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St. Joseph’s University – NU 209

Mental Status Exam and Psychiatric Nursing Care Plan

Student Name:

Patient’s initials:
Date of Admission:

Date of Assessment:

Click on the gray box to type. Put an “x” in all that apply. Tab between boxes.
Identifying Birth Gender: Male Female Preferred Gender:
Data: Age: Unit: Legal Status: Allergies
Recent travel (last 30 days): Yes / No
COVID vaccination? Yes / No Brand:

Date(s):
Monkeypox exposure: Yes / No

Reason for
Admission:

PMH/Surg Hx:

General Unkempt Unclean Well-groomed Posture:

Appearance:
Ht.: Wt.: Pulse : Blood Pressure:

Respirations: Temp: Pain (0 – 10)

Pain tolerable? Yes / No

Motor Tremors Tics Hyperactivity Restlessness
Activity: Aggressiveness Rigidity Psychomotor Retardation
Agitation Other:
Speech Slow Rapid Pressure of Speech Volume:
Patterns: Stuttering Other:
General Cooperative Uncooperative Friendly Hostile Defensive
Attitude: Disinterested Apathetic Attentive Guarded
Other:
Mood: Sad Depressed Despairing Irritable
Anxious Elated Euphoric Fearful
Guilty Labile Other:
Affect: Congruent with mood Blunted Constricted
Flat Appropriate Fearful Other:
Thought Flight of ideas Associative Looseness Circumstantiality

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Processes: Tangentiality Neologisms Concrete Thinking Clang

Word Salad Perseveration Mutism Poverty of Speech
Ability to concentrate: Yes / No How long?

Other:

Thought Content: Delusions/type:

Obsessions Paranoia Magical Thinking Religiosity

Phobias Poverty of Content Other:

Safety Suicidal: if positive for ideation, state plan:

Assessment:
Homicide: if positive for ideation, state plan:

What does the patient’s topic of speech tell you about what they are thinking?

Hallucinations/Type
Perceptual
Disturbances: Illusions Depersonalization Derealization

Were hallucinations present prior to admission? No Yes per chart? per

patient?

Ability to solve problems: as evidenced by:

Judgment
and Insight:
(impaired or intact) Ability to make decisions: as evidenced by:

Knowledge about self: as evidenced by:

Memory: Recent Memory: Impaired Intact

Disoriented Confused

Orientation:
Sociocultural
Factors:

 Work?
 School?
 Family?

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 Legal?
 Spiritual?
 Hobbies?
 Friends?
 Erikson
Stage of Dev.
What medical concerns does your patient have? Sleep concerns?

Fall Risk Assessment:

 Complete attached Morse Falls Risk Assessment

 Score:
o
Falls Precaution: Yes No

Skin Risk Assessment:

 Complete attached Braden Risk Assessment

 Score:
o
Risk? Yes No

Diet:

Fingersticks:

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Psychiatric Disorder(s)

Identify clinical behaviors that support the psychiatric diagnoses:

Medication: Brand Name: Generic Name:

Dose and Time: Date Ordered:

Purpose (for this patient):

Side Effects/Adverse Effects:

Nursing Considerations:

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Medication Effectiveness: Is this medication effective for your patient? Explain how it
is or how it is not.

What are the specific adverse effects your patient is experiencing? What significant
ones are they not experiencing?

Patient Teaching Needs:

Medication: Brand Name: Generic Name:

Dose and Time: Date Ordered:

Purpose (for this patient):

Side Effects/Adverse Effects:

Nursing Considerations:

Medication Effectiveness: Is this medication effective for your patient? Explain how it
is or how it is not.

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What are the specific adverse effects your patient is experiencing? What significant
ones are they not experiencing?

Patient Teaching Needs:

Medication: Brand Name: Generic Name:

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Dose and Time: Date Ordered:

Purpose (for this patient):

Side Effects/Adverse Effects:

Nursing Considerations:

Medication Effectiveness: Is this medication effective for your patient? Explain how it
is or how it is not.

What are the specific adverse effects your patient is experiencing? What significant
ones are they not experiencing?

Patient Teaching Needs:

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Labs Client Expected Labs Client Expected Labs Client Expected

Values Values Values Values Values Values
RBC 4.7-6.1 M BUN 10-20 Alkaline 44-147 U/L
4.2-5.4 F Phosphatase

Hgb 14-18 M Creatinine 0.6-1.2 Total Bilirubin 0.3-1.0 mg/dL

12-16 F

Hct 42-52 M ABG 7.35-7.45 Albumin 3.4-5.4 g/dL

37-47 F

Platelets 150,000- U/A Total Protein 6.0-8.3 g/dL

400,000

WBC 5,000-10,000 pH 4.6-8 (ALT) SGPT 8-46 U/L

Sodium 135-145 Color Amber (AST) SGOT 12-32 U/L

Potassium 3.5-5 Sp.Gravity 1.010-1.025 MCV 80-100 fl

Chloride 95-105 Protein None MCH 27.5-33.2 pg

Glucose (FBS) 70-110 Glucose None MCHC 30-34 gHb/100ml

CO2 - 35-45 Ketones None NRBC% 0 nucleated

RBC/100WBC

Calcium 8.5-10.5 Blood 0-2 RBCs MPV 7.5-12.0 fl

Magnesium 1.8 to 2.4 PT Phosphorus 2.5-4.5 mg/dL

mg/dL PTT/INR

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Abnormal Lab
Values/Diagnostic Tests: Test: Value:

Nursing Interventions:

Test: Value:

Nursing Interventions:

Test: Value:

Nursing Interventions:

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Use the following format: nursing diagnosis related to **** as evidenced by (or manifested by)****. (For example: ineffective
airway clearance related to pain, position, and possible complication on affected side as manifested by shortness of breath, shallow
respirations, use of accessory muscles.)

Use physical nursing assessment, measurable clinical findings, and values to formulate nursing diagnoses, patient goals, nursing
interventions based on evidence-based practice, and applicable evaluations. Evaluation – if they met goals, explain how you know
this; If not, why not.

Assessment Nursing Diagnosis Goals Interventions Evaluations

Subjective:

Objective:

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Assessment Nursing Diagnosis Goals Interventions Evaluations

Subjective:

Objective:

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Assessment Nursing Diagnosis Goals Interventions Evaluations

Subjective:

Objective:

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Long-term Within one month, the patient will:

Goals:

Discharge Planning
Issues/Considerations
:

Charting:

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