Care Plan Templates
Care Plan Templates
Care Plan Templates
School of Nursing
Mental Health Nursing Assessment
N/A not applicable
U/A unable to Assess (if this is used, please describe why it would be important)
Client History
I. General History of Client
Initials:
Age:
Sex:
Marital Status:
Unit:
Anger:
Anxiety:
Confusion:
Depression:
Hopelessness:
Powerlessness:
Suspiciousness:
Other:
4) Palpitations:
5) Weight loss or gain:
6) Other:
III. Personal History
A. Previous mental health hospitalizations (in/outpatient, onset, duration, & treatment):
B. Education:
C. Occupation:
1)
2)
3)
4)
Special Skills:
Employed:
Duration:
Company:
Previous Positions & Reasons for leaving:
Military Service (Combat):
D. Support System
1) Family, friends, colleagues, pets, others:
2) Describe a usual day:
E. Interests & Abilities
1) What does the client do in spare time?:
2) Identify strengths, talents:
3) What gives the client pleasure?:
F. Substance Use/Abuse
1) List herbal or OTC medications:
2) Alcohol & Street Drugs (Type, amount, frequency, duration):
3) Prior Rehab- (In/Out patient, date, results):
G. Coping with stress
1) What does the client do when upset?:
2) Whom can the client talk to?:
3) What helps to relieve stress?:
IV. Family History
A. Childhood
1) Who was important when client was growing up?:
2) Any physical or sexual abuse? (Age, duration & offender):
3) Who lived in the home (family/friends):
B. Adolescence
1) Describe feelings during adolescence:
2) Describe peer group, interests & activities:
Facial expressions:
Posture:
Gait:
Blocking:
Concrete Thinking:
Confabulation:
2. Cognitive Ability
Orientation: Person:
Place:
Time:
Student Name:
Client Initials:
ABNORMAL LABORATORY AND DIAGNOSTIC TEST INTERPRETATION
Lab Test
Client Values
High (H) /
Low(L)
Diagnostic Test
Expected
Values
Result
Significance to Client
Care
Appropriate Nursing
Interventions
Appropriate Nursing
Interventions
Pt. Initials:
Date:
Prescribed Dose:
Route Prescribed:
Client Education:
RATIONALE (Evidence-Based)
Not Met