Psychiatric Clinical Nursing Assessment and Care Plan

Psychiatric Clinical Nursing Assessment
Jennifer Stokes
Daytona State College

Directions: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom. Patient Initials | EM | Physician | Dr. Singh | Date | 08/07/2013 | | Not Present | Very Mild | Mild | Moderate | Moderately Severe | Severe | Extremely Severe | SOMATIC CONCERNS – preoccupation with physical health, fear of physical illness, hypochondriasis | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | ANXIETY------worry, fear, overconcern for present or future, uneasiness | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | EMOTIONAL WIYHDRAWAL---------lack of spontaneous interaction,isolation,deficiency in relating to others. | ☐ | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ | CONCEPTUAL DISORGANIZATION-----thought processes confused,disconnected,disorganized. | ☐ | ☐ | ☐ | ☐ | ☐ | ☒ | ☐ | GUILT FEELINGS----self blame, shame, remorse for past behavior. | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | TENSION-----physical and motor manifestations of nervousness, over-activation, agitation | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | MANNERISMNS AND POSTURING-------peculiar,bizarre,unnatural motor behavior(not including tic ). | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | GRANDIOSITY-----exaggerated self –opinion,,arrogance, conviction of unusual power or abilities. | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | DEPRESSIVE MOOD------sorrow, sadness, despondency, pessimism, | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | HOSTILITY-----animosity, contempt, belligerence, disdain for others. | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | SUSPICIOUSNESS----mistrust, belief others harbor malicious or discriminatory intent. | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | HALLUCINATORY BEHAVIOR----perceptions without normal stimulus correspondence. | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | MOTOR RETARDATION-----slowed, weakened movements or speech, reduced body tone. | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | UNCOOPERATIVENESS------resistance,guardedness, rejection of authority, non-compliant | ☒ | ☐ | ☐ | ☐ | ☐ | ☐ |