Nursing 25L Psychiatric-Mental Health Nursing Lab
Nursing History and Assessment
Instructions: Download this form and type in your responses. Complete all requested information. Include
rationales and references as directed. Submit per instructor’s directions either by email or in person.
Student Name:
Facility:
I.
Date of Care:
DEMOGRAPHICS
Client’s Initials:
Age/Gender:
Race:
Dominant Language:
Marital Status:
Admission Status:
Admission Date:
2. PSYCHIATRIC DIAGNOSIS
Axis I
Axis II
a. Describe the AXIS I and II disorders; include epidemiology, etiology and diagnostic criteria. Cite
references.
b. Describe your client’s specific symptoms and behaviors to validate the diagnoses.
c. If no diagnosis has been assessed, use your assessment skills, the DSM, and text to formulate a
diagnostic impression.
Axis III
Axis IV
Axis V Provide one set of GAF scores (choose one of the following sets)
Past 6 months: Past 12 months:
Current: Admission:
3. CLIENT’S PERCEPTIONS AND EXPECTATIONS
A.
How does the client describe or understand current stressors and illness?
B.
How does the client define his/her needs from this agency?
C.
What are the client’s expectations of the agency or staff?
D.
What are the client’s goals?
E.
What are the client’s self-described strengths and weaknesses?
4.
PSYCHIATRIC HISTORY
A. Client and family members’ histories of psychiatric problems and treatment
B. Genetic predisposition
5.
CULTURAL AND SOCIAL HISTORY
A. Environmental factors (family living arrangements, cultural influences)
B. Health Beliefs and Practices (personal responsibility for health, special self-care practices)
C. Religious Beliefs and Practices
D. Educational Background
E. Occupational History
F. Peer / Friendship Relationships
G. Significant Losses / Changes (include dates)
H. Previous Patterns of Coping with Stress
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6. CURRENT CONDITIONS
A. Support Systems: (who, what, when, how often?)
B. Economic Security (Does the patient handle his/her own money? If not, who does?)
C. Avenues of Productivity/Contribution
D. Current Job Status (volunteer or paid)
E. Role Contributions and Responsibility for Others
F. Participation in Group Activities and Interactions with Others
7.
SELF ESTEEM
A. Client’s level of self-esteem
B. Things client likes about self
C. Things client would like to change about self
8.
OBJECTIVE ASSESSMENT
A. Participation in Group Activities and Interactions with Others
B. Stage and Manifestations of Grief: describe the client’s loss and identify the
stage of grief. Describe client’s behaviors that are associated with
this stage of grieving.
C. Psychosomatic Manifestations (describe any somatic complaints that may be stress-related).
9.
MENTAL STATUS EXAM: Utilize text book and course materials to describe
A. Appearance
B. Behavior
C. Attitude
D. Speech
E. Mood and Affect
F. Perceptions
G. Thoughts
H. Sensorium/Cognition
I. Judgment
J. Insight
K. Reliability
10. MEDICAL INFORMATION
A. Previous major illnesses, surgeries, and hospitalizations
B. Lab tests ordered: elaborate on abnormal lab findings and test results pertinent
to psychiatric care.
11. HEALTH PRACTICE
A. Activity/Rest Patterns:
1. Exercise (amount, type frequency)
2. Leisure time activities
3. Patterns of sleep: number of hours per night, use of sleep aids, patterns of awakening
during the night, sense of feeling rested upon awakening?
B. Personal Hygiene/ADLs:
1. Describe patient’s ability for self care
2. Identify tasks for which the patient needs assistance
3. Describe personal hygiene
12. ALCOHOL AND DRUG USE/ABUSE
A.
substance used,
B.
when last consumed,
C.
pattern of use: when consumed, how often, how much in last two months, how much per day
D.
treatment history
13. SUMMARY OF INITIAL PSYCHOSOCIAL / PHYSICAL ASSESSMENT
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14. ASSESSMENT OF CLIENT’S STAGE OF DEVELOPMENT
(Erickson’s Psychosocial Theory of Human Development). Based on your assessment of your
client, utilize the course materials to determine the following:
A. Client’s theoretical stage (based on age)
B. Client’s behavioral stage (based on behavior)
C. Rationale for behavioral stage
15. ASSESSMENT OF CLIENT’S CURRENT PROBLEMS:
Based on information in the record and your interaction//assessment of your client, list the top 3
current patient problems (not DX) in order of priority. State a brief rationale for making each choice.
1.
2.
3.
16.
CULTURAL AND SPIRITUAL CONSIDERATIONS TO ADDRESS
17.
LIFESPAN ISSUES TO ADDRESS
18.
BASED ON ASSESSMENT, LIST THREE STRENGTHS OF THIS CLIENT TO
CONSIDER WHEN PLANNING CARE.
1.
2.
3.
19.
IDENTIFY 3 LEARNING NEEDS OF THIS CLIENT
1.
2.
3.
20.
CHOOSE ONE LEARNING NEED. Describe the information you taught or given the opportunity
would teach the patient on this topic. Include any barriers to teaching or learning which you
assessed.
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