Assessment/Question Tool

njmonsterboi80, BSN · Aug 20, 2006

I'm in the same position. I know my preceptor always starts with vitals and then goes into more notes.. Let me know if anyone has a good template.

Thanks.

I'm a new psychiatric nurse and could use some help. I'm trying to make a one page assessment sheet that I can use to help me with my assessment and charting. Being new at this, however, I'm not really sure what I'm looking for. Can anyone give me some ideas, or if anyone else has made a sheet like this, would you be willing to share it.
Thanks. I would to do the best that I can for these patients.

Meerkat · Aug 20, 2006

Hi Guys/Girls...Welcome to Psych!

As far as assessment, after vitals, I think the number 1 thing to evaluate is your patient's risk for suicide or homocide or assault within your facility. You can assess up and down physical stuff, but if you find a patient hanging in the bathroom, none of that will do you much good. Which brings me to my second point. During assessment, did the admit team search for contraband? Did they miss anything, like shoelaces? Check pockets?

Also skin assessments are important. Note any bruises, track marks, etc. Please don't do the skin assessment alone. Have another staff member of the same sex of the patient in there with you. If your patient is coming from jail, be aware that he or she is likely to have been exposed to TB, Hepatitis, etc. Does the patient appear to be responding to internal stimuli? Paranoia? Sexually inappropriate behaviour? Potential to elope? Make note of any threats the pt may make toward people 'outside'. We are obliged by Tarasoff Law under the Duty to Warn statute if we become aware that a pt intends to harm another person. I like to ask the pt what helps them de-escalate if he or she becomes agitated. Do they not like to be touched? Don't like people in uniform? Does music help? What chronic health conditions do they have that may put them in danger if they get upset (i.e., hypertension, asthma)?

I'm sure I'm forgetting a bunch of stuff, but that's all I can think of right now. Good luck!

neo808 · Jun 23, 2007

I found this site when I was in Nursing school. It was really helpful when charting. I hope this finds some use for someone.

http://www.swin.edu.au/victims/resources/interview/MSE-FORM.pdf

A hui ho.

funinsun · Jun 23, 2007

Aloha all..

I agree with all that has been posted. Having a standard assesment that flows well (because the patients are in varying states of crisis) is crucial to patient care.

I think that medical questions and obtaining a history is as important, because it seems so much falls in the cracks regarding their past meds, or past conditions. When obtaining their history and asking questions about them truly (as much if not more than 'medical' pts) and not just the content of their delusional thoughts (if not in immediate risk of course) like past hospitalizations, what they like/dislike, you are obtaining data but also are able to evaluate judgement, LOC, etc while smiling/engaing with them (gaining trust too).

To me, having questions that flow help a lot, or else both patient and nurse can feel uncomfortable and confused..

purplekath · Jun 24, 2007

I use this template:

Risk factors: (risk self-harm/suicide, absconding, physical/verbal aggression, reputation etc)

Mental State: (Mood, affect, speech, thought content, cognition etc, as well as any details you want to add about delusional content etc)

Physical: Include vitals, tests taken, results, complaints of pain and what you did etc.

Psychosocial: Any drug and alcohol issues, issues with children, relationships, visits that took place and how they went, upcoming court cases etc.

Leave status/CRA/discharge planning etc.

purplekath · Jun 24, 2007

Oops, I also include a section for medication....any PRN I have given and why, and any medication changes I have requested or have been made, any adverse reactions observed.