Nursing

CASE PRESENTATION

Dx:

Brief History :

Family History :

Spiritual/Cultural Needs :

Patient Educational Needs :

Systems Review :

General Medical Condition:

Allergies:

GYN: 

Past Medical History:

Past Surgical History: 

Family Medical History:

Substance Abuse:

Home Medication Review:

Review of Systems:

Physical Examination:

· VITAL SIGNS –

· Ht.:

· Wt.: BMI:

· BP:

· Pulse:

· RR:

· Temp:

· Pain:

· Neurological –

· Head

· Eyes

· ENT/Mouth –

· Neck –

· Respiratory –

· Cardiovascular –

· Chest/Breast –

· GI –

· Extremities –

· Lymph –

· Musculoskeletal –

· Skin –

Labs - performed on

Past Psychiatric History :

Mental Status Exam :

· Appearance and General Behavior

· Sensorium

· Speech

· Mood and Affect

· Thought Process and Perception (e.g., logical, coherent, tangential, flight of ideas, delusions, hallucinations)-

· Attitude and Insight (e.g. emotional tone)–

*format is consistent with hospital categorization of the mental status exam

Safety Assessment :

· Elopement –

· Fall Risk –

· Braden Scale –

· (GAF) Global Assessment of Functioning Scale –

Suicide Assessment :

A SAD PERSONS suicide assessment was conducted on admission, the patient responded as follows:

· Within the last 48hrs/1month were things ever so bad that you had thoughts that life was not worth living, that you would be better off dead

· Within the last 48hrs/1month have you had thoughts about suicide; if so, how long do they last? Patient stated

· Do you have a plan for doing this? Patient stated

· Does the patient have access to firearms/weapons?

· Does the patient seem to be answering honestly and fully?

Socio-environmental Assessment : 

Student Client Evidence-based Interaction Toward Achievement of Outcome:

One priority client outcome:

Nursing Intervention and Rationales:

Evaluation: