Psychiatric Clinical Nursing Assessment
Daytona State College
Directions: Please assess your client and place an X in the appropriate box to represent level of severity of each symptom. Patient Initials | EM | Physician | Dr. Singh | Date | 08/07/2013 | | Not Present | Very Mild | Mild | Moderate | Moderately Severe | Severe | Extremely Severe | SOMATIC CONCERNS – preoccupation with physical health, fear of physical illness, hypochondriasis | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | ANXIETY------worry, fear, overconcern for present or future, uneasiness | ☐ | ☐ | ☒ | ☐ | ☐ | ☐ | ☐ | EMOTIONAL WIYHDRAWAL---------lack of spontaneous interaction,isolation,deficiency in relating to others. | ☐ | ☐ | ☐ | ☐ | ☒ | ☐ | ☐ |
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Client will remain inpatient for the duration of 4 weeks. | Nursing Diagnosis: Disturbed thought process R/T non-reality based confabulations and hallucinations AEB patient’s perception of situation and suicide ideation leading up to Baker Act.Goal Statement: Client will consistently refrain from acting on hallucinations and delusions, be free from suicide ideation and will adhere to medication regimen during hospitalization.Interventions:1) Establish trust with patient in a one-to-one nurse-patient relationship.Rationale: Patients who form positive alliances with their caregivers are more likely to achieve better outcomes.2) Administer medications ordered by physician.Rationale: Medications prescribed by physician can alter psychotic symptoms.3) Watch for signs of physical and neurological side effects of medications: EPS, TD, etc…Rationale: Neuroleptics are beneficial for the patient with sensory alterations, but they are not without related side effects. Evaluation: Ongoing.