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Psychiatric Nursing Assessment Guide

This document contains forms for collecting information about a psychiatric patient such as their name, age, living situation, and presenting problems. It includes sections to document the patient's mental status including appearance, motor behavior, speech, mood, perceptions, thoughts, attitudes, and defenses. The forms are used to inform diagnosis and treatment planning.
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0% found this document useful (0 votes)
24 views26 pages

Psychiatric Nursing Assessment Guide

This document contains forms for collecting information about a psychiatric patient such as their name, age, living situation, and presenting problems. It includes sections to document the patient's mental status including appearance, motor behavior, speech, mood, perceptions, thoughts, attitudes, and defenses. The forms are used to inform diagnosis and treatment planning.
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Psychiatric Nursing History and Mental

Status Assessment
GENERAL ADMISSION INFORMATION

Name: (Please Use Alias) ______________________________________________


Age/Gender: ___________________ Marital Status: ____________________
Racial and Ethnic Data: ___________________________
Number and Ages of Children/Siblings: __________________________________
Living Arrangements: _________________________________________________
Educational Attainment: _______________________________________________
Occupation: _________________________________________________________
Religious Affiliations: _________________________________________________

CONDITIONS OF ADMISSION

Voluntary: __________ Involuntary: ________________


Accompanied to Facility by (Family Friend Police Other): ___________________
Route of Admission (ambulatory, wheelchair, stretcher) _____________________
Admitted from: (home, other facility, street, place of destination) ______________
PRESENTING PROBLEM (Chief Complaint)

_________________________________________________________________________
________________________

● Statement in the client’s own words of why he or she is hospitalized or seeking


help

____________________________________________________________________
____________________________

____________________________________________________________________
____________________________

● Onset / precipitating factors

____________________________________________________________________
_____________________________

____________________________________________________________________
_____________________________

PSYCHIATRIC NURSING HISTORY AND MENTAL HEALTH STATUS ASSESSMENT


DAY _ DAY _
GENERAL APPEARANCE
Present Absent Analysis Present Absent Analysis
Facial Expression

Animated

1 | Page
Fixed or Immobile

Sad or Depressed

Angry

Pale

Reddened

Posture

Slouched

Stooped

Upright (erect)

Stiff
2 | Page
Gait

Smooth Rhythmic

Shuffling

Staggering
Dress

Appropriately Dressed

Inappropriately Dressed

Pressed

Wrinkled
Grooming

Well Groomed

Unkempt

3 | Page
Hygiene

Clean

Untidy

Odor (Body/Breath)

None

Alcohol

Acetone Pungent

Cigarette Smoke

Foul Smelling

Physical Deformity

4 | Page
Specify: ______________

5 | Page
Eye Contact

Maintains Good Eye Contact

Poor Eye Contact (Lacks Eye


Contact)

Eye Cast (Client squints his


eyes, pupils dilated)

MOTOR BEHAVIOR (Gestures, stereotyped behavior, pacing, any purposeless activity should be
described.)

Purposeful and Coordinated


Movement

Catatonia

Echopraxia

Tics

6 | Page
Spasm

Compulsive

Waxy Flexibility

Parkinson-like symptoms

Akathisia

Dyskinesia

Apraxia

Catatonic Stupor

7 | Page
Catatonic Excitement

Hyperkinesia

Catalepsy

Cataplexy

SPEECH (How the client is communicating, rather than what the client is telling you. Rate, volume,
modulation and flow.)
Rate

Rapid

Slow

Volume

Loud

8 | Page
Soft/mumbled

Quantity

Paucity

Muteness

Voluminous

Quality

Articulate

Congruent

Spontaneous

Monotonous

9 | Page
Talkative

Repetitious

Pressured Speech

EMOTIONAL STATE (Mood/Affect) (Expression of emotion as seen by others;what examiner infers


from patient’s facial expression/behavior)

Appropriate

Inappropriate

Flat

Pleasurable Affect

Euphoria

Exaltation

10 | P a g e
Ecstacy

Unpleasurable

Depression

Anxiety

Fear

Agitation

Ambivalence

Aggression

Mood Swings

11 | P a g e
Lability

Panic

Anger

12 | P a g e
Perceptions (Process by which physical stimuli are brought to mental awareness )
Hallucinations

Auditory

Visual

Tactile

Gustatory

Olfactory

Illusions

Depersonalization

Derealization

Thinking (The way the person functions intellectually; the process or way of thinking or analysis of
the world: the wayof connecting or associating thoughts; the overall organization of thoughts.)

(1)   Thought Content-What a client is thinking

13 | P a g e
1.1           Delusions

a.      Delusions of
Grandeur

b.     Delusions of
Reference

c.      Delusions of
Persecution

d.     Religious Delusion

e.      Somatic Delusion

f.      Paranoid Delusion

1.2 Phobia: Specify

(2)   Thought Process - How a person thinks

a.    Blocking

14 | P a g e
b. Flight of Ideas

c.      Word Salad

d.     Perseverance

e.      Neologism

f.      Circumstantialism

g.     Echolalia

h.     Obsession

i.       Verbigeration

15 | P a g e
j.       Rhyming

k. Punning

l. Mutism

ATTITUDES (The learned tendency to respond to people, concepts, and events in an evaluative
way.)

a.      Cooperative

b.     Outgoing

c.      Withdrawal

d.     Evasive

e.      Sarcastic

16 | P a g e
f.      Aggressive

g.     Perplexed

h.     Apprehension

i.       Arrogant

j.       Dramatic

k.     Submissive

l.       Fearful

m.   Seductive

17 | P a g e
n.     Uncooperative

o.     Impatient

p.     Resistant

q. Impulsive

18 | P a g e
DEFENSE MECHANISMS (Automatic psychological process that protects the individual against
anxiety and from awareness of internal or external stressors or dangers.)

a.      Denial

b.     Repression

c.      Rationalization

d.     Reaction Formation

e.      Sublimation

f.      Compensation

g.     Projection

19 | P a g e
h.     Displacement

i.       Identification

j.       Conversion

k.     Regression

l.       Introjections

m.   Undoing

n.     Substitution

o.     Intellectualization

20 | P a g e
p. suppression

21 | P a g e
GENERAL ADMISSION INFORMATION

Name: (Please Use Alias) ______________________________________________


Age/Gender: ___________________ Marital Status: ____________________
Racial and Ethnic Data: ___________________________
Number and Ages of Children/Siblings: __________________________________
Living Arrangements: _________________________________________________
Educational Attainment: _______________________________________________
Occupation: _________________________________________________________
Religious Affiliations: _________________________________________________

DIAGNOSIS:

_________________________________________________________________________
________________________

22 | P a g e
THERAPEUTIC
COMMUNICATIO DAY _
N TECHNIQUE

NURSE PATIENT
  Use Not Rationale/ Respons Interpretation/
d Used Justification e Analysis

Accepting

         

Broad openings

         

Consensual
validation

         

Encouraging
comparison

         

Encouraging
description of
perceptions

         

Encouraging
expression

         

Exploring

         

23 | P a g e
Focusing

         

Formulation a
plan of action

         

General leads

         

Giving
information

         

Giving
recognition

         

Making
observations

         

Offering self

         

Placing event in
time or sequence

         

24 | P a g e
Presenting
reality

         

Reflecting

         

Restating

         

Seeking
information

         

Silence

         

Suggesting
collaboration

         

Summarizing

         

Translating into
feelings

         

25 | P a g e
Verbalizing
implied

         

Voicing doubt

         

SUBMITTED BY: SUBMITTED TO:

_____________________
______________________

26 | P a g e

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