NURS 223L - Psychiatric Nursing Process Worksheet (2).docx...

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Course: NURS 223LPSYCHIATRIC NURSING PROCESS WORKSHEET:Daily Charting 1Student Name:Gerald Bauzon_Date:09/29/2020Client History:Name (initials only):_MH__ Age: ___N/A__ Gender: __M___ Unit: _____ Date of Admission:___09/29/2020__Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con):N/A5150 Advisement (quote): N/APsychiatric Diagnosis: BIPOLAR DISORDERMedical and (or) physical problems: N/APsychosocial and Environmental Problems: N/A(problems with primary support group, education, occupational, housing, economic, access to health care)Presenting ProblemReason for hospitalization (Client’s own words):Suicide attempt, manic, hypermania episode, anddepression. M.H. did not feel in the morning when he woke up in the morning. He talked about having a grayfog in his head that occurs often. He struggles with daily task and sometimes getting up in the morning can bea challenging task. His intervention such as meditation, and social conversation with others make it throughthe day. Majority of the time, M.H, feels hopelessness, helplessness, and guilt. He recalls that six years ago,M.H. reached a breaking point and attempted suicide. During his manic phase, he is usually full of energy,feels creative and creates music. One day he decided to use that energy and tried to end his life. M.H. hasbeen working hard to control his depression without any invasive treatment and only uses sports andbreathing exercise that has been shown to prove effective.Current stressors: anxiety due to upcoming speech presentation.Mental Status ExaminationAppearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavymakeup): Ungroomed appearance, long hair, scruffy facial hair, pt. wearing clean clothes.

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Term
Spring
Professor
Emghaboo

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