THE COLLEGE OF THE BAHAMAS

SCHOOL OF NURSING AND ALLIED HEALTH PROFESSIONS

DEPARTMENT OF NURSING
Psychiatric/Mental Health Nursing
Case Study Worksheet
OBJECTIES
!a"s # $ %
Specific Objectives
1. Select a patient with a mental disorder (diagnosed according to DSM-IV) appropriate for
your case study.
2. Document the psychopathology of the condition to include
a. Definition
!. Incidence"epidemiology
c. #tiology
d. $lassification
e. $linical features
f. Diagnostic criteria
%. Document an appropriate nursing"non-nursing theory related to the care of your patient.
&. $ollect a detailed health history for your patient using the tool pro'ided.
(. )ssess the patient*s le'el of functioning on the psychosocial domains as stated on the tool
and document these.
+. ,erform a re'iew of systems
-. ,erform a mental status assessment using the tool pro'ided and document findings. this
assessment must include the patient*s suicidal ris/.
0. 1se the multi-a2ial system of psychiatric assessment to outline
3. Document the prescri!ed treatment as ordered !y the physician"psychiatrist and complete
the drug process utili4ing the format pro'ided.
15. De'elop a list of nursing pro!lems !ased on the assessment findings and e2amine the
application of the nursing process in the management of the client and document
findings.
11. De'elop a health education plan for your selected patient and family.
TJC & DB Lecturer COB SNAHP-Revised 2014
STUDENT: _______________________ ID : ______________ DATE: _____________
Ps!c"i#t$ic Di#%&'sis: ________________________________________________________
PS(CHOPATHOLOG( OF CONDITION
TJC & DB Lecturer COB SNAHP-Revised 2014
THEORETICAL FRAME)OR* GUIDING CARE
TJC & DB Lecturer COB SNAHP-Revised 2014
DEMOGRAPHIC INFORMATION
$lient*s Initials 6666666666666 )ge 666666 7ender 66666666 8eight 666669!s"66666:g ;eight 66666666
Vital Signs < 666666 ,66666 = 66666 >, 6666666 )llergies 666666666666666666666666666666666666666666666
#ducational 9e'el 666666666666666666666666666666666666 Socio-economic 9e'el 6666666666666666666666666666666666
Marital Status 666666666666 =eligion 66666666666666666666 ?ccupation 6666666666666666666666666666666666666
$urrent ,sychiatric Diagnosis 6666666666666666666666666666666666666666666666666666666666666666666666666666666666
$o-e2isting Medical Diagnosis 666666666666666666666666666666666666666666666666666666666666666666666666666666666
CLIENT+S HEALTH HISTOR(
&eason 'or seeking healthcare(
History o' Present Illness
TJC & DB Lecturer COB SNAHP-Revised 2014
Past Illnesses )*edical+ surgical or ,sychiatric-(
.a*ily History(
Social History(
/rug History/Su"stance 0se )OTC 1 Illicit-(
Personal History(
.orensic History(
PS(CHOSOCIAL DOMAINS
Nutrition 1 Eli*ination(
TJC & DB Lecturer COB SNAHP-Revised 2014
Slee, 1 &est
Sel'$,erce,tion 1 Sel'$conce,t
&oles 1 &elationshi,s
Co,ing 1 Stress
alues 1 Belie's
RE,IE) OF S(STEMS
Integu*entary
Heent
TJC & DB Lecturer COB SNAHP-Revised 2014
Cardio2ascular
&es,iratory
3astrointestinal
Neurological
MENTAL STATUS E-AMINATION
3eneral 4,,earance
Motoric Beha2iour
TJC & DB Lecturer COB SNAHP-Revised 2014
4ttitude
Mood
4''ect
S,eech 1 !anguage
Thought Processes
MENTAL STATUS E-AMINATION
Thought Content
Perce,tions
Judg*ent 1 Insight
TJC & DB Lecturer COB SNAHP-Revised 2014
Orientation
4ttention 1 Concentration
Me*ory )re*ote+ recent 1 i**ediate-
4"stract Thinking
MULTIA-IAL S(STEM OF PS(CHIATRIC ASSESSMENT
45ES /ESC&IPTION
I
II
III
TJC & DB Lecturer COB SNAHP-Revised 2014
I

PATIENT+S CURRENT MEDICATIONS

Me.ic#ti'& Us/#0
D's#%e
P#tie&ts
D's#%e
D$/% Acti'& Si.e Effects C'&t$#i&.ic#ti'& N/$si&%
Resp'&sibi0it!
TJC & DB Lecturer COB SNAHP-Revised 2014
Nursin Pr!"#e$ %denti&ed'
THE NURSING PROCESS
Nee. 1M#s0'23 Di#%&'sis G'#0 I&te$ve&ti'&s R#ti'&#0es Ev#0/#ti'&
TJC & DB Lecturer COB SNAHP-Revised 2014
Subjective:
Objective:
TJC & DB Lecturer COB SNAHP-Revised 2014
DISCHARGE PLAN FOR THE PATIENT
TJC & DB Lecturer COB SNAHP-Revised 2014
REFERENCES
TJC & DB Lecturer COB SNAHP-Revised 2014
RUBRIC FOR ASSESSESSMENT OF THE NURSING CARE STUD(
St/.e&t N#4e: ___________________________________ ID : __________________
CONTENT M#5i4/4
M#$6s
Act/#0
M#$6s
C'44e&ts
I&t$'./cti'&:
,sychopathology of the mental health
condition
7
De4'%$#p"ic .#t#
Re0ev#&t Hist'$!
Ps!c"'s'ci#0 D'4#i&s
8
9
7
Me.ic#0 M#&#%e4e&t:
=e'iew of Systems
Mental ;ealth )ssessment including
multi a2ial system of psychiatric
assessment.
Suicidal )ssessment
Medications
8
:;
;
<
N/$si&% M#&#%e4e&t: 1< p$i'$it! .i#%&'ses3
)ssessment
Diagnosis
,lan
Implementation @ =ationale
#'aluation
=
:;
7
:;
7
T"e'$etic#0 F$#4e2'$6 U&.e$pi&&i&% C#$e <
Disc"#$%e P0#& 8
Refe$e&ces <
TOTAL :>> M#$6s
TJC & DB Lecturer COB SNAHP-Revised 2014