Suffolk County Community College

School of Nursing
Mental Health Nursing Assessment
N/A not applicable
U/A unable to Assess (if this is used, please describe why it would be important)
Client History
I. General History of Client
Initials:

Age:

Sex:

Marital Status:

Unit:

Racial and ethnic data:

Siblings and children (specify 1st name, relationship, age):
Current Housing:
Living Arrangements (Name & relationship):
Religious affiliation/beliefs:
Medical/Psychiatric Diagnosis:
II. Chief Complaint
A. State in clients own words (why he /she is hospitalized or seeking help):
B. Stressors (If present, please describe)
1) Relationships:
2) Current Mental Health Symptoms:
3) Other (Work, Finances, etc):
C. Symptoms: (If present, please describe)
1)
2)
3)
4)
5)
6)
7)
8)

Anger:
Anxiety:
Confusion:
Depression:
Hopelessness:
Powerlessness:
Suspiciousness:
Other:

D. Physical Complaints: (If present, please describe)

1) Constipation:
2) Lethargy/Fatigue:
3) Insomnia:

4) Palpitations:
5) Weight loss or gain:
6) Other:
III. Personal History
A. Previous mental health hospitalizations (in/outpatient, onset, duration, & treatment):
B. Education:
C. Occupation:
1)
2)
3)
4)

Special Skills:
Employed:
Duration:
Company:
Previous Positions & Reasons for leaving:
Military Service (Combat):

D. Support System
1) Family, friends, colleagues, pets, others:
2) Describe a usual day:
E. Interests & Abilities
1) What does the client do in spare time?:
2) Identify strengths, talents:
3) What gives the client pleasure?:
F. Substance Use/Abuse
1) List herbal or OTC medications:
2) Alcohol & Street Drugs (Type, amount, frequency, duration):
3) Prior Rehab- (In/Out patient, date, results):
G. Coping with stress
1) What does the client do when upset?:
2) Whom can the client talk to?:
3) What helps to relieve stress?:
IV. Family History
A. Childhood
1) Who was important when client was growing up?:
2) Any physical or sexual abuse? (Age, duration & offender):
3) Who lived in the home (family/friends):
B. Adolescence
1) Describe feelings during adolescence:
2) Describe peer group, interests & activities:

C. Family Drug use

1) Identify member, drug (Prescription, ETOH or street) use pattern and effect on
family:
D. Family physical or mental health issues.
1) Family history of violence, physical or emotional abuse:
2) Family member with physical or mental health issues (suicide or attempt, type,
duration, treatment) and effect on family:
E. Any Unusual or Outstanding event:
Mental Status Assessment
A. Appearance
Dress: Appropriate/Inappropriate (describe):
Grooming: Neat/Poor (describe):
Physical Handicaps:
B. Behavior
Eye Contact:

Facial expressions:

Posture:

Gait:

Level of Activity (Lethargic, Restless, Agitated):

Gestures/Mannerisms:
C. Speech
Clear/Mumbled/Slurred (circle, then describe):
Rapid/Pressured/Constant/Mute (circle, then describe):
Barriers to communication (ESL, Hearing, delusions, confused, withdrawn):
D. Mood
Client self-report & any changes:
E. Affect
Describe and identify if appropriate and/or congruent with mood?:
F. Thought Process
1. Characteristics (Check if present, then describe)
Flight of Ideas:
Loose Associations:

Blocking:
Concrete Thinking:
Confabulation:
2. Cognitive Ability
Orientation: Person:

Place:

Time:

Recent Memory (Describe):

Remote Memory (Describe):
Concentration (Describe):.
Problem Solving (Describe):
Interpretation of Proverbs:
G. Thought Content
1) Present Themes:
2) Describe what is important to client:
3) Self Concept: How does client view self?:
4) Any areas of desired change?:
5) Judgment:
6) Insight:
7) Suicidal or homicidal ideation (No, Yes - Describe Lethality/plan/access):
8) Hallucinations (Describe if present):
9) Delusions:
10) Illusions: None observed.
11) Obsessions/Compulsions:
12) Phobias:
13) Religiosity:
H. Spiritual Assessment
1) Importance of religion/spirituality:
2) Influence of spiritual beliefs on illness, self-care behaviors and treatment:
3) Who or what provides hope?:
I. Cultural Influences
1) What cultural group does client identify with?:
2) Cultural remedies or practices client uses for current condition & efficacy:
3) Alternative or complementary medicines/herbs/practices used regularly:
J. Discharge Needs
1) Housing:
2) Medications:
3) Follow-up (Treatment Program/Support Groups):

Student Name:

Client Initials:
ABNORMAL LABORATORY AND DIAGNOSTIC TEST INTERPRETATION

Lab Test

Client Values
High (H) /
Low(L)

Diagnostic Test

Expected
Values

Result

Significance To Client Care

(Cause/Etiology of Lab Value)

Significance to Client
Care

Appropriate Nursing
Interventions

Appropriate Nursing
Interventions

DRUG EVALUATION GUIDE

Student Name:

Pt. Initials:

Date:

Drug name (Generic and Brand):

Classification:
Action:
Indications for use:

Prescribed Dose:

Route Prescribed:

24 hour total dose:

Is prescribed dose safe?:

Alternate Routes available:

Major Side Effects and Toxicity:

Nursing Implications (include client assessments and pertinent lab data):

Contraindications and Precautions:

Client Education:

Reason Why This Client Is Taking Medication:

NURSING CARE PLAN FORM

ASSESSMENT DATA FOR NURSING DIAGNOSIS:
NURSING DIAGNOSIS/COLLABORATIVE PROBLEM
DESIRED OUTCOME/GOAL
INTERVENTIONS
NURSING INTERVENTION

RATIONALE (Evidence-Based)

ACTUAL OUTCOME: Met

Explain:

Not Met

EVALUATION (Clients Response)