Format for the Psychiatric/Mental Health Case Study

Admission Date: _________________ Student Name /Date of Clinical /Unit I. Demographics A. Client initials B. Age C. Gender II. III. Medical diagnoses and summary of physical health history/ needs DSM IV TR Diagnosis A. Address all axis B. Current GAF C. Pathology for Axis I diagnosis (Located on page 3-5 of this document) IV. Psychiatric History A. Treatments &/or hospitalizations B. Mutilation or self-harming/ suicide attempt 1. When, where, how and #of times C. Alcohol and nicotine use/ amount/ how long D. Drug abuse/ amount/how long E. Eating Disorders F. Cognitive of perceptual distortions G. Family history V. Genogram A. Include 3 generations B. Refer to chapter 10 in Stuart for completing a family assessment.

VI.

Assessment Data A. Intermediate Mental Status Exam (Located on pages 6-9 of this document) B. Baseline vital signs C. Significance of abnormal labs D. Medication 1. Current medications (Located on page 10 of this document) 2. Allergies E. Assessment Tools used from Varcarolis and discuss results

VII. VIII. IX. X.

Top 3 nursing diagnoses Care plan for highest priority diagnoses (Located on pages 11-12 of this document) Resources you used to complete the assignment. Self-Evaluation

Diagnostic criteria for Schizophrenia

Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): (1) delusions

Patient Data

(2) hallucinations

(3) disorganized speech (e.g., frequent derailment or incoherence)

(4) grossly disorganized or catatonic behavior

(5) negative symptoms, i.e., affective flattening, alogia, or avolition

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset C. Duration: Continuous signs of the disturbance persist for at least 6 months.

Criteria for Major Depressive Episode

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

Patient Data

Diagnostic Criterion Bipolar 1

Bipolar I disorder: You've had at least one manic episode. You may or may not have had a major depressive episode (see Depression Criteria). Criteria for a manic episode A manic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least one week (or less than a week if hospitalization is necessary). During the period of disturbed mood, three or more of the following symptoms must be present (four if the mood is only irritable):

Inflated self-esteem or grandiosity Decreased need for sleep (i.e.feel rested after only three hours of sleep) Unusual talkativeness Racing thoughts Distractibility Increased goal-directed activity (either socially, at work or school, or sexually) Engagement in pleasurable activities that have a high potential for painful consequences for example, unrestrained buying sprees, sexual indiscretions or foolish business investments

To be considered a manic episode:

The mood disturbance must be severe enough to cause noticeable difficulty at work, at school or in usual social activities or relationships; to require hospitalization to prevent harm to yourself or others; or to trigger a break from reality (psychosis). Symptoms do not meet the criteria for a mixed episode (see criteria for mixed episode below). Symptoms are not due to the direct effects of something else such as alcohol or drug use, taking a medication, or a having a medical condition such as hyperthyroidism.

N3425 Psychiatric Clinical Students Name Baylor University Louise Herrington School of Nursing

Date of Clinical ________________________

THE MENTAL STATUS EXAM (This assignment is to be typed. This template is provided for that use.) Clients Initials: ______ Gender: M F Age: Room Number _______

Axis I Axis II Axis III Axis IV____________________________________________________________ Axis V ____________

Use this format to document your findings in each of the following MSE categories. For Example: The clients ____(choose a category below)_____ is______(clinical judgment)_____ as evidenced by (assessment data). [Remember, judgments need to be supported by more than one piece of assessment data.] Need to include DEPTH and THOROUGHNESS in assessment. Appearance: Ms R.C., a 45-year-old overweight black female is approximately 5 feet and 7 inches tall and weighs 200 lbs. She appears older than her stated age. She has long, black, braided hair and dark brown /black eyes. The clients appearance was neat and poised as evidenced by clean hair and skin and matching clothes and shoes consistent with the cooler weather. She wore clean blue jeans, a white sweater, a blue jacket, and white socks and closed toed slip-on on leather slides. The client had applied some makeup to her face and did not have any body order or halitosis. The clients posture was upright, but her shoulders were slumped forward when she sat and walked. Her gait was steady and even, and she walked at a normal pace. She had a mildly flat affect with limited facial expressions. She never smiled throughout the interview. Her eye contact was limited, but more sustained when I was talking. Her general state of health was fair as she mentioned her heart problems and her uterine fibromas. The client appeared well nourished. The client reported no change in her appetite or problem with eating. The client was conscientious of her appearance as evidenced by her application of makeup and effort in doing her hair and dressing neatly.

Speech: 6

Psychomotor Activity:

Mood/Affect:

Perceptions:

Thought Content:

Thought Process:

Level of Consciousness and Orientation

Memory:

Level of Concentration, Calculation & Attention:

Capacity to Read and Write:

Visuospatial Ability:

Abstract Thinking:

Fund of Information and Intelligence:

Judgment:

Insight:

MEDICATION SHEET

Medication (Generic/Trade) Dosage, Route

Classification

Why is your client taking this drug?

Nursing Implications

Side Effects

Medication Teaching Needs: (Be specific)

Cultural Influences: (Think broadly here. Every patient has cultural influences)

Referrals indicated: (Again, think broadly. Every patient will need community support)

Socioeconomic Influences

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BAYLOR UNIVERSITY - LOUISE HERRINGTON SCHOOL OF NURSING NURSING CARE PLAN

Client's Initials Age Sex Current Admitting Medical Diagnosis:

Student's Name Date of Contact Place of Contact

Medical Diagnosis/Surgical Procedure Interventions

Interdependent Nursing

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Baylor University Louise Herrington School of Nursing

Human Need: Assessment: Student Name: Nursing DX: Client Goal:

Nursing Interventions

Rationale

Outcome Criteria

Evaluation

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