NURS3910 MENTAL HEALTH NURSING

NURSING ASSESSMENT FORM

Student Name: ________Nikki Thao________________Date: ____3/10/14______
Patient data:
Admission
Age:
Gender: Significant Other/marital status and children:
Male
Married x5, Divorced x4, 2 sons
Date:
Employment:
Educational
Pt. Legal
Legal history:
Primary
Level:
Status:
Language:
Unemployed
Served Jail
English
5150 DTS
Time
Chief complaint: What patient says prompted them to present at the hospital:
Pt left a suicide note and overdosed on his mothers pain medications (unknown meds). He was
transported to the hospital by ambulance and then sent to Behavioral Health Center.
What is the documented cause for hospitalization?
Depression; He is a danger to self.
Patients living situation at time of admission: Patient is currently living with his mother and
his son, one of them in serving jail time.
DSM IV AXES from chart
I: Depression
II: none noted
III:
IV: unemployment, his doctor took him
Chronic Pain, BKA (Below Knee Amputation)
off his pain medications, family stressors
related to his two sons, financial
problems, inadequate housing, and
stressor related to death, stressor r/t death
of brother, years ago.
V:(With rationale) N/A
PATIENT HISTORY
Medical History: He had a splenectomy and a BKA due to motorcycle accident that left him in
a coma for two months.
Current medical issues of importance to nursing management of patient: (present
all relevant information from review of systems):
Patient is BKA, which causes him to have chronic neuropathic pain from his pelvis down to both
his legs. He is fitted with prosthesis and has an unbalanced gait, which puts him at potential risk
for fall. Patient is on Gabapentin and Hydroco/APAP, which increases his risk for suicidal
thoughts, considering that he is diagnosed with depression.
Psychiatric history: Patient has a long history of depression, Post traumatic stress disorder
related to his brothers death.
Alcohol and Other Drug Abuse: He is a tobacco user, pot smoking 35+ years.
Abuse (physical/sexual): N/A
FAMILY HISTORY
Mental Health: Mother (takes some kind of psych medications).
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Alcohol and Other Drug Abuse:

Sons (Heroin)
MENTAL STATUS EXAM
General Appearance:
Dress & Grooming:
Patient appeared well- groomed and neat. Facial
hair combed, bald. He was wearing a hospital
gown, jeans, and shoes. No odor detected.
Posture and Gait:
Patient has an imbalanced gait due to his
prosthesis. His posture was relaxed and he was
sitting comfortably on the sofa in the day room.
Ambulated as slow, stride without assistance.
Motor behavior: (describe)
Patient was relaxed and sitting in straight posture
during the interview. Eye contact present. No
spastic movements observed interview.
Physiological responses (tremor, nystagmus,
sweating):
None observed
Affect and Mood
Appropriateness:
Calm, relaxed. Affect was congruent with mood.
Stability (patients report of swings, and
interviewers observation of changes):
Pt appeared to be stable. No extreme mood swings.
Speech
Volume:
Clear and loud voice
Thought Content
Theme:
Patients though process was logical and relevant to
topic being discussed. He sometimes goes on a
tangent and needed to be redirected to main focus.
Coherent.
Phobias:
2

Facial Expression:
Patient appeared calm, responsive and
made eye contact.
Physical Characteristics:
Irish/ White; Patient has a tall, buff body
frame. He is approximately 59-6 tall. He
is bald with a full gray/ white beard. Fair
skin complexion with tattoos from the back
of his neck to both forearms. Scruffy, rough
hands.
Attitude toward interview and mood
(observed):
Patient was very cooperative and openminded to the interview. Sometimes he
would go on a tangent and would need to
be redirected. Liked to make jokes.

Range:
Normal range
Describe (e.g., anxious, depressed,
disengaged, etc.):
Pt appeared to be happy, got emotional
when he talked about his brother,
Rate (flow, speed):
Clear, normal flow and speed
Delusions (persecution, influence,
reference, thought insertion):
None observed
Obsessions:

Patient feared being taken advantage of, being

exploited. Ex: his meds being taken away.

None observed, Patient denied.

Compulsions:
None observed, Patient denied.

De-realization, depersonalization:
None observed

Disorders of Perception (give an example of

those that apply)
Hallucinations (type with description):
None observed
Clarity and organization: N/A
Other unusual experiences
Hypnogogic phenomena:
None observed, Pt denied.
Dj vu Experiences:
Patient denied.

Memory & Cognition

Orientation to self: Yes, Patient was able to
state his full name.
Orientation to day & date: Yes, Patient was
able to state the day and date.
Attention: ability to count digits forward
(provide digits for patient to repeat)
Patients attention span is present. He was able
to count digits and repeat following numbers
given to him. For example, 1,2,3 & 2,4,6
Recent memory: (assess via memory for
how long has been in hospital, memory for
recent meal, home address etc.)
Patient can recall that he was admitted to the
Behavioral Health center three days ago. He
stated that he was from Citrus Height. He
remembered eating a bagel and drinking an
orange juice for breakfast this morning.
Fund of information: (ask general
information such as: how many days in a
week, how many months in a year, what
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Illusions (described as shadows, or

reported as misinterpretation of
stimuli):
None observed, Patient denied.
Tone/inflection: N/A

Dreams: N/A
Nightmares/Night Terrors:
Patient stated that he has nightmares about his
little brother being run over. Vividly
remembers what happen that day and it still
haunts him.
Orientation to Place: Yes, Patient was able to
state where he was.
Serial 3s and serial 7s: (count backward
from 100 by 3 or 7)
Patient claimed that he is dyslexic; therefore he
could not count backwards.
Confabulation: (ask patient if he has seen
the examiner before, assuming he has not
or ask for another detail which gives the
patient the opportunity to fill in the gaps of
memory)
An hour after the interview, I came back to see
the patient to see how court went for him.
Patient was able to response that he went to
court and was going to be discharge later that
day.
Vocabulary: (observe the words used
and/or present several words and ask the
patient to tell you what they mean)

makes water boil? Name the four seasons

of the year, where does the sun set?)
Yes, Patient was able to answer that there are
seven days in a week, 12 months in a year, and
365 days in a year. He also named the four
seasons of the year; Spring, Summer, Fall and
Winter.
Abstraction: ask to tell you what a proverb
means
I asked the patient if he knew what a proverb
meant. Patient started with a story and said that
a proverb was a saying. He ended with Time
flies when youre having fun.

Patients a wide range of vocabulary that was

appropriate and related to the interview
questions. He was able to give a meaning to
several words presented to him.

Similarities: state two objects (orange and

apple) and ask how they are similar or
alike
Patient verbalize that the similarity between an
apple and an orange was that they were round
and they were a fruit and vegetable.

Judgment and Comprehension: provide

examples of common events or situations
and ask pt what he would do in those
situations.

Perception and Coordination: (have patient

write his own name, copy a circle, a cross
(x), a square, a diamond or a row of dots
on a blank sheet of paper.)

Patient talked about his roommate not liking

him because of his race. Instead of having a
confrontation or causing tension, he chose to
walk away and sleep in the day room.

Patients perception and coordination was

present, evidenced by Patient being able to
write his signature.

Suicidal Ideation: Yes

No (If yes, complete suicide assessment)
Patient denied any thoughts of harming himself and verbalized he will not hurt himself.
Homicidal Ideation:
Yes
No (If yes, complete homicide assessment)
Patient denied thoughts of harming others.
What does this person do when angry, stressed or uptight?
Pt verbalized that when he gets angry, stressed, or uptight; he tries to not act out. Instead he
chooses to work on his motorbike to deal with the anger and stress.
Patients description of him/herself. What does she like best best/least about
her/himself?
Pt described himself as a man of his words. He stated, I am a father. What he liked about
himself was that he was getting back on his feet. He hates that sometimes he does not have
control of his life.

Include real or potential strengths of the client.

Clients strength was that he has self- awareness and knows that he does have problems. He
seemed open- minded and caring when he talked about his sons. He has a great sense of humor.
When I asked the patient was kind of jobs he held before, he stated that he used to be a domestic
counselor for couples.
Routine Medications (including category, dose, standard dose, target effects,
interactions and side effects)
Allergies: ASA(acetylsalicylic acid)
1. Hydro/ APAP 10/325mg (Norco)
Dose: 1 Tab PO BID Prn Pain
Standard Dose: 2.5-10mg q 3-6hr as needed, should not exceed 4g/day and should not
Exceed 5 tabs/day of ibuprofen-containing products.
Target Effect: Decrease moderate pain level
Interaction: - Use in extreme caution in Pts receiving MAO inhibitors (may produce
severe unpredictable reactions).
Side Effects: confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea
2. Gabapentin (Neurontin)
Dose: 600mg, 2 Caps PO TID Sch
Standard Dose: 100mg TID initially.
Titrate weekly by 300mg/day up to 900-2400mg/day (Max=3600mg/day)
Target Effect: To decrease neuropathic pain, leg restlessness.
Interaction: - Antacids can absorption of Gabapentin, separate time of usage of both
medications.
- risks of CNS depression with other use of CNS depressants, opioids,
and sedative/hynoptics.
Side Effects: suicidal thoughts, confusion, depression, drowsiness, ataxia
3. Acetaminophen (Tylenol)
Dose: 650mg, 2 Tabs PO q4h Prn Pain, Temp >38C
Standard Dose: 325-650mg q 4-6hr or 1g 3-4 times daily or 1300mg q 8hr (not to exceed
4g/day).
Target Effect: mild pain, fever
Interaction: - Chronic high dose of acetaminophen (>2g/day) may risks for bleeding
with warfarin.
- Hepatotoxicity to usage over max dose.
- Concurrent NSAIDS the risk of adverse renal effects (avoid concurrent
use).
Side Effects: Hepatic failure, hepatotoxicity, renal failure, rash
4. Lorazepam (Ativan)
Dose: 1mg, 1 Tab PO q2h Prn Anxiety, IM q2h Prn Anxiety, IM once Prn
Standard Dose: 1-3mg 2-3 times daily (up to 10mg/day)
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Target Effect: anxiety level

Interaction: - Additive CNS depression with other CNS depressants.
- Smoking may metabolism and effectiveness.
Side Effects: dizziness, drowsiness, lethargy

5.

Mag-Hydrox- Alum
Dose: 30mL PO q4h Prn Dyspepsia, GI distress
Standard Dose: 5-30mL between meals and at bedtime.
Target Effect: Promote bowel movements
Interaction: - Absorption of tetracyclines, phenothiazines, ketoconazole, itraconazole,
iron salts, fluroquinolones, and isoniazid may be (separated at least 2 hr).
Side Effects: constipation, diarrhea

6. Zolpidem (Ambien)
Dose: 10mg, 1 Tab PO Bedtime Prn Insomnia
Standard Dose: 10mg at bedtime
Target Effect: sedation and induction of sleep
Interaction: - CNS depression may with sedatives, opioid analgesics, or antihistamines.
Side Effects: daytime drowsiness, dizziness, anaphylactic reactions
Pertinent Lab values:
Date: 3/7/2014
Test: Acetaminophen Level
Patient Value: <10mcg/mL
Normal Value: 10-25mcg/mL
Nursing Implications: Monitor level, Max dosage= 4g/day. Assess pain medications.
Date: 3/7/2014
Test: RBC
Patient Value: 4.07 million/uL
Normal Value: 4.7-6 million/uL
Nursing Implications: Assess for bleeding.

Written Summary (Give summary of relevant findings from above. Discuss congruence
and incongruence between DSM criteria & patient assessment)
Compared to the patients DSM I criteria diagnosis of Depression, the patient appears to be
stable. His symptom s of Depression is being managed by his medications and attending group
therapy. According to the patient, he is feeling fine, now that he is put back on his medications.
Depression is a disorder involving the loss of interest or pleasure in the usual activities and
pastimes (Townsend, M.C., 2012).
According to medical records, the patient was admitted because he left a suicide note and
overdosed on his mothers psych medications. Patient verbalized that there were many stressors
in his life that contributed to his depression. He admits that he has poor coping skills. Patient is
currently living with his mother and is unemployed. He is having a family crisis, because his sons
positive for drug abuse and one of them is in jail. The environmental stressors noted in DSM
criteria IV are a contributing factor to the patients depression, including the death of his brother,
years ago. During the patient assessment, the patient verbalize that whenever he thinks about his
little brother, he becomes very emotional and does not know how to cope with it. Whenever he is
stress or angry, he tries to work on his motorbike.
Three Nursing Diagnoses according to priority (include plan of care for each,
expected outcomes, and attach nursing care plan)
1. Potential Self-harm risk r/t Depression
o Outcome/Goal: Patient verbalizes that he will not harm self .
o Interventions: (Townsend, 2012)
a. Ask patient directly if he is having any thoughts of harming himself.
b. Maintain close observation of client, do every 15 min checks, and if at risks
provide one-on-one.
- One-on-one observation should be continued as long as the patient is
actively suicidal. Observation should be done by a hospital employee
who is trained in safety maintenance (Guptill, J., 2011).
c. Maintain special care in administration of medications.
d. Encourage verbalizations of honest feelings, stressors.
e. Create a safe environment for the client.
- Sharp instruments, such as glass, pencils etc., should be removed from
the patients room; medications should be stored in nursing station, and
ropes, belts, or ties should be kept inaccessible. Nursing staff must
consider all possibilities that suicidal patient might use (Guptill, 2011).
f. Make rounds at frequent, irregular intervals.
- Patients may form a short contract from self- harm, but manipulation can
be attempted to succeed in suicide. Individual with the desire to harm
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themselves can appear calm and rational, but may attempt to commit
suicide whenever chance is given (Guptill, 2011).
2. Chronic Pain r/t BKA evidenced by Patient grimacing.
o Outcome/ Goal: Patient will verbalize pain level is at an acceptable level.
o Interventions: (Cox, F., 2010)
a. Assess pain level, location
- Pain is complex and is based on the individuals perception of
experience. Rating the pain from 0= no pain to 10= worst pain
imaginable, is used solely to measure pain intensity (Cox, 2010).
b. Provide pain relief with medication
- Pain can be managed by both pharmacological and non-pharmacological
techniques. Caution should be made for patients taking strong opioids, as
they can be susceptible to adverse effects (Cox, 2010).
c. Evaluate effectiveness periodically
- Unrelieved pain can be physiologically and psychologically affecting to
the patients social functioning (Cox, 2010).
d. Have patient identify non-pharmacological pain relief methods
3. Risk for Impaired Social Interaction
o Outcome/ Goal: Patient will interact in an age- appropriate manner with nurse and staff,
by time of discharge from treatment.
o Intervention: (Townsend, 2012)
a. Develop trusting relationship with client.
b. Encourage patient to attend group.
c. Provide patient contact with others in the day room and stay with client.
d. Have patient identify two behaviors that may discourage other from seeking
contact

Students response to experience with this patient:

The clinical experience with this patient has been a really great encounter on the basis that I
learned a lot about my patient and his diagnosis. Spending time with this patient allowed me to
have an in-depth conversation with him, which gave me the chance to understand the stressors
that led to his admittance at St. Joes. Before meeting my patient, I had a pre-conceived view of
him because of the way he look with his tattoos and tall, buff body build (reminded me of the
bikers in Sons of Anarchy). After talking to my patient, I noticed that my patient was different
from what I thought of him initially. He was very open-minded and willingly to cooperate in the
interview. He also had a great sense of humor and somewhat it made me think that he was not
depressed. The patient was very open to discuss the life factors, such as his brothers death, that
in some part contributes to his illness. This experience was an eye opener for me because I learn
to use therapeutic techniques that helped me understand about my patient. My perceived thought
of mentally ill patients change because of the time I spent talking to my patient.

Student Name: Nikki Thao

Reference
Cox, F. (2010). Basic principles of pain management: assessment and intervention.
Nursing Standard. 25(1), 36-39.
Guptill, J. (2011). After an Attempt: Caring for the Suicidal Patient on the MedicalSurgical Unit. MEDSURG Nursing, 20(4), 163-168.
Townsend, M.C. (2012). Psychiatric Mental Health Nursing: Concepts of Care in
Evidence-Based Practice (7th ed.) Philadelphia, PA: F.A. Davis Company.

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