ASSOCIATE DEGREE NURSING PROGRAM
NURS 205P: MENTAL HEALTH NURSING
SYLLABUS: SPRING 2007
Methodical
Instruction
for
CLINICAL LAB #8 (2 hours)
Theme: Mental Status Assessment
Instructor: Dr. Lyubov
Milevska - Vovchuk,
STUDENT
OBJECTIVES:
A.
Perform
a mental health assessment on a client agreed upon with your instructor.
B.
Explain
three principles the nurse follows in planning actions to reach agreed upon
outcome criteria.
C.
Construct
a plan of care for a client with a mental health problem.
D.
Identify
three advanced practice psychiatric nursing interventions.
E.
Demonstrate
one of the basic nursing interventions (with your instructor’s guidance) and
evaluate your care using your stated outcome criteria.
MENTAL STATUS ASSESSMENT (to accompany nursing care
plan)
Student: ____________________________________
Patient Initials: ______ Sex: ______ Age: ______ Date of Care: ______
Under each category, circle the descriptors that apply to this patient. In each comment section add additional brief comments for clarification or support of your assessment.
I. GENERAL APPEARANCE
A. Dress B. Posture C. Facial
Expression
appropriate erect sad bizarre slumped angry
inappropriate tense/rigid suspicious
unkempt unusual anxious
hygiene: appropriate bizarre warm/friendly impaired elated makes
eye contact
other
D. Motor Behavior
tremors
tics
restless
slow/retarded
hyperactive
agitated
grimacing
posturing
repetitive movements
abnormal gait
compulsions
Comments:
II. SPEECH
A. Flow B. Volume
normal normal
rapid loud
pressured soft
retarded monotone
mutism hostile tone
reduced quantity
Comments:
III. THOUGHT PROCESSES – Describe the characteristics of the patient’s response:
A. Flow/Form
logical tangentiality
retarded neologisms
speeded perseveration
blocking present clang associations
associative disorder flight of ideas
concrete thinking echolalia
circumstantiality attention span
poverty of speech word salad
B. Content – Central Theme: What is important to the patient?
delusions (type) religiosity
illusions preoccupation
ideas of reference suicidal ideation
phobias homicidal ideation
somatic concerns ruminations
paranoia obsessions
hallucinations (type) poverty of speech
depersonalization
Comments:
IV. INTELLECTUAL ASSESSMENT
A. Intellectual Functioning B. Orientation
adequate vocabulary time
general knowledge fund person
ability to read/write place
ability to abstract situation
C. Memory D. Judgment (according to history)
recall of recent events good
recall of remote events impaired
exhibiting confabulation
E. Insight
recognizes illness
recognizes effects of illness of life
accepts responsibility for own actions
demonstrates adaptive coping
strategies
Comments:
V. AFFECT
A. sad
angry
fearful
elated
flat/blunted
labile
congruent with speech/behavior
other
Comments:
VI. ASSESSMENT OF ANXIETY:
level of anxiety _____________________________________________________
objective & subjective data to support level of anxiety noted:_________________
__________________________________________________________________
VII. COPING MECHANISMS (Defense Mechanisms): How does the patient cope with stress:
reported by patient __________________________________________________
identified by nurse __________________________________________________
VIII. SOCIOCULTURAL ASSESSMENT:
Erikson’s developmental stage __________________________________________
role in family _______________________________________________________
occupation ________________________________________________________
hobbies/recreational activities/interests __________________________________
support system _____________________________________________________
IX. PATIENT’S PROBLEM IN PATIENT’S WORDS:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
X. PREVIOUS HOSPITALIZATION AND MENTAL HEALTH TREATMENT
________________________________________________________________________
XI. PATIENT’S DSM-IVTR DIAGNOSIS: _________________________________
________________________________________________________________________
XII. IDENTIFIED PREDISPOSING FACTORS: (genetic influences, past experiences, drug or alcohol use, existing conditions)
________________________________________________________________________
________________________________________________________________________
XIII. IDENTIFIED PRECIPITATING EVENTS: ____________________________________
________________________________________________________________________
XIV. PSYCHOPATHOLOGY/THEORIES OF ETIOLOGY
Write a summary,
in your own words, of the major
etiological theories of your patient’s diagnosis. Include genetic, biochemical,
and psychosocial theories. Describe typical behaviors, symptoms, and
characteristics of your patient’s diagnosis. Individualize the psychopathology
to your patient. Attach a separate paper
with this component of the assessment (XII) to your Mental Status Assessment
Form.
XV. NURSE’S ASSESSMENT OF PATIENT’S LEVEL of SELF-ESTEEM: (Circle one)
High Moderate Low
XVI. BEHAVIORS ASSOCIATED WITH A STAGE OF
GRIEVING
(Circle stage that applies if
grief is an identified reaction in your
patient.)
Denial Anger Bargaining Depression Acceptance
XVII. COMMUNITY RESOURCES APPLICABLE TO PATIENT/FAMILY: __________
________________________________________________________________________
________________________________________________________________________
XVIII.
Medications Please list all
patient's medications on the medication work sheet and attach to your
assessment form. Identify the
psychotropic meds, state the reason drug is used, side effects, and nursing
implications related to the drug.
XVIII. BASED ON YOUR MENTAL STATUS ASSESSMENT OF THE PATIENT, DEVELOP THREE COMPLETE MENTAL HEALTH (NANDA) NURSING DIAGNOSES USING THE ADN PROGRAM CARE PLAN FORM.
CLINICAL LAB Outline /
students Assignments
|
# |
Clinical lab Outline |
Assignments |
|
1 |
Mental
status assessment |
Varcarolis: chapter 9 |
Prepared by Lyubov Milevska – Vovchuk
21/03/07
Approved by Department of General Patient Care. Minute #________ from ____________2007
Head of the Department Prof. Oleksandr Oliynuk, MD, Ph.D,
Doctor of Medicine