Appendix B | Jordan University of Science & Technology | Faculty of Nursing Mental Health Nursing Clinical (NUR433) Psychiatric Nursing Assessment Tool For Mentally-ill patients ‘The students will use this form during doing the assessment for mentally ill patients. Physical Dimension Biographic data a) Client initials...... b) Date of Admission: Psychiatric and Medical Diagnoses: ©) Mode Of Admission: Voluntary Involuntary" Emergency Criminal Act ) Date of Birth. e) Gender: Male Female f) Marital Status: Single Married Divorced Widowed _ 2) Educational Level: literate Elementary Primary High School a. Intermediate College University fh) Occupation: i) Religion: 2- History of present problem ‘Patient state the problem in their own words .. Side Effects | Nursing Action (most common)3 General Appearance : a) Dress Cloths : Appropriate or Inappropriate to Age & Weather b) Style: Formal, Informal, Dressy ©) Cosmetics : No makeup, Heavy makeup, Appropriate ) Hygiene : Clean, Dirty ©) Odor: No smell, Perfume, Alcoholic, Bad smell 1) Posture : Stiff, Relaxed \ 4- Activities Of Daily Living: a) Sleep: to determine client's sleep patterns | (Number Of hours, Dreams) b) Nutrition: to determine adequacy of client’s diet (Type of Diet, Appetite, Nutritional Status): 5- Recreation & Hobbies: \ 4 Habits: a) Alcohol: b) Smoking: ©) Medications: d) Caffeine e behavior: to determine client’s potential for harm to self and i) Aggression, family history of psychiatric illnessb) Major depression ©) Suicide 4) Schizophrenia €) Mental retardat 1) Substance abu 2) Stress-related illness 8 Body image: To determine client's perception of hiv her body a) Physical description of self | b) Thoughts and feelings about body \ 9 Physical abuse: to determine history of abuse in the client a) Incest b) Sexual abuse ©) Child abuse 4) Spouse abuse ©) Elderly abuse ) (mugging, robbery, disaster) Emotional Dimension 1- Mood: ‘It’s the Patient's Self Report about His Emotional State “a) Affect: It's the Patient's Emotional State Observed by the Nurse (Facial Expression) : Sad, Angry, Guilt, Depressed, Hostile » ‘Congruency of Affect with patient’s self report Appropriateness of Affect to Situation Duration to determine the depth, the intensity, and the state of the client's al, Intense, Immature, Mood Swings) s; to determine any trauma that may contribute to client's whether client's perceptions are realistic or false Sensory Perception of One The Senses Which | Stimuli3. Gustatory, 4. Tactile, 5. Olfactory b)_ Mlusion: It's Misinterpretation of external Stimuli 2- Thought Content: A- Delusion: False Fixed Belief, not Shared with Others can't be changed by Logic ‘Types of Delusion: 1. Grandiose 2. Persecution 3. Somatic, 4, Nihilistic 5. Hypochondriacally 6, Idea of references 7. Idea of being controlled B- Form of Thought: _ a. Speech Pattern: 1. Flow of Speech: Mute, talking, Talkative, Stuttering of Speech: Slow, Fast (Volume): Loud, Soft, Whisper3 - Cognition: to determine ME functioning of client's cognitive | emo ing of client's cognitive abilities 4) Immediate: within Past 24 Hours | b) Recent: Within Past 6 Weeks ©) Remote: More than 6 Weeks b- Orientation: a) Time, i b) Place, ©) Persons ¢- Fund of Information: d- Insight to illness: (Insightful, Partial Insight, Lack of Insight) ‘The Patient's Ability to Recognize Signs & Symptoms of his Illness, his Need for Help, & Accept Help & Treatment ‘© Logical Reasoning: a) Abstract Thinking : Ability to Make Connection Between Events b) Concrete Thinking :Inability to Make Connection Between Events £ Social Judgment: ft to elicit the client’s overall view of self of how he would like to be2-Interpersonal Relations: Crust, Dependency or Independency, Support System) a. Level of trust 1. Family: 2. School: 3. Work: 4. Community: b. Level of Independ : eter ee independency | 2. School: | 3. Work: | 4. Community: c. Family unit 1. Relationship Birth order role function: to determine the client's ability to function in his social ‘Conflict: to determine conflicts in client’s roles : to determine problems from unclear role expectations gruity: to determine changes in attitudes or values required of to function in role(s) to determine client’s ability to cope with demands at home, the job with criminal justice system: ‘or meaning about Life) cit client’s views concerning what is important in his ss: to assist in understanding client’s beliefs and8) Religious: (client’s religion, belief, and Practice) ») Spiritual beliefs: to elicit client's deeper meaning and purpose for life ©) Perception of faith: to understand client’s view relationship to health and illness. “ Sreerhanale 3- Sense of Transcendence: To Determine Client's ability to accept Illness a) Hope and despair: b) Suicide: 4 Self-actualization: to determine client's ability to live a rewarding enriched life 'a) Creativity: to elicit client’s ability to feel self-satisfaction when expressing himself creativity b) Aesthetic Sense: to elicit client's ability to Appreciate Nature & Beauty Beliefs about Life & death: to determine value client places on life and Ais ability to face death realistically and prepare for it