PSYCHIATRIC NURSING ASSESSMENT

I. General Information:
Patient Name: Floyd B. Carampatan
Age: 45 years old
Sex:Male
Address: Sitio Apas Lahug, Cebu City
Significant Psychiatric History:
Family History of psychiatric Illness: None
Depression: Yes
Suicidal Tendencies: Yes
Physical Abuse: None
Aggressive Behavior: Yes

Civil Status:Single

Substance Abuse: Yes

Sexual Abuse: Yes
Mood Swing: Yes

Significant Physical History:

Nutritional Status:_______________________________________________________________
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Sleep Pattern: __________________________________________________________________
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Alcohol use: ___________________________________________________________________
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Smoking: _____________________________________________________________________
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Illnesses: ______________________________________________________________________
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Surgeries: _____________________________________________________________________
II. Condition of Admission:
Date:
Time of Admission: 11:00 AM
Voluntary
____ Committed
Accompanied by: Policemen
Route of Admission: ___: Wheelchair
Y: Ambulatory
__: Stretcher

III. Predisposing Factors: (Genetic Influences)

Genogram:
Family of Origin

Present Family

Family Dynamics (describe significant relationship between family members)

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Support System: (amount of contact, nature/quality of relationship and availability)
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Past Experiences:
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Environment Factors (Family living arrangements, type of neighborhood, special working conditions)
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Religious Beliefs and Practices:
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IV. Precipitating Events: (describe the situation or events that precipitated this illness/hospitalization)
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V. Adaptation Response:
Anxiety Level (Check the behaviors that apply)
___Mild ___Moderate ___Panic ___Calm ___Friendly ___Passive ___Alert ___Correctly
___Perceives Environent ___Cooperative ___Impaired Attention ___Jittery ___Hyper vigilant
___Unable to concentrate ___Tremors ___Rapid Speech ___Withdrawn ___Confused
___Disoriented ___Fearful ___Hyperventilating ___Misinterpreting the environment
___Depersonalization ___Obsession ___Compulsions ___Excessive Hyperactivity
___Somatic complains
Mood/Affect (Circle as many as apply)
Happiness
Sadness
Dejection
Suspiciousness
Apathy
Ambivalence
Anger

Despair
Flat
Hostility

Thought Processes (Check as many as apply)

___Clear Logical
___Easy to follow
___Blocking
___Delusional
___Slowness in thought association
___Illusion
___Helplessness
___Suicidal Ideation ___Phobias

___Relevant
___Confused
___Rapid flow of thought
___Suspicious
___Hallucination
___Worthlessness
___Guilt
___Preoccupied

Memory
___recent
___remote
___confabulation

Elation
Blunt
Rage

___loss
___intact
___amnesia ___blackouts
___others specify:________________________________

Communication Pattern (Circle as many as apply and describe)

Clear
Coherent
Slurred Speech
Incoherent
Flight of Ideas
Loss of association aphasia
Slow impoverish speech
mutism
sluttered
Reality Orientation (Check as many as apply)
Oriented to: ___Time ___Place
___Person
Level of Self-Esteem (check one)
___Low
___Moderate

Euphoria
Dull

___High

___Situation

Neologisms
loquaciousness

Things patient likes about self:

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Things patient would like to change about self:
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VI. Insight: (degree of problem and their cause: )
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VII. Judgment: (soundness of problem solving and decisions)
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VIII. Motivation (degree of motivation for treatment)
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This is also your guide as to:

MENTAL STATUS EXAM

Appearance - overall impression, posture, clothes, grooming, health, apparent age,

angry/afraid
General Behavior - mannerisms, gestures, combative, rigid, twitching, psychomotor
retardation
Attitude toward examiner - cooperative, hostile, defensive, seductive, evasive, ingratiating
State of consciousness - lethargic, alert, hyper alert
Attention - concentration, attend, digit recall
Orientation - person, place, time, situation
Psychomotor Activty - increased, reduced, agitated, abnormal movements
Mood - overall emotional state (sad, happy, depressed, elated, anxious, irritable)
Affect - current emotional state (full, labile, restricted, flat, inappropriate, suicidal/homocidal,
Speech - rate (incr, pressured, slow), tone (soft, angry) volume, articulation, language
(aphasia)
Form of thought - circumstantial, flight ideas, evasiveness, loosening associations,
perseverence, blocking
Content of thought - preoccupations, obessessions, phobias, rituals, delusions,
depersonalization
Perceptions - misperceptions, illusions, hallucinations,
Judgement Memory - immediate (digit span), recent (three objects at 5 minutes), remote (days to years)
Insight - do they realize they are ill
Intellectual Functioning- fund of knowledge, calculations, abstraction (proverbs,
similarities)