KenJacksonChart.docx

RN Progress Note

Shift: D Day Evening

Orientation

Person Place Time Situation

Cognition

Alert Patient Asleep Disorganized Non-Verbal Concrete Thought Blocking
Poor Concentration Poor Judgment Confused Racing Thoughts Minimize Issues

Mood/Affect

Appropriate Cheerful Bright Euphoric Neutral Agitated Hostile Irritable
Reactive Labile Fearful Anxious Sad Tearful Poor Motivation Hopeless Flat Blunted Restricted Patient Asleep Non-Verbal

Behavior

Participating Cooperative Guarded Withdrawn Isolative Avoiding eye contact
Lethargic Crying Pacing Oppositional/Defiant Destroying Property Agitated
Angry Outbursts Impulsive lntrusive Hyperactive Pressured Speech Resistive to Care Disorganized Sexually Inappropriate Verbally Aggressive Physically Aggressive Eyes closed Resting Harming Self by:
Other (specify):

Speech

Coherent Incoherent Slurred Hyper Rapid Delayed Loud Yelling/Screaming Soft Mute Repetitive Non-Verbal

Psychotic
Symptoms

NIA Hallucinations: Auditory Visual Tactile Olfactory Preoccupied Delusions: Somatic Paranoid Grandiose Persecution

Physical Problem

a None Cardiac Respiratory

GU

No Pain a Pain (1-10) NO HURT HURTS HURTSMORE EVEN HURTSMORE WHOLE HURTSLOT WORSTHURTS
Description of Pain: Dull Sharp Aching Burning Stabbing Shooting Other:

Aggravates Pain: Physical Activity D Sitting 13 Standing Walking O Other:
Effects of pain on daily-activities: Cl None Somewhat limiting Very limiting Interventions implemented«.

Medication administered within last 24 hours: Yes No
Educated patient on alternative interventions for pain management: Refused alternative options
Positioning Hot/Cold therapy Guided imagery Exercise/Stretching Deep breathing
Refocusing/Distraction Music therapy Modified environment Other:

Pain

Medical Issues Addressed

Injuries: N/A yes Consults: N/A Yes Abnormal Labs: N/A. Yes
Tests: N/A Yes

Skin
Assessment

No Wound Wound Description: Location:

Wound Care:

Output

GU: Normal Incontinent Urgency Dysuria
Gl: Bowel Movement: Yes No Normal Nausea Vomiting Diarrhea Constipation

Medication

Compliant Non-Compliant
Side effects/Adverse drug reactions:

RN Teaching/ Education

Coping Skills: Yes No Hand Hygiene: Yes No Health Issues: Yes No
Medication teaching provided to: Patient Parent Method: Handout 1:1 Instruction

Observation Level

Q15 1:1 Line of sight

Precautions

Suicide If currently on Suicide precautions, complete Daily Suicide Risk Assessment. If problem is newly identified, initiate suicide protocol and contact therapist.
Self-Harm Assault Homicide Elopement Seizure Fall Medical Risk
Arson Sexual Victimization Sexual Aggression NONE

Continue documentation on Backside
RN Signature: RN Date: Time:

Revised 5/2018 Page 1 of 2
RN Progress Note
Assigned RN must explain physical/mental status, behavior, nursing interventions, response to interventions, and plan:

Ken Jackson is a 21 year old male, came to mental health clinic for follow up visit, escorted by his sister Emily.
Patient was last seen at the clinic about 6 months ago. Patient is alert and oriented x4, At 6 month ago from the last visit, patient was diagnosed with schezophrenia and Risperidone was prescribed. Patient stopped taking the medication a while ago, due to thought of “His pharmacist trying to poison him”. Patient denies any medical illness. Patient has lost 20lbs since last visit, stated he is on regular diet but recently has lost appetite. Patient stated, he drinks 1-2 beers in a week at Bingo and has reported being on cocaine for the past one year. Patient denies presently smoking, stated, he stopped smoking 2 years ago. Patient reported hallucinations, delusions, disorganzed speech, and impaired cognitive ability behavior. New presciption of Paliperidone injection was given to patient today and another dose in 2 weeks and then monthly injections was ed. Patient urine was also collected for drug screening, result came back positive for Marijuana and negative of cocaine. Patient was educated on stress management techniques, such as breathing exercise, relaxation techniques, meditaion and also diet management, by eating 3 meals daily to maintain weight. Also patient was provided with information about smoking cessation, drug recreational and referal to group therapy.

RN Signature: RN Date Time:

Revised 5/2018 Page 2 of2