Managing clinical groups
Clinical orientation will occur on Sept 9, 10 & 13 in the Nursing Lab, from 0700 - 1700. Thursday clinical groups will meet on 9/9; Friday clinical groups on 9/10; and, Monday groups on 9/13.St. Joseph’s College – NU 209
Mental Status Exam and Psychiatric Nursing Care Plan
Student Name:
Patient’s initials: _________
Date of Admission: ________________
Date of Assessment: ______________
Click on the gray box to type. Put an “x” in all that apply. Tab between boxes.
Identifying
Data: Gender: Male0 Female0 Non-Binary 0
Age: Unit: Legal Status: Allergies
Reason for Admission:
General
Appearance: Unkempt0 Unclean0 Well-groomed0 Posture:
Ht.: Wt.: Pulse : Blood Pressure:
Respirations: Temp: Pain/Other:
Motor
Activity: Tremors 0 Tics 0 Hyperactivity 0 Restlessness 0
Aggressiveness 0 Rigidity 0 Psychomotor Retardation 0
Agitation 0 Other:
Speech
Patterns: Slow 0 Rapid 0 Pressure of Speech 0 Volume:
Stuttering 0 Other:
General
Attitude: Cooperative 0 Uncooperative 0 Friendly 0 Hostile 0 Defensive
Disinterested 0 Apathetic 0 Attentive 0 Guarded 0
Other:
Mood:
Sad 0 Depressed 0 Despairing 0 Irritable 0
Anxious 0 Elated 0 Euphoric 0 Fearful 0
Guilty 0 Labile 0 Other:
Affect:
Congruent with mood 0 Blunted 0 Constricted 0
Flat 0 Appropriate 0 Fearful 0 Other:
Thought
Processes: Flight of ideas 0 Associative Looseness 0 Circumstantiality 0
Tangentiality 0 Neologisms 0 Concrete Thinking 0 Clang 0
Word Salad 0 Perseveration 0 Mutism 0 Poverty of Speech 0
Other:
Form: Ability to concentrate 0 Attention span – How Long?
Content: Delusions/type: _______________________________________________
____________________________________________________________
Obsessions 0 Paranoia 0 Magical Thinking 0Religiosity 0
Phobias 0 Poverty of Content 0 Other:
Suicidal: if positive for ideation, state plan:
Homicide: if positive for ideation, state plan:
What does the patient’s topic of speech tell you about what he or she is thinking?
Perceptual
Disturbances:
Judgment
and Insight: (impaired or intact)
Hallucinations/Type
Illusions 0 Depersonalization 0 Derealization 0
Were hallucinations present prior to admission? No 0 Yes 0 per chart? 0 per patient? 0
Ability to solve problems: as evidenced by:
Ability to make decisions: as evidenced by:
Knowledge about self: as evidenced by:
Memory: Recent Memory: Impaired 0 Intact 0
Disoriented 0 Confused 0
Orientation:
Sociocultural
Factors:
• Work?
• School?
• Family?
• Legal?
• Spiritual?
• Hobbies?
• Friends?
What medical concerns does your patient have? Sleep concerns?
Psychiatric Disorder(s)________________________________________________________
___________________________________________________________________________
Identify clinical behaviors that support the psychiatric diagnoses:
Medication: Brand Name: Generic Name:
Dose and Time: Date Ordered:
Purpose (for this patient):
Side Effects/Adverse Effects:
Nursing Considerations:
Medication Effectiveness: Is this medication effective for your patient? Explain how it is or how it is not.
What are the specific adverse effects your patient is experiencing? What significant ones are they not experiencing?
Patient Teaching Needs:
Medication: Brand Name: Generic Name:
Dose and Time: Date Ordered:
Purpose (for this patient):
Side Effects/Adverse Effects:
Nursing Considerations:
Medication Effectiveness: Is this medication effective for your patient? Explain how it is or how it is not.
What are the specific adverse effects your patient is experiencing? What significant ones are they not experiencing?
Patient Teaching Needs:
Medication: Brand Name: Generic Name:
Dose and Time: Date Ordered:
Purpose (for this patient):
Side Effects/Adverse Effects:
Nursing Considerations:
Medication Effectiveness: Is this medication effective for your patient? Explain how it is or how it is not.
What are the specific adverse effects your patient is experiencing? What significant ones are they not experiencing?
Patient Teaching Needs:
Abnormal Lab Values/Diagnostic Tests: Test: Value:
Nursing Interventions:
Test: Value:
Nursing Interventions:
Test: Value:
Nursing Interventions:
Use the following format: nursing diagnosis related to **** as evidenced by (or manifested by)****. (For example: ineffective airway clearance related to pain, position, and possible complication on affected side as manifested by shortness of breath, shallow respirations, use of accessory muscles.)
Use physical nursing assessment, measurable clinical findings, and values to formulate nursing diagnoses, patient goals, nursing interventions based on evidence-based practice, and applicable evaluations. Evaluation – if they met goals, explain how you know this; If not, why not.
Assessment Nursing Diagnosis Goals Interventions Evaluations
Subjective:
Objective:
Assessment Nursing Diagnosis Goals Interventions Evaluations
Subjective:
Objective:
Assessment Nursing Diagnosis Goals Interventions Evaluations
Subjective:
Objective:
Long-term
Goals: Within one month, the patient will:
Discharge Planning
Issues/Considerations
Charting:
Sample Solution
In conclusion, the results themselves show that the majority of people do not take symptoms seriously and would only know about a certain disease when it is too late. It also shows that Tuberculosis, as tragic as it can be, is not known by many teenagers and adults. This means that people are not aware of Tuberculosis and would certainly mistake it with other diseases. This would lead to them not taking the right precautions, which would probably put their life in danger if they do not visit a doctor or are not consulted by someone fast enough. The importance of this research comes from the fact that by raising awareness, hundreds of thousands of lives would be saved every year, and people diagnosed with the disease will try to take more caution when being among others. This by itself would contribute to help in eradicating this disease which is indeed one of the many goals of the World Health Organization and other health related groups around the world. Knowing that Tuberculosis is a life-threatening disease displays the necessity of raising awareness about this matter. I believe that the best way in doing so is by making Tuberculosis campaigns all around the country, which aim at increasing the people’s knowledge about this disease. Another way would be to show information about this disease on social media platforms such as Facebook, Instagram, and Reddit. In my opinion, It is really necessary for schools to put together lectures every once in a while for students and teachers in order to make them aware of the danger of Tuberculosis. This will also mean that the students who attend the lecture will make sure that their parents and siblings will also know about the Tuberculosis disease. Finally, by raising awareness about Tuberculosis, we can surely help in fully eliminating this deadly disease.