RELATED LEARNING EXPERIENCE

NURSING CARE MANAGEMENT 117 (NRSG 317b) CARE OF CLIENTS

WITH MALADAPTIVE PATTERNS OF BEHAVIOR, ACUTE AND CHRONIC

COURSE DESCRIPTION:
The course is designed to provide students a comprehensive foundation for the practice of mental
health or psychiatric nursing into a wholistic approach that addressed the five dimensions of the person
as an organizing framework for the nursing process. The RLE provide the students with activities to
develop (SKA) skills, knowledge and attitude and values on health promotion and identification and
management of risk factors. Students will be able to provide a meaningful and patient-centered nursing
experience in the clinical area necessary for the understanding of the patient’s behaviour and for
meeting his various needs.

Area of Competence: Psychiatric Ward, Rehabilitation Centers

Objectives:

After 3 weeks of clinical affiliation, the student will be able to:

Skills
1. Develop skills on assessing factors that predisposed an individual to an illness at any stage of human
development.
2. Utilize the nursing process for the care and management of a client
3. Provide safe and therapeutic environment for the client.
4. Implement health teachings to help create a therapeutic environment for client, family and group.
5. Communicate effectively with members of health team and other allied professionals.
6. Participate in different therapeutic activities rendered to patients in the ward.

Knowledge
1. Relate psychopathologic changes brought about in the care of the client through the use of selected
theories of personality development and human behaviour.
2. Identify stress and stress provoking factors that would further affect the client, his family and
treatment
3. Analyze the socio-economic, cultural and political factors in relation to the occurrence of illness or
disease
4. Identify components of the nurse-client relationship and its barrier.
5. Assess common behavioural problems that affect health and illness,
6. Explain the drug’s mechanism of action, side effects, adverse reactions and nursing implications.
7. Analyze patient’s behavioural problems in relation to the psychodynamic of human behaviour.

Attitude
1. Appreciate the values in rendering quality nursing care to psychiatric patient
2. Assume responsibility for the confidentiality of care
3. Respect the dignity of man
4. Realize the importance of restoring the lost image of God in man
 ACTIVITIES AND CLINICAL GUIDELINES
Clinical Duty

Activity Days 6am to 10am Activity Days 10am to 2pm

shift shift
Worship/Breakfast Mon-Fri 4:30am-5:30am Worship/Breakfast Mon-Fri 6:00am-7:00am
Preconference Mon-Fri 5:30am-5:45am Making of Requirements Mon-Fri 7:00am-8:00am
Departure Mon-Fri 5:45am-6:00am Team Conference Mon-Fri 8:00am-9:00am
Endorsement Mon-Fri 6:00am-6:30am Therapy Practice Mon-Fri 9:00am-9:30am
ADL/Breakfast/ Mon-Fri 6:30am-7:30am Preconference Mon-Fri 9:30am-9:45am
Medications
Morning Stretch Mon-Fri 7:30am-7:45am Departure Mon-Fri 9:45-10:00am
NPI Mon-Fri 7:45am-9:00am Endorsement Mon-Fri 10:00am-10:15am
Group Therapies Mon-Fri 9:00am-9:45am NPI Mon-Fri 10:15am-11:00am
Returning clients to the Mon-Fri 9:45am-10:00am Group Therapies Mon-Fri 11:00am 11:45am
Ward
Post-conference Mon-Fri 10:00am-11:00am Returning of Clients to Mon-Fri 11:45am-12:00pm
the Ward
Home/Lunch Mon-Fri 11:00am-12:00pm Lunch Break Mon-Fri 12:00pm-1:00pm
Siesta Hour Mon-Fri 12:00pm-1:00pm Continue NPI Mon-Fri 1:00pm-1:30pm
Team Conference Mon-Fri 1:00pm-2:00pm Returning Clients to the Mon-Fri 1:30pm-1:45pm
Ward
Making of requirements Mon-Fri 2:00pm-3:00pm Post-conference Mon-Fri 1:45pm-2:30pm
Therapy Practice Mon-Fri 3:00pm-3:30pm Siesta Hour Mon-Fri 2:30pm-3:30pm
CP Visits/ Making of CP Mon-Fri 3:30pm-5:00pm CP Visits/ Making of CP Mon-Fri 3:30pm-5:00pm
Output Output
Free Time Mon-Fri 5:00pm-6:00pm Free Time Mon-Fri 5:00pm-6:00pm
Curfew from the city/ CP Mon-Fri 6:00pm Curfew from the city/ CP Mon-Fri 6:00pm
Visits visits
Worship Mon-Fri 6:00pm-6:30pm Worship Mon-Fri 6:00pm-6:30pm
Dinner Mon-Fri 6:30pm-7:00pm Dinner Mon-Fri 6:30pm-7:00pm
Making of Requirements, Mon-Fri 7:00pm-10:00pm Making of Requirements, Mon-Fri 7:00pm-10:00pm
Case Presentation, Group Case Presentations,
Therapies Group Therapies
Sleep Mon-Fri 10:00pm Sleep Mon-Fri 10:00pm

Note: Except Friday curfew at 5:30pm

First Week: Basic Life Support Training (Tuesday and Wednesday)

Second Week: Educational Tour (Sunday)
Third Week: Culmination/Socialization Day with the Clients (Tuesday)
Preparation for Case Presentation (Wednesday, deadline of
submission for manuscript on or before 5:00pm)
Case Presentation Day (Thursday 8:00am to 5:00pm)
 PSYCHIATRIC NURSING SCHEDULE OF ACTIVITES
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Leaving for Orientation Basic Life Basic Life

Cebu Support Support Duty Duty Rest Day
Training Training

Lecture Return
Demonstration

Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14

Educational Duty Duty Duty Duty Duty Rest Day

Tour

Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21

Duty Duty Duty Preparation Case Free day Rest Day

Culmination/ for Case Presentation Leaving for
Socialization Presentation Iligan
(7:00pm)

Note:
1. Clinical Duty is within three weeks. First day will be orientation and patient loading
2. Sign in and out must be observed during clinical and class hours.
3. No making of requirements during duty hours.
4. All extension duties will be complied in Iligan City
Preconference
1. Time: 5:45 am (6:00 am Shift) and 9:45 am (10:00 am shift)
2. Attire:
a. Complete CHN uniform
b. Prescribe haircut for men
c. Hair for women must be braided with hairnet
d. With nameplate and badge, no nameplate, no duty
e. Must wear long boyleg (Ladies)
3. Attendance
a. Will be checked by the CI
b. Incomplete uniform means extension duty
c. Tardiness will be noted (Refer to the clinical guidelines for the specific consequences)
4. Addendum:
Reminders by CI
Instructions and orientation of therapy by the Group leaders.
Others
Note:
1. Observe proper decorum.
2. Submit an assessment tool after the preconference.
3. Refer to RLE program for therapy assessment format.
Duty Time
1. Observe compliance of the daily routine schedule of activities.
2. be responsible with respective patient. Always attend to patient and endorse him/her to a classmate
or to Clinical Instructor if need arises.
3. Giving of food/money to patients is discouraged.
4. Take note of geographic limitations of working area in the ward.
5. Sharp pins, barbecue sticks and other objects should be not given to the patient. Inspect for any of
these materials before leaving them in the ward.
6. Be on guard for cigarette keeping or smoking patient(s), either male or female. Student nurses will be
held responsible for any of these.
7. After activities of daily living (ADL) assist patient in any activity done that day.

Group Activities
1. All patient activity will be initiated, coordinated and led by Group Therapy leaders. An assessment tool
is used for rating any activity. See to it that the tool is handed to the CI.
2. Props and other materials meeded for patient activities should be prepared and ready at the start of
the activity, including the sound system. No group will be allowed to buy from the city or nearby store
anything not available for said activity.
3. Prepare at least 4 – 5 objective to all activities.
4. Ask for the list of names of all therapy participants for that day from the nurse on duty.
5. Delegate to the members the responsibility to gather the participants and to prepare the conference
room.
6. Start and end all activities on time (time limit at most 30-45 minutes for group therapy and 15
minutes for exercise or morning stretch).
7. For hourly checking and close monitoring activity, student will observe patient’s behaviour every 15
and 30 minutes then record.
8. All student nurses are expected to cooperate and participate with their patients in any activity.
9. Outline of therapy must be given to the CI the night before the presentation.
10. The group must practice their presentation (Audition will be a night before).

General Policies of any Activity

1. The therapist should provide nametags for each patient in every activity, so that there would be
proper identification.
2. Activities done should be time-bounded; the therapist should limit the activity to 45 minutes only and
less than 30 minutes so that patients will not get bored after a very long activity. On the other hand, too
short activity will not draw the patient’s full attention.
3. The therapist should instruct the patients to behave properly. They should avoid standing, shouting,
smoking, and most of all listen carefully to maintain order all throughout the activity.
4. The therapist should instruct the patients to raise their right hand if questions and clarifications will
be asked.
5. Before starting any activity, the therapist should introduce himself/herself to the group. Orient the
patient to time, place, day and activity to be done so that they would be guided accordingly.
6. The therapist should ask the patients to give their own guidelines (“lagda”) to be followed throughout
the activity.
7. The therapist should explain properly the procedures and instructions to the patients to facilitate a
systematic and well-oriented activity.
8. After every activity the therapist should let the patient verbalize their feelings to evaluate the effect of
the activity on them.
9. In ending up the session; the therapist should acknowledge patient’s presence and cooperation.
Acknowledgement improve their self-esteem and boost their ego.

Postconference
1. Evaluation of activities led by respective therapist
2. All activities done in the area will be assessed
3. Quizzes
4. Reminders
5. Others

Requirements
1. Process Recording/ Nurse-Patient Interaction (NPI-daily))
2. Nursing Care Plan (weekly)
3. Mini-Mental Status Examination (daily)
4. Comprehensive Mental Status Examination (weekly)
5. Reflection Journal (weekly)
6. Annotated Readings (weekly)
7. Group Therapy (by group-weekly)
8. Peer Assessment (every after group therapy)

MINI MENTAL STATUS EXAMINATION FORM

Name of Patient: __________________________________________ Date: _____________
DSMR IV TR Diagnosis/Impression: ______________________________________________
Age: ____ Gender: ______ Civil Status: _____ Attending Physician: ____________________

Areas of Mental Function Maximum Actual Evaluation Activity

Evaluated Score Score
Orientation to Time 3 May ask:
 What day is today?
 What month is it today?
 What year is today?
Orientation to Place 1 May ask:
 Where are you now?
Attention and Immediate 3 May ask:
Recall  Repeat these words now, bell,
book, and candle (1 point per word)
 Remember the words and I will ask
you to repeat them in few minutes
Abstract Thinking 3 May ask:
a. What does the saying “No use
of crying over spilled milk”?
Recent Memory 3 May ask:
 b. Say three words I asked you to
remember earlier
Naming Objects 2 Point to any object example “eyeglasses”
and ask what is this? Repeat with other
item. (2 points possible)
Ability to follow simple 2 May ask:
verbal commands c. Tear this paper in one half and
throw it in the trash can
Ability to follow simple 2 Write a command on a piece of paper (e.g.
written commands Touch your nose), give the paper to the
patient and say “Do what it says on this
paper. (1 point for correct action)
Ability to use language 3 Ask the patient to write a sentence (3
correctly points if sentence has a subject, a verb,
and has a valid meaning)
Ability to concentrate 4 “Say the month of the year in reverse,
starting with December.” (1 point each for
every correct answers from November
through August, 4 points possible)
Understanding spatial 5 Draw a clock; put in all the numbers; and
relationships set the hands on 3 o’clock. (clock circle- 1
point; numbers in correct sequence- 1
point; numbers placed on clock correctly- 1
point; two hands on the clock- 1 point
hands set at correct time- 1 point) (5
points possible)
Total Score

Scoring: 21-30 – normal; 11-20 – mild cognitive impairment; 0-10 – severe cognitive impairment

Assessed by: _____________________________ Date: _____________ Time: ____________

COMPREHENSIVE MENTAL STATUS

EXAMINATION

Patient’s Name: ______________________________________ Date: _____________

Age: _____ Gender: _____ Status: _________
DSMR IV TR Diagnosis/Impression: ___________________________________________
Attending Physician: ________________________________ Ward: ________________
I. Presentation
A. General Appearance
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

B. General Mobility
a. Posture and Gait:

b. Activity
i. Normoactive
ii. Psychomotor Retardation
iii. Hyperactive
iv. Agitated

c. Behavior
Friendly Impulsive Angry Embarrassed Negativistic

Evasive Seclusive Indifferent Withdrawn

d. Nurse Patient Interaction

Cooperative

Uncooperative
Initially All Throughout

e. Quality
Warm Distant Hostile Suspicious
Talkative Dependent
Others: ____________________________________________

C. Speech Patterns

a. Character
Spontaneous Deliberate Pressured Blocking

b. Organization of Talk
Relevant Loose Association Tangentiality Irrelevant
Flight of Ideas Neologism Others: ___________________

c. Accessibility
 Good Self Absorbed Defensive Fair
Mute Inaccessible

D. Emotional State and Reaction

1. Mood
Euthymic Depressed Euphoric Labile Irritable
Guilty Anxious Fearful Sad Despairing

2. Affect
Appropriate Inappropriate

3. Quality
Flat Blunt Restricted Labile

4. Rate of Mood (1-10) _________

5. Describe: _________________________________________________________
____________________________________________________________________
____________________________________________________________________

E. Thought Content

 Central Theme; What is important to the client?

________________________________________________________________________
__________________________________________________________________

 Self-Concept; How does the client view himself or herself?

_____________________________________________________________________
_____________________________________________________________________

 Delusion?
Type: ________________________________________________________________
_____________________________________________________________________

 Suicidal or Homicidal Ideas

_____________________________________________________________________
_____________________________________________________________________

 Preoccupation and Rumination

_____________________________________________________________________

_____________________________________________________________________
  Obsessions/Paranoia/Phobias/Ritual
_____________________________________________________________________
_____________________________________________________________________

 Perceptual Disturbances
i. Hallucinations: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
ii. Depersonalizations or Derealizations: ____________________________________
_____________________________________________________________________
iii. Illusions: ___________________________________________________________
iv. Others: ____________________________________________________________
F. Neurovegetative Functions

a. Sleep

Normal Insomnia Hypersomnia

b. Appetite: ___________________________________________________________

c. Diurnal Variation: ____________________________________________________

d. Weight: ___________________________________________________________

e. Libido: ____________________________________________________________

G. General Sensorium and Intellectual Status

A. Orientation
i. Time: __________________________________________________________
ii. Person: ________________________________________________________
iii. Place: _________________________________________________________
iv. Level of Consciousness: ___________________________________________
_________________________________________________________________
v. Calculation: _____________________________________________________
_________________________________________________________________
vi. Concentration: __________________________________________________
_________________________________________________________________
vii. General Information: _____________________________________________
_________________________________________________________________
viii. Abstract Thinking: _______________________________________________
__________________________________________________________________
__________________________________________________________________
ix. Judgment: _______________________________________________________
__________________________________________________________________
__________________________________________________________________
x. Memory:
1. Immediate: ___________________________________________________
_______________________________________________________________
2. Recent: ______________________________________________________
_______________________________________________________________
3. Remote: ______________________________________________________
_______________________________________________________________
xi. Insight: _________________________________________________________
__________________________________________________________________
xii. Adaptive Use of Coping/Ego Mechanisms: ____________________________
__________________________________________________________________
__________________________________________________________________

Assessed by: ___________________________________ Date: ___________ Time: _________

THERAPY FORMAT

THERAPY: ____________________________ DATE CONDUCTED: ________________

GROUP NUMBER: _____________________ PLACE CONDUCTED: ________________
Objectives Time Materials Outline Resource Evaluation
Allotted Needed Mechanics person
Note: CI must check this form a night before therapy. Students must make the activity
interesting. Allow creativity artistic prowess, and resourcefulness to come in to play. Reserve
more icebreakers and games just in case needs one

PSYCHIATRIC NURSING PROCESS RECORDING/ NURSE

PATIENT INTERACTION (NPI) FORMAT
Client’s Initial:
Age:
Diagnosis:
Physician:

I. OBJECTIVES (Patient Centered)

General Objectives: (formulate 1 objective for the whole exposure. E.g. Within 3 weeks…)

Specific Objectives: (formulate 5 objectives)

II. TIME AND SETTING

Time of interaction:
Description of the environment:

III. APPEARANCE OF THE CLIENT

Verbal communication
Non-verbal communication

IV. EVALUATION OF INTERACTION

V. NURSE –PATIENT-INTERACTION

Student Nurse Client Analysis and Documentation

Verbal and non-verbal Verbal and non-verbal Personal Analysis/
communication communication Therapeutic Communication
Technique
VI. EVALUATION OF OBJECTIVES
General Objectives
Specific Objectives

Note:
 Should be recorded daily
 Monday and Tuesday NPI will be submitted Wednesday during Preconference
 Wednesday and Thursday NPI will be submitted Friday during Preconference
 PSYCHIATRIC-MENTAL HEALTH NURSING
CARE PLAN FORMAT

Cues Nursing Interventions Rationale Evaluation

Outcomes
Subjective: Short Term Nurse Patient
Goals: Relationship
(Independent)

Objective: Long Term Milieu Management:

Goals: (Dependent)

Psychopharmacology
Theory: (Collaborative)
 PSYCHIATRIC NURSING STUDY FORMAT

I. INTRODUCTION

II. OBJECTIVES

III. INFORMANT
Name, relationship to the patient, intimacy, and length of acquaintance. Interviewer’s
impression of informant’s reliability. What place or situation does the current interview took
place and whether the current disorder is the first episode of that type for that patient. Sources
of interview took place, the sources of information.
A. ANAMNESIS: (past personal history) History of the patient’s life from infancy to the present
to the extent that can be recalled, gaps in history as spontaneously related by the patient,
emotions associated with these life periods- pain, stressful, and conflictual. Each health history
and developmental milestone. Anchor these theories.
a. Prenatal/Perinatal History
b. Infancy
c. Toddler
d. Preschooler
e. School Age
f. Adolescent: social, relationships, school history, cognitive and motor development, emotional
and physical problems and sexuality
g. Early Adulthood
h. Middle Adulthood
i. Late Adulthood: occupational history, marital relationship history, education history, religion,
social activity, current living situation, legal history
B. ONSENT OR HISTORY OF PRESENT ILLNESS: A comprehensive and Chronological picture
of the events leading up to the current moment in the patient’s life or background and
development of the symptoms or behavioral changes culminating in the patient’s life activities
and personal relations – changes in personality, memory, speech, psychological symptoms.
a. What was the onset of the current episode?
b. What were the immediate precipitating event events or that triggers?
c. Why did the patient come to the doctor at this time?
d. What were the patient’s life circumstances at the onset of the symptoms or behavioral
changes?
e. How did they affect the patient so that the presenting disorder manifest?
f. The evolution of the patient’s symptoms should be determined and summarized in an
organized and systematic way. Symptoms not present should also be delineated.
g. What past precipitating events was part of the chain leading up to the immediate events?
h. In what way has the patient’s illness affected his/her life activities (Work, Relationships)?
i. What is the nature of the dysfunction (changes in personality, memory, speech)?
j. Are there psychological? If so, they should be described in terms of location, intensity and
fluctuation. If there is no relationship between physical and psychological symptoms it should
be noted.
k. A description of the patient’s current anxieties, whether they are generalized and non-
specific (free floating) are specifically related to particular situations.
l. How does the patient handle those anxieties?
m. How did this all begin?
C. HISTORY OF PAST ILLNESS: Emotional or mental disturbances, psychosomatic disorders,
mental conditions and neurological disorder.
If the symptoms extent of incapacity, type of treatment received, name of hospital, length of
each illness, effects of prior treatment and degree of compliance should be explored and
recorded chronologically.
 Pertinent childhood illness or facts concerning growth and development.
 In chronological order; operations, other hospitalizations, significant injuries, and significant
illnesses not resulting to hospitalizations.
 Specific injury should be made concerning head injury and neurological illness.
D. GENOGRAM AND FAMILY HISTORY: Elicited from patient and from someone else
because quite different descriptions may be given of the same people and events; ethnic,
national and religious traditions; other people in the home, description of them – personality
and intelligence and what become of them since the patient’s childhood; descriptions of
different households live in; present relationship between patient and other people who were
in the family; role of illness in the family; history of mental illness and treatment.
Family history of medical, neurological, psychiatric and substance abuse.
Family history: Details of parents’ siblings; details of family psychiatric illness or other medical
conditions e.g. epilepsy, delinquency, alcoholism, drug use, suicide or attempted suicide. This
should be in particular focus on the atmosphere in childhood and any early stresses, including
death and separation.
1. Is there a family history of alcohol and other substance abuse or antisocial behavior?
2. Provide description of personalities and the intelligence of the various people living in them
patient’s home from childhood to the present and description of the various household lived in.
3. Define the role of each person has played in the patient’s upbringing and the current
relationship with the patient.
4. What have been the family ethnic, national and religious traditions?
5. Family’s attitude towards the patient and insight of the patient’s illness
6. Does the patient feel that the family members are supportive, indifferent or destructive?
7. What is the role of the illness in the family?
8. What are the patient’s attitude toward her/his parents and siblings?
9. Ask the patient to describe each member of the family.
10. What does the patient mention first?
11. Whom does the patient leave out?
12. What does each of the parents do for a living?
13. What do the siblings do?
14. How does that compare with that the patient is currently doing and does the patient feel
about it?
15. Whom does the patient feel he/she is most like in the family?
IV. PSYCHODYNAMIC FOMULATION
(With documentation) Causes of the patient’s psychodynamic breakdown, influences in the
patient’s life that contributed to the present illness, environmental, genetic and personality
factors relevant in determining patient’s symptoms, primary and secondary gains, outline of the
major defense mechanism used by the patient.
V. PROGRESS NOTES
VI. A. MENTAL STATUS ASSESSMENT (refer to Mental Health Manual)
Medicare requires a listing of the five axis for psychiatric patients according to DSM-IV-R. Thus
at the end of the case study restate your assessment in this format (Axis I-V) according to DSM
criteria. If you do not make a diagnosis in an axis but may possibly do so in the future, state,
“none formulated” on that axis. Remember, if you happen to state “ruled out” or “deferred”, at
some point during the hospitalization you must go back to the issue and change it from
“deferred” to have a specific diagnosis or “no diagnosis”. Axis I are the Clinical Syndromes. Axis
II are primarily Personality and Developmental Disorders. Axis III are Physical Disorders. Axis IV
are Psychosocial Stressors. Axis V denotes Global Assessment of Functioning.
B. LABORATORY DATA:
In addition to medical test, one should record the result of any psychometric test.
C. PSYCHOMETRIC AND NEUROPSYCHOLOGICAL TESTS (Test can be done by
psychologist in the hospital)
VII. NURSING CARE PLAN AND TREATMENT PLAN:
Modalities of treatment recommended, role of medication, inpatient or outpatient, treatment,
frequency of sessions, probable duration of therapy, type of psychotherapy, individual, group
or family therapy, symptoms of problems to be treated.
VIII. PROGNOSIS
Opinion as to the probable future course, event and extent and outcome of the illness; goals of
therapy.

Prognosis Documentation
Onset of Illness (if chronic/acute)
Precipitating Factors (if present/absent)
Family Support (if strong/weak/poor/absent)
Depressive feature (if present/absent)
Mood and Affect (if appropriate/
Inappropriate)
Willingness to take medications

Note: Prognosis can be either be Good, Fair, or Poor. Summarize by making a conclusion in the
overall prognosis of the client based on the criteria above. Cite documentation about the
prognosis of the disease according to the book. Write the reference.
IX. RECOMMENDATIONS
A. PATIENT
 B. FAMILY
C. NURSE
D. PHYSICIAN
E. COMMUNITY
X. REFERENCES
XI. APPENDIX
 CASE STUDY FORMAT

Contents:
Title Cover
Table of Contents
The Authors
Acknowledgment
Dedication
Objectives of the Study
 Patient Centered
 Student Centered
Introduction
Definition of the Case, Types, History, Etiology, Epidemiology, Prevalence (Global and
National), Recent Studies and Findings
Chapter I: Assessment
A. Psychiatric Nursing History
a. Vital Information
b. Informants
c. Chief Complaints
d. Personal Identification
e. History of Present Illness
f. History of Past Illness
g. Allergies
h. Medication and Drug Study
i. Family History
j. Personality
k. Psychosexual History
l. Current Social Situation
m. Assets
n. Dreams, Fantasies and Value System
B. Anamnesis
C. Genogram
D. Mini Mental Status Examination (Include daily MMSE and compare for each day)
E. Mental Status Examination (Include weekly MSE and compare for each week)
F. Physical Assessment (Perform it weekly)
G. Spiritual Assessment
H. Diagnostic Studies (From admission until the week of care)
I. Nurses Progress Notes (From orientation phase until termination phase)
Chapter II: Diagnosis and Analysis
A. Psychodynamics
B. Psychodynamics Concept Map
C. Life Chart (refer to sample given)
 D. Diagnostic and Statistical Manual of Mental Disorder
Chapter III: Planning and Implementation
A. Nursing Care Plan
B. Psychotherapies
C. Nurse Process Recording (NPI only the significant interaction)
Chapter IV: Psychopharmacology
Chapter V: Discharge Plan (M.E.T.H.O.D.S.)
Chapter VI: Evaluation (Prognosis and Recommendations)
Appendices (Pictures, Letters, etc)
Glossary
Bibliography
 Make a scrapbook

Note:
 Chief Complaint: Exactly why the patient came to the psychiatrist, preferably in the
patient’s own words; If this information does not come from the patient, note who
supplied it. The patient’s explanation, regardless of how bizarre or irrelevant it should
be recorded verbatim in the section of the chief complaint.
 Personal Identification: brief, non-technical description of the patient’s appearance and
behavior as a novelist may write
 Personality: the patient’s illness and attitudes and beliefs, moral values, standards and
reaction to stress
 Psychosexual History: e.g. how the patient acquired sexual information, varieties and
frequency of sexual practice and fantasy, marital history with details of engagement,
marriage and pregnancies and their outcome. In females there should be careful inquiry
about psychiatric disturbance during and after pregnancy.
 Current Social Situation: where does the patient live – neighborhood and particular
residence of the patient; is home crowded; privacy of family members from each other
and from other families; sources of family income and difficulties obtaining it; who is
caring for the children.
Biological father/mother/brothers/sisters; state their age, health, education, occupations,
psychological functioning and job history. Please include the adaptive or step parents and
others. Upbringing (family constellation, socioeconomic status, religion). School and
occupational history (grade completed and age stopped, for what reason, ability, performance
and behavior in school). Type of work and job, and its history. Sexual and marital history (details
of not only sexual experience, but also of the family dynamics and patient’s may be of
importance. Premorbid personality of patient before the onset of an acute psychiatric illness.
Describe briefly his premorbid activities, interest, general mood and social patterns.
 Assets: Medicare requires statements regarding the patient’s assets. Briefly mention
patient’s attributes such as talents, compliance, supportive people in the patient’s life,
insurance status, education and job status, housing wealth that may contribute to the
patient’s treatment.
 Dreams, Fantasies and Value Systems: If patient has nightmares, what are their
repetitive themes? Can a patient describe a recent dream and discuss its possible
 meanings? Fantasies and daydreams are another value source of unconscious material.
What are the patient’s fantasies about the future? If the patient could make any change
in his or her life, what would it be? What are the patient’s most common favorite
current fantasies? Does the patient experience daydreams? Are the patient’s fantasies
grounded in reality or is the patient unable to tell the difference between fantasy and
reality? Ask the patient’s system of values both social and moral, including values that
concerns work, money, play, children, parents, friends, sex, community concerns and
cultural issues. For instance, are children seen as a burden or a joy? Is work experienced
as a necessary evil, an avoidable chore or an opportunity? What is the patient’s concept
between right and wrong?
 Spiritual Assessment: Ask the patient; what importance does religion or spirituality have
in your life? Do your religious or spiritual beliefs influence the way you take care of
yourself or illness? How? Who or what supplies you with hope?
 Cultural Assessment: Ask the patient; with what cultural group do you identify? Have
you tried any cultural remedies or practices for your condition? If so, what do you use
any alternative or complimentary medicine/herbs or any practices?

PSYCHIATRIC NURSING COMPETENCY

ASSESSMENT
I. KNOWLEDGE
A. Relate Psychopathophysiology changes brought about to the care of the client through the
use of selected theories of personality development and human behavior.
B. Identify stress and stress provoking factors that would further affect the client, his family
and treatment.
C. Analyze the socioeconomic, cultural and political factors in relation to the occurrence of
illness and disease.
D. Identify the components of the nurse-client relationship and its barrier.
E. Assess common behavioral patterns that affect health and illness.
II. ATTITUDE
A. Demonstrate honesty and trustworthiness in all interactions.
B. facilitate development of honesty in others.
C. Consistently on time reporting to duties, in meeting appointments, in submission of
requirements; no absences/tardiness. Takes initiative to help others to be on time.
D. Criticizes constructively and suggest positive methods of action.
E. Uses time for benefit of the client
F. Shows concern and respect for the dignity of the client by:
1. Obtaining consent before doing procedure
2. Involving the clients and SO in decision-making in the plan of care.
3. Providing confidentiality in shared informatio4. Showing concern for modesty and privacy
in doing procedures.
G. Alert during conferences
H. Flexible, adjust easily to new learning experiences, initiates appropriate change
I. Wears prescribed uniform and well groomed
J. Brings paraphernalia
K. Cooperates and collaborates with peers and health care tram members.
L. Receptive to teaching and constructive criticism.
M. Talks softly, no boisterous laughing.
N. Respects supervisors, clinical instructors, clients and co-students.
O. Exhibits cheerful countenance.
III. SKILLS
A. Develop skills on assessment factors that predisposed an individual to an illness at any
stage of human development.
B. Utilize a nursing process for the care and management a client.
C. Provide safe and therapeutic environment for the client.
D. Implement health teachings to help create a therapeutic environment from client, family
and group
E. Communicate effectively with members of health team and other allied professionals.
F. Participate in different therapeutic activities rendered to patients in the rehabilitation
center.