mental health process paper 12-12

7/27/2019 Mental Health Process Paper 12-12

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Breckinridge School of Nursing@ITT Technical InstituteClinical Research Tool

Nursing 250Student name:Date of Patient Care:

1.

Initials: Room#: Sex:

Age: Occupation: Education:Living Situation: Primary Language: Religion:Marital Status: Allergies: Code Status:Admission Date: Admission Type: Program:Precautions:

2a.

Admitting Diagnosis:

Axis I Axis IV

Axis II Axis V

Axis III

Note: If Axis not listed, use admitting diagnosis for I and hypothesize for II-

V.

2b.

History of Current Illness (describe reason for/events leading up to admission):

3. Past Psychiatric History



4. Past Medical History

5. Family Psychiatric and Medical History:

6. Psychotropic Medications include name (generic and brand), dose, route, class,critical side/adverse effects)If hand writing please use separate paper.

7. Abnormal Labs, TestsInclude patient value, expected value, reason for change and 2 nursinginterventions if value is abnormal.



8. Priority Teaching Needs (at least 3):

9. Priority Psychological Nursing Diagnosis with R/T and AEB: (at least 3)

10.

Responding Strategies YOU implemented during your interaction with thepatient:



Student Name: Patient’s initials:Date Assessed:Presenting Problem:

ASSESSMENT OF MENTAL STATUS

In each area, circle all that are appropriate descriptors based on your

assessment. Provide details where needed and/or applicable.

1. AppearanceDress Appropriate for setting

Inappropriate for settingDescribe:

Grooming Neat, Disheveled, UnkeptHygiene Clean

If not, describe:

Eye Contact Maintained appropriately, maintained intermittently,absent, intense

Posture Erect, slouched, open, closedGait Steady, shuffling, staggering, rigid

Other:Appearance vs.stated age

Appears stated age, appears younger than stated age,appears older than stated age

Unusual physicalcharacteristics

NoneIf yes describe:

2. BEHAVIOR AND ACTIVITY Behavior Appropriate, cooperative, relaxed, augmentative,

agitatedOther:

Activity level Hyperactive, calm, restless, motor retardation, catatonia,akathisia, rigidityOther:

Movements,mannerisms

Tremors, tics, rocking, facial grimacing, unusualmovements or gestures Other:None

3. ATTITUDE

Attitude towardyou

Cooperative, uncooperative, warm, friendly, distant,suspicious, combative, guarded, aggressive, hostile,aloof, apatheticOther:

Attitude towardothers

Cooperative, uncooperative, warm, friendly, distant,suspicious, combative, guarded, aggressive, hostile,



aloof, apatheticOther:

4.SPEECH

Quantity Impoverished, mute, voluminous, pressured, rambling,appropriate

Quality Articulate, inarticulate, dispirited, lively,Other:

Rate Rapid, slow, appropriateLevel Quiet, loud, appropriate

5. MOOD AND AFFECTAs reported bypatient(usepatient’swords)As assessedby you

Elated, euphoric, sad, depressed, irritable, anxious, fearful,guilty, worried, angry, hopeless, constricted, labileOther:

Intensity Mild, moderate, severe, labileDuration Morning only, afternoon only, all shiftHow patienthandlesnegativeemotions

Expresses appropriately, denies, suppresses, rationalizesIf expresses inappropriately describe:

6. THOUGHT PROCESS

Associativeability

Organized, clear, coherent, loose association(poorlyconnected thoughts), flights of ideas(quick changes of thoughts), perseveration(repetition of words, concepts)Other:

Thinkingability

Concrete thinking, abstract thinkingCan he/she interpret proverbs(Proverbs are short and pithy sayings that express some traditionally held

truth. They are usually metaphorical and often, for the sake of memorability,

alliterative. A chain is only as strong as its weakest link )

7. THOUGHT CONTENTExpressedconcerns(patient’s words)Impact of thoughts

Productive and contributing to well-being, nonproductive andcontributing to emotional problems (give details)

http://www.phrases.org.uk/meanings/the-weakest-link.html

http://www.phrases.org.uk/meanings/the-weakest-link.html



Disturbances

Delusions, suicidal thoughts, homicidal thoughts,preoccupations, phobias, paranoia, magical thinkingOther:

8. PERCEPTUALDISTURBANCES

Perceptions Illusions, visual hallucinations, auditory hallucinations, otherhallucinations, depersonalization (feeling detached),derealization (altered reality)Other:

9. MEMORY ANDRECOGNITION

Orientation Person, place, time, situationLevel of alertness

Alert, lethargic, stuporous

Recentmemory

Intact, disturbed

Remotememory

Intact, disturbed

Intellectual

capabilities

Comparable to grade school education, comparable to high

school education, comparable to college education10. INSIGHT AND

JUDGEMENTAwarenessof illness

Present (if so, what makes you say this)If not, discuss

Understanding of reasons forcurrentsituation


Awarenessof responsibility forcurrentsituation


Ability to Present (if so, what makes you say this)



behave inappropriatemanner,controlimpulses,

defergratification

If not, discuss

Ability tomakerationaldecisions




Student’s name: Date of interview:Patient’s initials: Length of interview

PROCESS RECORDING1. What personal growth goal did you have for this interview? Did you

achieve it?

2. What were your thoughts and feelings before and after the interview?

3. Do you think the interview was therapeutic for the patient? Why?

4. What do you feel best about? What would you do differently?(“nothing” is not an acceptable answer)

5. Interview-at least 3 pages of working phase discussion. See followingpages



Your statement Patient statement/anynon-verbal behavior

Analysis: techniquesused, “oops”

experiences, yourthoughts, feelings,

questions.

“N/A” not an answer



Nursing 250Mental Health Nursing

Maslow Applied to the Patient with Mental Health NeedsIdentify if needs are met at each level

1

.

Physiological

Food, water, oxygen, elimination, rest and sex. Other considerationsinclude: potential side effects of the psychotropic medications may createa need in this area

2.

Safety

When the need for emotional safety predominates, a person may go to extreme lengths to

protect self from perceived dangers. The person may be mistrustful, withdrawn, isolative,

have difficulty establishing rapport, or having difficulty trusting and engaging in thetherapeutic relationship. Protection from elements, security, order, law, limits, stability, etc.

3.

Love and belonging

These include needs for belonging, love, and affection. Maslow considered these needs to beless basic than physiological and security needs. Relationships such as friendships, romanticattachments, and families help fulfill this need for companionship and acceptance, as does

involvement in social, community, or religious groups.

4.

Esteem and recognition

After the first three needs have been satisfied, esteem needs becomes increasingly important.These include the need for things that reflect on self-esteem, personal worth, social

recognition, and accomplishment.

5 Self-actualization



.Self-Actualizing people are self-aware, concerned with personal growth, less concerned withthe opinions of others, and interested fulfilling their potential.

6.

Self Transcendence

To connect to something beyond the ego or to help others find self-fulfillment and realize

their potential. A higher psychic, or spiritual state of development that emphasizesvisionary intuition, altruism, and unity consciousness.

Identify patient stage according to Erickson and according to yourassessment. Is the patient in the correct stage of life, why or whynot?



Nursing Case Study

NU250 Mental Health Nursing

The focus of the case study is the patient’s mental health status. Discuss the

patient in each of the following areas. Fill in answers on this form.

1. What symptoms did the patient present at the time of admission? Are

they still present?

2. How does the patient deal with stress? Discuss both functional and

dysfunctional coping

mechanisms and defense mechanisms you assessed.

3. What is the quality of the patient’s relationships? How does this impact on

his or her

self-esteem.

4. How motivated do you think the patient is to change? How likely is

improvement?

5. What is the content of the patient’s thoughts? What is the impact of these

thoughts

on his//her current situation?

6. How aware is the patient of his/her feelings? Which feelings does he/sheexpress? Are there

feelings you think he/she might be suppressing?

7. Who does the patient consider to be supportive? Are there other people

you think are

supportive that the patient does not recognize?

8. What talents, strengths, assets do you think the patient has? Does he/she

recognize them?

9. What is the patient’s overall physical and emotional health?

10. How did you respond to this patient? What thoughts and feelings did you

have while

working with him/her?



Nursing Case Study For Movie

NU250 Mental Health Nursing

The focus of the case study is the character’s mental health status. Discuss

the character in each of the following areas.

Name of Movie:

Character Name:

Mental Disorder (identified as per DSM):

1. What signs and symptoms did the character present? Were they still

present at the end?

2. How does the character deal with stress? Discuss both functional and

dysfunctional coping

mechanisms and defense mechanisms you assessed.

3. What is the quality of the character’s relationships? How does this impact

on his or her

self-esteem.

4. How motivated do you think the character is to change? How likely is

improvement?

5. What is the content of the character’s thoughts? What is the impact of

these thoughts

on his/her current situation?

6. How aware is the character of his/her feelings? Which feelings does

he/she express? Are there feelings you think he/she might be suppressing?

7. Who does the character consider to be supportive? Are there other peopleyou think are

supportive that the character does not recognize?

8. What talents, strengths, assets do you think the character has? Does

he/she recognize them?



9. What is the character’s overall physical and emotional health?

10. How did you respond to this character? What thoughts and feelings did

you have while

Watching this movie?

mental health process paper 12-12

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