PSYCHIATRIC NURSING HISTORY COLLECTION FORMAT F.

PERSONAL HISTORY
A. DEMOGRAPHIC DATA a. Prenatal History
a. Name i. Mateernal infections
b. Age ii. Exposure to radiation
c. Sex iii. Check-ups
d. Marital Status iv. Any complications
e. Religion v. Natal history - type of delivery
f. Occupation vi. Any complications
g. Socio Economic Status vii. Breath and cried at birth
h. Address viii. Neonatal infections
i. Informant ix. Milestones: normal or delayed
j. Information (relevant or not) adequate or not b. Behavior During Childhood
B. CHIEF COMPLAINS/ PRESENTING COMPLAINTS (LIST WITH DURATION) i. Excessive temper tantrums
a. In patients own words and in informants own words ii. Feeding habit
i. ex . sleeplessness x 3 weeks iii. Neurotic symptoms
ii. Loss of appetite and hearing voices x 2 weeks iv. Pica
iii. Talking to self v. Habit disorders
C. PRESENT PSYCHIATRIC HISTORY/ NATURE OF THE CURRENT EPISODE vi. Excretory disorders
a. Onset c. Illness During Childhood
i. Acute (within a few hours) i. CNS infections
ii. Subacute (within a few days) ii. Epilepsy
iii. Gradual (within a few weeks) iii. Neurotic disorders
b. Duration iv. malnutrition
i. Days, weeks, months d. Schooling
c. Course i. Age of going to school
i. Continuous, episodic ii. Performance in the school
d. Intensity iii. Relationship with peers
i. Same iv. Relationship with teachers
ii. Increasing v. Specifically look for learning disability and attention deficit)
iii. Decreasing vi. Look for conduct disorders e.g truancy, stealing
iv. Varying e. Occupational History
e. Precipitating factors i. Age of joining job
i. Yes, no ii. Relationship with superiors, subordinates, and colleagues
ii. What causes it? iii. Anu changes in the job - if any given details
f. History of current episode iv. Reasons for changing jobs
i. Explain in detail regarding the presenting complaints v. Frequent absenteeism
g. Associated disturbances f. Sexual History
i. Includes present medical problems (e.g. disturbances in sleep, appetite, i. Age of attaining puberty (female menstrual cycle)
IPR, social functioning, occupation etc. ii. Source and extent of knowledge about sex, any exposures
D. PAST PSYCHIATRIC HISTORY G. PREMORBID PERSONALITY
a. Number of episode with onset and course a. Attitude to others in social, family and sexual relationship
b. Complete or incomplete remission b. Attitudes to self
c. Duration of each episode c. Moral and religious attitudes and standards
d. Treatment details and its side effects if any d. Mood
e. Treatment outcomes e. Leisure activities and hobbies
f. Details if any precipitating factors if present f. Fantasy life
E. FAMILY HISTORY g. Reaction pattern to stress
a. Genogram for 5 generations h. Habits
H. GORDON’S FUNCTIONAL HEALTH PATTERN d. Thoughts
a. Health Perception - health Management i. Form of thought/ formal thought disorder - not understandable/ normal/
b. Nutrition - Metabolic circumstantiality/ tangentiality/ neologism/ word salad/ preservation/
c. Activity - Exercise ambivalence.
d. Elimination ii. Stream of thought/ flow of thought - pressure of speech/ flight of ideas/
e. Sleep-Pattern thought retardation/ mutism/ aphonia/ thought block/ clang association.
f. Cognitive Perceptual iii. Content of thought
g. Self-Perception - Self Concept iv. Delusions - specific type and give example - persecutory/ delusion of
h. Role-Relationship reference, delusion of influence or passivity, hypochondriacal delusions,
i. Sexuality - Reproductive delusions of grandeur, nihilistic/ derealization/ depersonalization/
j. Coping - Stress delusions of infidelity
k. Value - Belief v. Obsession
I. COMPREHENSIVE HEALTH ASSESSMENT vi. Phobia
a. VitaL Signs vii. Preoccupation
b. Pain Assessment viii. Fantasy - creative/ daydreaming
c. Anthropometric Data e. Mood and Affect
d. General Appearance i. appropriate / inappropriate (relevance to situation and thought
e. PE congruent)
f. Review of System ii. Pleasurable affect - euphoria / elation / exaltation / ecstasy
J. MENTAL STATUS EXAMINATION iii. Unpleasurable affect - grief / mourning / depression
a. General Appearance and Behavior iv. Others affect - anxiety / fear / panic/ free floating anxiety / apathy /
i. Facial expression (anxiety, pleasure, confidence, blunted, pleasant) aggression / mood swing / emotional lability
ii. Posture (stooped, stiff, guarded, normal) f. Disorders Perception
iii. Mannerisms (stereotype, negativism, tics, normal) i. Illusion
iv. Eye to eye contact (maintained or not) ii. Hallucinations - specify type and give examples - auditory / visual /
v. Rapport (built easily or not built or built with difficulty) olfactory / gustatory / tactile
vi. Consciousness (conscious or drowsy or unconscious) iii. Others - hypnologic / hypnopompic / lliputian / kinesthetic / macropsia /
vii. Behavior (includes social behavior - overfriendly, disinherited, micropsia
preoccupied, aggressive, normal) g. Cognitive Function
viii. Dressing and grooming - well-dressed/ appropriate/inappropriate (to i. Attention and concentration
season and situation)/ neat and tidy / dirty 1. Method of testing ( asking to list the months of the year
ix. Physical features - look older/younger than his/her age forward and backward)
1. underweight/overweight/physical deformity 2. Serial subtraction (100-7)
b. Psychomotor Activity ii. Memory
i. Increases, decreased 1. Immediate (teach address and after 5 months. Asking for
ii. Compulsive, echopraxia recall)
iii. Stereotype 2. Recent memory - 24 hours recall
iv. Negativism 3. remote - asking for dates of birth or events which are occurred
v. Automatic obedience long back
c. Speech (one sample of speech - verbatim in 2 to 3 sentences) a. Amnesia / paramnesia / retrograde amnesia /
i. Coherent, incoherent anterograde amnesia
ii. Answer the questions appropriately - relevant, irrelevant b. Confabulation
iii. Volume - soft, loud, normal c. Deja vu/ james vu
iv. Tone - high pitch, low pitch, normal/monotonous d. Hyperamnesia
v. Manner - excessive formal, relaxed, inappropriately familiar iii. Orientation
vi. Reaction time - time taken to answer the question - increased, 1. Time approximately without looking watch, what time si it?
decreased, normal 2. Place - where he/she is now?
3. Person - who has accompanied him or her
 iv.Abstraction
1. Give a proverb ask the inner meaning
a. Feathers of a bird flock together / rolling stones
gather no mass
v. Intelligence and General information
1. Test by carry over sums / similarities and differences / general
information / digit score test
vi. Judgment - personal (future plans)
1. Social (perception of the society)
2. Test (present a situation and ask their response to the
situation)
vii. Insight
1. Complete denial of illness
2. Slight awareness of being sick
3. Awareness of being sick attribute it to external / physical factor
4. Awareness of being sick, but due to something unknown in
himself
5. Intellectual insight
6. True emotional insight
viii. General Observations
1. Sleep
a. Insomnia - temporary/ persistent
b. Hypersomnia - temporary/ persistent
c. Non-organic sleep - wake cycle disturbance
d. EMA - Early Morning Awakening
2. Episodic Disturbances
a. epilepsy/ hysterical/ impulsive behavior / aggressive
behavior / destructive behavior
ix. Summary and Clinical Diagnosis
K. INTERPERSONAL PROCESS RECORDING
L. NURSING CARE PLANS
M. DOCUMENTATION
N. REFERENCES
Initials of client: Date:

Student nurse:

Individualized Patient Report

Introduction

General Objectives

Specific Objectives for student nurses

Specific Objectives for the client

Patient’s Appearance

Environmental Condition

Summary

Evaluation

References

INTERPERSONAL COMMUNICATION PROCESS RECORDING DAY 1

Patient’s Initials: Date:

Student Nurse’s Name: Place of Interaction:

INTERVIEWE TECHNIQUE USED PATIENT’S NURSES’

R VERBALIZATI INTERPRETATION/
(Label for the ON ANALYSIS
(what the technique used (T)
student nurse for therapeutic and
said) (NT) for
non-therapeutic