mental health nursing

Shift: D Day Evening

Orientation

Person Place Time Situation

Cognition

Alert Patient Asleep Disorganized Non-Verbal Concrete Thought Blocking

Poor Concentration Poor Judgment Confused Racing Thoughts Minimize Issues

Mood/Affect

Appropriate Cheerful Bright Euphoric Neutral Agitated Hostile Irritable

Reactive Labile Fearful Anxious Sad Tearful Poor Motivation Hopeless Flat Blunted Restricted Patient Asleep Non-Verbal

Behavior

Participating Cooperative Guarded Withdrawn Isolative Avoiding eye contact

Lethargic Crying Pacing Oppositional/Defiant Destroying Property Agitated

Angry Outbursts Impulsive lntrusive Hyperactive Pressured Speech Resistive to Care Disorganized Sexually Inappropriate Verbally Aggressive Physically Aggressive Eyes closed Resting Harming Self by: Other (specify):

Speech

Coherent Incoherent Slurred Hyper Rapid Delayed Loud Yelling/Screaming Soft Mute Repetitive Non-Verbal

Psychotic

Symptoms

NIA Hallucinations: Auditory Visual Tactile Olfactory Preoccupied Delusions: Somatic Paranoid Grandiose Persecution

Physical Problem

a None Cardiac Respiratory

GU

No Pain a Pain (1-10) NO HURT HURTS HURTSMORE EVEN HURTSMORE WHOLE HURTSLOT WORSTHURTS

Description of Pain: Dull Sharp Aching Burning Stabbing Shooting Other:

Aggravates Pain: Physical Activity D Sitting 13 Standing Walking O Other:

Effects of pain on daily-activities: Cl None Somewhat limiting Very limiting Interventions implemented«.

Medication administered within last 24 hours: Yes No

Educated patient on alternative interventions for pain management: Refused alternative options

Positioning Hot/Cold therapy Guided imagery Exercise/Stretching Deep breathing

Refocusing/Distraction Music therapy Modified environment Other:

Pain

Medical Issues Addressed

Injuries: N/A yes Consults: N/A Yes Abnormal Labs: N/A. Yes

Tests: N/A Yes

Skin

Assessment

No Wound Wound Description: Location:

Wound Care:

Output

GU: Normal Incontinent Urgency Dysuria

Gl: Bowel Movement: Yes No Normal Nausea Vomiting Diarrhea Constipation

Medication

Compliant Non-Compliant

Side effects/Adverse drug reactions:

RN Teaching/ Education

Coping Skills: Yes No Hand Hygiene: Yes No Health Issues: Yes No

Medication teaching provided to: Patient Parent Method: Handout 1:1 Instruction

Observation Level

Q15 1:1 Line of sight

Precautions

Suicide If currently on Suicide precautions, complete Daily Suicide Risk Assessment. If problem is newly identified, initiate suicide protocol and contact therapist.

Self-Harm Assault Homicide Elopement Seizure Fall Medical Risk

Arson Sexual Victimization Sexual Aggression NONE