Student: Caitlyn Chatpman

Clinical Agency_____Boonton_________Unit__Voluntary ____

Date_____________03/10/2020_________________

County College of Morris

Psychiatric Nursing Patient Assessment

1. General Information

______________________________________
Date of Admission ______________________________________
Age: ______________________________________
Sex: ______________________________________
Race/ Culture: ______________________________________
Primary Language: ______________________________________
Marital Status: ______________________________________
No. Marriages: ______________________________________
If married: Divorced____ Separated______ Widowed ___
Number and ages of
Children/siblings: ______________________________________
Precipitating Event: ______________________________________
Allergies: ______________________________________
Diet: ______________________________________
Height/Weight: ______________________________________
Vital Signs: TPR/BP ______________________________________
City of residence: ______________________________________
Diagnosis on Admission _____________________________________
Current DSM Diagnosis _____________________________________

Admitted from: ______________________________________

Type of Admission Voluntary/Involuntary

2. a. Family dynamics (describe significant relationships between family members)

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

b. Family’s/Pts. Understanding of hospitalization:

_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
3. Medical History:
Patient ___________________________________________________
_________________________________________________________

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 _________________________________________________________
_________________________________________________________
Family Members___________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

4. Psychiatric History:
Patient ___________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Family Members___________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

5. Cultural and Social History:

a. Environmental factors (family living arrangements, type of neighborhood,
Special working conditions): ______________________________
______________________________________________________
______________________________________________________
b. Health beliefs and practices: _______________________________
______________________________________________________
______________________________________________________
c. Religious beliefs and practices: _____________________________
______________________________________________________
______________________________________________________
d. Educational background: __________________________________
_______________________________________________________
_______________________________________________________
e. Significant losses/changes (include dates): _____________________
_______________________________________________________
______________________________________________________

f. Peer/friendship relationships: _______________________________

_______________________________________________________
_______________________________________________________
g. Occupational history: _____________________________________
_______________________________________________________
_______________________________________________________
h. Previous pattern of coping with stress: ________________________
_______________________________________________________
_______________________________________________________

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 6. Support systems: (amount of contact, nature/quality and availability of support):
__________________________________________________________

7. Economic security:___________________________________________
___________________________________________________________

8. a. Current job status:_________________________________________

___________________________________________________________
b. Role contributions and responsibility for others: _________________
___________________________________________________________

9. Anxiety level (circle level, and check the behaviors that apply):
Mild Moderate Severe Panic
Calm____ Friendly_____ Passive_____ Alert_______ Perceives Environmental Correctly____ Cooperative____

Impaired Attention______ “Jittery”____ Unable to Concentrate_____ Hyper Vigilant______ Tremors________

Rapid Speech_______Withdrawn_____Confused______Diroriented_______Fearful_______Hyperventilating____

Misinterpreting the Environment________ (Hallucinations or Delusions)______ Depersonalization__________

Obsessions _______ Compulsions________ Somatic Complaints_______ Excessive Hyperactivity_________

Other_____________________________________________________________________________________

10. Mood/Affect (circle as many as apply): happiness sadness dejection despair

elation suspiciousness apathy (little emotional tone) anger/hostility labile
hopeless guilty irritable anxious other_____________________________

11. Appearance
Grooming/dress________ Identifying features (marks/scars/tattoos_________
Hygiene______________ Appearance vs. stated age_____________________
Posture_______________ Overall appearance__________________________

12. Attitude
Is client: cooperative_________ uncooperative_______ suspicious_________
combative________ warm/friendly_______ distant____________
aggressive_________ guarded____________ hostile____________
aloof______________

13. a. Level of self-esteem (circle one) low moderate high

b. Objective assessment of self-esteem:

Eye contact___________________________________________________
General appearance____________________________________________

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 ____________________________________________________________
____________________________________________________________

14. Assessment of Grief (if applicable)

denial anger bargaining depression acceptance
Describe the patient’s behaviors that are associated with this stage of grieving in
response to loss or change:
________________________________________________________________
________________________________________________________________
________________________________________________________________

15. Thought process (circle as many as apply):

clear logical easy to follow relevant confused blocking delusional
rapid flow of thoughts slowness in thought association suspicious phobias
obsessions poverty

Recent memory loss: loss intact Remote memory: loss intact

Other __________________________________________________________
______________________________________________________________

16. Communication patterns (circle as many as apply): clear coherent slurred speech
incoherent neologisms loose associations flight of ideas preservation
rumination tangential speech loquaciousness slow, impoverished speech
speech impediment (describe) ________________________________________
Other ____________________________________________________________

17. Interaction patterns (describe patient’s pattern of interpersonal interactions with

staff and peers on the unit, e.g. manipulative, withdrawn, isolated, verbally or
physically hostile, argumentative, passive, assertive, aggressive, passive-aggressive,
other): ___________________________________________________________
_________________________________________________________________
_________________________________________________________________

18. Reality orientation (check those that apply):

Oriented to: time________ person________ place_________
situation_______ judgment________ impulse control________
insight (awareness of the nature of the illness)_________

19. Suicidal ideation/Plans Homicidal Ideation/Plans

Explain___________________________________________________________
_________________________________________________________________

History of Attempts: means, lethality, family history (explain):

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 _________________________________________________________________
_________________________________________________________________

20. Psychosomatic manifestations (describe any somatic complaints that may be

stress-related):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

21. Significant physical findings:__________________________________________

__________________________________________________________________
__________________________________________________________________

22. Any concerns about sexuality/sexual activity:______________________________

__________________________________________________________________
________________________________________________________________

23. Analyze lab values and possible significance:

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

24. Activity/rest patterns:

Exercise (amount. type. frequency) _______________________________
_____________________________________________________________
Leisure time activities:___________________________________________
_____________________________________________________________
Patterns of sleep: Number of hours per night _________________________
Use of sleep acids?______________________________________________
Pattern of awakening during the night? ______________________________
______________________________________________________________
Feel rested upon wakening? _______________________________________

25. Personal hygienic/activities of daily living:

Patterns of self-care: independent __________________________________
Requires assistance with: Mobility_______________________________
Hygiene________________________________
Toileting_______________________________
Feeding________________________________
Dressing_______________________________
Other__________________________________

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 Statement describing physical assessments: _____________________________
________________________________________________________________
________________________________________________________________

26. Other pertinent physical assessments: __________________________________

_________________________________________________________________
________________________________________________________________

27. List all medications patient is currently taking. Describe the classification, the action
of medication, usual dosage and an explanation of why your patient is taking it.
Attach separate sheet if needed. (Do not use med cards or print-outs).

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 28. Evaluation of assessment data:
KNOWLEDGE DEFICITS IDENTIFIED/TEACHING/LEARNING NEEDS:

NURSING DIAGNOSES INDICATED: (At least two) (prioritize)

Immediate
NURSING INTERVENTIONS (At least four) (use textbook as reference- list pg.
#’s)

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 ASSESSMENT

Student: Date:

Chief Complaints: Admitting Diagnosis:

Medical-Surgical History:

Age Group: Gender:

P
E
R
S
O
N

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 County College of Morris
Nursing IV Psychiatric Nursing Rotation
Crisis Intervention Experience
St. Clare’s Denville Campus
Psychiatric Emergency Services

Prior to your experience:

1. Define Crisis Intervention.

2. List possible goals you believe the Crisis Team has for their services.

During your experience:

1. Introduce yourself to the crisis staff and explain your purpose for
being there.

2. Identify various team members and their roles on the unit.

3. Explain the commitment process and role of a screening center.

4. Describe at least one case either observed on the unit or explained by a

a staff member.

5. Evaluate your experience.

Prepare no more than a two-page paper within one week of your experience.

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 County College of Morris
Nursing IV – AA Community Experience Guide
Select a meeting labeled “O” (open) and “S” (speaker)
Locate meetings at aanj

1. Who can benefit from the organization?

2. What are the prerequisites for membership?

3. What are the 12 steps?

4. Please summarize your cognitive and perceptual reaction to the meeting

you attended:

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