Psychiatric Nursing Assessment

GENERAL INFORMATION:

Patients/Client’s initials: ______Age:______Gender______

Date of Admission:______Dominate Language:______Marital Status:______

Advanced Directive: Medical Yes ■ No ■ Psychiatric Yes ■ No ■

Legal Status: Detainer ■ KROL ■ 30 day Eval ■ Means ■ Other ■

A. CHIEF PSYCHIATRIC COMPLAINT/PRESENTING PROBLEM (As stated by the patient):

______

How does the client perceive the precipitation event?

Irrelevant-No response______

Benign-Positive______

B. IDENTIFYING INFORMATION/REASON FOR ADMISSION (precipitating event, cause for admission)

______

C. HISTORY OF PRESENT ILLNESS & PRESENT PRESENTATION:

______

D. DRUG ALLERGIES-- FOOD ALLERGIES-- OTHER NON-FOOD ALLERGIES

Describe the reaction

______

E. CURRENT MEDICATIONS:

Medication /Dose/Frequency/Adverse reactions/Nursing considerations/Patient education

______

______ ______------Y O N

______

SUBSTANCE ABUSE HISTORY

Active Use Within Past 30 Days Yes ■ No ■

Current admission is related to abuse of Alcohol or drugs Yes ■ No ■

List drugs/substances used:

______

Comments/Clarification: ______

VI. SOCIAL HISTORY/STRESSORS CONTRIBUTING TO ADMISSION

■ Family ■ Marital ■ Separation/divorce ■ Relationship issues

■ Legal ■ Financial ■ School/employment ■ Frequent moved

■ Social ■ Medical ■ Death/loss ■ Incarceration

■ Institutionalization

Abuse History:

■ Physical ■ Emotional ■ Sexual ■ Domestic violence ■ None

EXPLAIN BELOW:

______

VII. FAMILY PSYCHIATRIC/MEDICAL HISTORY

______

VIII. MENTAL STATUS EXAM

Appearance

■ Casually Dressed ■ Disheveled ■ Well-groomed ■ Fearful

■ Restless ■ Distracted ■ Tense posture ■ Other______

Narrative Description: ______

______

Behavior & Attitude and Reaction to Interview:

■ Calm & Cooperative ■ Attentive ■ Interested ■ Ingratiating ■

■ Full Eye Contact ■ Minimal Eye Contact ■ Playful ■ Seductive

■ Uncooperative ■ Apathetic ■ Guarded ■ Sarcastic

■ Hostile ■ Paranoid ■ Evasive ■ Defensive

■ Gestures ■ Rigid ■ Combative ■ Belligerent

■ Appropriate/relaxed ■ Hyperactive ■ Agitated ■ Mannerisms

■ Tics ■ Psychomotor ■ Other ______■ Other ______

Describe the client’s behavior that justifies your choice: ______

______

Speech

■ Normal Tone & Volume ■ Spontaneous ■ Slow ■ Delayed Reaction Time

■ Hesitant ■ Rapid ■ Productive ■ Under Productive

■ Repetitive ■ Pressured ■ Soft ■ Loud

■ Monotonous ■ Emotional ■ Dysarthric ■ Slurred

■ Mumbles ■ Stutter ■ Mute ■ Other ______

Describe the client’s behavior that justifies your choice: ______

______

C O N F I D E N T I A L M A Y O N L Y B E D I S C L O S E D W I T H P R O P E R A U T H O R I Z Mood

■ Euthymic ■ Despairing ■ Labile ■ Elated ■ Irritable ■ Hostility ■ Suspiciousness ■ Happy ■ Sad

■ Guilty ■ Irritable ■ Depressed ■ Self-contemptuous ■ Fearful ■ Dejection

■ Dysphoric ■ Expansive ■ Euphoric ■ Anxious

■ Angry ■ Other ______■ Other ______■ Other ______

Describe the client’s behavior that justifies your choice: ______

Affect

■ Appropriate ■ Labile ■ Inappropriate ■ Constricted ■

■ Blunted ■ Flat ■ Depressed ■ Shallow

■ Broad ■ Expansive ■ Anhedonic ■ Fearful

■ Anxious ■ Other ______■ Other ______■ Other ______

Describe the client’s behavior that justifies your choice: ______

Perceptions

■ Depersonalization ■ Derealization ■ Auditory Hallucinations ■ Visual Hallucinations

■ Command Hallucinations ■ Somatic Hallucinations ■ Tactile Hallucinations

■ Other ______

■ Content: ______

■ Illusions: ______

Narrative Description: ______

______

Thought process

Rate of Thought: Slowness or Rapidity of thought (Spontaneous, slow, racing or paucity)

■ Goal directed ■ Organized ■ Disorganized ■ Circumstantial

■ Tangential ■ Blocking ■ Flight of ideas ■ Poverty of Ideas

■ Loose Associations ■ Perseverative ■ Incoherent ■ Irrelevant

■ Confabulation ■ Distractibility ■ Obsessions Religiosity

■ Meaningless responses ■

■ Other ______■ Other ______:

Describe the client’s behavior that justifies your choice: ______

______

Thought content

■ Suicidal Ideas ■ Suicidal Plan ■ Suicidal Urges/Intent ■ Homicidal Ideation

■ Homicidal Plan ■ Homicidal Intent ■ Assaultive Ideation

■ Persecutory Delusions ■ Paranoid Delusions ■ Grandiose Delusions ■ Bizarre Delusions

■ Delusions: *Reference * Somatic * Somatic* Nihilistic * Control or influence

■ Preoccupations ■ Obsessions ■ Compulsions ■ Phobias ■ Magical thinking ■Meaningless response

■ Other ______■ Other ______■ Other ______■ Other ______

Describe the client’s behavior that justifies your choice: ______

______

Thought Progression (Thought organization or form of thought)

■ Loose association ■ Circumstantially ■ Tangentially ■ Blocking ■ Flight of ideas ■ Neologisms

■ Clang associations ■ Word salad ■ Perserveration ■ Echolalia

Cognition

■ Immediate recall l______

■ Recent memory ______

■ Remote memory ______

■ Concentration ______

■ Judgment: (is the client able to solve problems and make decisions in a socially acceptable manner?) ______

■Abstraction (As the client, “What brought you to this hospital?”)

______

■ Intelligence (How does the client learn?)

______

■ Insight

Does the client understanding his/her illness and the current limitations?

Does the client think help is need?

Does the client understand what could happen if she or he does not seek and accept medical

help?

______

■ Sensorium (Level of alertness and consciousness)

Alert Stuporous Comatose Lethargic Delirium ______

■ Orientation to Person, Time and Place

______

■ Impulse Control (ask the client if there are times that he/she does something without thinking and wishes that they had not. Does it happen often?

______

■ General Fund of Knowledge /Educational background:

■ Secondary Cognitive Appraisal:

Availability of Coping Strategies

Perceived effectiveness of coping strategies

Is response to stress adaptive or maladaptive? Give a justification for your answer.

■ Religious beliefs/practices:______

* Spiritual (purpose and meaning in life)______

______ A Y O

1. Special diet needed based on religious beliefs ■ Yes ■ No

2. Distinctive usage of religious phrases, ideas, themes or characters ■ Yes ■ No

3. Claims his/her hospitalization is a result of a religious experience or the result

of a stated religious purpose (e.g., God’s or the Devil’s plan) ■ Yes ■ No

4. Expresses delusional thoughts which contain religious ideas ■ Yes ■ No

5. Participates in regular (daily or weekly) religious practices ■ Yes ■ No

Comments/Clarification:

Posture:

■ Erect ■ Relaxed stooped ■ Slouched ■ Arms held close to body sides ■ Sitting ■ Lying

■ Open/close

■ Describe the client’s behavior that justifies your choice:______

Motor Activity:

■ Tremors ■ Tics ■ Grimaces ■ Rigidity or limpness of extremities ■ Gesture ■ Purposeful

■ Restlessness ■ Overactive ■ Underactive ■ Echopraxia ■ Apraxia ■ Hypomania

■ Mania ■ Mannerism ■ Motor Retardation (catatonia or slow movements) ■ Agitation

■ Freedom of Movement ■ Dystonia ■ Akathisia ■ Akinesia ■ Dyskinesia

■ Pakinsonia movement

Describe the Client’s behavior that justifies your choice:

______

A. Violence Risk Assessment (review chart)

Describe, if known, specific dangers that patient presents to self and/or others (including dates & details):

1. Reported history of violent legal offenses ■ Yes ■ No ■ Incomplete information

2. Reported history of violence towards others ■ Yes ■ No ■ Incomplete information

3. Reported history of damage to property ■ Yes ■ No ■ Incomplete information

4. Expresses current violent ideation ■ Yes ■ No ■ Incomplete information

5. Expresses violent intent/threats to harm ■ Yes ■ No ■ Incomplete information

6. Expresses command hallucinations to harm others ■ Yes ■ No ■ Incomplete information

7. Expresses persecutory delusions ■ Yes ■ No ■ Incomplete information

Comments/Clarification:

B. Sexual Aggression Risk Assessment (review chart)

Describe, if known, specific dangers that patient presents to self and/or others.

1. History of sex offenses ■ Yes ■ No ■ Incomplete information

2. Documented history of inappropriate sexual ■ Yes ■ No ■ Incomplete information

3. Sexual preoccupation ■ Yes ■ No ■ Incomplete information

4. Delusions and/or hallucinations with ■ Yes ■ No ■ Incomplete information

5. Past diagnosis of paraphilia ■ Yes ■ No ■ Incomplete information

6. History of sexual abuse as a child ■ Yes ■ No ■ Incomplete information

7. Diagnosis of Anti-social Personality (psychopathy) ■ Yes ■ No ■ Incomplete information

Comments/Clarification:

______

C. Sexual victim Risk Assessment (review chart)

Describe, if known, specific dangers that patient presents to self and/or others (including dates & details):

1. Compromised IQ ■ Yes ■ No ■ Incomplete information

2. Sexual preoccupation ■ Yes ■ No ■ Incomplete information

3. Confused/disoriented/helpless/unable to defend self ■ Yes ■ No ■ Incomplete information

4. Highly dependent with strong needs for ■ Yes ■ No ■ Incomplete information

5. History of being victim of rape/attempted rape ■ Yes ■ No ■ Incomplete information

Comments/Clarification:

______ N F I D E N T I A M A Y O N L Y B E D I S C L O S E D W I T H P R O P E R A U T H O R I Z A

D. Suicide Risk Screening (review chart)

Describe, if known, specific dangers that patient presents to self and/or others.

Below are preliminary ESTIMATES of risk based on available background information, previous discharge summaries,

significant others, etc. and current screening interview:

1. Reported history of suicidal ideation ■ Yes ■ No ■ Incomplete information

2. Reported history of suicide gestures/attempts ■ Yes ■ No ■ Incomplete information

3. Expresses current suicidal ideation ■ Yes ■ No ■ Incomplete information

4. Expresses current plan ■ Yes ■ No ■ Incomplete information

5. Expresses current intent to suicide ■ Yes ■ No ■ Incomplete information

6. Expresses self-injurious command hallucinations ■ Yes ■ No ■ Incomplete information

7. Has moderate to severe depression. ■ Yes ■ No ■ Incomplete information

Comments/Clarification:

______Y O N L Y B E D I S C L O S E D W I T H P R O P E R A U T H O R I Z A T I O N .

HABITS (check all that apply)

■ Smoke: Packs daily ______How long? ______Interested in stopping? ■ Yes ■ No

■ Coffee: Cups daily______Other caffeine: ______

■ Alcohol: Type ______Amount: ______Drugs: ______

■ Sleep: Difficulty falling asleep ______Snoring: ______

■ Other:

______

PAIN IDENTIFICATION SCREENING

Does patient report any pain? ■ Yes ■ No

If checked yes, assess for the following:

Location: ______

Intensity (scale of 1–10): ______

Pain Character: ______

Frequency: ______

Duration: ______

Pain Modifiers: ______

Does pain radiate to another location? ■ Yes ■ No

If yes explain: ______

DX at Adm.

AXIS I: ______

AXIS II: ______

AXIS III: ______

AXIS IV:______

AXISV:______

DX current

AXIS I: ______

AXIS II: ______

AXIS III: ______

AXIS IV:______

AXIS V:

STRENGTHS

■ Insight into illness ■ Health consciousness or awareness

■ Good Impulse control ■ Has steady income/financial resources

■ Problem solving/coping skills ■ Supportive and caring family

■ Motivated for treatment ■ Good relationship with spouse/significant other

■ Able to communicate ■ Intelligence or educational achievement

■ Other ______

Weaknesses

______

Psychosocial Assessment

■ Describe relationships between you and each family member

■ Environmental (type of neighborhood, living arrangements, # of people, # of rooms, etc.)

■ Financial/personal responsibility for health.

■ Significant losses/changes.

■ Occupational history? When did you last work? Tell me about your job? Current job status

■ Previous pattern of coping with stress (physical violence, drinking, sleeping, problem solving, praying, ect.)

■ Hobbies? Group involvement? Volunteering?

■ Support systems: How does this problem relate to other problems the client has had in the past, Who is your

greatest supports?

Review of Physical Exam and History:

Abnormal laboratory values?

Patient’s weigh HighDiet__

Therapeutic Activities:

State of Development (Erikson)

Theoretically:______

Behaviorally:______

Rationale:______

Client’s Goals:______

Medication Interest:______

How does the patient feel about her/his medication?

Client’s readiness to change:______

Pre-contemplation, Contemplation, Preparation, Action, Maintenance/Relapse Prevention and Relapse

Psychiatric Nursing Assessment