Vous êtes sur la page 1sur 6

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) ______________

I. PRESENTING PROBLEM
A. Statement in the client’s own words of why he or she is hospitalized or
seeking help
B. Recent difficulties/alterations in
1. Relationships
2. Usual level of functioning
3. Behavior
4. Perceptions or cognitive abilities
C. Increased feelings of
1. Depression
2. Anxiety
3. Hopelessness
4. Being overwhelmed
5. Suspicious
6. Confusion
D. Somatic changes, such as
1. Constipation
2. Insomnia
3. Lethargy
4. Weight loss or gain
5. Palpitations

II. RELEVANT HISTORY – PERSONAL:


A. Previous hospitalizations and illness __________________________________
B. Educational background ___________________________________________
C. Occupational background __________________________________________
1. if employed, where? ___________________________________________
2. How long at the job? ___________________________________________
3. Previous positions and reasons for leaving __________________________
4. Special skills _________________________________________________
D. Social patterns
1. Describe friends _____________________________________________
2. Describe a usual day __________________________________________
E. Sexual patterns
1
1. Sexually active? _______________
2. Sexual orientation ___________________________________
3. Sexual difficulties ___________________________________
4. Practice safe sex or birth control ________________________
F. Interest and abilities
1. What does the client do in his or her spare time
______________________
2. What is the client good at? ______________________________________
3. What gives the client pleasure? ___________________________________
G. Substance use and abuse
1. What medication does the client take? ______________________________
How often> ______________ How much? __________________
2. Any herbal or-the-counter medicati ons?__________________________
How often? ________________ How much? __________________
3. What psychotropic drugs does the client take? ____________________
How often? _______________ How much? ___________________
4. How many drinks of a alcohol does the client take? _______________
per day? ___________ Per week? _________________
5. Does the client identify use of drugs as a problem? _______________
H. How does the client cope with stress? ___________________________
1. What does the client do when he or she gets upset? ________________
_________________________________________________________
2. Whom can the client talk to? __________________________________
3. What usually helps to relieve stress? ____________________________
4. What did the client try this time? _______________________________

III. RELEVANT HISTORY – FAMILY


A. Childhood
1. Who was important to the client growing up? _________________________
2. Was there physical or sexual abuse? ________________________________
3. Did the parents drink or use drugs? _________________________________
4. Who was in the home when the client was growing up?
_________________
B. Adolescence
1. How would be client describe his or her feelings in adolescence?
___________
_______________________________________________________________
2. Describe the client’s peer group at the time.
___________________________
C. Use of drugs
1. Was there use or abuse of drugs by any family member?
_________________
Prescription _________________ Street __________ By whom? _________
2. What was effect on the family? ______________________________________
D. Family physical or mental problems
1. Is there any family history of violence or physical/sexual abuse?
______________
2. Who in the family had physical or mental problems?
_______________________
3. Describe the problem ________________________________________________
4. How did it affect the family? __________________________________________
E. Was there an unusual or outstanding event the client would like to mention
________
____________________________________________________________________

IV. SPIRITUAL ASSESSMENT


2
A. What importance does religion or spirituality have in your life?
_______________
__________________________________________________________________
B. Do your religious or spiritual beliefs influence the way you take care of
yourself or your illness?
How? __________________________________________________
C. Who or what supplies you with hope? ___________________________________

V. CULTURAL INFLUENCES
A With what cultural group do you identify? _______________________________
Have you tried any cultural remedies or practices for your condition? If so, what?
________________________________________________________________
C. Do you use any alternative or complimentary medicines/herbs/practices?
________________________________________________________________
MENTAL STATUS EXAMINATION
General Appearance Day
1 2 3 4 5
Facial Expression
Animated
Fixed or Immobile
Sad or Depressed
Angry
Pale
Reddened
Posture
Slouched
Stooped
Upright (erect)
Stiff
Gait
Smooth Rhythmic
Shuffling
Staggering
Dress
Appropriately Dressed
Inappropriately Dressed
Pressed
Wrinkled
Grooming
Well Groomed
Unkempt
Hygiene
Clean
Untidy
Odor (Body / Breath)
None
Alcohol
Acetone
Pungent
Cigarette Smoke
Foul Smelling
Physical Deformity:
(specify)_____________________
Eye Contact
Maintains Good Eye Contact
Poor Eye Contact (Lacks Eye Contact)
3
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
Spasm
Compulsive
Waxy Flexibility
Parkinson-like symptoms
Akathisia
Dyskinesia
Apraxia
Catatonic Stupor
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
Soft/mumbled
Quantity
Paucity
Muteness
Voluminous
Quality
Articulate
Congruent
Spontaneous
Monotonous
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
Ecstacy
Unpleasurable
4
Depression
Anxiety
Fear
Agitation
Ambivalence
Aggression
Mood Swings
Lability
Panic
Anger

Perceptions
Process by which physical stimuli are
brought to mental awareness
Hallucinations
Auditory
Visual
Tactile
Gustatory
Olfactory
Illusions
Depersonalization
Derealization

Thinking
The waythe person functttions
intellectually; the process or way of
thinking or analysis of the world: the
way of connecting or associating
thoughts; the overall organization of
thoughts.

(1) Thought Content-What a client is


thinking

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. Flight of Ideas
.b Looeness of Association
.c Blocking
.d Confabulation
.e Tangetidity
.f Neologism
.g Circumstantiality
.h Perserveration

5
.i Confabulation
.j Word Salad