Our Services

Get 15% Discount on your First Order

[rank_math_breadcrumb]

Nursing homework

MENTAL STATUS EXAM GUIDE

Previous Mental Health Treatments (e g: psychopharmacology, inpatient stabilization, Occupational Therapy, Vocational Therapy, Marriage/Family Therapy, Group Therapy, Detox, ECT &/or social services):

What is the initial impression of the admitting examiner found in the initial evaluation, triage, or social worker note:

Compare your impression of the patient’s status now to the initial impression:

BRIEF MENTAL STATUS EXAM

Instructions; Most information can be obtained during an interaction with the patient without asking specific questions. The information must be described to support your conclusion.

GENERAL DESCRIPTION

Appearance (e.g. grooming, manner of dress, level of hygiene, facial expression, remarkable features, height, weight, nutritional status, presence of piercings, tattoos, scars, the relationship between appearance and age, etc.):

Attitude toward examiner
(INCLUDED IN BEHAVIOR) – Does the patient have good eye contact? Are they cooperative, friendly, attentive, interested, frank, seductive, defensive, playful, apathetic, evasive, guarded, etc.:

Speech characteristic –

What are the qualities of the patient’s speech include tone, inflection, volume, pronunciation (clear or slurred; mumbling; defects, lisp, stuttering), speed:

What is the quantity of the patient’s speech? Does the patient verbalizes freely, provide monosyllabic answers, have pressured speech, and/or are they hyperverbal:

Psychomotor activity
(INCLUDED IN BEHAVIOR)

Is the patient experiencing hypoactive psychomotor activity that can include generalized slowing down of body movements, aimless, purposeless activity, etc.? Write your description and conclusion:

Is the patient experiencing hyperactive psychomotor activity that can include restlessness, agitation, combativeness, wringing of hands, pacing, etc.? Write your description and conclusion:

MOOD/AFFECT

Mood – is the sustained/consistent emotion that colors their perception of the word.

Is the patient’s mood sad, labile, euphoric, euthymic, expansive, anhedonic, etc.

Is the patient anxious, angry and/or depressed? Assess for mild, moderate, or severe and document findings that support your conclusion.

IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.

Affect – Patient’s current emotional reaction that is being inferred from the patient’s facial expression.

What is the range of the patient’ affect (full or restricted)? What findings support your conclusion:

Is the patient’s affect appropriate; is the emotional expression congruent with the thought content? What findings support your conclusion:

Is the intensity of the patient’s affect blunted or flat, shallow, labile, proud, angry, fearful, anxious, guilty, etc.? What findings support your conclusion:

Does the patient have difficulty in initiating, sustaining, or terminating an emotional response? What findings support your conclusion:

DISORDERS OF THE FORM OF THOUGHT

The thought process refers to the way a person puts together ideas and associations. Is the patient disorganized, coherent, has a flight of ideas, though blocking, tangential, circumstantial, rambling, evasive? Is there a lack of cause and effect relationship and goal-directed thinking:

Thought content refers to what the person is thinking and speaking about. Does the patient have preoccupations: about illness, environmental problems, obsessions, compulsions, phobias; obsessions about suicide, homicide, hypochondriacal symptoms, and specific antisocial urges:

IMPORTANT: Ask the patient if they are having any suicidal or homicidal thoughts, if the patient indicates in any way that they, then ask them if they have a plan and report these findings to the staff immediately so measures can be taken to safeguard the patient.

Does the patient’s thought content contain delusional material? If yes, describe the types of delusion(s)? Include in your description details about the extent and nature of the delusions:

PERCEPTION
(INCLUDED IN THOUGHT CONTENT)

Hallucinations are a form of disturbance of the sensory system. To determine if someone is experiencing them you can the person “Have you ever heard voices or sounds that no one else can”? “Smelled something that no one else can?” “Felt like bugs were crawling all over you?” “Seen something that no one else can see?” Include in your description details about the extent and nature of the hallucination and how you reached this conclusion:

Illusions are a misperception of a person-environment such as an exit sign that looks like the devil.

COGNITION

Orientation

Person:

Place:

Time:

Is the patient’s orientation good, fair or poor; support your conclusion:

Memory functions are usually divided into remote memory, recent past memory, recent memory and immediate retention and recall.

Remote – Can the patient provide childhood data; important events: time and place of birth; various schools attended; number of children and ages and names. Is the patient’s remote memory good, fair or poor; support your conclusion:

Recent Past Memory – Can the patient tell you what they did yesterday, what did they have for breakfast, lunch, dinner? Is the patient’s recent past memory good, fair or poor; support your conclusion:

Tell the patient that you are going to ask them to repeat the three words you are going to tell them, pen, apple, watch. After the patient is finished, remind him/her that you will be asking them these in a few minutes,

Recall /Immediate Retention Memory – Ask the patient to repeat the three word you have just finished saying. Is the patient’s recent memory good, fair or poor; support your conclusion:

Recent Memory – Ask the patient to repeat the three words you told them a few minutes ago. Is the patient’s recent memory good, fair or poor; support your conclusion:

Concentration and attention is the ability to remain focused. Is the patient’s attention span good, slight, moderate or severely distractible?

Abstract/Concrete thinking is the ability to deal with concepts. Proverbs or “similarities” can determine if the patient is an abstract or concrete thinker. Ask “What do people generally mean when they say… Don’t count your chickens before they’re hatched?”. When using similarities, ask, “In what ways are an apple and a banana alike?” Is the patient’s ability to abstract good, fair or poor; support your conclusion:

JUDGMENT AND INSIGHT

Judgment is the patient’s understanding of socially conforming behavior and the ability to understand the outcome of their behavior. If you are not aware of the patient’s judgment as what is the thing to do if you are the first person in the theatre to discover a fire and/or what will you do when you are discharged from the hospital. Is the patient’s judgment good, fair, poor; support your conclusion.

Insight is the patient’s awareness of the illness and the understanding of the outcome. Is the patient’s insight good, fair, poor; support your conclusion:


BIOLOGICAL DATA

Oxygenation:

Respiration: (Quality and quantity):
Temp:

B/P:

Pulse: (Quality and quantity):


Metabolism

Ingestion includes the patient’s nutritional intake. How many times does he/she eat full meals or snacks per day? What do the meal and snack consist of, is the patient on a specific diet, and is the patient’s report congruent with the diet limitations:

Digestion includes gas/burping, reflux, acid indigestion, nausea/vomiting, pain, ulcer, bloating, etc. Does the patient have any digestion difficulties?

Elimination includes gas/flatulence, diarrhea, loose stools, constipation, etc. How many BMs/day? Is the consistency normal? Is there any blood in the stool:

Sleep Patterns

Quality – Does the patient have difficulty falling asleep or falling back to sleep? Are they tired upon awakening? Do they have early morning awakening, bad dreams, and nightmares? Do they wet the bed, walking in sleep, etc.:

Quantity – How many hours of sleep does the patient need to feel good in the morning? How many hours of sleep do they get now? What time do you go to sleep & wake up:

SOCIAL HISTORY

Support system: (Is there support from family, friends, church, work, etc.):

Occupation – (Any job in the past or present, employee or volunteer; would the patient like to have a job, what would that job be):

Spiritual Assessment

What importance does religion/spirituality have in the patient’s life:

Do the patient’s beliefs help with stressful situations:

Education – What was the highest level of school completed; any vocational training programs attended; would the patient like to go back to school or vocational training:

Financial Support – who works in the household; what other means of financial support is there for the household:

Interests – What does the patient do in their spare time (e.g. watch TV; exercise; fishing; woodcraft; reading; theatre; movies; bowling; walking; running; crossword puzzles etc.):

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

module 2

my pico question: In adults diagnosed with schizotypal personality disorder, how does cognitive behavioral therapy compared to pharmacological treatment with Risperidone affect overall social functioning?  Your literature review must consist of only US-based research. You must include only Level 1 or 2 research addressing your intervention and comparison groups.

Discussion Post

What is the impact of using teach back to educate Latino men on the importance of lifestyle changes, exercise and medication adherence to blood pressure medication?

Case Study ICU

NRS-460 Benchmark – Case Study: Timothy Smith – Intensive Care Unit (ICU) Directions: Read the case study below. Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit the completed template to the assignment dropbox. The purpose of this assignment is to

Capstone Project proposal budget requirement

  Use this link (Capstone Project Proposal Budget Requirements Download Capstone Project Proposal Budget Requirements) to find the template that you need to fill out, including the information below.  Budget item: List the item(s) required for your project. Description: Describe the item and state what it will be used for.

NUR504 W3A

For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of interest to you. Content Requirements You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following: 1. Subjective

NUR601 W 3

ANSWER QUESTIONS ABOVE AND THE FOLLOWING: · Define and describe the primary goals of screening. · Discuss your thoughts on the relationship between economics and nutrition. How would you advise people of low socioeconomic status to eat healthy on a budget? How would you respond to patients whose financial restraints

NUR504 W3

ANSWER QUESTIONS: · What other subjective data would you obtain? · What other objective findings would you look for? · What diagnostic exams do you want to order? · Name 3 differential diagnoses based on this patient presenting symptoms? · Give rationales for your each differential diagnosis. INSTRUCTIONS: · Your

APN Business Planning

APN Business Planning Based on your textbook reading, discuss the process of Advanced Practice Nurse (APN) business planning from a system approach.   Submission Instructions: · The paper is to be clear and concise and students will lose points for improper grammar, punctuation and misspelling. · The paper is to

WEEK 3 PP

POWERPOINT  For this assignment, you will develop a presentation on a realistic clinical case on a topic that is of interest to you. Content Requirements You will create a PowerPoint presentation with a realistic case study and include appropriate and pertinent clinical information that will be covering the following: 1.

Nursing homework question 71125

ACTonALZ. (2014, December 2).  Delivering an Alzheimer’s disease diagnosis [Video]. YouTube.   Case Scenario  You are the APRN at a large hospital outpatient memory clinic. You are working with a team that includes a geriatrician, neurologist, neuropsychologist, social worker, and ancillary providers. The current protocol for patient evaluation of cognitive conditions

CL3

· Official name of the program or group you observed.( NA , narcotics annoymous · When and where did you go to the group? ( South Miami 7190 Sw 72nd ST, south miami, FL 33143 · Why did you choose this specific meeting? Because my close friend made 5 year

WK 8 BLOG

The Intersection of Social Determinants of Health on HIT and Patient Outcomes Health literacy is defined by the World Health Organization (WHO) as, “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain

Ihuman wk 7

Comprehensive Case Study: 18-Year-Old Male: Reason for Encounter: Passed Out (Class 6512) | iHuman Case Analysis Week #7 | Includes HPI, PE, Differential Diagnosis, and Management Plan | I HUMAN CASE WEEK #7 18-Year-Old Male Patient: REASON FOR ENCOUNTER; SYNCOPE (6512) |

Nursing Assignment

Rational Emotive Behavioral Therapy 1. Describe the therapy: 2. Brief historical summary 3. Critique the theory or model a. Describe the major concepts/components of the theory b. Determine the complexity of the theory (how elaborate or simple is it?) c. Determine the scope of the theory (where does it stand

Nursing Literature Review & Evidence Matrix Assignment

Conduct a search of literature relevant to the problem/topic:   Research problem: There may be plenty of standardized tools for mental health screening in pediatric oncology, but they aren’t used consistently and may not be effective. This is a problem because emotional distress can go undetected, which can impact recovery,

The Literature Review

What is the importance of a literature review and what should you avoid when conducting a literature review?