STUDENT NAME _______________________________ CLINICAL DATE ______________
METROPOLITAN COMMUNITY COLLEGE
Mental Health Nursing Critical Thinking Tool
NURS2310 Mental Health Nursing II
Client’s Initials _______ Sex ___ Age ______ Marital Status __________ Religion __________
Occupation _________________________ Allergies _________________ Room # __________
Erikson’s Psychosocial Stage _____________________________________________________
Developmental Task ____________________________________________________
Physician(s) ___________________________________________________________________
List specialty ( if numerous assigned physicians)
Chief Complaint ________________________________________________________________
Primary Diagnosis ___________________________ Secondary Diagnosis _________________
Past Medical History ____________________________________________________________
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Textbook description of the client’s condition.
(Include signs/symptoms and pathophysiology)
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Signs/symptoms noted on arrival to the hospital.
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Additional manifestations occurring during hospitalization.
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Metropolitan Community College
Diagnostic tests R/T the signs/symptoms or manifestations of client’s condition.
Refer to the table on Page 4
Medications R/T the signs/symptoms or manifestations of client’s condition.
Refer to the table on Page 5
Other medical treatments/interventions R/T client’s condition.
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Nursing interventions implemented to treat these manifestations.
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Teaching
Describe the teaching that needs to be completed regarding any of the above issues while the
client is still in the hospital.
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Describe the teaching that needs to be completed regarding any of the above issues related to
the client’s discharge.
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Other Considerations
What should you be on alert for with this client today?
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What are the important assessments to make for this client?
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Metropolitan Community College
What complications may occur, or what could go wrong?
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What interventions may prevent complications?
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Impact of Illness
What is the impact of the illness on the client and his/her family?
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What can the nurse do to help the client and family cope?
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Reflection
As a result of this activity, I have learned how to:
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This activity gave me insights into collaborating with others because:
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This activity gave me insights into communication because:
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This activity shows that I have learned more about:
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Metropolitan Community College
Laboratory Values/Diagnostic Test Results
Laboratory/Diagnostic
Test
Date of Test
Normal Values
Client Values
Metropolitan Community College
Relationship/Correlation
to Client
What is causing this result
for this client?
Medication Information Sheet
List first the medications you will administer, then PRN medications, then other medications client will receive.
Drug Name /
Classification
Dose, Route,
Frequency
Action
Use for This Client
Side Effects /
Interactions
Nursing
Considerations
administration concerns
Metropolitan Community College
Medication Information Sheet (cont’d)
Drug Name /
Classification
Dose, Route,
Frequency
Action
Use for This Client
Side Effects /
Interactions
Nursing
Considerations
administration concerns
Metropolitan Community College
Mental Health Assessment
Diet:
Activity:
Vital Signs:
Seclusion:
Restraints:
Wounds:
Precautions:
Assistive Devices:
Wheelchair
Pain: Yes No
Pain Scale:
Location:
Orient to:
Person
Appearance:
Movement:
Clean
Normal
Tics
Place
Walker
Cane
Intensity:
Time
Well-groomed
Crutches
Duration:
Event
Consciousness:
Disheveled
Bizarre
Decreased
Agitated
Tremors
Repetitive
Impulsive
Alert
Lethargic
Stuporous
Malodorous
Memory:
Good
Behavior:
Speech:
Affect:
Cooperative
Uncooperative
Guarded Threatening Agitated
Evasive
Combative
Poor Recent
Normal
Slurred
Loud
Pressured
Slow
Mute
Appropriate
Labile
Restricted
Blunted
Flat
Congruent
Incongruent
Poor Remote
Confabulation
Blocking
Mood:
Normal
Depressed
Anxious
Euphoric
Irritable
Congruent
Incongruent
Thought Process:
Intellect:
Insight:
Coherent
Logical
Tangential
Circumstantial
Loose
Paranoid
Concrete
Flight of Ideas
Average
Good
Delusions:
Fair
Above Average
Poor
Judgment:
Below Average
Good
Fair
Hallucinations:
Poor
Absent
Present
Paranoid
Persecutory
Grandiose
Referential
Somatic
Metropolitan Community College
None
Auditory
Visual
Tactile
Psychiatric/Mental Health Assessment Tool
None
1
2
Moderate
3
4
Thoughts of
harming self
Thoughts of
harming
others
Depression
Hopelessness
Anxiety
Anger
Fatigue
Do you feel your psychiatric medications are effective?
Are you experiencing any medication side effects?
Do you have any concerns about your treatment?
Metropolitan Community College
Severe
5
Nursing Diagnosis
At which level of Maslow’s Hierarchy of Needs does this client fall on this shift?
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What is this client’s priority nursing diagnosis for this shift?
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What is the goal for this client with regards to his/her condition?
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List 5 nursing interventions for this client in order to meet this goal.
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List the rationale for each of the above diagnoses.
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Did the client meet his/her goal?
(If not, explain, and describe how the interventions/goal could be revised)
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Metropolitan Community College
Shift Assessment Documentation
(i.e. how this client’s cares would be documented on paper)
Metropolitan Community College