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    22 views8 pages

    Students Name

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    © All Rights Reserved
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    Mental Health Nursing Assessment. student's Name:_ Wp “Coe DaterWeeks WEA YO 1. Client Assessment A. Cliept’s Demographic Pata Client's initials: Client’s Age: 24 Client location/room: %@¥-A_ Admit date: Gender:_Wo}q-_ Marital Status: fisted Children; 4 Career We dre Last worked: sor vt0EEducation:_W Cultural background; 9e¢ 4 — Primary lnguoge. 2 To Spiritual belief Religion: —-C.\cisi", Legal Xtus:_Srverea) Seale Aieeed Privileges: Preca Living arrangements;_GxS G1. ADIs! Family/community supports: he developmental stage: Goa se ee B. Admitting Diagnoses: Psychiatric Diagnoses, bie 18D, Subs abare J iseck- Medical Diagnoses “Vcricany — Cor acelin C. Psychopathology Leading to Current Admission (Behavior, thought processes, dysfunction, crisis event, and past history or mental illness or addictions) Dike awd via Meron of and Myc D. Contributing History or Events (ie, social, cultural, fai Nos} tuctnd: a S eaths aso fod esa fe cron ieee a E. Discharge + dois agke gine I, Mental Status Exam Flow Sheet A. Identifying Data 1 Client initials Living arrangements: Achmad lowes — Gender_ (AUT Ree ZO Religious petenee: Ces Race/Culture: —a-D a Occupation: 7-710 F Special diet — Significant Other: Scge-etu B. General Description 1. Appearance Grooming/dress:__4o Hair coloritexture: _ goa) Hygiene; 2S pects wears REC oer Posture: nA) ‘Appears age?: sya Height/weight: ry ABS Level of eye contact: NORM, 2. Motor activity Tremors:__v® Rigidity; ‘Ties/movements:_ DO. Gait Mannerisms: 4g Echopraxia 38 Restlessness:__12) Psychomotor retardation: Agitaion: 65 Range of motion: =) 3. Speech pattems Slow or rapid pattern: Volume Pressured speech: ‘Speech impediment: ication: Tsar osama Ae Coopers ee Tnteresvapathy: fostile/defensive: juarded/suspicious: Qo C. Emotions 1. Mood sad:_NS) Depressed:_“YUS __Despiring:__‘Q-0 Invitable:_ se) Amidous:__A ated: Eo Euphoric: Fearful: ___spi Guilty: te Labile: an Comments: 2 affect O\ yx Congruence with mood: Constricted or blunted: Flat:__\ya Appropriate or raperopeaie: a qqct@Res Euphoria or Mania: Mood swings or a nO B D. Thought Process If present, provide examples 3. Form of thought Flight of ideas: ° Associative looseness: _ Cibunnamge— AO ‘Tangentialiy: a Neologisms:_ 0 Concrete thinking — Ws Cling associations — a. Word salad 2 Perseveration: ‘Able to conezntrater ya Echolalia: Roce Poverty of Speech -n@ ‘tention span’ gaol 4. Content of thought Delusions: Persecutory:__‘VS___Grandiose:_\yo__Reference: Religious:_ vo Somatic: ae Other,_" 7 Suieidal/homicidal ideas: _gCvaa ney Qbsessions/Compulsions_gyo Paranoia/suspiciousness: Magical thinking: oa E, Perceptual Disturbances Hallucinations: Auditory oie Visual:__T? Tactile: na Olfactory: a Mlusions: Depersonalization: 7 3S F. Sensory and Cognitive Ability Level of alertness/consciousness. Orientation: / Memory: / Time: Recent: Place: Remote 2 Person: Confabulation!_ a Circumstances: Capactylbstract thought: 5720 G. Impulse Control Ability to control impulses related to the following (Circle and describe if applicable) Aggression, Hostility, Guilt, Fear, Aflection, Sexual Feelings 2 remerd Flak ostfred Ye yy bebo’ H. Judgment and Insight (give example if can/eannot perform the following) Ability to solve problems Ne ee a Ability to make decisions Ui Yon gut el ty whe Knowledge about self ler of limitations, awareness of consdquences of actions, awareness of illness Adaptivelialadaptive use of ~ Aion noalee i ior Using textbook chapters, briefly Wefine the psychiatric diagnosis of this patient: coping strategies and ego defense mechanisms Snrdlagq OG g ‘Q Beda, Oimaur 5s avdly bee nym) — Sy Ate Meacindid “= 00 pee Ne inn. du Won i fete lites cudaric , grangsios S Qewdin, depevaren aes fring gh A urmineS pe aMeprecy en Clinical Reflective Journal Personal Journ Students will submit 2 minimum 250 word journal to their clinical supervisor for each clii

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