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Assessment Tool in Psychiatric Nursing I.

IDENTIFYING DATA Name: Address: Age: Gender: Marital Status: Religion: Ethnic Group: Date of interview: Informant: Nationality: Education: Occupation:

Birth date: Telephone:

PATIENT S PRESENTING PROBLEM Patient s statement of the problem: Onset and duration: Interval history: Reasons for seeking help a.) b.) Current status: Present medications: Name of drug Dosage & Frequency Route Curative Effects Side Effects

PERSONAL HEALTH HISTORY ILLNESS (medical, neurological, psychiatric) Specific surgical intervention Date

Complications if any

INJURIES Type

Date

Complications if any

ALLERGIES: TRAUMA [ ] INCEST [ ] BATTERY [ ] CHILD ABUSE [ ] SPOUSE DIAGNOSIS (Psychiatric/DSMIV-TR)

II. SOCIO-CULTURAL DIMENSION A. FAMILY/SIGNIFICANT OTHERS a.) Patient s psycho-physical genogram (4 levels)

b.) Patient-environment sociogram

c.) Family History of Psychiatric Illness and/or Maldaptive Behaviors Bipolar Major Depressant Mental Retardation [ ] Suicide [ ] Schizophrenia [ ] Substance abuse [ ] Stress Related Illness [ ] Panic and Phobias [ ] Violence

B. SELF-CONCEPT (Write all the responses of the patient to each of the questions in verbatim in the spaces provided) a.) Ideal Self: (What kind of goals do you have for yourself?)

b.) Perceived self: (What kind of person would you say you are?)

(How do you think others see you?)

c.) Self-esteem: (How much do you like yourself?)

Who are you important to?

Who are important to you?

C. PATIENT S RELATIONSHIP WITH, OR ATTITUDE TOWARDS HEALTH CARE PERSONEL (doctor, staff nurse, clinical instructor, student nurse) [ ] Domineering [ ] Submissive, overly, compliant [ ] Suspicious [ ] Uncooperative [ ] others: D. Implications of the patient s socio-cultural data [ ]Intrusive [ ] Manipulative

III. PHYSICAL DIMENSION A. APPEARANCE NOT PRESENT Physically unkempt, unclean Clothing dishevelled, dirty Clothing atypical, bizaare SLIGHTLY PRESENT MARKEDLY PRESENT

Unusual physical characteristics B. ACTIVITIES OF DAILY LIVING Eating Pattern: [ ] Eats regular time [ ] Sufficient nutrition Sleeping Pattern: [ ] Normal (8-8 hours) [ ] Insomnia [ ] Hypersomia Self-care status: [ ] Independent [ ] Needs parital assistance [ ] Fully dependent Lifetsyle: Past [ ] Active [ ] Semi-active [ ] Sedentary Present [ ] Active [ ] Semi-Active [ ] Sedentary -If active, example of activities:

Sexual Activity: Are you comfortable/satisfied with your sex life? [ ] Yes Any other concern? [ ] STD? [ ] HIV Others C. PATTERN OF HABITS Alcohol: Smoking: Caffeine: Drugs: [ ] No

[ ] Frequent [ ] Frequent [ ] Frequent [ ] Frequent

[ ] Average [ ] Average [ ] Average [ ] Average

[ ] Occasional [ ] Occasional [ ] Occasional [ ] Occasional

[ ] Non-User [ ] Non-User [ ] Non-User [ ] Non-User

D. PSYCHOMOTOR BEHAVIOR POSTURE NOT PRESENT Slumped Rigid, tense Atypical, inappropriate MILD MODERATE SEVERE

General Body Movement