Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications

(^) 13. Medical diagnosis 3. Posture^ 10. Allergies 2. Hygiene 1. Grooming and dress 4. Height and weight 11. Special diet considerationsAppearance● 12. Chief complaint (^) 5. Level of eye contact d. Neat; unkempt a. Perform accurate measurements. GENERAL DESCRIPTION a. Note unusual modes of dress. b. Evidence of soiled clothing? c. Use of makeup a. Note evidence of body or breath odor. b. Condition of skin, fi a. Note if standing upright, rigid, slumped over. b. What seems to be the problem? a. Do you have any special diet requirements? a. Are you allergic to anything? b. Foods? Medications? b. Diabetic? Low sodium? a. For what reason did you come for help today? ngernails APPENDIX M ●^611

2506_Appendix_M_610-617.indd 611 2506 _AppendixM 610 - 617 8. Evaluation of client’s appearance compared with chronologi- 7. Evidence of scars, tattoos, or other distinguishing skin 6. Hair color and texture^ Motor Activity 1. Tremors.indd c. Rashes? a. Intermittent?cal age. c. Sustained and intense? a. Is hair clean and healthy-looking? b. Occasional and fl a. Do hands or legs tremble? b. Greasy, matted, tangled? d. No eye contact? marks a. Note any evidence of swelling or bruises. b. Birth marks? 61 • At specifi• Continuously? 1 c times? eeting? 1 10/1/10 9:31:49 AM 0 / 1 / 10 9 : 31 : 49 AM