Nursing Process Care Plan Format

Patient’s Initials: ____________________

Student’s Name: ____________________
Date: _______________________

Assessment Nursing Diagnosis Planning Implementation Rationale Behind Evaluation

Intervention
Patient had a Deficient - By discharge - Medications are - Patient expressed
suicide attempt knowledge related patient and - Inform patient and usually indicated and demonstrated
with drug overdose. to unfamiliarity significant other significant other for treatment. They she is free of
with causes, signs will verbalize that depression is do not solve the suicidal thinking.
Patient complaints and symptoms and accurate treatable. stressor or - Patient
of low back pain treatment of information about - Encourage small, problems that may demonstrated
and headaches with depression. possible causes of high-calorie, and have precipitated progress in dealing
increasing difficulty depression, signs high-protein snacks the depression, but with hopelessness
sleeping. Hopelessness and symptoms and and fluids they provide the and frustrations,
related to stresses use of medications, frequently energy to deal with participates in
and basic psychotherapy as throughout the day these issues. work/self-care
She is hopeless
symptoms of treatment. and evening. Antidepressants or activities at own
with feelings of
depression. - Patient will - Provide a safe psychotherapy or a pace, and verbalizes
frustration.
verbalize feelings environment for the combination of a sense of progress
Self-care deficit and acceptance of client. both generally toward resolution
VS: T=98.6°F; related to severe life situations over - Continually assess of hope for the
relieves the
HR=100bpm anxiety as which she has no the client’s future.
symptoms of
RR: 20 bpm and evidenced by control and does potential for - Patient
depression in
BP:110/70 mmHg. weight loss. not demonstrate suicide. Always demonstrates
weeks.
suicidality. remain aware of - Teach about the behaviors
The patient was - Patient will mechanism of consistent with
assessed for gradually return to this suicide action, side effects, increased self-
depression in the weight consistent potential. and special esteem.
ER using the for height and age - Observe the client instructions - Patient verbalizes
Hamilton or baseline before closely, especially regarding accurate
Depression Scale illness. under the following medications. information about
every other day. - Administer the circumstances: - Minimize weight prescribed
antidepressant After antidepressant loss, constipation, medications and
She has lost 10 lbs medicine as doctor medication, after and dehydration. their potential side
in the past month ordered. any dramatic effects.
- It is vital to
due to lack of - Monitor patient behavioral change.
provide patients
appetite. suicidal thought- - Reorient the client
with resources for
observations every to person, place,
support and safety
15 minutes. and time as
when thoughts and
- Complete the indicated.
feelings about
Hamilton mental - Teach the client
suicide become
health depression about positive
difficult to manage.
scale every other coping strategies
day. and stress
- Provide Suicide management skills,
precautions and such as increasing
safety checks- physical exercise,
continually assess expressing feelings
the client for verbally or in a
potential of suicide. journal, or
meditation
techniques.
Patient background:

Susan Jackman is a 35-year-old female who presented to the ER accompanied by her husband, Mr. Charles Jackman. Mr. Jackman reported that upon his return
home today, he found his wife crying on the bathroom floor surrounded by several empty pill bottles. He reported that his wife told him ‘’she can’t live like this’’; and
‘’she simply cannot function this way anymore’’. She has been admitted from the ER with major depression and suicide attempt.