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ADN PMH Assessment Guide

ADN PMH Assessment Guide

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Published by Shannon Nuttall
Assessment guide for mental health nursing
Assessment guide for mental health nursing

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Published by: Shannon Nuttall on Sep 22, 2013
Copyright:Attribution Non-commercial


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University of Arkansas – Fort Smith

Student: Date:

Assessment Guide
Instructions: Complete the assessment guide on the day of assessment. No Blanks! May use N/A for not applicable. Star (*) significant data in red.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Presenting Problem (What led the client to seek treatment? History of the current problem onset, symptoms, severity,

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Axis I: Axis II: Axis III: Axis IV: Axis V:

objective in nature): >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> .Brief Definition of Admitting Diagnosis (look up when you get home): >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Currently Ordered Medications: Drug Dose and Route Home Medications: Frequency Drug >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> General Description (one paragraph.

etc) Last BM GI Complaints Current Weight ______________ . tremors. headaches.PHYSICAL Integumentary (general appearance of skin): Sensory Neurological (seizures. etc) Cardiovascular Respiratory B/P _____________ P ____________ (rhythm _________) R _________ Gastrointestinal (GI) Usual Diet/Favorite foods Ordered Diet Food Allergies Dental Health Nutritional Status IBW __________________ Recent loss/gain Genitourinary (GU) /Reproductive Sexual Dysfunction Urinary Elimination Pattern Bowel Elimination Pattern Musculoskeletal (muscle tone/strength. motor ability.

WBC with Clozaril. tests to rule out thyroid disorder. etc. Caffeine. Tobacco.) Date Lab Test Results Significance Alcohol. OTC Drugs. Lithium. anticonvulsants. Street Drugs >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> SAFETY AND SECURITY Motor Activity Speech Patterns . liver studies on alcoholics.Significant Lab Findings: (Lab tests used to monitor therapeutic blood levels of Depakote. etc.

evaluate plan and available means Perception Sensorium and Cognitive Ability Orientation Memory Impulse Control .Emotions General Attitude Thought Processes Violent Ideation (self or others) If yes.

children. special self-care practices) .Judgment and Insight >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> LOVE AND BELONGING Developmental Level (Erickson): (Circle Developmental Task Achieved) Stage of Family Development (Duvall): Family Dynamics (significant family relationships) /Support Systems (significant others): Significant others (spouse. friends) Who is the most important person in your life? Are people available to you when you are in need? Who/what provides you with strength and hope? Productivity/Contribution (role contributions and responsibilities): Currently Employed? Health Beliefs and Practices (personal responsibility for health.

etc) Significant Losses/Changes (include approximate date and note how this affects behavior) {Stage of Grief: N/A denial anger bargaining depression acceptance} Anxiety Level Ego Defense Mechanisms (describe how used by client) Pattern of Coping with Stressors—Describe behavior when feeling: Anxious Sad Angry >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> . type of neighborhood.Living Situation (living arrangements.

Self Esteem/Self Actualization Level of Self-Esteem (circle one) Things client likes about self low moderate high Things client would have liked to change about self Objective Assessment of Self-Esteem: Eye Contact Posture Grooming/Hygiene Dress Expressed Feelings of Inferiority Willingness to Initiate Conversation Participation (group activities. interactions with staff/other clients. etc) Charting Day 1: Charting Day 2: .

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