NURSE’S PRAYER

Bless me Oh Lord
For I am about to begin the day’s work.
Teach me to receive the sick in Thy name.
Give to my efforts success, sweet Jesus,
For the glory of Thy Holy name.

It is Thy work without Thee I cannot succeed.

Grant that the sick Thou hast placed in my care,
May be abundantly blessed and not one of
Them be lost because of anything
That is lacking in me.

Help Thou me to overcome every temporal

Weakness and strengthen in me,
Whenever may enable me to bring
The sunshine of joy to the lives
That are gathered around me
Day by day.

Make me beautiful for the sake of the sick ones,

And those lives which will be influenced by them

Amen.
TABLE OF CONTENTS
 PSYCHIATRIC NURSING GRADING SYSTEM

WORK BOOK Rating Sheet

CONTENT RATING TOTAL SCORE

1. Psychiatric Assessment 1 point/item
2. Drug Study 10 points/drug
3. Nursing Care Plan 15 points/problem
4. SOAPIE 10 points/problem
5. Laboratory/Psychological test 10 points
6. Psychodynamics 10 points
7. NPI 10 points/interaction
8. Daily Progress Notes 10 points/DPN
TOTAL
GRADE

CASE STUDY Rating Sheet

PERFECT SCORE
SCORE
1. CONTENT 50
2.PRESENTATION 15
a. Creativity and Ingenuity (5)
b. Ability to hold the interest of others (5)
c. Ability to stimulate group participation(5)
3. DELIVERY 10
a. Grooming (5)
b. Voice/Diction (5)
4. RESPONSE TO QUESTIONS 15
a. Making sound judgement(7.5)
b. Ability to express oneself (7.5)
5. ATTITUDE 10
a. Attitude towards comments and suggestions
TOTAL SCORE 100
GRADE
EXPECTATIONS
Filled in on the first day of the affiliation.
Submitted on Monday of the first week.

AFFILIATION
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PATIENT
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NURSING STAFF
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CLINICAL INSTRUCTOR
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GROUPMATES
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TRANSPORTATION
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SNACKS
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EVALUATION
Filled in on the last day of the affiliation.
Submitted on Saturday of the second week.

AFFILIATION
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PATIENT
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NURSING STAFF
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CLINICAL INSTRUCTOR
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GROUPMATES
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TRANSPORTATION
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SNACKS
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 PSYCHIATRIC NURSING ASSESSMENT

GENERAL INFORMATION

Name:
Address:
Age:
Sex:
Marital Status:
Name of Spouse:
Religion:
Number and ages of sibling:

Number and ages of children:

Occupation: (Specify Past Occupation/s)

Parent’s Name:
Father:_________________________________ Age:____ Occupation:____________________
Mother:________________________________ Age:____ Occupation:____________________

Educational Attainment:
Name of School School Year
Elemantary:_______________________________________________ ____________
Secondary :_______________________________________________ ____________
College :_______________________________________________ ____________

INITIAL PARAMETERS

Vital Signs
BP: Temp: RR: HR:
Known Food and Drug Allergy: (Specify in RED pen if positive)

Use of Drugs:

Use of Alcohol:
FAMILY PSYCHIATRIC HISTORY

1. Is there a history of mental illness in the family? (ifyes,who?)

2. Is there a history of medical disorders in the family? (If yes, who?)

3. Is there a history of substance abuse in the family? (if yes, who?)

4. Has the client received any treatment/hospitalization in the past?

If yes, when?
where?

5. What were the medications prescribed?

Brand Name Dosage Reason

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6. Did the client received any treatment Modalities? (indicate)

ASSESSMENT OF STATUS

D1 D2 D3 D4 D5 D6 D7 D8 D9 D10
A. APPEARANCE
Grooming
Clean
Dirty
Dress
Appropriate
Inappropriate
Posture
Erect
Slouched
Stooped
Eye contact

B. BEHAVIOR/ACTIVITY
Hyperactive
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Agitated
Psychomotor retardation
Calm
Tremors
Tics
Unusual movements/gestures
Catatonia
Akathisia
Facial movements (jaw/lip
smacking)

C. SPEECH
Soft
Loud
Slow
Rapid
Pressured
Hesitant
Slurred
Superior
Frightened
Mute

D. ATTITUDE
Cooperative
Uncooperative
Warm/friendly
Suspicious
Guarded
Hostile/combative
Aggressive
Distant / aloof

E. MOOD AND AFFECT

Mood
Euthymic
Elated
Sad / depressed
Angry
Labile
Worried /fearful
Affect
Appropriate
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Inappropriate
Blunt
Flat
Broad
Restricted

F. THOUGHT PROCESS
Concrete thinking
Circumstantiality
Tangentiality
Loose association
Echolalia
Flight of ideas
Perseveration
Clang associations
Word salad
Neologism
Verbigeration
Stilted language

G. THOUGHT CONTENT
Delusions
Persecution / paranoid
Grandiose
Religious
Somatic
Nihilistic
Ideas of reference
Thought broadcasting

H. PERCEPTUAL DISTURBANCES
Hallucinations
Auditory
Visual
Olfactory
Gustatory
Tactile
Illusion
Depersonalization
Derealization
Identification
Déjà Vu
Jamias Vu
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I. ORIENTATION AND MEMORY
Identifies date correctly
Estimates time of day
Knows where he is
Knows the SN
Recalls immediate memory
Recalls recent memory (within
24 h)
Recalls remote memory ( 1
week

J. SLEEP AND REST PATTERN

Normal sleep
Insomnia
Hypersomnia
Middle night awakening

K. CONCENTRATION

L. ABSTRACT THINKING ABILITY

M. JUDGEMENT

N. Non-compliance to medication
Undesirable side effects
Failed to produce the desired
results
Difficulty obtaining
medications
Medication is too expensive

O. Ability to perform ADL

DISCHARGE PLAN

1. Future plans

2. Resources

3. Home visit schedule

4. Outpatient appointment

5. Home medications

MULTI-AXIAL SYSTEM OF DIAGNOSIS

AXIS I

AXIS II

AXIS III

AXIS IV

AXIS V
DRUG STUDY (6 PAGES)

NCP (3)
 SOAPIE

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 LABORATORY EXAMINATION RESULTS

Laboratory Exam Result Implication

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PSYCHODYNAMICS
 NURSE PATIENT INTERACTION
(ORIENTATION PHASE)

Date:
Day:

Name of Client:_________________________
Daiagnosis:_____________________________

Physical Description of the Client:

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Specific Objectives:

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DAY 1
DATE :________________

N-P-I Communication Interpretation

Technique
 NURSE PATIENT INTERACTION
(WORKING PHASE)

Date:
Day:

Name of Client:_________________________
Daiagnosis:_____________________________

Physical Description of the Client:

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Specific Objectives:

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DAY 2
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N-P-I Communication Interpretation

Technique
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DAY 3
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N-P-I Communication Interpretation

Technique
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DAY 4
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N-P-I Communication Interpretation

Technique
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DAY 5
DATE :________________

N-P-I Communication Interpretation

Technique
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DAY 6
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N-P-I Communication Interpretation

Technique
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DAY 7
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N-P-I Communication Interpretation

Technique
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DAY 8
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N-P-I Communication Interpretation

Technique
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DAY 9
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N-P-I Communication Interpretation

Technique
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DAY 10
DATE :________________

N-P-I Communication Interpretation

Technique
 NURSE PATIENT INTERACTION
(TERMINATION PHASE)

Date:
Day:

Name of Client:_________________________
Daiagnosis:_____________________________

Physical Description of the Client:

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Physical description of the Setting:

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Specific Objectives:

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N-P-I Communication Interpretation

Technique
ANALYSIS AND INTERPRETATION

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EVALUATION

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 DAILY PROGRESS NOTES

Day 1
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Day 2
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Day 3
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Day 4
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Day 5
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Day 6
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Day 7
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Day 8
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Day 9
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Day 10
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 PSYCHIATRIC CASE STUDY FORMAT

I. Introduction

A. Overview
B. Objectives (SMART: specific, measurable, attainable, realistic, time bounded)
C. Scope and Limitation
D. Spot Map
D. Patient’s Profile

II. Anamnesis

A. Paternal and Maternal Lineage

Give the important characteristics which might influence the personality
parents and client.
B. Parents
Give the important personality traits of each and his/her relationship
with each of the siblings and, more especially, the client.
C. Client
1. Starting from conception to the time the client was admitted in the
hospital.
2. Give the important traits on the different stages of the development.
3. Include the precipitating and predisposing factors

III. Course in the Hospital

A. Mental Status Examination (MSE) upon initial introduction and succeeding

visitation.
B. Progress Notes and other observations on the succeeding interactions
(include home visits if any)

IV. Psychodynamics

A. Schematic Presentation (hard copy)

B.

V. Laboratory Exam and Results of Psychological Test

A. Neuropsychological Test
B. Laboratory Test

VI. Diagnosis
Classify the problem according to DSM-IV TR

VII. Multi-Axial Diagnosis

VIII. Nursing Management (NCP and discharge plan)
With emphasis on the psychological problem and health teachings

IX. Medical Management

Chemotherapy (drug study) and special therapies if any

X. Prognosis and Recommendation

For the client, family and community
Criteria:
A. Onset of illness
B. Duration of illness
C. Precipitating factors
D. Mood and affect
E. Attitude toward taking medication and treatment
F. Any depressive features
G. Family support

XI. Bibliography
 GUIDE FOR HISTORY TAKING/ANAMNESIS

1. INFORMANT

1.1 Name
1.2 Address
1.3 Relationship to Patient
1.4 Length of time know n to patient
1.5 Apparent understanding of present illness of patient
1.6 Other characteristics and attitude of informant

2. FAMILY HISTORY

2.1 Maternal and Paternal Grand Lineage

2.1.1 History of nervous and mental disease, alcoholism, delinquency, drug

addiction, suicide attempts, heredity, dependency, chronic
unemployment, unstable job and other traits of inefficiency ( laziness,
procastination )
2.1.2 Has any of them took care of the patient and how long. Mention also the
reason why and how this grand relative took care of the patient, if any.

2.2 Father

2.2.1 What kind of a man is the father? Give his salient personality traits. Give
his routinefamily discipline and personal philosophy about husband and
wife relationship and about upbringing of children
2.2.2 What is his social and financial status, his education and experiences.
What are hisachievements and failures that might have influenced the
family life especially those of his children’s personalities, or that of the
patient’s illness.
2.2.3 If dead, was his death premature, and to have caused financial difficulty
or rupture of family ties. What are the consequencies on the patient.
2.2.4 What are his habits – both natural and acquired? (Note alcoholism, drug
addiction, etc)
2.2.5 Does he gamble , sacrificing the whole family? Is he sexually pervert as to
sacrifice family finance for women of ill – refute or for other women?

2.3 Mother

2.3.1 What kind of woman is the mother?

2.3.2 Is she working to supplement the family budget, entrusting his care of
the children to relative or the neighbors?
 2.3.3 Methods of disciplining the children
2.3.4 How is her relationship towards her husband and other member of the
household.

2.4 Siblings

2.4.1 Number of brothers and sisters

2.4.2 Influences of the siblings on the parents
2.4.3 Cause of death and age of dead siblings ( importance / relationship
(bond) strong /weak)
2.4.4 Relationship of siblings towards of each other and towards the other
members of the households.
2.4.5 History of delinquency, anti – social behaviors or special personality
traits (may be personality disorders)

3. PERSONALITY DISORDERS

3.1 Prenatal (Intrapsychic trauma)

3.1.1 Is it a planned pregnancy?

3.1.2 Attitude of the mother towards this pregnancy (planned or unplanned)
3.1.3 Did she had adequate obstetrical supervision (prenatal check up)
3.1.4 Well nourished / illness while pregnant
3.1.5 Describe mother’s emotion during the entire pregnancy which might
have influenced the growing fetus.

3.2 Birth

3.2.1 Full term or premature and date of birth (placed in an incubator for how
many days/ months)
3.2.2 Unusual incidents attending birth
3.2.3 a) Difficulty of labor
b) Instrumentals sequels (used of forceps/suction)
3.2.4 Place – home or hospital
3.2.5 Attended by whom

3.3 Infancy and Childhood Characteristics

3.3.1 Breast and bottle feed (mother/ father?)

a) Describe feeding habit
b) Cuddling feeding time
c) Describe how weaning was implemented
 3.3.2 Was left under the care of the mother or the “yaya” or older siblings/
grandma/father.
3.3.3 Age of teething, talking and walking
3.3.4 When and how the subject toilet trained ( rigid/poorly)
3.3.5 Note history of enuresis, thumbsucking, night terrors, tantrums,
stammering, history of falls, infantile convulsions, and other childhood
diseases, include duration and how it started.

3.4 Psychosexual History

3.4.1 Age of sex awareness ( malice)

3.4.2 Masturbatory practices observed. Note frequency and reactions of both
subject and parents.
3.4.3 Age of menstruation – note regularity of period and reactions
3.4.4 In male – age when voice lowered in pitch, appearance of seminal
secretions. Age of circumcision.

3.5 Play Life

3.5.1 What games played or preferred (group/isolated/individual game).

3.5.2 Plays with those of his sex or opposite sex.
3.5.3 plays with older or younger children.
3.5.4 Leader or follower in the game
3.5.5 Plays near or far from home or neighborhood
3.5.6 Any influence of sequel in habit formation brought by the particular
games or particular playmates.
3.5.7 Does he abandon home work or school work for the sake of playing?

3.6 School History

3.6.1 Age of cutting school

3.6.2 Age of leaving school
3.6.3 Grade completed
3.6.4 Attitude toward school
3.6.5 Any school maladjustment – reasons for this maladjustments
3.6.6 Relations to teachers
3.6.7 Attendance – regular or irregular
3.6.8 Time spent for homework or lessons
3.6.9 Interest in studies
3.6.10 Does he pass every year or every semester?
3.6.11 His grades or marks obtained
3.6.12 Special liking to different subjects

3.7 Religious and Social Adaptability

3.7.1 Number of friends , their ages, sex, social levels, and character
 3.7.2 Social attitudes and characteristics ( friendly, shy, jealous, cruel,
stubborn, moody, irritable, oversensitive, self – assertive , submissive,
choosy , daydreamer, selfish, conceited and other peculiar habits)
3.7.3 Degree of religious interest and involvement
3.7.4 Reactions towards failure and success.

3.8 Occupational History

3.8.1 Present occupation

3.8.2 Kind of work undertaken or job hold
3.8.3 Length of time of different undertakings or in different jobs
3.8.4 Reasons for changes of jobs
3.8.5 Salaries and savings
3.8.6 Attitudes towards work with superiors and subordinates
3.8.7 Measures employed to increase production

3.9 Marital History

3.9.1 Love affair and disappointments

3.9.2 Circumstances of marriages
3.9.3 Attitude of each other towards sex relations and degree of sex satisfaction
3.9.4 Age of marriage
3.9.5 Moderate or excessive sexual desires
3.9.6 Synchronicity of climax during coitus
3.9.7 Perverted or overt sexual practice – abnormal method of gratification
with same or opposite sex
3.9.8 Miscarriage or abortions, sterility
3.9.9 Refusal of partners sexual intercourse
3.9.10 Birth control measures
3.9.11 Infidelity of either one
3.9.12 Reasons for divorce or separation
3.9.13 Any nervous symptoms before, during or after menstruation
3.9.14 Climacterism (manupause)
a) Age when menstruation stopped or begin to be irregular, nervous
symptoms during the period

3.10 Onset of Present Illness

3.10.1 What incident precipitated subject’s present condition?

3.10.2 Describe the symptoms manifested by the subject which prompted the
relative to sought hospitalization. (Note: any referral to quack doctor)
 ACTIVITY THERAPY

I. Major Consideration in Conducting an Activity Therapy

A. Don’t attempt an activity therapy if you have never observed one.

B. Preparation:
1. Make specific objectives for the activity.
a. skills
b. knowledge
c. attitude
2. Write the outline of the activity.
C. Selection of clients
-Recommended by the hospital staff.

II. Major steps of the activity

A. Greeting members of the group

1. Greet the group.
2. Introduce the therapist and members of the therapist.
3. Orientation of the group to place, day, date, time.
B. Reviewing of rules while attending group therapy.
1. Everybody is expected to finish the entire therapy.
2. Eating, drinking are not allowed while attending the group therapy.
3. Clients are expected to meet physical needs before attending group
therapy.
4. If a client wishes to say something, he could raise his hand and be
recognized by the therapist.
5. If a client becomes unruly, let the therapist review the rules and
regulation.
C. Giving the overview of the activity (brief explanation)
D. Conducting the Activity Therapy
F. Closure
1. Therapist asks a question.
Ex., What have you learned about the Activity Therapy.

III. Types of Activity Therapy

A. Educational Therapy
B. Music Therapy
C. Dance Therapy
D. Art Therapy
E. Reality Orientation and Remotivation Therapy
 ACTIVITY THERAPIES UTILIZED DURING THE AFFILIATION

1. SOCIALIZATION THERAPY

2. ART THERAPY

3. DANCE THERAPY

4. MUSIC THERAPY

5. SENSORY STIMULATION

6. NEWS THERAPY

7. REMOTIVATION THERAPY

8. BALLGAMES AND INDOOR GAMES

 Bibliography

Videbeck, Sheila L. (2011).Psychiatric Mental Health

Nursing.Philadelphia: Lippincott Williams and Wilkins

Care Study Format. Davao City. Davao Medical Center,

Department of Psychiatry.

Pedersen, Darlene D. (2005).Psyche Notes Clinical Pocket

Guide. Philadelphia: F.A. Davis Company

Antai-Otong, Deborah. (2008). Psychiatric Nursing:

Biological &Behavioral Concepts (2nded.). Cengage
Learning Asia

Mental Status Examination.In Wikipedia. Retrieved

February 1, 2013 from
http://en.wikipedia.org/wiki/Mental_status_examination