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:
