Develop a relationship with an individual diagnosed with a mental health condition/problem and utilize therapeutic communication and document review to obtain a psychosocial history.

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Mental Health Experience and Data Collection

Objectives

1)     Develop a relationship with an individual diagnosed with a mental health condition/problem and utilize therapeutic communication and document review to obtain a psychosocial history. (Human Flourishing)

2)     Begin to develop connections between a primary mental health diagnosis and the etiologic factors and manifestations of the disease, and collaborative patient management, with emphasis on the role of the nurse. (Nursing Judgment & Spirit of Inquiry)

3)     You will use this assignment as the basis for an assignment in Psychosocial Nursing where you will: Consider future nursing opportunities in relation to clinical findings, including current issues in mental health care and potential applications for advocacy and support related to clients with mental health diagnoses and their families. (Human Flourishing)

Assignment Expectations:

Assessment: (10 points)

Each student will be assigned a patient diagnosed with a mental health condition during their psych rotation. Examples of possible diagnoses are schizophrenia, schizoaffective disorder, bipolar, anxiety, OCD, depression, dementia, PTSD, addiction, and many others. If you are unsure, please verify with your clinical faculty member.

 After your mental health rotation, reflect on your thoughts before and after your clinical day. Was your patient what you expected? Was the facility what you expected? What stood out to you, both positive and negative? What additional resources, treatments, supports, evaluations, etc. do you think would benefit the patient and their family? *These reflections will assist you when you complete your reflection paper in Psychosocial Nursing. (5 points)

  Client Data Collection

Client Initials

 

Date of Birth

 

Psychosocial Medical Diagnosis

 

Behavioral, Cognitive, & Social
Manifestations you observed

 

Patient Medications

 

Relevant Test Results (Labs, imaging, etc.)

 

Priority Psychosocial Nursing Diagnoses x3.

Write 3 separate diagnosis.

(1.5 points)

1.)

 

 

2.)

 

 

3.)

 

 

Patient Goal

(0.5 points)

 

 

Relevant Nursing Interventions x6

(3 points)

1.)

 

2.)

 

3.)

 

4.)

 

5.)

 

6.)