mental health

Student

Date

Instructor

Course

Patient Initials

Date of Admission

Legal Status

(Vol, 5150, 5250, Conservatorship)

Patient DOB

Unit

Chronological and Apparent Age

Gender

Ethnicity

Allergies

Height/Weight

Temp (location)

Pulse (location)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure (location)

Pain Scale 1-10 (location, character, onset)

Psychiatric Diagnosis and DSM 5 Diagnostic Criterion

History of Present Psychiatric Illness:

Presenting signs & symptoms/ Previous Psychiatric Admission / Outpatient Mental Health Services/5150 Advisement

Psychopathology of admitting and/or related psychiatric diagnosis

Biophysical and/or related medical diagnosis

Description of how this diagnosis relates to your patient

With APA citations

Erickson’s Developmental Stage

Include Rationale Based on the Patient

With APA citations

Appearance

Presenting Appearance

(nutritional status, physical deformities, hearing impaired, glasses, injuries, cane)

Basic Grooming and Hygiene

(clean, disheveled and whether it is appropriate attire for the weather)

Gait and Motor Coordination

(awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest),

posture

(slouched, erect),

any noticeable mannerisms or gestures

Level of Participation in the Program/Activity

(Group attendance and milieu participation, exercise)

Manner and Approach

Interpersonal Characteristics and

Approach to Evaluation

(oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)

Behavioral Approach

(distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing).

Coping and stress tolerance.

Speech

(normal rate and volume, pressured, slow, loud, quiet, impoverished)

Expressive Language

(no problems expressing self, circumstantial and tangential responses, difficulties finding words, echolalia, mumbling)

Receptive Language

(normal, able to comprehend questions, difficulty understanding questions)

Orientation, Alertness, and Thought Process

Recall and Memory

(recalls recent and past events in their personal history). Recalls three words (e.g., Cadillac, zebra, and purple)

Orientation

(person, place, time, presidents, your name)

Alertness

(sleepy, alert, dull and uninterested, highly distractible)

Coherence

(responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)

Concentration and Attention

(naming the days of the week or months of the year in reverse order, spelling the word "world", their own last name, or the ABC's backwards)

Thought Processes

(loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization).

Values and belief system

Hallucinations and Delusions

(presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)

Judgment and Insight

(based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)

Mood and Affect:

Mood or how they feel most days

(happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry).

Affect or how they felt at a given moment

(comments can include range of emotions such as broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation.

Rapport

(easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)

Facial and Emotional Expressions

(relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful, pessimistic, optimistic)

Response to Failure on Test Items

(unaware, frustrated, anxious, obsessed, unaffected)

Impulsivity

(poor, effected by substance use)

Anxiety

(note level of anxiety, any behaviors that indicated anxiety, ways they handled it)

Risk Assessment:

Suicidal and Homicidal Ideation

(ideation but no plan or intent, clear/unclear plan but no intent)

Self-Injurious Behavior

(cutting, burning)

Hypersexual, Elopement, Non-adherence to treatment

Discharge Plans and Instruction:

Placement, outpatient treatment, partial hospitalization, sober living, board and care, shelter, long term care facility, 12 step program

Teaching Assessment and Client / Family Education:

(Disease process, medication, coping, relaxation, diet, exercise, hygiene)

Include barriers to learning and preferred learning styles

Pertinent Lab Tests Results

(normal ranges in parentheses)

Rationale for Abnormals

Valproic Acid (50 – 120 mcg/mL)

Lithium (0.5 – 1.2 mEq/L)

Carbamazepine (5 – 12 mcg/mL)

CBC (WBC with diff, ANC, RBC)

Urine Drug Screen

Thyroid Panel

Liver Function (AST/ALT, LHD, Albumin, Bilirubin)

Kidney Function (BUN, creatinine)

Blood Alcohol Level

Diagnostic Test Results

(with dates)

Rationale for Abnormals

Substance Abuse and other Addictions

(gambling, sex, shopping, smoking)

Type:

Amount / Frequency:

Duration:

Last Used:

Withdrawal Symptoms:

Type:

Amount / Frequency:

Duration:

Last Used:

Withdrawal Symptoms:

C.A.G.E. Questionnaire

Have you ever felt you should cut down on your drinking?

Yes / No

Have people annoyed you by criticizing your drinking?

Yes / No

Have you ever felt bad or guilty about your drinking?

Yes / No

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Yes / No

Abnormal Involuntary Movements

Code: 0 = None 1 = Minimal 2 = Mild 3 = Moderate 4 = Severe

I: Facial and Oral Movements: (movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling,

grimacing, puckering, pouting, smacking, biting, clenching, chewing, mouth opening , lateral movement , tongue darting in and out of mouth)

0 1 2 3 4

II: Extremity Movements:

Upper (arms, wrists, hands, fingers) Include choreic movements (i.e. rapid objectively purposeless, irregular, spontaneous athetoid movements.

Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot

0 1 2 3 4

III: Trunk Movements: (Rocking, twisting, squirming, pelvic gyrations)

0 1 2 3 4

IV: Global Judgment: (Severity of abnormal movements, Incapacitation due to abnormal movements. Awareness of abnormal movements.)

0 1 2 3 4

V: Dental Status: (Current problems with teeth and/or dentures/Endentia?)

Yes No

Diagnosis

Minimum of 2 NANDA - actual and/or potential.

Include etiology and signs and symptoms.

*Include

definition of the nursing diagnoses with APA citations

Planning

Outcome Criteria

Minimum of 2 measureable

goal per diagnosis related to the nursing diagnosis

Implementation

Minimum of 4

independent and collaborative nursing intervention include further assessment, intervention, and teaching that is related to the outcome criteria

Rationales for interventions

(With APA citations )

Evaluation

Goal Met

Goal not Met

(If not met, what revisions would you make?) How did the patient respond to your interventions

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Medications

Generic / Trade

Class/Rationale for the patient

Dose/Route/ Time (Frequency)

Range / Therapeutic Levels

Mechanism of action / Onset of action

Common side effects / Food and drug interaction

Nursing considerations specific to this patient