Psychosocial Assessment Form

Student Name:                                                                                                    Date:                .                            

HISTORY AND MENTAL STATUS EXAM:

PT INITIALS______________AGE____________M/F   UNIT____________ Date of Admission_____________

Brief explanation for this admission including legal status (including Riese and Meredith status), main complaint (by the patient or by report) acute and chronic medical issues, nursing considerations, brief background such as where patient lives and with whom:

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Personal History:

Where was patient born and circumstances of family life. Course of childhood including memorable events, relationships, medical or psychiatric issues. School life, special friends. Leaving home, work, college. Career, marriage, romantic relationships. Activities, hobbies, interests.

Psychiatric history if any, medical history. Memorable events, especially losses and disapointments.

Add sheets as necessary. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Developmental Age (Erikson) ________________________________________ Appropriate?

Explain how your patient does or does not meet this task:

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Maslow’s Hierarchy: Describe each stage, where is the patient currently? Where has the patient been in life? What does the future hold for this patient? Is there potential for growth into higher stages?

Physical _______________________________________________________________________________________________

Safety/Security ______________________________________________________________________________________

Love/Belonging ______________________________________________________________________________________

Self Esteem ___________________________________________________________________________________________

Self-Actualization ____________________________________________________________________________________

Cultural Implications: Do not write “none.” Where was patient born and raised? Language, religion, ethnicity, etc?

Educational level:

Teaching Needs:

Patient’s goal(s): (What does she/he want?)

Nursing Goals: What do you as the nurse think would be good goals?

What are the institution’s goals for this patient?

Any other important information such as past psychiatric history, psychosocial and/or legal issues? List  medical concerns and risks here. (If not covered above.)

COLLECT THE FOLLOWING DATA: PSYCHIATRIC ASSESSMENT TOOL/MENTAL STATUS EXAM:

1. General appearance and attitude toward the interviewer: What the patient looks like including dress, posture, and grooming. Attitude: cooperative, friendly, guarded, paranoid, etc.

• Behavior and Motor Activity: Describe behavior, motor activity, and mannerisms, i.e., calm, hyperactive, bizarre gestures, posture, gait, tics, tremors, psychomotor retardation, restlessness, pacing, etc.

• Speech: Describe how patient speaks; i.e., rate, rhythm, flow and tone. Clear vs. slurred, pressured, etc. List any barriers to communication.

• Thought Process: logical, coherent, goal directed, circumstantial, flight of ideas, loose associations, distractible, etc. Give examples.

• Thought Content: What does the patient talk about usually if not prompted? What does he tell you about what is on his mind and troubles him? Does he/she have thoughts of suicide, homicide or other harm? List any phobias, obsessions, compulsions, somatic complaints that you may notice or the patient tells you about.

• Perception: Hallucinations (auditory, visual, olfactory, gustatory, tactile, proprioceptive) and/or Delusions (bizarre, somatic, persecutory, paranoid, grandiose, religious). Describe.

• Orientation and Intellectual functioning: Alert and oriented x4? Memory, concentration, attention span. How is the patient’s judgment? responsibility? Abstraction or sophistication in his/her thinking?

• Mood/Affect: Euthymic, angry, anxious, expansive, euphoric, irritable, sad. Does patient display range of affect or is affect blunted, restricted, flat?

• Socialization and Interpersonal Relationships: Describe. Home vs. Hospitalization. How does the patient interact on the unit? Isolates? Instigates? Participates? Support from others?

1. Stress and Coping: Self esteem? How does the patient deal with his/her anxiety? How cope with difficulties?  Describe coping strategies; “negative vs. positive”. Notice any defense mechanisms?

How does the patient make you feel?

1. Conclusion: What did you find overall? Describe the significant verbal vs. nonverbal behavior. What are your feelings about your interactions with this patient?

MEDICATIONS Can use a separate paper. Include all meds: routine and PRN

Name	Dose	Route	Time	Scheduled or PRN	Indication	Nursing Considerations

Allergies:

Significant Labs if any:

List 2 possible opening statements to this patient that will help you initiate a therapeutic relationship.

Primary Nursing Diagnosis:

2 Goals: 1 long term goal and 1 short term goal.

1.

2.

Interventions: 2 interventions per goal

1A.

1B.

2A.

2B.

Nursing Care Plan
Nursing Diagnosis.

Multidisciplinary Care/treatment Plans (Add additional pages as necessary.)

At least one short term, length of stay for example, and one long term, working toward discharge from your facility’s care).

Assessment Data	Nursing Diagnosis	Goal/Outcome	Nursing Interventions with  Rationale	Evaluation

SAMPLE SOLUTION

Student Name:                                                                                        Date: 28/8/2020               .                            

HISTORY AND MENTAL STATUS EXAM:

PT INITIALS__MS____________AGE__16years__________M/F   UNIT____________ Date of Admission_____________

Brief explanation for this admission including legal status (including Riese and Meredith status), main complaint (by the patient or by report) acute and chronic medical issues, nursing considerations, brief background such as where patient lives and with whom:

            The patient (MS) is a 16-year-old female weighing 105 lbs, a height of 5’ e”, and BMI of 18.6. She is admitted for major depressive disorder (MDD) and PTSD. She harmed herself after overdosing with Prazosin and Prozac drugs after having a fight with her boyfriend. She has an allergy NKDA.

The Riese and Meredith status following the patient’s admission for major depressive disorder and PTSD is positive as the patient accepted psychiatric | GET AN EXPERT FOR YOUR ASSIGNMENT |all the medication processes are followed upon the patient’s admission, and the stipulations in line with the two conditions are adhered to.

The patient is admitted because of major depressive disorder (MDD) or major depression, and PTSD. Before admission, the patient complained of persistent loss of interest in activities and | GET AN EXPERT FOR YOUR ASSIGNMENT | patient complaint of persistent cognitive problems, which include difficulties with concentration and memory resulting in the therapeutic interventions(Smith et al., 2019). The patient exhibits few acute…