Mutah University

Faculty of Nursing

Psychiatric/ Mental Health Nursing

Assessment Sheet

St. Name: ‫عمران علي القطاونه‬

St.NO: 420181401535

Personal Data:
Name: Mr.Q……………………………………………………………..……….

Age: 28y ……………………………………………………………

Sex: male..………………………………………………………………..……

Marital Status: separated ……………………………………………………..………

Address: Null ……………………………...………………………………………..

Nationality: Null

Patient Occupation: Null

Psychiatric Diagnosis: Schizophrenia………………………………….

Referral Source: 3 ‫………………………………………… منشآت‬.

Reason of Referral: ‫اعتداء على زوجته وحماه‬

Signs & Symptoms: Auditory hallucination , self steam weak .

Source of Information: primary source of data

1. General Appearance:
Physical Condition:

Weight: Null

Height Null

Physical illness: Null …………………………………………………………

Physical deformities: Null …………………………………………………………

Proportion of body part to each other: all body proportion ……………………………………

Facial Expressions:

Anxious: ( ) Apathy: ( )

Hostile: ( ✔ ) Preoccupied: ( )

Sad: ( ) Happy: ( )

Worry: ( ) Anger: ( ✔ )

Appropriate expressions: ( )

Example: ‫كان عدواني وغير متقبل كالم مقدمي الرعايه‬

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Body posture:

The patient holds him/herself: ( )

Any unusual posture: ( ) Null

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Personal Hygiene: (Null)

Clean: ( ) Unclean: ( ) Bad odor: ( )

. Require assistance with hygiene:
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. The patient dress: appropriate to his/her age, sex, and environmental condition: ( Null )

. Statement describes personal hygiene and dress: ‫المريض يلبس مالبس غير مناسبه لحجمه وسنه‬
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2. General Activity:
General Level:

Overactive: ( ✔) Retarded: ( )

Need to be encouraged to participate: ( ) Negativism: ( )

Stereotypy: ( ) Mannerism: ( )

Mimicry: ( ) Catatonic: ( )

Stupor: ( ) Echopraxia: ( )

Ambivalence: ( ) Restlessness: ( )

Compulsion: ( )

Example:

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The relationship with staff:

Likes to talk to others: ( ) Refuse to talk to others: ( )

Argumentative: ( ) Verbal or physical hostile: ( ✔ )

Manipulative: ( ) Incoherent: ( )

Example:

-------------------------------‫يعمل عكس ما يطلب منه مقدمي الرعايه‬

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Eating and Drinking:

State of appetite: ------------------------ Null (‫يلتزم في نظام غذائي صحي‬

-)------------------------------------------------------------

Way and manners of eating or drinking:

Eats quickly: ( Null ) Eats slowly: ( Null )

Noising with food: ( Null ) Eats with hand: ( Null )

Eats with spoon: ( Null ) Dropping food on his/her clothes:( Null )

Hypophagia: ( Null ) Hyperphagia: ( Null )

Diet restriction:

Type of food which he/she likes: ‫التزم في نظام غذائي صحي اثناء العالج‬
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Amount of food: NA

Sufficient: ( NA ) Insufficient: ( ) Ask more amount of food: ( )

Sleeping: NA

Sufficient: ( ) Waking early: ( )

Insufficient: ( ) Night sedation: ( )

Interrupted: ( ) Difficulty in getting off sleep: ( )

Easily aroused: ( )

Duration of sleep: Null----------------------------------------------------

Sleep during the day:-------

NA----------------------------------------------------------------------------------------------------------------
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3. Speech: Null
 Disturbances in speech:

Pressure of speech: ( )

Volubility (logorrhoea): ( )

Poverty of speech: ( )

Non spontaneous speech: ( )

Poverty of content of speech: ( )

Dysprosody: ( )

Dysarthria: ( )

Excessively loud or soft speech: ( )

Example:

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4. Thought process: Null

Characteristics of thinking:

Logic: ( ) Illogic: ( )

Autistic: ( ) Concrete thinking: ( )

Dereism: ( )

Example:

‫بسأل المريض في حال حدوث حريق ماذا تفعل ؟‬

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Disturbance in form of thinking:

Losing in association: ( ) Blocking: ( )

Echolalia: ( ) Clang association: ( )

Circumstantiality: ( ) Coherent: ( )

Neologism: ( ) Preservation: ( )

Incoherent: ( ) Verbigeration: ( )

Flight of ideas: ( )

Example:

-------------------------------------‫بالحظ كلمات المريض الي بتعبر عن افكاره‬

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Disturbance in content of thinking:

Delusion: ( )

Types of delusion:
--------Null-------------------------------------------------------------------------------------

Example:

‫كيف ترى نفسك ؟‬

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Obsession: ( Null )

Example:

‫يعيد… الشخص تكرار االفكار بأنه غير متأكد مثال تأكده من اغالق الباب أكثر من مره‬
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5. Perception:
Hallucination: ( ✔ )

Types: Auditory hallucination

Illusion: ( )

Types: Null

Example:
‫سألته هل بتسمع اصوات احنا ما بنسمعها ؟‬
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6. Mood: Null
Happiness: ( ) Sadness: ( )

Elation: ( ) Anxiety: ( )

Liability: ( ) Incongruity: ( )

Apathy: ( ) Depression: ( )

Example:

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7. Memory: Null
Immediate: Intact ( ) Impaired ( )

Example:

‫ ساعه مثال شو افطرت‬24 ‫افكار حديثه خالل‬

‫الصبح ؟‬-------------------------------------------------------------------------------------------------------------
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Recent: Intact ( ) Impaired ( )

Example:

‫احداث مدتها اسبوع‬

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Remote: Intact ( ) Impaired ( )

Example:
‫ اسابيع لسنوات مثال شو تاريخ ميالدك‬3 ‫احداث مدتها من‬
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8. Attention: Null
Attentative: ( ) Distractibility: ( )

Preoccupation: ( ) Selective inattention: ( )

Example:

‫من خالل تعابير الوجه وتفاعله مع مقدم الرعايه‬

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9. Orientation:
Time: Oriented ( ) Disoriented ( )

Example:

‫اسأله هل الوقت مساءا ام‬

‫صباحا ؟‬-----------------------------------------------------------------------------------------------------------------------
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Person: Oriented ( ) Disoriented ( )

Example:

‫اثناء المقابله مثال بسأله مين‬

‫انا ؟‬---------------------------------------------------------------------------------------------------------------------------
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Place: Oriented ( ) Disoriented ( )

Example:

‫بسأله عن مكان وجوده‬

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 10.Judgment:
Realistic: ( )

Unrealistic: ( )

Example:

‫حدث حريق شو بتعمل ؟‬

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11. Insight:
Insightful: ( )

Partial insightful: ( )

Insight less: ( )

Example:

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12. Self-concept:
See him/herself as any person: ( )

See him/herself as a very important person: ( )

Self-depreciation: ( ✔ )

Example:

‫عنده مفهوم ضعيف للذات‬

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13. Medication:
Name: Olanzapine

Dose: 10 mg per day

Route: Oral

Classification: Olanzapine

Name: amisulpride

Dose: 400 to 800 mg/day

Route: oral 

Classification: antipsychotics

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