Download Psychiatric Nursing Assessment

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):
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How does the client perceive the precipitation event?
Irrelevant-No response___________________________________________________________
Benign-Positive_________________________________________________________________
B. IDENTIFYING INFORMATION/REASON FOR ADMISSION (precipitating event, cause for admission)
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C. HISTORY OF PRESENT ILLNESS & PRESENT PRESENTATION:
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D. DRUG ALLERGIES-- FOOD ALLERGIES-- OTHER NON-FOOD ALLERGIES
Describe the reaction
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E. CURRENT MEDICATIONS:
Medication /Dose/Frequency/Adverse reactions/Nursing considerations/Patient education
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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:
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Comments/Clarification:
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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:
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VII. FAMILY PSYCHIATRIC/MEDICAL HISTORY
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VIII. MENTAL STATUS EXAM
Appearance
■ Casually Dressed ■ Disheveled ■ Well-groomed ■ Fearful
■ Restless ■ Distracted ■ Tense posture ■ Other___________________
Narrative Description:
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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:
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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:
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CONFIDENTIALMAYONLYBEDISCLOSEDWITHPROPERAUTHORIZ
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:
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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:
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Perceptions
■ Depersonalization ■ Derealization ■ Auditory Hallucinations ■ Visual Hallucinations
■ Command Hallucinations ■ Somatic Hallucinations ■ Tactile Hallucinations
■ Other ______________
■ Content:
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■ Illusions:
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Narrative Description:
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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:
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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:
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Thought Progression (Thought organization or form of thought)
■ Loose association ■ Circumstantially ■ Tangentially ■ Blocking ■ Flight of ideas ■ Neologisms
■ Clang associations ■ Word salad ■ Perserveration ■ Echolalia
Cognition
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■ Immediate recall
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■ Recent memory
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■ Remote memory
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■ Concentration
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■ Judgment: (is the client able to solve problems and make decisions in a socially acceptable manner?)
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■Abstraction (As the client, “What brought you to this hospital?”)
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■ Intelligence (How does the client learn?)
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■ 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?
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■ Sensorium (Level of alertness and consciousness)
Alert
Stuporous
Comatose
Lethargic
Delirium
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■ Orientation to Person, Time and Place
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■ 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?
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■ 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:
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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:
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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:
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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:
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NFIDENTIAMAYONLYBEDISCLOSEDWITHPROPERAUTHORIZA
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:
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YONLYBEDISCLOSEDWITHPROPERAUTHORIZATION.
HABITS (check all that apply)
■ Smoke: Packs daily _______________ How long? __________Interested in stopping? ■ Yes ■ No
■ Coffee: Cups daily________________ Other caffeine:
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■ Alcohol: Type ____________________ Amount: _____________ Drugs: ________________
■ Sleep: Difficulty falling asleep ______________________ Snoring: _____________________
■ Other:
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PAIN IDENTIFICATION SCREENING
Does patient report any pain? ■ Yes ■ No
If checked yes, assess for the following:
Location:
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Intensity (scale of 1–10):
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Pain Character:
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Frequency:
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Duration:
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Pain Modifiers:
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Does pain radiate to another location? ■ Yes ■ No
If yes explain:
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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
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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
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greatest supports?
Review of Physical Exam and History:
Abnormal laboratory values?
Patient’s weigh ___________ High_______________
Diet_________________________
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
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