Psychiatric Clinical Nursing Assessment and Care Plan

Topics: Nursing, Schizophrenia, Nursing care plan Pages: 7 (2448 words) Published: August 18, 2013
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| ☒| ☐| ☐| ☐| ☐| ☐| ☐| UNUSUAL THOUGHT CONTENT----unusual, odd, strange, bizarre thought content| ☐| ☐| ☐| ☐| ☐| ☒| ☐| BLUNTED AFFECT----reduced emotional tone, reduction in formal intensity of feelings, flatness| ☐| ☐| ☐| ☒| ☐| ☐| ☐| .EXCITEMENT----emotional tone, agitation, increased reactivity.| ☒| ☐| ☐| ☐| ☐| ☐| ☐| DISORIENTATION-----confusion or lack of proper association for person, place, or time.| ☐| ☐| ☐| ☒| ☐| ☐| ☐| Global Assessment Scale (Range 0-100)| |

☒MENTAL STATUS/ ASSESMENT OF PSYCHIATRIC SYMPTOMS
INSTRUCTIONS: CHECK ☒BOX WHERE APPLICABLE. IF NORMAL IS CHECKED GO TO NEXT SECTION. X| GENERAL APPEARANCENORMAL for Age/Culture ☐Facial Expressions: Sad ☐Expressionless ☒Hostile ☐Worried ☐Avoids Gaze ☐DRESS: Meticulous ☐Clothing, Hygiene Poor ☒Eccentric ☐Seductiive ☐MOTOR ACTIVITYNORMAL for Age/Culture ☐Increased Amount ☐Decreased Amount ☒Agitation ☐Tics ☐Tremor ☒Peculiar Posturing ☐Unusual Gait ☐Repetitive Acts ☐SPEECHNORMAL for Age/ Culture ☐Excessive Amount ☐Poverty of ☐Pressure of ☐Slowed ☒Loud ☐Soft ☐Mute ☐Slurred ☒Stuttering ☐INTERVIEW BEHAVIORNORMAL for Age/Culture ☐Expansive ☒Suspicous ☒Withdrawn ☐Angry Outbursts ☐Irritable ☐Impulsive ☐Hostile ☐Silly ☐Sensitive ☐Apathetic ☐Evasive ☐Passive ☒Aggressive ☐Naïve ☐Overly Dramatic ☐Manipulation ☐Dependant ☐Uncooperative ☐Demanding ☐Negative ☒Callous ☐| FLOW OF THOUGHTNormal for Age/Culture ☐Blocking ☒Circumstantial ☒Tangential ☒Perseveration ☐Flight of Ideas ☐Loose Association ☐Indecisive ☐Incoherence ☐Neologisms ☐AFFECT:Normal for Age/Culture ☐Inappropiate ☐Labile ☐Range ☐Restricted ☐Blunted ☒Flat ☐MOODNormal for Age/Culture ☐Elevated ☐Euphoric ☐Dysphoric ☒Depressed ☐Anxious ☐Irritable☐SENSORIUM☐Normal for Age/Culture ☐Orientation Impaired ☒Time ☒Place ☐Person ☐Memory ☒Clouding of Consciousness ☒Inability to Concentrate ☐Amnesia ☐Poor Recent Memory ☒Poor Remote Memory ☒Confabulation ☒INTELLECTNormal for Age /Culture ☐Above Normal ☐Below Normal ☐Paucity...
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