Data Collection in-Patient Aug 07

8/14/2019 Data Collection in-Patient Aug 07

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Student Name

DATE OF ADMISSION: DATE OF CARE:

AGE: GENDER: Male/Female RACE: African-American, AsianHispanic/Non-Hispanic American-Indian, White, Other:SYMPTOMS & Behaviors Day of Admission: (Danger Self/Danger Others)

(AXIS I) PSYCH DX:

(AXIS II) (Personality d/o, mental retardation)

(AXIS III) ACUTE/CHRONIC DISEASES/HEALTH HX:

Include any surgical procedure.

(AXIS IV) RECENT STRESSORS (LIST SPECIFIC STRESSORS):

Educational Level/Occupation:Hobbies/Interests: (enjoyments):Disabilities:

Living Arrangements (# in household):

Legal Guardian (if minor or vulnerable adult):

Advanced Directives/Living Will/Medical Power of Attorney:CODE STATUS:

No Code, Full Code,

Partial Code (meds only,

CPR only)(AXIS V) GAF:

Equipment:

IVs:

Dressing Change Orders

(list any drains/woundspresent and care):Treatments:

PT/OT/ST/RT/MSW or Other Referrals:

Substance Abuse History: Drug(s) of Choice:

Date of Last Use: How much?How often used in past week/month?

Longest period without use:Number admissions treatment:

CAGE:

Activity Level: Up Ad Lib, BR, BRP, BSEC, Unable to move self

Hygiene/Bathing: Self Care, Assistance, Total Care

Elimination: Void/Foley/Ostomy/Dialysis

DIET: Supplements:Dentures (full or partial), no teeth, teeth poor condition, dysphagia

SLEEP QUALITY: # hrs _____, difficulty falling asleep, difficultystaying asleep, early awakening, hypersomnia, nightmares/terrors

MEDICATIONS (current):

Home Medications:

OTC/Alternative Meds:PAIN: acute/chronic Intensity: Scale 1-10 Location:

Characteristics:

ALLERGIES:

DATA COLLECTION

TOOL

Inpatient Mental Health

SAFETY CONCERNS YES NO

FALL RISKBED ALARM ON

SEIZURE PRECAUTIONS

RESTRAINTS

VITAL SIGNS Admission Last Recorded

Blood Pressure

Heart Rate/Pulse

Respiratory Rate

Temperature

Intake/OutputHeight/Weight


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PAGE 2

THIS PAGE IS the TEXTBOOK PICTURE of the selected DSM-IV DiagnosisCOMPLETE FOR ADMITTING PROBLEM (harm to self or others)

PATHOPHYSIOLOGYETIOLOGY

DSM-IV TRDiagnostic Criteria

Management/TreatmentPharmacology/Therapy

Nursing Diagnoses withSelected Outcomes

Nursing Interventions

*Include risk factorsAny cultural/ethnic factors

Demographics/prognosis

Management CommonlyPrescribed for Diagnosis

This is textbook picture ofthe diagnosis.

Include cultural/ethnic/raceand religious/spiritual

specific interventions

Incidence:

General Population:

Male:Female:

Other:

EtiologyGenetic:

Biochemical:

Psychosocial:

Personality Factors/Other:

(For clinical Highlight or

circle your patients

symptoms that were

present upon admissionand dialogue whether theyare present now.)

Medications Normally

Prescribed for thisDiagnosis:

(For Clinical Circle Patient

Medications)

Do any of these meds

need blood levels drawn?

Lab/Diagnostics RoutinelyOrdered To Monitor

Adverse Effects ofMedication?

PSYCHIATRIC DIAGNOSIS (Axis I, Axis II)


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THIS PAGE IS the TEXTBOOK PICTURE of the selected DSM-IV Diagnosis

COMPLETE FOR ADMITTING PROBLEM (harm to self or others) page 2a (if needed)PATHOPHYSIOLOGY

ETIOLOGY

DSM-IV TR

Diagnostic Criteria

Management/Treatment

Pharmacology/Therapy

Nursing Diagnoses with

Selected Outcomes


*Include risk factors

Any cultural/ethnic factorsDemographics/prognosis

Management Commonly

Prescribed for Diagnosis

This is textbook picture of

your diagnosis..

Include cultural/ethnic/race

and religious/spiritualspecific interventions

Incidence:General Population:

Male:

Female:Other:

Etiology

Genetic:

Biochemical:

Psychosocial:

Personality Factors/Other:

(For clinical Highlight orcircle your patients

symptoms that were

present upon admission

and dialogue if they arepresent now.)

Medications Normally

Prescribed for this

Diagnosis:

(For Clinical Circle PatientMedications)

Do any of these meds

need blood levels drawn?

Lab/Diagnostics Routinely

Ordered To MonitorAdverse Effects of

Medication?

PSYCHIATRIC DIAGNOSIS (Axis I, Axis II)


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PSYCHIATRIC MEDS PAGE 3

Complete for all psychiatric meds prescribed (include prns):

1. Medication

2. Classification

3 Mode of Action4. Pregnancy Safety Category

1. Physicians Orders

2. Dosage ranges (child,adult, geriatric/IM/IV/SQ)

3. Why is patient taking thismedication?

COMMON Adverse

Effects

(Very important for patient

education and teaching)

SERIOUSAdverse Effects

(Symptoms to report to provider. Symptoms may

be life-threatening or leadto serious complications.


(include incompatibilities)on IV/IM/SQ include dilution

amount, site selection, rate of

administration

1. Medication

2. Classification

3 Mode of Action

4. Pregnancy Safety Category


2. Dosage ranges (child,

adult, geriatric/IM/IV/SQ)


COMMON Adverse

Effects



SERIOUS Adverse Effects

(Symptoms to report to

provider. Symptoms may





administration

MEDICATIONSOrder of meds listed:

1 PO 2 S /IM 3 IV 4 PRNs


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PSYCHIATRIC MEDS PAGE 4

Complete for all psychiatric meds prescribed (include prns):

1. Medication

2. Classification3 Mode of Action4. Pregnancy Safety Category


2. Dosage ranges (child,adult, geriatric/IM/IV/SQ)


COMMON Adverse

Effects(Very important for patient



(Symptoms to report to provider. Symptoms may





administration

1. Medication

2. Classification

3 Mode of Action

4. Pregnancy Safety Category


2. Dosage ranges (child,

adult, geriatric/IM/IV/SQ)


COMMON Adverse

Effects




(Symptoms to report to

provider. Symptoms may





administration

MEDICATIONSOrder of meds listed:

PO 2) SQ/IM 3) IV 4) PRNs


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PAGE 5

NON PSYCHIATRIC MEDICATIONS NON PSYCHIATRIC MEDICATIONS

List only major medications (no more than 10)

PAGE 6

MEDICATION

(classification)

MD ORDER REASON

PT TAKING

HOME

MED

Any psych S/S this

med may cause?

Any contraindications

with psych d/o or med?

1 Yes/No

2 Yes/No

3 Yes/No

4 Yes/No

5 Yes/No

6 Yes/No

7 Yes/No

8 Yes/No

9 Yes/No

10 Yes/No

LABORATORYAND DIAGNOSTIC


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ADX, Blood Alcohol, Liver Profile, Chemistry, CBC, HIV, Thyroid Profile, Hepatitis Panel, Urinalysis, etc.

(Circle laboratory work performed.) CHECK PHYSICIANS ORDERS!

PAGE 7

List Abnormals ONLY VALUE = High () Normal (WNL) Low ()

TestLab Manual Normal Ranges VALUE/Date

Admit Most Recent Interpretation of Tests R/T Diagnosis and Medications

DIAGNOSTIC TESTName of Test

Date Conducted Interpretation of Tests r/t Diagnosis and MedicationsASSESSMENT FORM


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*Mental Status Assessment Admitting Assessment Your Findings Day of CareGENERAL:Include physical appearance, presence,

stated age vs. apparent age, proportion of both l imbs to

trunk, body and breath odors, hygiene, eye contact, hair

color and appearance, distinguishing marks

MOTOR ACTIVITY: tremors, tics, mannerisms,gestures, rigidity, hyperactivity, restlessness oragitation, aggressiveness, gait pattern,echopraxia,

psychomotor retardation, range of motion

SPEECH PATTERNS: slow or rapid, pressured,tone, volume, aphasia, speech impediment

GENERAL ATTITUDE: cooperative oruncooperative, friendly, hostile, defensive,uninterested, apathetic, attentive, interested,

guarded, suspicious

EMOTIONS (MOOD): sad, depressed,despairing, irritable, anxious, elated, euphoric,

fearful, guilty, labile (ASK PATIENT)

AFFECT: congruent with mood, constricted,blunted, flat, appropriate or inappropriate

THOUGHT PROCESSES: flight of ideas,looseness of associations, ci rcumstantiality,tangentiality, neologisms, concrete thinking, clang

associations, word salad, perseveration, echolalia,mutism, poverty of speech, concentration ability,attention span

CONTENT OF THOUGHT:Delusions(persecutory, grandiose, reference, control or influence,somatic, nihilistic), suicidal or homicidal ideations,obsessions, paranoia, suspiciousness, magicalthinking, religiosity, phobias, poverty of content (vague,meaningless)

PERCEPTUAL DISTURBANCES:Hallucinations (auditory, visual, tactile, olfactory,gustatory), illusions, depersonalization, derealization

SENSORIUM AND COGNITIVE ABILITY:Level of alertness /consciousness, Orientation (time,

place, person, situation), Memory (recent, remote,confabulation), Abstract, Concrete

IMPULSE CONTROL:Ability to controlaggression, hostility, fear, guilt, affection, sexualimpulses/feelings

JUDGEMENT:ability to solve problems or makedecisionsINSIGHT:awareness of limitations, consequencesof actions, illness

*Townsend (2005), Psychiatric/Mental Health Nursing (5 th Ed), Appendix B, pages 916-917

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SYSTEM ASSESSMENT CRITERIA Findings from chart Subjective from patient interview orYour observation


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ENT:

SKIN:

Wounds/incisional sites/dressings/drains

CHEST:

CARDIOVASCULAR

MUSCULOSKELETAL:

GASTROINTESTIONAL:

ENDOCRINE:Blood Sugar Patterns: ac & HS, bid ac

GENITOURINARY:GENITOREPRODUCTIVE:

OTHER:

PAIN: Location, radiation, quality, intensity, characteristics ofpain, aggravating factors, alleviation factors

RISK ASSESSMENT: Precautions: falls, seizure,

restraints, confusionSAFETY: side rails up/down, call light in reach, armband,allergy band, fall band, bed alarm on/off

NUTRITIONAL: Include height/weight (IBM/BMI,changes) diet and caloric intake (adequacy), risk factors

malnutrition, hydration status

PSYCHOSOCIAL:Include impact of illness on self-perception, coping strategies, social support, financial resources,

substance use history (Use Maslows Hierarchy of Needs)

DEVELOPMENTAL: Include impact of illness on roleperformance and ability to achieve expected developmental status.

(use Eriksons developmental stages) Immunization status

VALUES AND BELIEFS: Include cultural andreligious values/beliefs that affect health practices and clients

expression of current spiritual needs. Chaplain/minister needed?

PATIENT/FAMILY TEACHING PLAN:Includeassessment ofpatient/family teaching needs, goals of teaching plan,

strategies, and evaluation of plan

DISCHARGE PLANNING:Discharge destination,anticipated problems, available resources, referrals needed.

FACTORS hindering care: transportation, finances, housing,

disabilities (physical or mental), lack of support

Come to clinical with prepared questions (both assessment and therapeutic interactions) PAGE 9 PROCESS RECORDING


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*minimum of six (6) interactions

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STUDENT NURSE

VERVAL AND NONVERBAL

COMMUNICATION

TECHNIQUE

PATIENT

VERBAL AND NONVERBAL

How could interaction have

Been reworded or rephrased?

Verbal (Quotes):

Nonverbal:

Therapeutic/Nontherapeutic(circle)

Type of Technique Used:

Verbal (Quotes):

Nonverbal:

Critique your interaction:

Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:


Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:


Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:


PROCESS RECORDING


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*minimum of six (6) interactions

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STUDENT NURSE

VERVAL AND NONVERBAL

COMMUNICATION

TECHNIQUE

PATIENT

VERBAL AND NONVERBAL

How could interaction have

Been reworded or rephrased?

Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:


Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:


Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:


Verbal (Quotes):

Nonverbal:



Verbal (Quotes):

Nonverbal:

Critique your interaction:NSG DX:PT outcome: PT will

**Related findings:

Nursing Interventions:

Evaluation:


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Select three (3) nursingdiagnoses to expand!

Hospital Day #

SETTING PRIORITIES:

Remember MASLOW: Physiological before Psychological This page is a complete pictureRemember ABCs: Airway before breathing, circulation of your patient on the date of care.Remember Patient Safety: First of all Do No Harm (*Are there any barriers to providing

PREVENT Death and Disability care (religious, ethical, educational,

RELIEVE Suffering financial, age, gender, other?)Remember GAF RememberPatient Priorities

No. NURSING DIAGNOSIS

1

2

3

4

5

67

8

9

10

Belonging

SAFETY

Clothing, food, shelter

NSG DX:PT outcome: PT will

Related findings:


Evaluation:

NSG DX:PT outcome: PT will

Related findings:


Evaluation:

SUMMARY OF PATIENT DATA

Data Collection in-Patient Aug 07

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