LIVELIFE HOMECARE

# B6 L19-21 Sto. Rosario Drive Phase1C Pacita1 Sto.Rosario Drive, San Pedro City, Laguna
Visit us at www.livelifehomecare.com
Tel Nos. (02) 80894-50 / (02) 99446-68 / (0908) 8848769

Nurses Daily Psychiatric Assessment Checklist

Patients Name: ______________________________________ Ward No.: __________________

DATE: __/__/__ NOD: _________________________Shift: DATE: __/__/__ NOD: ________________________Shift:

AM AM
Nursing Diagnosis: Nursing Diagnosis:
___________________________________ ___________________________________
A. Conscious Lethargic Unconcious A. Conscious Lethargic Unconcious
B. Ambulatory Semi-Ambulatory Non-Ambulatory B. Ambulatory Semi-Ambulatory Non-Ambulatory
C. Fairly Kempt Unkempt C. Fairly Kempt Unkempt
D. During Instructions: Able to follow Unable to D. During Instructions: Able to follow Unable to
follow follow
E. During Interactions: Responsive Limited E. During Interactions: Responsive Limited
Guarded None Guarded None
F. Speech: Hypoproductive Hyperproductive F. Speech: Hypoproductive Hyperproductive
Normoproductive Normoproductive
G. Eye Contact: Good Poor G. Eye Contact: Good Poor
H. Affect: Euthymic Restricted Flat Blunt Labile H. Affect: Euthymic Restricted Flat Blunt Labile
Inappropriate Inappropriate
I. Behavior: Tranquil Restless Irritable Anxious I. Behavior: Tranquil Restless Irritable Anxious
Preoccupied Preoccupied
Others: Others:
___________________________________ __________________________________
J. Hallucinations: Auditory Visual None J. Hallucinations: Auditory Visual None
Others: Others:
___________________________________ __________________________________
K. Delusions: Specify: ____________________________ K. Delusions: Specify: ____________________________
None None
L. Appetite: Good Fair Poor L. Appetite: Good Fair Poor
M. Nursing Interventions: M. Nursing Interventions:
___ Vital Signs Taken: ___ Vital Signs Taken:
________________________________ ________________________________
___ ADLs Done with Supervision ___ ADLs Done with Supervision
___ Medication Given ___ Medication Given
___ Safety Prioritized ___ Safety Prioritized
___ Increase Fluid Intake ___ Increase Fluid Intake
___ Monitored Suicidal and Homicidal Precaution ___ Monitored Suicidal and Homicidal Precaution
___ Psychoeducation and Health Teaching ___ Psychoeducation and Health Teaching Provided
Provided ___ Monitored Patients Condition and Behavior
___ Monitored Patients Condition and Behavior N. With Somatic Complains None
N. With Somatic Complains None Remarks:
Remarks: __________________________________________
__________________________________________ __________________________________________________
__________________________________________________ NOD: _____________________________________ Shift:
NOD: ______________________________________ Shift: PM
PM Nursing Diagnosis:
Nursing Diagnosis: ___________________________________
___________________________________ A. Conscious Lethargic Unconcious
A. Conscious Lethargic Unconcious B. Ambulatory Semi-Ambulatory Non-Ambulatory
B. Ambulatory Semi-Ambulatory Non-Ambulatory C. Fairly Kempt Unkempt
C. Fairly Kempt Unkempt D. During Instructions: Able to follow Unable to
D. During Instructions: Able to follow Unable to follow
follow E. During Interactions: Responsive Limited
E. During Interactions: Responsive Limited Guarded None
Guarded None F. Speech: Hypoproductive Hyperproductive
F. Speech: Hypoproductive Hyperproductive Normoproductive
Normoproductive G. Eye Contact: Good Poor
G. Eye Contact: Good Poor H. Affect: Euthymic Restricted Flat Blunt Labile
H. Affect: Euthymic Restricted Flat Blunt Labile Inappropriate
Inappropriate I. Behavior: Tranquil Restless Irritable Anxious
I. Behavior: Tranquil Restless Irritable Anxious Preoccupied
Preoccupied Others:
Others: __________________________________
___________________________________ J. Hallucinations: Auditory Visual None
J. Hallucinations: Auditory Visual None Others:
Others: __________________________________
___________________________________ K. Delusions: Specify: ____________________________
K. Delusions: Specify: ____________________________ None
None L. Appetite: Good Fair Poor
L. Appetite: Good Fair Poor M. Sleeping Pattern:
M. Sleeping Pattern: 8pm 9pm 10pm 11pm 12am 1am 2am 3am
8pm 9pm 10pm 11pm 12am 1am 2am 3am 4am 5am
4am 5am Remarks:
Remarks: __________________________________________
__________________________________________ __________________________________________________
__________________________________________________