Initial Nursing Assessment/ Psychiatry
Patient name : ID NO: Age : Telephone:
Emergency Other (Specify).. Friend Other Family Friend Patient Non-Voluntary (Specify).. Married Divorced Separated
Address :
Clinic Family Spouse Voluntary Single
Physician : Dx:
Admitted From:
Acompanied By: Information: Admission Status: Marital Status: Religion : Muslim Christian Reason For Admission Previous Psychiatric Hospitalization: No Family History Of Psychiatric Disorders:
Other
Widow
Widower
Other
Yes Describe:
Chief complain: History Of Current Illness
Illness: Surgical: Allergy: Hospitalization:
Name of Medication
No No No No
Yes Yes medication food others :______________________ Yes Describe: ________________
HEALTH HISTORY Describe: ________________ Describe:_________________
MEDICATION HISTORY
Dose/Schedule Last Dose: Date/Time
SEXUALITY / REPRODUCTION
Onset Of Menopause:----------------------Onset Of Menarche :----------------------Contraceptives No Yes Type ------Birth Control Pills Diaphragm Number Of Pregnancies LMP-------------------
Vaginal Spermicidal Rhythm Method Miscarriages Yes
Cervical Cap Others--------------Describe Abortions
Live Births-----No
Recent Change In Sexual Behavior?
SPIRITUAL ASSESSMENT
Muslim
General Appearance:
Christian
Clean Neat Unkempt Odorous Obese
Other
PHYSICAL APPEARANCE
Dirty Thin Disheveled Emaciated Well-Nourished
Facial expression: Posture: Dress:
Relaxed
Normal Tense
Animated Erect
Masked
Sad
Depressed Waxy flexibility
Angry
Blank Narcissism
Slouching
Catatonic
Mannerisms
Style Neat Clean Appropriated to age. Hygiene, Oder and grooming:________________________________
Motor activity, Gait:
Agitated Duskiness
Restless Tremor Parkinson movement
Motor retardation Akathisia Akinasia Negativism Ambivalence Echoproxia
NUTRITION/ MEAL PATTERN
Diet: Number Meals/ Day: ------------------------- Meal Times: Eating pattern: Roblems With Eating: Feeding Aids: Appetite : Weight change: ENERGY LEVEL: Describe: ROM: BALANCE/ GAIT: Describe: Full Steady Partial Describe: Unsteady Risk for failing Independent No No full Appetite No Usual Tires easily Depentdent Assistance: Describe: Nausea Vomiting lack of Appetite Describe
Diffifuclt Swallowing Yes Tubes
Special Utensils. Describe:
Recent Loss Of Appetite Yes Describe:
ACTIVITY/ REST
High fatigue Low Other
SLEEP
Hours. Sleep/Night Hours Sleep/ Day . Feel rested? No Yes Sleeping Aids: (Medications/ Others) No SLEEP PROBLEMS Insomnia - Early-MiddleLate Awakes Easily Bedtime.. Yes Describe: Fear Associated With Sleep Night Terrors Wake-up time..
Recent Change Nightmares
ALCOHOLS, DRUGS AND SUBSTANCES
Caffeine None Coffee Tea Cola Chocolate How Much? How Long? TOBBACO Non Cigarettes Cigars Pipe Other (Specify) How Much? How Long? DRUGS: None Cocaine Heroin Other (Specify) Inhalants Amphetamines Barbiturates Other How Much? How Long? Last Ingestion: Do You Think You Have A Problem Related To Your Drug Intake? No Yes-----------------------------------------------------------ALCOHOL: None Yes (Specify) How Much? How Long? SYMPTOMS: None Miss Work Miss School Pass Out Loss Of Memory Family History Of Alcohol Abuse? No Yes. Describe: No Yes. Describe: NO YES DESCRIBE Do You Think You Have A Drinking Problem?
DESTRUCTIVE BEHAVIOR
SUICIDE POTENTIAL Do You Feel You Have Control Over The Events Of Your Life? 1) Feel Like Giving Up? 2) Feel Guilty? 3) Current Thoughts Of Harming Self? 4) Past Attempts At Harming Self?
5) Past Thoughts of Suicide?
6) Past Suicide Attempts?
7) Current Thoughts of Suicide? 8) Plan for Suicide?
9) Ability to Contract?
10) Recent Suicide Attempt?
11) Attempt in Hospital?
12) Family History Of Suicide? POTENTIAL FOR AGRESSION 1. 2. 3. 4. Have You Ever Hurt Someone? Have You Ever Broken Things/ Destroyed Property? Are You Having Thoughts Of Hurting Someone? Do You Plan To Hurt Someone? NO YES DESCRIBE NO YES DESCRIBE
OTHER POTENTIAL RISKS 1. Impulsive Behavior 2. Seizures 3. Falls 4. Escape Risk 5. Major Side Effects Of Psychotropic Or Other Meds 6. Others
EMOTIONAL ASSESSMENT Mood:____________________________________________________________ Affect:
Appropriate to situation Euphoria Exaltation Depression Anxiety Fear Agitation Ambivalence Aggression Mood swings Flat Affect duration:______________ Quality of affect Quality:________________ COGNITION (INTELLECTUAL) ASSESSMENT
PERCEPTION No Hallucinations Auditory Visual Tactile Olfactory Gustatory De-realization Depersonalization Yes Describe
illusion Disturbance in thought process
Loose association Circumstantialities Tangentiality Flight of idea Preservation Blocking Neologism Confabulation Poverty thought
Delusions Persecutory Grandiose Religious
Disturbance in thought content
Nihilistic Idea of reference : Obsession
Phobia: Type of thinking: Memory: Intact memory
Abstract thinking
Impairment of recent memory
Concrete thinking Impairment of immediate memory Impairment of remote memory
Judgment: appropriate to situation Impairment of social judgment Impairment of Employment judgment Impairment of financial judgment judgment Impairment of family
Orientation: Insight to illness:
Time
Place
Person Partial insight Lack of insight
Full insight
COMMUNICATION Disturbance of speech rate
NA
Flight of idea Blocking
Clang association
Retardation
Mutism
Aphasia
Aphonia
Disturbance in the form of speech
NA
Word-salad
Incoherence
Neologism
Circumstantiality
Global Assessment of Functioning (GAF)
Score:
PT/Family Oriented to:
Call Light Elect. Safety
ORIENTATION TO UNIT Bed Bath Telephone/ TV Control Room Unit Time of Room # Kitchen Meals
Side Rails Room Tel. #
Smoking Regulations visiting hours
Process of Calling Operator physician name
BELONGINGS SEARCHED: No Yes. By Whom? Stored
Other _______________________________
Articles were: EXPLANATION OF PROHIBITED ARTICLES Safety Razors Razor Blades Glass Articles Other Sharps Drugs Alcohol Televisions Medications
Given to family
Other,
Scissors Cigarettes Cameras Matches
Weapons Pipe Recording Devices Light
RN Signature ____________________________________
Date & Time _________________________________________
.Day of discharge final checklist
INSTRUCTIONS: Verify at the time of discharge that the patient/family has received the following. If No explain. Appointments: Yes Discharge Summary Yes Patient Referral to other hospital Yes Sick time/work excuse Yes Laboratory Slips Yes X-Ray Forms Yes Dressings Home with patient Supplies Home with patient Medicatio ns Home with patient No No No No No No None None None N/A N/A N/A N/A N/A N/A N/A N/A N/A Prosthesi s Clothing Valuable s Devices Sutures Drains Home with patient Home with patient Home with patient Home with patient In In None None None None Out Out Yes N/A N/A N/A N/A N/A N/A No
Related pt/family education Patient family member discharg ed by Any delay Yes No of discharge
others (specify):--------------Reason:--------------------------
SIGNATURE: ___________________________________________ TITLE: ________________________________________________ ----------------------------------------------------- ---------:ID#:--------------------------------------------------------------------DATE/TIME
