NURS3910 MENTAL HEALTH NURSING

NURSING ASSESSMENT FORM

Student Name: Harpreet Kaur Date: 04/28/14
Patient data:
Admission Date:
Age:
Gender:
02/28/14
48
Female
Employment:
Unemployed

Educational
Level: High
school.

Significant Other/marital status and children:

Pt. is single. She has two children: a daughter and a
son. Pt. stated that her daughter is 31 years old and
her son is 32 years old.
Pt. Legal Status: Legal history:
Primary
5150 DTS, DTO, None.
Language:
GD.
English.

Chief complaint: What patient says prompted them to present at the hospital: Pt. stated that the
Homeland Security and the police department were chasing her because she has some information
that they want.
What is the documented cause for hospitalization? Substance Induced Psychotic Disorder
Patients living situation at time of admission: Patient stated that she was living with her friends at
the time of admission. In the chart, it was stated that she is homeless and moved from Oregon 3 weeks
ago.
DSM IV AXES from chart
I: Provisional diagnosis of substance induced psychotic
II: Deferred.
disorder, amphetamine abuse versus dependence, and rule
out Bipolar I disorder, most recent episode manic, severe,
with psychotic feature. PTSD
III: Asthma
IV: Other psychological environmental
problems related to Axis I, chronic
methamphetamine and transient and
homeless.
V:(With rationale) 15/20. The patient has some degree of
hurting self or others.
PATIENT HISTORY
Medical History: Asthma, currently in remission, Anxiety.
Current medical issues of importance to nursing management of patient: (present all relevant
information from review of systems)
None
Psychiatric history: Bipolar disorder.
Alcohol and Other Drug Abuse: On admission, patient admitted using methamphetamine on
02/26/14.
Abuse (physical/sexual): Patient denied being physically abused. However, she stated that she was
sexually abused twice in her lifetime. Recent abuse was abused was 2 years ago by a person she knew.

FAMILY HISTORY
Mental Health: None.
Alcohol and Other Drug Abuse: None.
MENTAL STATUS EXAM
General Appearance:
Dress & Grooming: Dressed in street clothes;
Neatly groomed; and Appropriate for weather.

Facial Expression: Consistently pleasant.

Appropriate and direct eye contact.

Posture and Gait: The patient had an erect

posture and steady gait.

Physical Characteristics: Patient looks the stated

age. Tall and slender.

Motor behavior: (describe) Moved back and

forth in the chair. Rubbed the arm of the chair
whenever felt anxious.

Attitude toward interview and mood (observed):

Patient was excited to be interviewed. She stated
that she likes participating in research studies
because she enjoys sharing her thoughts. In
addition, she said that her parents have always
participated in studies too.

Physiological responses (tremor, nystagmus,

sweating): none noted
Affect and Mood
Appropriateness: Congruent with mood
Stability (patients report of swings, and
interviewers observation of changes):
Stabile.
Speech
Volume: Normal. Ordinary.
Thought Content
Theme: Coming to the hospital and Finding
research studies to participate in.

Range: Normal.
Describe (e.g., anxious, depressed, disengaged,
etc.):
Client appeared lively and pleasant throughout the
interview.
Rate (flow, speed): Pressured (Fast)
Delusions (persecution, influence, and reference,
thought insertion): Persecution regarding homeland
security chasing her and Grandiose delusions
regarding sharing her knowledge.

Phobias: Denied

Obsessions: Denied

Compulsions: Denied

De-realization, depersonalization:
- Patient said that she saw heaven and light at the
end of tunnel. She also said sometimes she has out
of body experiences.

Disorders of Perception (give an example of

those that apply)
Hallucinations (type with description):
Denied
Clarity and organization: Scattered in the
beginning, but got more organized and clear as
the interview continued.
Other unusual experiences
Hypnogogic phenomena: Denied

Illusions (described as shadows, or reported as

misinterpretation of stimuli): Denied.
Tone/inflection: Appropriate/Normal.

Dreams: Denied.

Dj vu Experiences: Patient said that she feels Nightmares/Night Terrors: Patient said that she
some instances have occurred before.
dreams about people chasing her because they want
the information that she has on her phone and
computer. Also, she said that theyre always
targeting her.
Memory & Cognition
Orientation to self - yes
Orientation to Place - yes
Orientation to day & date - yes
Attention: ability to count digits forward
Serial 3s and serial 7s: (count backward from 100
(provide digits for patient to repeat)
by 3 or 7)
Patient was able to count forward. Given
- Yes, patient was able to count backward by 3s
number: 1, 2, 3, 4
until 91.
Recent memory:
Patient verbalized when she came to the
hospital and what meal she had in the morning.

Confabulation: Patient stated that she remembers

the examiner from this morning and has seen her
before while riding bus or shopping around town.

Fund of information: Patient verbalized the

number of days in the week, months in a year,
and names of the season.

Vocabulary: Patient was able to explain what

emphasize means. She said that is means
highlighting things or making something appear
larger or special.
Similarities: Patient said that oranges and apples
are both round and are fruits.

Abstraction: Patient was asked to explain the

proverb Dont cry over spilled milk. She said
that it means to not worry about whats already
happened and move on.
Judgment and Comprehension: Patient was
asked about what she would do if she saw a
bunch of keys and she knew that they belonged
to a nurse. Patient said that she would find the
nurse and return them to her.
Suicidal Ideation:

Perception and Coordination: Patient was able to

write her own name, copy a circle, a cross (x), and
a square.

Yes No (If yes, complete suicide assessment)

Patient denied any current suicidal thoughts. According to the chart, upon admission, patient wanted
to commit suicide by overdosing on Seroquel.

Homicidal Ideation: Yes No (If yes, complete homicide assessment)

Patient denied any homicidal thoughts. According to the chart, upon admission, patient wanted to kill
everyone by blowing them up.
What does this person do when angry, stressed or uptight?
Patient likes to do artwork and pointed towards the wall that contained the drawings she colored.
Patients description of him/herself. What does she like best best/least about her/himself?
Patient likes her smile. She says that people have complimented her over her smile. On the other hand,
patient doesnt like that she talks a lot, as some people may find it annoying.
Include real or potential strengths of the client.
Patients real strength is that:
She feels safe in the hospital and trusts the staff.
She is open for conversations and likes to share her views with others.
Patients potential strength may be support from friends and family. Patient stated that she doesnt
have any visitors.
Routine Medications (including category, dose, standard dose, target effects, interactions and
side effects)
See Attached page
Pertinent Lab values: (see attached page)
Written Summary (Give summary of relevant findings from above. Discuss congruence and
incongruence between DSM criteria & patient assessment)
The patient remained pleasant throughout the interview. She demonstrated delusions of persecution
and grandiosity. She denied any suicidal or homicidal thoughts. However, she admits to a previous
attempt and a potential plan of overdosing on Seroquel. In the beginning of the interview, patient
exhibited flights of ideas and needed to be redirected; however, she was able to focus towards the end
of the interview. Patient had all normal labs values expect for Glucose, POC being 115.
The first criterion of Diagnostic Criteria for Substance Induced Psychotic Disorder requires
prominent hallucinations or delusions. (Reid & Wise, 1995/ 2012). The patient demonstrated signs of
delusions of persecution and grandiose, as she verbalized being chased by the homeland security and
wanting to share knowledge, respectively. Secondly, the criteria requires evidence from history,
physical examination, or laboratory finding of either (1) The substance in Criterion A developed
during, or within a month of, Substance Intoxication or Withdrawal OR (2) Medication use is
etiologically related to the disturbance (Reid & Wise, 1995/ 2012). The patient admitted using
methamphetamine two days prior to admission and showed symptoms upon admission. In addition,
upon admission, patient stated that she was in chaos and was presented to the hospital by ambulance.
The third criterion requires that the disturbance is not better accounted for by a Psychotic Disorder
that is not substance induced (Reid & Wise, 1995/ 2012). It means that symptoms occur prior to the
onset of substance abuse or dependence, and they stay for over a month after the end of acute
withdrawal or severe intoxication; or the symptoms are in excess of what would be expected given
the type of the substance used or the duration of use; or there is evidence that suggests the existence

of an independent non substance-induced disorder Psychotic Disorder (e.g., history of recurrent nonsubstance-related episodes) (Reid & Wise, 1995/ 2012). According to the interview and the chart, the
patients symptoms followed the substance abuse; however it could not be determined if the
symptoms persisted for a month because the interview took place within 12 days of substance abuse.
In addition, the symptoms are within the expectations of substance used. Nevertheless, the patient
does have a history of Bipolar disorder; thus, this criterion does not apply to the patient. Lastly, the
DSM IV TR requires that the disturbance does not occur exclusively during the course of delirium
(Reid & Wise, 1995/ 2012). During the interaction, I did not notice any symptoms of delirium, and it
was not mentioned in the chart.
Three Nursing Diagnoses according to priority (include plan of care for each, expected
outcomes, and attach nursing care plan)
1) Disturbed thought process r/t withdrawal into herself as evidenced by grandiose delusions,
persecution delusions, and altered attention span
A) Plan of Care:
1. Assist and support client in his or her attempt to verbalize feelings of anxiety, fear,
or insecurity.
2. Reinforce and focus on reality. Discourage long ruminations about the irrational
thinking. Talk about real events and real people.
3. Do not argue or deny the belief.
4. Convey your acceptance of clients need for the false belief, while letting him or
her know that you do not share the belief.
5. Administer medications as ordered.
B) Peer reviewed references:
1. Using Specialist supportive care, a psychotherapy based on supportive
psychotherapy and American Psychiatric Association, following interventions are
suggested:
a. Explore issues related to medication adherence (Crowe et al., 2012)
b. Provide support for patients psychological adaptive defensive while
challenging unrealistic beliefs (Crowe et al., 2012).
c. Promote the patients sense of safety and self-esteem (Crowe et al., 2012).
d. Focus on here and now (Crowe et al., 2012).
C) Outcomes:
1. Verbalizations reflect thinking processes oriented in reality.
2. Client is able to maintain activities of daily living (ADLs) to his or her maximal
ability.
3. Client is able to refrain from responding to delusional thoughts, should they occur.
2.) Knowledge deficit r/t medication administration as evidenced by unfamiliarity of Nicoderm patch
application.
A) Plan of Care:
1. Assess motivation and willingness of patient and caregivers to learn.
2. Assess ability to learn or perform desired health-related care.
3. Identify priority of learning needs within the overall plan of care.
4. Identify any existing misconceptions regarding material to be taught.
5. Provide physical comfort for the learner.
6. Provide instruction for specific topics.

7. Refer patient to support groups as needed.

8. Pace the instruction and keep sessions short. Kept the instruction short.
B) Outcomes:
1. Patient demonstrates motivation to learn.
2. Patient identifies perceived learning needs.
3. Patient verbalizes understanding of the content.
3. Risk for suicide r/t history of prior suicide attempt and substance abuse as evidenced by score of 4
on a suicide risk assessment.
A) Plan of care:
1. Conduct a suicide risk assessment.
2. Ask client directly: Have you thought about harming yourself in any way? If so,
what do you plan to do? Do you have the means to carry out this plan?
3. Create a safe environment for the client. Remove all potentially harmful objects
from clients access.
4. Maintain close observation of client. Depending on level of suicide precaution,
provide one-to-one contact, constant visual observation, or every-15-minute
checks.
5. Maintain special care in administration of medications.
6. Make rounds at frequent, irregular intervals (especially at night, toward early
morning, at change of shift, or other predictably busy times for staff).
7. Formulate a short-term verbal or written contract with the client that he or she will
not harm self during specific time period. When that contract expires, make
another, and so forth.
B) Peer Reviewed interactions:
1. To create a safe environment, identify at risk patients by asking assessment
questions including suicidal intent, mental state, psychosocial history, and current
suicidal thoughts (Adams, 2013).
2. The Nurses Global Assessment of Suicide risk tool, proven effective through a
pilot study, include assessing hopelessness, life events, persecutory voices, suicidal
intent, plan for suicide, family history of suicide, recent loss of relationship, history
of mental illness, a prior suicide intent, poverty, alcohol abuse, and a terminal
illness (Adams, 2013).
3. Form a no-harm or safety contract along with therapeutic relationship (Adams,
2013).
4. One to one observation should be conducted by hospital staff (Adams, 2013).
5. All dangerous items, including matches, razors, belts, bathroom cords, and drinking
glasses, should be removed from patients rooms (Adams, 2013).
C) Outcome:
1. Client verbalizes no thoughts of suicide.
2. Client commits no acts of self-harm.
3. Client is able to verbalize names of resources outside the hospital from whom he or
she may request help if feeling suicidal.
Please include a separate sheet for references (see attached page).

Students response to experience with this patient:

Because of patients pleasant nature and excitement to share her feelings, I felt comfortable doing the
interview. She was willingly taking her medications and discussing the reason for admission.
However, as the conversation began, it was a bit hard to stay on topic because of her flight of ideas
and pressured speech. I felt distracted, as she talked about jumped from one point to another. Slowly
but surely, I was able to bring her to the topic and continue the interview. Towards the end of the
conversation, she was much more focus and exhibited no flight of ideas.
Student Name: Harpreet Kaur

References
Adams, N. (2013). Developing a Suicide Precaution Procedure. MEDSURG Nursing, 22(6), 383386.
Crowe, M. M., Inder, M. M., Carlyle, D. D., Wilson, L. L., Whitehead, L. L., Panckhurst, A. A.,
& ... Joyce, P. P. (2012). Nurse-led delivery of specialist supportive care for bipolar
disorder: a randomized controlled trial. Journal Of Psychiatric & Mental Health Nursing,
19(5), 446-454. doi:10.1111/j.1365-2850.2011.01822.x
Reid, W. H., & Wise, M. G. (2012). Schizophrenia and other psychotic disorders. In Routledge.,
DSM-IV training guide (pp. 140). Retrieved from http://books.google.com/books?
id=RBoCAwAAQBAJ&printsec=frontcover#v=onepage&q=substance%20induced
%20psychotic%20disorder&f=false (Original work published 1995)