Description
this assignment has two part. First part is you do a reflection over my day how it went and what i had during my clinical in kids side at psychiatric unit. second part of the assignment is you do prep sheet on my patient. I will provide the info.
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Student Name _______________________________________
Client’s Initials:
Age:
Room Number:
Ethnicity:
Facility:
Legal
Status:
DSM V:
Date ________________________
Gender
M
F
Admission Date: _______________
Unit:
Minor
Vol.
Invol.
Checks/Precautions:
MEDICATIONS (Include generic/trade name, classification/use, dose, schedule, common side effects)
Generic Name Trade Name Classification/Use Dose Schedule Side Effects
LABS/DIAGNOSTIC TESTS:
(Only those not WNL, Tox Screen, and medication lab levels)
Presenting Problem:
Physical, sexual abuse history:
Medical History:
Family History:
Substance Abuse History:
Recent Stressors/Losses:
Education:
Legal:
Marital History:
Support Systems (with whom does the client live with):
Occupational:
Mental Status Assessment (Include general appearance and behavior,
mood/affect, other):
Appearance:
Physical handicaps _______________________________________________________
Dress/Grooming: Appropriate
Inappropriate Sloppy Poor Hygiene
Gait & Motor coordination (awkward, stagers, shuffling, rigid, steady) ______________
_______________________________________________________________________
Relationship between appearance and age _____________________________________
Behavior
Agitated
Calm
Lethargic
Restless
Anxious
Angry
Tearful
Distractible Evasive Cooperative Follows commands
Negative Fearful
Alert
Movements: Excessive Reduced WNL
Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of
consciousness, balance and gait) _____________________________________
Abnormal movements (e.g., tardive dyskinesia, tics, tremors) _____________________
Level of eye contact (keep cultural differences in mind) _________________________
Speech
Rate: Rapid Slow
Normal
Volume: Loud Soft
Normal
Clear
Mumbling
Pressured Slurring Stuttering
Constant Mute or silent
Disorganized
Tongue-tied speech
Barriers to communication
Specify (e.g., client has delusions or is confused, withdrawn, or verbose) ____________
_______________________________________________________________________
Mood
What mood does the client convey? __________________________________________
_______________________________________________________________________
Affect
Is the client’s affect bland, apathetic, flat, dramatic, bizarre, or appropriate? Describe.
_______________________________________________________________________
Thought process
1. Characteristics: Flight of ideas Looseness of association Blocking
Concrete thinking Confabulation Disorganized Neologisms
Circumstantiality Coherent
Describe the characteristics of the client’s responses ___________________________
______________________________________________________________________
2. Cognitive ability:
Proverbs: Concrete
Abstract
Serial sevens: How far does the client go? _____________________
Can the client do simple math? Yes No
What seems to be the reason for poor concentration? ___________________________
Orientation to Time
Place
Person
Situation
Thought content
1. Central theme: What is important to the client? ______________________________
Describe. ____________________________________________________________
2. Self-concept: How does the client view him/herself? __________________________
____________________________________________________________________
What does the client want to change about him/herself? _______________________
____________________________________________________________________
3. Insight: Does the client realistically assess his/her symptoms? Yes No
Describe. ____________________________________________________________
Realistically appraise his/her situation? Yes No
Describe. ____________________________________________________________
4. Is the client a Reliable historian? _______________Describe:__________________
_____________________________________________________________________
5. Suicidal or homicidal ideation? Yes
No Suicide potential? ______________
Family history of suicide or homicide attempt or successful completion? Yes No
Explain. _____________________________________________________________
6. Preoccupations: Does the client have
Hallucinations Type: Auditory Visual Tactile Olfactory
Delusions Type: Grandiosity Jealous Persecutory Somatic
Obsessions
Rituals Phobias Religiosity Worthlessness Illusions
Describe. ____________________________________________________________
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