffected)


(poor, effected by substance use)


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

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

Discharge Plans and Instruction:

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

Teaching Assessment and Client / Family Education:

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

Include barriers to learning and preferred learning styles

Pertinent Lab Tests Results

(normal ranges in parentheses)

Rationale for Abnormals

Valproic Acid (50 – 120 mcg/mL)

Lithium (0.5 – 1.2 mEq/L)

Carbamazepine (5 – 12 mcg/mL)

CBC (WBC with diff, ANC, RBC)

Urine Drug Screen

Thyroid Panel

Liver Function (AST/ALT, LHD, Albumin, Bilirubin)

Kidney Function (BUN, creatinine)

Blood Alcohol Level

Diagnostic Test Results

(with dates)

Rationale for Abnormals

Substance Abuse and other Addictions

(gambling, sex, shopping, smoking)


Amount / Frequency:


Last Used:

Withdrawal Symptoms:


Amount / Frequency:


Last Used:

Withdrawal Symptoms:

C.A.G.E. Questionnaire

Have you ever felt you should cut down on your drinking?

Yes / No

Have people annoyed you by criticizing your drinking?

Yes / No

Have you ever felt bad or guilty about your drinking?

Yes / No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Yes / No

Abnormal Involuntary Movements

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

I: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,

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

0 1 2 3 4

II: Extremity Movements:

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

0 1 2 3 4

III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)

0 1 2 3 4

IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)

0 1 2 3 4

V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)

Yes No



As evidenced by



Related to

Signs and



Minimum of 2 NANDA – actual and/or potential.

Include etiology and signs and symptoms.


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

Rationales for interventions

(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:














Nursing Diagnosis Definition:















Generic / Trade

Class/Rationale for the patient

Dose/Route/ Time (Frequency)

Range / Therapeutic Levels

Mechanism of action / Onset of action

Common side effects / Food and drug interaction

Nursing considerations specific to this patient

Course: NURS 223L


Page 1 of 8


Page 8 of 8

Healthcare Policy