QuestionAnswered step-by-stepPATIENT DEMOGRAPHICS and PSYCHOSOCIAL ASSESSMENT(Check applicable field

QuestionAnswered step-by-stepPATIENT DEMOGRAPHICS and PSYCHOSOCIAL ASSESSMENT(Check applicable fields and provide supporting data/evidence for each checked item)Patient Initials:      Age:      Date of admission:      Psych Diagnosis:             Medical Diagnosis:Gender: Male __ Female __ Admission Status: Voluntary __ Involuntary __ Legal Problems: Y __ N __ type ___Ethnicity Caucasian __ Hispanic __ Black __ Asian __ Native American __ Other: _________Symptoms Anxiety __ Depressed Mood __ Anhedonia __ Sleep Disturbance __ Fatigue __Appetite Change __ Racing Thoughts __ Guilt __ Grief __ Hopelessness __ Worry __ Hallucinations __ Crying Spells __ Risky Behavior __ Irritability __ Other: _____Psychosocial Stressors Support __ Family __ Abuse __ Housing __ Economic __ Employment __ Trauma __ Education __ Life-Cycle Transition __ Healthcare Access __ Other: __________Family History Depression __ Suicide __ Violence __ Anger __ Homicide __ Bipolar __ ADHD __ Schizophrenia __ PTSD __ Anxiety __ Alcohol Abuse __ Other Substance Abuse __ Personality Disorder __ Dementia’s __ Psychosis __ Other: __________________Healthy Behaviors Diet __ Exercise __ Spiritual Practice __ Socialization __ Traditions __ Other: ____Substance Use Behaviors Caffeine: Y __ N __ amt ___ Tobacco: Y __ N __ amt ___ Alcohol: Y __ N __ amt ___ Street Drugs Y __ N __ amt ___ type ___ Prescription Drugs: Y__ N __ amt ___ type ___ Mental Status AssessmentAppearance Appears Younger __ Older Than Age __ Scars ___ Piercings ___ Tattoos ___               Well-nourished __ Malnourished __ Obese __ Other: _______ Supporting Data: Grooming Well-kempt __ Self Neglect __ Disheveled __ Malodorous __ Flamboyant __ Other: ___Supporting Data:Attitude Cooperative __ Uncooperative __ Hostile __ Aggressive __ Inappropriate __ Other: ____Supporting Data:Speech Clear __ Coherent __ Normal __ Pressured __ Soft-spoken __ Stuttering __ Profanity __ Impoverished __ Monotone __ Mumbled __ Slurred __ Animated/Excited __ Abrupt __ Difficulty finding words __ spontaneous speech __  Confavulation __ Loud __ Soft __ Impressionistic __ Little detail __ Hesitant/Halting __ Slurring words __ No speech __ Poor articulation __ Perseveration __ Other: __________________Supporting Data:Psychomotor Normal gait __Propulsive gait __ Shuffling gait __ Ataxic __ Uncoordinated __ Grimaces __ Abnormal movements __ Tics __ Hand wringing __ Posture stooped __ Hyperactive __ Bradyukinesia __ Retarded __ Agitated __ Clumsy __ Unsteady __ Falls easily __ Other: __________Supporting Data:Mood Euthymic __ Depressed __ Elevated __ Reserved __ Irritable __ Sad __ Angry __ Despondent __ Anxious __ Blunted __ Melancholic __ Tearful __ Other: _____________Supporting Data:Affect Normal Range __ Flat __ Tearful __ Labile __ Normal Range __ Blunt __ Constricted __ Sad __ Depressed __ Bright __ Broad __ Restricted __ Inappropriate __ Congruent __ Other: _________Supporting Data:Thought Process  Organized __ Clear/Understandable __ Logical __ No formal thought disorder __ Concrete __ Illogical __ Paranoia __ Simplistic __ Strained __ Loose associations __ Preoccupations __ Preservation __ Some disorganization __ Disorganized __ Suspiciousness __ Obsessive thoughts __ Tangential __ Circumstantial __ Neologisms __ Clang associations __ Word salad __ Difficult to follow __ Other: ___________________Supporting Data:Thought Content Delusions __ Illusions __ Audio Hallucinations __ Visual Hallucinations __ Phobias __ Compulsions __ Obsessions __ Preoccupations __ Suicide __ Homicide __ Aggression __ Paranoid ideation __ Depersonalization __ Other: ________________Supporting DataInsight Good __ Fair __ Poor __ Awareness of behavior and impact on others: Y__ N__ Understanding problems related to illness: Y __ N __Agrees that illness requires treatment: Y __ N __ Other: ____________________Supporting Data:Judgement Good __ Fair __ Poor __ Difficulty predicting results of choices: Y __ N __ Able to learn from some experiences: Y __ N __ Able to anticipate outcomes Y __ N __Able to use feedback & learn from mistakes: Y __ N __ Other: _______________Supporting Data:Cognition Alert & Oriented Y __ N __ No distractibility __ Distracted __ High distractibility __ Short -term memory intake Y __ N __ Long-term memory intact Y__ N __ Other: _________Supporting Data:Intellectual Ability Average __ Above average __ Below average __ Intellectual Disability Diagnosis Y __ N __ Risk AssessmentSuicide Denies __ Ideation: Y __ N __ Plan: Y __ N __ Lethality: Y __ N __ Past History: Y __ N __Suicide Risk: Low__ Medium __ High __ Homicide Denies __ Ideation: Y __ N __ Plan: Y __ N __ Lethality: Y __ N __ Past History: Y __ N __Homicide Risk: Low__ Medium __ High __Aggression Denies __ Ideation: Y __ N __ Plan: Y __ N __ Lethality: Y __ N __ Past History: Y __ N __Aggression Risk: Low__ Medium __ High __Substance Use Denies __ Current Use __ Past History __ Past Treatment __ Previous 12-Step Group __Current Use: Y __ N __ Type __________ Amount __________ Frequency ___________Substance Use Risk: Low __ Medium __ High __Psychosis Distortion of reality __ Loss of contact with reality __ Delusions __ Hallucinations __ Thought disorder __ Social withdrawal __ Impaired role functioning __ Drug intoxication __Psychosis Risk: Low __ Medium __ High __Falls Age: <59 __ 60-69 years __ 70-79 years __ 80+ years __ Fall History ________________Medications: On 1 high fall risk drug __ On 2 or more high fall risk drugs __Mobility: Requires assistance or supervision for mobility, transfer, ambulation __ Unsteady gait __ Visual or auditory impairment affecting mobility __ Cognition: Altered awareness of immediate environment __ Impulsive __ Lack of understanding of physical/cognitive limitations __Falls Risk: Low __ Medium __ High __ Patients Perspective (use quotes)Chief Complaint(per client)  Beliefs regarding mental illness  Identifies/Describes Diagnosis  Identifies/Describes Meds & Purpose  Patient goals for this treatment  Maslow’s Hierarchy of Needs: What are your safety concerns, prioritized problems/needs, and rationales based on Maslow’s Hierarchy of needs?   Erikson Stages of Development: Identify which stage patient is functioning in and describe behavior to support your findings. Example: Intimacy vs. Isolation   NURSING PROCESS 1st PriorityWhat is your priority need for this patient?  What psych nursing diagnosis alights with this priority?  What are the patient goals for your priority diagnosis (How will you know if your plan is working)? Shift goal (Short-Term): Discharge goal (Long-Term):What nursing interventions are needed to help your patient achieve each goal and resolve priority need (Nursing Problem)? Provide an evidenced based rationale for each intervention.  Shift Goal 1.Rationale: 2. Rationale: 3. Rationale: Discharge Goal 1.Rationale: 2. Rationale: 3. RationaleDOCUMENTATION 1st PriorityP. Patient Problem:Your assessment of the identified nursing priority and related behaviors, emotional status, etc.  I. Nursing Interventions:How you addressed your patient’s problem. This includes the specific nursing interventions implemented, teaching provided to your patient.   E. Evaluation/Patient Response to care. Describes the actual response of your patient after you have implemented your interventions for each problem. Was the goal met and if not, what do you need to do now?  NURSING PROCESS 2nd PriorityWhat is your second need for this patient?  What psych nursing diagnosis aligns with this priority?   What are the patient goals for your priority diagnosis (how will you know if your plan is working)?  What nursing interventions are needed to help your patient achieve each goal and resolve priority need (Nursing Diagnosis)? Provide an evidenced based rationale for each intervention. Shift Goal 1.Rationale: 2. Rationale: 3. Rationale: Discharge Goal 1.Rationale: 2. Rationale: 3. RationaleDOCUMENTATION 2nd PriorityP. Patient Problem:Your assessment of the identified nursing priority and related behaviors, emotional status, etc.  I. Nursing Interventions:How you addressed your patient’s problem. This includes the specific nursing interventions implemented, teaching provided to your patient.   E. Evaluation/Patient Response to care: Describes the actual response of your patient after you have implemented your interventions for each problem. Was the goal met and if not, what do you need to do now?   MEDICATIONSGeneric/Trade NameDose/Route/Time Classification/Therapeutic Effect of Med Side, Adverse Effects/Nursing Actions Identify teaching needed for each psych med Time you completed teaching your patient about their meds                                              DISCHARGE/TEACHING PLAN (Identify Each Parameter)Current Stressors and what you will teach to help patient adapt  Potential barriers to change & how to minimize  Patient/Family Teaching   SELF ASSESSMENTSummarize the highlights of this clinical day: What did you learn and how will you apply this to your professional practice?  How do you think what you did affected your patient?   Health ScienceScienceNursingNURS 4564Share Question

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