Initial Nursing Assessment/ Psychiatry

Patient name : ID NO: Age : Telephone:

Emergency Other (Specify).. Friend Other Family Friend Patient Non-Voluntary (Specify).. Married Divorced Separated

Address :
Clinic Family Spouse Voluntary Single

Physician : Dx:

Admitted From:

Acompanied By: Information: Admission Status: Marital Status: Religion : Muslim Christian Reason For Admission Previous Psychiatric Hospitalization: No Family History Of Psychiatric Disorders:

Other

Widow

Widower

Other
Yes Describe:

Chief complain: History Of Current Illness

Illness: Surgical: Allergy: Hospitalization:

Name of Medication

No No No No

Yes Yes medication food others :______________________ Yes Describe: ________________

HEALTH HISTORY Describe: ________________ Describe:_________________

MEDICATION HISTORY
Dose/Schedule Last Dose: Date/Time

SEXUALITY / REPRODUCTION
Onset Of Menopause:----------------------Onset Of Menarche :----------------------Contraceptives No Yes Type ------Birth Control Pills Diaphragm Number Of Pregnancies LMP-------------------

Vaginal Spermicidal Rhythm Method Miscarriages Yes

Cervical Cap Others--------------Describe Abortions

Live Births-----No

Recent Change In Sexual Behavior?

SPIRITUAL ASSESSMENT
Muslim
General Appearance:

Christian
Clean Neat Unkempt Odorous Obese

Other

PHYSICAL APPEARANCE
Dirty Thin Disheveled Emaciated Well-Nourished

Facial expression: Posture: Dress:

Relaxed

Normal Tense

Animated Erect

Masked

Sad

Depressed Waxy flexibility

Angry

Blank Narcissism

Slouching

Catatonic

Mannerisms

Style Neat Clean Appropriated to age. Hygiene, Oder and grooming:________________________________

Motor activity, Gait:

Agitated Duskiness

Restless Tremor Parkinson movement

Motor retardation Akathisia Akinasia Negativism Ambivalence Echoproxia

NUTRITION/ MEAL PATTERN

Diet: Number Meals/ Day: ------------------------- Meal Times: Eating pattern: Roblems With Eating: Feeding Aids: Appetite : Weight change: ENERGY LEVEL: Describe: ROM: BALANCE/ GAIT: Describe: Full Steady Partial Describe: Unsteady Risk for failing Independent No No full Appetite No Usual Tires easily Depentdent Assistance: Describe: Nausea Vomiting lack of Appetite Describe

Diffifuclt Swallowing Yes Tubes

Special Utensils. Describe:

Recent Loss Of Appetite Yes Describe:

ACTIVITY/ REST
High fatigue Low Other

SLEEP
Hours. Sleep/Night Hours Sleep/ Day . Feel rested? No Yes Sleeping Aids: (Medications/ Others) No SLEEP PROBLEMS Insomnia - Early-MiddleLate Awakes Easily Bedtime.. Yes Describe: Fear Associated With Sleep Night Terrors Wake-up time..

Recent Change Nightmares

ALCOHOLS, DRUGS AND SUBSTANCES

Caffeine None Coffee Tea Cola Chocolate How Much? How Long? TOBBACO Non Cigarettes Cigars Pipe Other (Specify) How Much? How Long? DRUGS: None Cocaine Heroin Other (Specify) Inhalants Amphetamines Barbiturates Other How Much? How Long? Last Ingestion: Do You Think You Have A Problem Related To Your Drug Intake? No Yes-----------------------------------------------------------ALCOHOL: None Yes (Specify) How Much? How Long? SYMPTOMS: None Miss Work Miss School Pass Out Loss Of Memory Family History Of Alcohol Abuse? No Yes. Describe: No Yes. Describe: NO YES DESCRIBE Do You Think You Have A Drinking Problem?

DESTRUCTIVE BEHAVIOR
SUICIDE POTENTIAL Do You Feel You Have Control Over The Events Of Your Life? 1) Feel Like Giving Up? 2) Feel Guilty? 3) Current Thoughts Of Harming Self? 4) Past Attempts At Harming Self?

5) Past Thoughts of Suicide?

6) Past Suicide Attempts?

7) Current Thoughts of Suicide? 8) Plan for Suicide?

9) Ability to Contract?
10) Recent Suicide Attempt?

11) Attempt in Hospital?

12) Family History Of Suicide? POTENTIAL FOR AGRESSION 1. 2. 3. 4. Have You Ever Hurt Someone? Have You Ever Broken Things/ Destroyed Property? Are You Having Thoughts Of Hurting Someone? Do You Plan To Hurt Someone? NO YES DESCRIBE NO YES DESCRIBE

OTHER POTENTIAL RISKS 1. Impulsive Behavior 2. Seizures 3. Falls 4. Escape Risk 5. Major Side Effects Of Psychotropic Or Other Meds 6. Others

EMOTIONAL ASSESSMENT Mood:____________________________________________________________ Affect:

Appropriate to situation Euphoria Exaltation Depression Anxiety Fear Agitation Ambivalence Aggression Mood swings Flat Affect duration:______________ Quality of affect Quality:________________ COGNITION (INTELLECTUAL) ASSESSMENT
PERCEPTION No Hallucinations Auditory Visual Tactile Olfactory Gustatory De-realization Depersonalization Yes Describe

illusion Disturbance in thought process

Loose association Circumstantialities Tangentiality Flight of idea Preservation Blocking Neologism Confabulation Poverty thought
Delusions Persecutory Grandiose Religious

Disturbance in thought content

Nihilistic Idea of reference : Obsession

Phobia: Type of thinking: Memory: Intact memory

Abstract thinking

Impairment of recent memory

Concrete thinking Impairment of immediate memory Impairment of remote memory

Judgment: appropriate to situation Impairment of social judgment Impairment of Employment judgment Impairment of financial judgment judgment Impairment of family

Orientation: Insight to illness:

Time

Place

Person Partial insight Lack of insight

Full insight

COMMUNICATION Disturbance of speech rate

NA

Flight of idea Blocking

Clang association

Retardation

Mutism

Aphasia

Aphonia

Disturbance in the form of speech

NA

Word-salad

Incoherence

Neologism

Circumstantiality

Global Assessment of Functioning (GAF)

Score:

PT/Family Oriented to:

Call Light Elect. Safety

ORIENTATION TO UNIT Bed Bath Telephone/ TV Control Room Unit Time of Room # Kitchen Meals

Side Rails Room Tel. #

Smoking Regulations visiting hours

Process of Calling Operator physician name

BELONGINGS SEARCHED: No Yes. By Whom? Stored

Other _______________________________

Articles were: EXPLANATION OF PROHIBITED ARTICLES Safety Razors Razor Blades Glass Articles Other Sharps Drugs Alcohol Televisions Medications

Given to family

Other,

Scissors Cigarettes Cameras Matches

Weapons Pipe Recording Devices Light

RN Signature ____________________________________

Date & Time _________________________________________

.Day of discharge final checklist

INSTRUCTIONS: Verify at the time of discharge that the patient/family has received the following. If No explain. Appointments: Yes Discharge Summary Yes Patient Referral to other hospital Yes Sick time/work excuse Yes Laboratory Slips Yes X-Ray Forms Yes Dressings Home with patient Supplies Home with patient Medicatio ns Home with patient No No No No No No None None None N/A N/A N/A N/A N/A N/A N/A N/A N/A Prosthesi s Clothing Valuable s Devices Sutures Drains Home with patient Home with patient Home with patient Home with patient In In None None None None Out Out Yes N/A N/A N/A N/A N/A N/A No

Related pt/family education Patient family member discharg ed by Any delay Yes No of discharge

others (specify):--------------Reason:--------------------------

SIGNATURE: ___________________________________________ TITLE: ________________________________________________ ----------------------------------------------------- ---------:ID#:--------------------------------------------------------------------DATE/TIME