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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 ________________________________________________________________________________ ________________________________________________________________________________ 1 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 ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 2 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: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 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: ________________________________________________________________________________ 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: _______________________________________________________________________________ 3 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 4 ■ 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: 5 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: 6 ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 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: ________________________________________________________________________________ YONLYBEDISCLOSEDWITHPROPERAUTHORIZATION. 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: ________________________________________________________________________________ 7 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 8 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 9