Psychosocial Assessment
Psychosocial Assessment
Patient has a medical diagnosis of Schizophrenia, cannabis abuse and S/P surgery on the left toe.Patient is allergy to penicillin.Past medical history. This is the 4th psychiatric hospitalization at Spring Grove for Mr W.M.Patient is 23 years old who was born in Baltimore, Maryland.Patient has history of assault towards peers and staff when not taking his medication.In the past he has been found Incompetent to Stand Trial and has been subsequently civilly committed from the bench.He is a school dropout in 10th grade as he has difficulty with attention and was involved in fights.He is unmarried and has no children and is currently admitted at Spring Grove Hospital since July 6th 2018.His mother has schizophrenia.He was charged with 2nd degree Assault on June 17th 2018.Also failure to comply with peace order and dangerous weapon with intent to injure.Also history of Alcohol at the age 17 years and Cannabis at the age of 15 years, cigar in December 2017.
Rubric
Psychosocial Assessment (written – Maximum 10 pages including title page,
reference list and appendices). 20%
a. Introduction
In the introduction provide an account of the patient and his/her illness from his/her perspective. Briefly describe how he has dealt with the diagnosis/treatment and how he has lived in the past/ present.
b. Complete a full bio-psychosocial assessment including the mental
status assessment. (See Chapter in Boyd, The Psychiatric Nursing
Process). Include a genogram of family relationships.
c. Present the results of a Mini Mental Status Examination (MMSE) or
any appropriate psychiatric assessment tool (CAGE, MAST, SANS, etc…) conducted during a one-to-one interview with the client.
d. Identify client’s DSM V diagnoses and current treatment including
medication regimen. Describe the observed behaviors that meet the DSM criteria.
e. Identify nursing diagnoses and list in order greatest to least in
priority.
f. Develop a care plan for the top three nursing diagnoses.
g. Perform a literature review that summarizes six to ten references:
etiology, S/S, manifestations of the psychiatric diagnosis and nursing
interventions pertaining to nursing diagnoses. One article should be a meta-analysis pertaining to either nursing or psychiatric
diagnosis/treatment. For all research articles, provide a description of the purpose, sample, methodology, findings, implications for
practice, and author’s (s’) conclusions. State rationale for selecting each article, including a statement of how it applies to patient’s
psychiatric diagnosis, nursing diagnoses and/ or treatment. Cite all references in APA format.
Students are advised to submit the paper to Safe Assign in order to avoid incorrect referencing that violates the University policy on plagiarism and that is subject to receiving zero credit for the assignment which represents 20% of the clinical
