DATA COLLECTION TOOL Inpatient Mental Health

DATE OF ADMISSION: DATE OF CARE: Educational Level/Occupation: Hobbies/Interests: (enjoyments): Disabilities: Living Arrangements (# in household):

Student Name

AGE: GENDER: Male/Female RACE: African-American, Asian Hispanic/Non-Hispanic American-Indian, White, Other: SYMPTOMS & Behaviors Day of Admission: (Danger Self/Danger Others) (AXIS I) PSYCH DX: (AXIS II) (Personality d/o, mental retardation) (AXIS III) ACUTE/CHRONIC DISEASES/HEALTH HX: Include any surgical procedure. (AXIS IV) RECENT STRESSORS (LIST SPECIFIC STRESSORS): Equipment: IV’s: VITAL SIGNS Blood Pressure Heart Rate/Pulse Respiratory Rate Temperature Intake/Output Height/Weight
Admission Last Recorded

Legal Guardian (if minor or vulnerable adult): Advanced Directives/Living Will/Medical Power of Attorney: CODE STATUS: No Code, Full Code, SAFETY CONCERNS YES NO Partial Code (meds only, FALL RISK CPR only) BED ALARM ON (AXIS V) GAF: SEIZURE PRECAUTIONS RESTRAINTS Activity Level: Up Ad Lib, BR, BRP, BSEC, Unable to move self Hygiene/Bathing: Self Care, Assistance, Total Care Elimination: Void/Foley/Ostomy/Dialysis DIET: Supplements: Dentures (full or partial), no teeth, teeth poor condition, dysphagia SLEEP QUALITY: # hrs _____, difficulty falling asleep, difficulty staying asleep, early awakening, hypersomnia, nightmares/terrors MEDICATIONS (current): Home Medications: OTC/Alternative Meds: PAIN: acute/chronic Intensity: Scale 1-10 Characteristics: ALLERGIES: Location:

Dressing Change Orders (list any drains/wounds present and care): Treatments: PT/OT/ST/RT/MSW or Other Referrals:

Substance Abuse History: Drug(s) of Choice: Date of Last Use: How much? How often used in past week/month? Longest period without use: Number admissions treatment: CAGE:

PSYCHIATRIC DIAGNOSIS (Axis I, Axis II)

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THIS PAGE IS the TEXTBOOK PICTURE of the selected DSM-IV Diagnosis COMPLETE FOR ADMITTING PROBLEM (harm to self or others) PATHOPHYSIOLOGY DSM-IV TR Management/Treatment ETIOLOGY Diagnostic Criteria Pharmacology/Therapy *Include risk factors Management Commonly Any cultural/ethnic factors Prescribed for Diagnosis Demographics/prognosis Incidence: General Population: Medications Normally Male: Prescribed for this Female: Diagnosis: Other: Etiology Genetic: Biochemical:

Nursing Diagnoses with Selected Outcomes This is textbook picture of the diagnosis.

Nursing Interventions Include cultural/ethnic/race and religious/spiritual specific interventions

(For Clinical Circle Patient Medications) Do any of these meds need blood levels drawn?

Psychosocial:

Personality Factors/Other: Lab/Diagnostics Routinely Ordered To Monitor Adverse Effects of Medication?

(For clinical Highlight or circle your patient’s symptoms that were present upon admission and dialogue whether they are present now.)

PSYCHIATRIC DIAGNOSIS (Axis I, Axis II) THIS PAGE IS the TEXTBOOK PICTURE of the selected DSM-IV Diagnosis COMPLETE FOR ADMITTING PROBLEM (harm to self or others) PATHOPHYSIOLOGY DSM-IV TR Management/Treatment ETIOLOGY Diagnostic Criteria Pharmacology/Therapy *Include risk factors Management Commonly Any cultural/ethnic factors Prescribed for Diagnosis Demographics/prognosis Incidence: General Population: Medications Normally Male: Prescribed for this Female: Diagnosis: Other: Etiology Genetic: Biochemical:

page 2a (if needed)
Nursing Diagnoses with Selected Outcomes This is textbook picture of your diagnosis.. Nursing Interventions Include cultural/ethnic/race and religious/spiritual specific interventions

(For Clinical Circle Patient Medications) Do any of these meds need blood levels drawn?

Psychosocial:

Personality Factors/Other: Lab/Diagnostics Routinely Ordered To Monitor Adverse Effects of Medication?

(For clinical Highlight or circle your patient’s symptoms that were present upon admission and dialogue if they are present now.)

PSYCHIATRIC MEDS

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MEDICATIONS
Order of meds listed: 1) PO 2) SQ/IM 3) IV 4) PRN’s Complete for all psychiatric meds prescribed (include prn’s): 1. Physician’s Orders 1. Medication COMMON Adverse 2. Dosage ranges (child, 2. Classification Effects adult, geriatric/IM/IV/SQ) 3 Mode of Action (Very important for patient 3. Why is patient taking this 4. Pregnancy Safety Category education and teaching)
medication? SERIOUS Adverse Effects

(Symptoms to report to provider. Symptoms may be life-threatening or lead to serious complications.

Nursing Interventions (include incompatibilities)
on IV/IM/SQ include dilution amount, site selection, rate of administration

1. Medication 2. Classification 3 Mode of Action 4. Pregnancy Safety Category

1. Physician’s Orders 2. Dosage ranges (child, adult, geriatric/IM/IV/SQ) 3. Why is patient taking this medication?

COMMON Adverse Effects (Very important for patient education and teaching)

SERIOUS Adverse Effects

(Symptoms to report to provider. Symptoms may be life-threatening or lead to serious complications.

Nursing Interventions (include incompatibilities)
on IV/IM/SQ include dilution amount, site selection, rate of administration

PSYCHIATRIC MEDS

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MEDICATIONS
Order of meds listed: PO 2) SQ/IM 3) IV 4) PRN’s Complete for all psychiatric meds prescribed (include prn’s): 1. Physician’s Orders 1. Medication COMMON Adverse 2. Dosage ranges (child, 2. Classification Effects adult, geriatric/IM/IV/SQ) 3 Mode of Action (Very important for patient 3. Why is patient taking this 4. Pregnancy Safety Category education and teaching)
medication? SERIOUS Adverse Effects

(Symptoms to report to provider. Symptoms may be life-threatening or lead to serious complications.

Nursing Interventions (include incompatibilities)
on IV/IM/SQ include dilution amount, site selection, rate of administration

1. Medication 2. Classification 3 Mode of Action 4. Pregnancy Safety Category

1. Physician’s Orders 2. Dosage ranges (child, adult, geriatric/IM/IV/SQ) 3. Why is patient taking this medication?

COMMON Adverse Effects (Very important for patient education and teaching)

SERIOUS Adverse Effects

(Symptoms to report to provider. Symptoms may be life-threatening or lead to serious complications.

Nursing Interventions (include incompatibilities)
on IV/IM/SQ include dilution amount, site selection, rate of administration

PAGE 5 NON PSYCHIATRIC MEDICATIONS
List only major medications (no more than 10) MEDICATION (classification) 1 2 3 4 5 6 7 8 9 10 MD ORDER REASON PT TAKING HOME MED Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Any psych S/S this med may cause? Any contraindications with psych d/o or med? NON PSYCHIATRIC MEDICATIONS

LABORATORY AND DIAGNOSTIC DATA

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ADX, Blood Alcohol, Liver Profile, Chemistry, CBC, HIV, Thyroid Profile, Hepatitis Panel, Urinalysis, etc. (Circle laboratory work performed.) CHECK PHYSICIAN’S ORDERS! List Abnormals ONLY Lab Manual Normal Ranges Test
VALUE = High (↑) Normal (WNL) Low (↓) VALUE/Date Admit Most Recent

Interpretation of Tests R/T Diagnosis and Medications

DIAGNOSTIC TEST Name of Test

Date Conducted ASSESSMENT FORM of Tests r/t Diagnosis and Medications Interpretation

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*Mental Status Assessment
GENERAL: Include physical appearance, presence,
stated age vs. apparent age, proportion of both limbs to trunk, body and breath odors, hygiene, eye contact, hair color and appearance, distinguishing marks

Admitting Assessment

Your Findings Day of Care

MOTOR ACTIVITY:

tremors, tics, mannerisms, gestures, rigidity, hyperactivity, restlessness or agitation, aggressiveness, gait pattern, echopraxia, psychomotor retardation, range of motion SPEECH PATTERNS: slow or rapid, pressured, tone, volume, aphasia, speech impediment GENERAL ATTITUDE: cooperative or uncooperative, friendly, hostile, defensive, uninterested, apathetic, attentive, interested, guarded, suspicious EMOTIONS (MOOD): sad, depressed, despairing, irritable, anxious, elated, euphoric, fearful, guilty, labile (ASK PATIENT)

AFFECT:

congruent with mood, constricted, blunted, flat, appropriate or inappropriate THOUGHT PROCESSES: flight of ideas, looseness of associations, circumstantiality, tangentiality, neologisms, concrete thinking, clang associations, word salad, perseveration, echolalia, mutism, poverty of speech, concentration ability, attention span CONTENT OF THOUGHT: Delusions (persecutory, grandiose, reference, control or influence, somatic, nihilistic), suicidal or homicidal ideations, obsessions, paranoia, suspiciousness, magical thinking, religiosity, phobias, poverty of content (vague, meaningless)

PERCEPTUAL DISTURBANCES:
Hallucinations (auditory, visual, tactile, olfactory, gustatory), illusions, depersonalization, derealization

SENSORIUM AND COGNITIVE ABILITY:
Level of alertness /consciousness, Orientation (time, place, person, situation), Memory (recent, remote, confabulation), Abstract, Concrete IMPULSE CONTROL: Ability to control aggression, hostility, fear, guilt, affection, sexual impulses/feelings JUDGEMENT: ability to solve problems or make decisions INSIGHT: awareness of limitations, consequences of actions, illness

*Townsend (2005), Psychiatric/Mental Health Nursing (5th Ed), Appendix B, pages 916-917

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SYSTEM ASSESSMENT CRITERIA Findings from chart Subjective from patient interview or Your observation

ENT: SKIN: Wounds/incisional sites/dressings/drains CHEST: CARDIOVASCULAR MUSCULOSKELETAL: GASTROINTESTIONAL: ENDOCRINE:
Blood Sugar Patterns: ac & HS, bid ac

GENITOURINARY:
GENITOREPRODUCTIVE:

OTHER: PAIN: Location, radiation, quality, intensity, characteristics of
pain, aggravating factors, alleviation factors

RISK ASSESSMENT: Precautions: falls, seizure,
restraints, confusion SAFETY: side rails up/down, call light in reach, armband, allergy band, fall band, bed alarm on/off

NUTRITIONAL:

Include height/weight (IBM/BMI, changes) diet and caloric intake (adequacy), risk factors malnutrition, hydration status

PSYCHOSOCIAL: Include impact of illness on selfperception, coping strategies, social support, financial resources, substance use history (Use Maslow’s Hierarchy of Needs)

DEVELOPMENTAL:

Include impact of illness on role performance and ability to achieve expected developmental status. (use Erikson’s developmental stages) Immunization status

VALUES AND BELIEFS: Include cultural and
religious values/beliefs that affect health practices and client’s expression of current spiritual needs. Chaplain/minister needed?

PATIENT/FAMILY TEACHING PLAN: Include
assessment of patient/family teaching needs, goals of teaching plan, strategies, and evaluation of plan

DISCHARGE PLANNING: Discharge destination,
anticipated problems, available resources, referrals needed. FACTORS hindering care: transportation, finances, housing, disabilities (physical or mental), lack of support

Come to clinical with prepared questions (both assessment and therapeutic interactions)

PAGE 9 PROCESS RECORDING

*minimum of six (6) interactions

STUDENT NURSE VERVAL AND NONVERBAL Verbal (Quotes):

COMMUNICATION PATIENT TECHNIQUE VERBAL AND NONVERBAL Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used:

How could interaction have Been reworded or rephrased? Critique your interaction:

Nonverbal: Verbal (Quotes):

Nonverbal: Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used: Critique your interaction:

Nonverbal: Verbal (Quotes):

Nonverbal: Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used: Critique your interaction:

Nonverbal: Verbal (Quotes):

Nonverbal: Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used: Critique your interaction:

Nonverbal:

Nonverbal:

PAGE PROCESS RECORDING 10

*minimum of six (6) interactions

STUDENT NURSE VERVAL AND NONVERBAL Verbal (Quotes):

COMMUNICATION PATIENT TECHNIQUE VERBAL AND NONVERBAL Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used:

How could interaction have Been reworded or rephrased? Critique your interaction:

Nonverbal: Verbal (Quotes):

Nonverbal: Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used: Critique your interaction:

Nonverbal: Verbal (Quotes):

Nonverbal: Therapeutic/Nontherapeutic(circle) Verbal (Quotes): Type of Technique Used: Critique your interaction:

Nonverbal: Verbal (Quotes):

Nonverbal: NSG DX: Therapeutic/Nontherapeutic(circle) Verbal (Quotes): PT outcome: PT will Type of Technique Used: **Related findings: Nonverbal: Nursing Interventions: Critique your interaction:

Nonverbal:

PAGE 11
Evaluation:

No.°

NURSING DIAGNOSIS Select three (3) nursing diagnoses to expand!

1 2 3 4 5 6 7 8 9 10

Hospital Day # SUMMARY OF PATIENT DATA This page is a complete picture of your patient on the date of care. (*Are there any barriers to providing care (religious, ethical, educational, financial, age, gender, other?)

SETTING PRIORITIES: Remember MASLOW: Physiological before Psychological Remember ABC’s: Airway before breathing, circulation Remember Patient Safety: First of all Do No Harm PREVENT Death and Disability RELIEVE Suffering Remember GAF Remember Patient Priorities

NSG DX: PT outcome: PT will Related findings: Nursing Interventions:

x

NSG DX: PT outcome: PT will Related findings:

Belonging SAFETY Clothing, food, shelter

Nursing Interventions:

Evaluation:

Evaluation: