SCHOOL OF NURSING

SCHOOL

OF NURSING




Clinical Packet









Course Title
: Adult Mental Health



Catalog Number
: N
U
R
1
36





Credits
: 4








Clinical












Revised
1
/
11

EAM


2


CLINICAL EXPERIENCES
:
9 hours a week for
½

semester course


4.5 hours a week for full semester courses


Hospital Clinical sessions begin at
the scheduled time.

Since the instructor plans for individual patient care
assignments, it is expected that the student ac
cept responsibility for
notifying the hospital unit or faculty

one
hour prior to the start of clinical

for :


A.

Absence from the clinical

B.

Late arrival at the clinical


Students must be in appropriate street clothes and ready for pre
-
conferences at

the
scheduled time.


Failure in any segment

of the clinical area may result in failure of the course.


DRESS CODE

All students in the nursing program are expected to behave and dress in an appropriate and professional manner.
During the Mental Health Rotation

white uniforms are not required
.


Professional Dress Code:

1.

Name pin
: white letters on blue background
:

Jane B
rown, SCCC Nursing Student.

This must be worn every clinical.


2.

Appropriate Attire: Casual business.

Clean and neat clothing. Low
-
heeled shoes.

Sweaters or blazer jackets may be worn.

Do not wear jeans, sweat pants, scrubs,

sneakers, high
-
heels, open toe or

suggestive or

revealing clothing
.

No anterior or posterior cleavage!


3.

Jewelr
y

:

L
imited to wedding band,

wristwatch

and single pair of smal
l button
-
type earrings.

Body pierced jewelry, with the exception of earrings, cannot be worn on the clinical unit.


Neck chains should be worn inside uniform, or clothing.



4.

Grooming:


Hair should be neat, off the face and collar, secured or up in back
.


Hair ornaments/barrettes and make
-
up should be conservative.



No artificial nails and natural n
ails must be kept short with
out polish.


Tattoos should be discreetly covered with clothing.


No perfume or gum chewing will be allowed i
n the clinical setting.



When you are representing the school and do not have to wear a uniform, students must wear
professional
—
looking clothing with their student nurse name pin. Students who do not adhere to the
dress code, will
receive a clinical war
ning. Any student se
nt home
due to inappropriate dress will also
receive a clinical absence
and will not be able to participate in clinical until compliance is achieved.









3




SUFFOLK COUNTY COMMUNITY COLLEGE

School of Nursing


STUDENT RESPONSIBILITY
FOR SAFE CLINICAL PRACTICE

Guidelines In Determining Student Clinical Grade


The clinical component of each nursing course provides nursing students with the opportunity to apply nursing
principles in a practice setting. This is an essential skill for ever
y competent practitioner of nursing.


The four overriding criteria for a satisfactory passing grade in the clinical area are:


1.

Using the steps of the nursing process for scientific problem solving.

2.

Maintaining medical and surgical asepsis.

3.

Maintai
ning physical safety.

4.

Maintaining psychological safety.


The critical behavior for evaluating student performance is the student’s

ability to make clinical

decisions for
safe patient care
. Such decision making reflects the ability of nursing students to

apply nursing principles in a
variety of situations. Meeting these criteria constitutes competent performance and a satisfactory passing grade.


When a student jeopardizes patient care by violating one of these principles, it shall constitute a failure
fo
r that clinical day.* A student fails a course when repeated failures occur. The specific standard for
failure in each course is:


1.

NUR101

Three (3)

failed clinical days.

5.


NUR246

Two (2) failed clinical days.

2.

NUR124

Two (2)


failed
clinical days.


6.


NUR248

Two (2) failed clinical days.

3.

NUR133

Two (2)


failed clinical days.


7.


NUR240

Two (2) failed clinical days.

4.

NUR136

Two (2)


failed clinical days.


*Please note that a failed clinical evaluation will constitu
te a failed clinical day.


Student’s responsibilities in this situation include:


1.

Taking responsibility for one’s own actions.

2.

Identify own error. Ask for assistance.



3. Develop and utilize strategies to assist in clinical decision maki
ng.



4. Please refer to document entitled "
Guidelines for student written report for student


incident resulting in student warning or failed clinical day
".


Faculty responsibilities in this situation include:


1.

Counseling t
he student.

2.

Providing a written notification regarding the failure.

3.

Provide recommendations for corrective action.



4

SUFFOLK COUNTY COMMUNITY COLLEGE

School of Nursing


GUIDELINES FOR STUDENT WRITTEN REPORT OF CLINICAL INCIDENT

RESULTING IN CLINICAL
WARNING OR FAILED CLINICAL DAY


Explanation


This is an additional assignment that is given when the faculty identifies student decisions and/or actions that
fail to meet the course objectives or standards of nursing practice during a given clinical class.

The assignment
is made in the spirit of student
-
centered learning and continued professional development. It provides a
framework that assists the student to analyze clinical events, to consult the nursing literature, and to plan future
nursing goals for
themselves that are in keeping with professional standards.


Instructions to Faculty


The student’s written report should be submitted on the clinical day following the critical incident. The faculty
must discuss the critical incident with the student bef
ore making this assignment. The completion of the written
assignment provides tangible evidence of the student’s perspective regarding the incident. Further discussion
with the student or further action may/may not be necessary depending upon the insight
demonstrated in the
written report as well as the student’s subsequent clinical practice.


Instructions to Students


1.

Provide a written report of the critical incident to the clinical instructor.

2.

The report is due on the next clinical day following th
e critical incident.

3.

The report should consist of your answers to three basic questions.



A.

What happened?



Describe the details of the incident.



What were your nursing actions? What was the patient’s response?



What were the

actual
and

the p
otential consequences for the patient?



Include any and all details

you deem pertinent.



B.

What should have happened?



Based upon your meeting with your clinical instructor after the incident, and based




upon the research you have do
ne since the incident, what should have happened in




this clinical circumstances?



C.

What Nursing Practices will you implement in the future to prevent the



recurrence of similar incidents?


4.

The report should include a bibliography of at least on
e pertinent nursing reference.



5

SCHOOL OF NURSING


STUDENT RESPONSIBILITY FOR SAFE CLINICAL PRACTICE

REPORT OF FAILED CLINICAL DAY


Learning Activities


1.

Utilize the nursing practice lab to simulate:

a.

Practice independently to become familiar with:


b.

Arrang
e an appointment with a nursing faculty member for supervised practice of this skill.


c.

Demonstrate competency in __________________________________ in clinical area.


2.

View video tapes on the following topics:

And/or complete the following Computer Assisted

Instructional (CAI) programs:





3.

Discuss the principles of the above video tapes/CAI with assigned clinical instructor.


4.

Review text material on the following topics:




5.

Apply this knowledge and these skills in the clinical setting.


CONCLUSION: Student
must successfully complete all the recommendations of this learning guide in order to
progress in the Nursing program. The student agrees to provide the faculty with a written summary of the
specified learning activities he/she has completed by __________
___________. (date)


Student Signature:________________________________________ Date_________________

Student Comments:




Faculty Signature:________________________________________ Date__________________

Faculty Comments:




Note: The clinical faculty mem
ber is responsible to distribute three copies of this report as follows:

Student, Clinical Faculty and student file by way of the Course Lecturer and the Academic Chair/Assistant Chair

FFL/ds











Rev 6/07



6


SUFFOLK COUNTY COMMUNITY COLLEGE

School of
Nursing


Clinical Skills Policy



Students are responsible for all skills taught throughout the
program.

Students are responsible to independently practice in the
nursing lab during their out
-
of
-
class time in order to gain skill proficiency.


Students can

make an appointment with the Professional Assistant in
the nursing lab for additional practice.




















7




SUFFOLK COUNTY COMMUNITY COLLEGE

SCHOOL OF NURSING

NUR

13
6 CLINICAL ASSIGNMENTS




STUDENT'S NAME ________________________________________
______________



ASSIGNMENTS

DUE DATE


1.
REFLECTIVE JOURNALS (2)


a. Initial


b. Final



2.
P
ROCESS RECORDING to include:


a.
Documen
tation of a 30 minute interaction


b. Identify verbal & non
-
verbal behavior


b.
Identify

therapeutic communication techniques


c.

Ego defense mechanisms


d.

Evaluate performance





3.
NURSING CARE PLAN to include:


a. Daily Nursing Process Plan


b. Nursing Assessment Form


c. Medication Sheets


d. Lab/Diagno
stic Tests Evaluation


e. One professional journal summary


f. Reference list (APA format)



4. STRESS INVENTORY & LOG ENTRY (3)


a. Complete
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Each assignment has specific

criteria delineated which must be followed. Students
must

satisfy
every one of
the criterion
in order to
pass

the required papers.

Attach a blank copy of the
appropriate criteria

when you
submit your assignment.

All assignments must be

submitted

on the d
esignated date by their instructor.


8



9

DETAILED DESCRIPTION

OF ASSIGNMENTS


1. Two Journals


An initial reflection that includes one’s personal objectives, strengths and concerns for this clinical rotation. A
final cumulative perception that summarizes one’
s experience

and indicates if personal objectives were met
.


2. One Process Recording


A

learning method for developing communication as a therapeutic tool. The student is to
document

a 30
-
minute
interaction between a client and themselves. Verbal communic
ation is recorded verbatim, and non
-
verbal
comm
unication is described on process recording sheets.

The student identifies

ego defense mechanisms used
by the client and therapeutic/non
-
therapeutic
communication technique
s

used

by the student

and evaluates

the
effectiveness of the technique.

See process recording sample towards end of packet.


3. One
Nursing Care Plan
-

Must include the following:

-

A Daily Process
Plan
and completed assessment form

reflecting PMH and current status.


Every clinical day the

students must complete the “Daily Nursing Process Plan & Mental

Status Assessment” for their clients.


-

Medication sheets and lab diagnostic tests
with analysis
are to be included on separate
pages.

-

A

minimum
of three
complete actual
nursing diagnos
es.

Collaborat
ive problems should be included
.


-

O
ne short
-
term and one long
-
term outcome

per nursing diagnosis

-

A
minimum of

five nursing interventions (assessment, teaching and collaboration) per outcome.

-

Scientific rationales for each intervention
.

-

E
valuation
s must
reflect

the patient’s response to each intervention.

-

A professional journal summary.

-

APA reference list.


4
.

Stress Inventory/Stress
Log


A goal of nursing is to facilitate positive client adaptation to life’s stressors. A nurse a
lso functions as a role
model for health promotion. This
activity will

increase your understanding of stress, stress management, health
promotion
–

and the barriers that interfere with behavioral change.


1.

Self
-
administer the “Symptoms of Stress Inventory”

2.

Highlig
ht responses with 3 or 4 rating and a
sses how you react to stres
s.

3.

Document b
iweekly
on the

“
Stress Log
”

-

H
ow you are responding to s
tress in a particular situation

(crying, clenching teeth,

et
c.)

-

Which management techniques you used and their effec
tiveness.

4.

Read “Is Stress interfering with your Life “ (last page of assignment)
.

5.

Submit to clinical instructor :

-

Symptoms of Stres
s

Inventory

-

Four

stress log

entries.

-

A

brief summation

of behavioral changes and any barriers to change you may have encount
ered
.





10

5
. Community
Observation


M
ake one visit to a mental health community program or self
-
help group and

be prepared to discuss the eight
guidelines below in post conference.

Agency selection is to be discussed with th
e clinical instructor prior to
v
isit.

Guidelines for Community Experience Report

1.

What are the goals, purpose and function of the program or support group?

2.

What population does the program or support group serve?

3.

Do the clients feel the program or support group meets their needs?

4.

Describe

how a nurse might refer a client to this program or self
-
help group.

5.

What are the strengths and limitations of the program or support group?

6.

What services could be added?

7.

How is the group funded?

8.

How did this experience help you as a member of the health
team?



6
.

Health Promotion Group


Students should assess the needs of
the clients and create an activity

that will address these needs.
The group
can last between 30 minutes to an hour.
Students may work in groups of 3
-
4 but each student must have a
disti
nctive role.


-

The topic, method of instruction, two objectives, content, activity and evaluation
must be approved



by the clinical instructor prior to presentation.

-

Provide
current, accurate information prese
nted in an interactive format. (games,
drawing, etc).

-

Use a poster to identify the objectives and highlights.

-

Have ample materials/handouts for all participants.

-

Assess environment to insure it can accommodate participants and activity.


-

Provide an opportunity for participants to evalua
te the activity

via a simple 3
-
4 question survey.



7.

Gerontology Assignment

Reminiscence Project
–

Students will interview an elder using the Life Review form and document verbal &
non
-
verbal communication. Students will assess the elder’s life experienc
es, identify their current status and
support system and present a verbal summary.





PLEASE NOTE
: One of

your clinical objectives is to hand in

assignments in on
TIME.

Due dates are determined by clinical instructor. Assignments must be submitted on th
e dates specified by the
instructor. A failing grade will be reco
rded for assignments received after
the designated date.




You
MUST
meet
ALL

clinical objectives in order to pass the course.












11

Name: __________________________

Date: ___________________


Process Recording

The process recording consists of verbatim documentation of an actual 30 minutes of conversation with another
person. The process recording must include identification of all techniques o
f communication used by the
author, as well as an analysis of the effectiveness of the communication process.


Grading Rubric for Process Recording


Standards

Criteria

Outstanding □

Satisfactory □

Unsatisfactory □

Identify therapeutic
communication
tec
hniques.

Correctly identifies each
therapeutic communication
technique used throughout
the entire interaction.

Correctly identifies ¾ of
the therapeutic
communication techniques
used throughout the
interaction.

Incorrectly identifies
communication techniqu
es.

Distinguish between
therapeutic and non
therapeutic
communication
techniques.

Outstanding □

Satisfactory □

Unsatisfactory □

Correctly distinguishes
between therapeutic and
not therapeutic
communication techniques
used throughout the entire
interaction.

Correctly distinguishes
between therapeutic and
non therapeutic
communication t
echniques
¾ of the time.

Incorrectly distinguishes
between therapeutic and not
therapeutic communication
techniques used throughout
the interaction.

Explain the rationale
for the
communication
techniques used.

Outstanding □

Satisfactory □

Unsatisfactory
□

Provides detail rationale
for all techniques used.

Provides detail rationale
for ¾ of the techniques
used.

Unable to provide rationale
for the techniques used.

Analyze barriers
created by the use of
non therapeutic
communication
techniques.

Outstandin
g □

Satisfactory □

Unsatisfactory □

Identifies and analyzes
barriers created by non
therapeutic communication
techniques. Recommends
alternative techniques to
prevent barriers.

Identifies and analyzes
barriers created by non
therapeutic communication
te
chniques.

Unable to identify and
analyze barriers created by
non therapeutic
communication techniques.

Describe the impact
of non verbal cues
on the
communication
process.

Outstanding □

Satisfactory □

Unsatisfactory □

Identifies non verbal cues
and desc
ribes the impact
on the communication
process. Modifies
communication strategies
to facilitate the process.

Identifies non verbal cues
and describes impact on
the communication
process.

Unable to identify non
verbal cues.

Presentation of
written paper.

O
utstanding □

Satisfactory □

Unsatisfactory □

Contains no more than 2
errors in spelling or
grammar, or punctuation.
Appropriate use of
terminology. Ideas are
presented in a clear logical
format.

Contains no more than 5
errors in spelling or
grammar, or

punctuation.
Appropriate use of
terminology. Ideas are
presented in a clear logical
format.

Contains more than 5
spelling, grammatical and
punctuation errors.
Inappropriate use of
terminology. Ideas are not
presented in a clear logical
format making
c
omprehension difficult.


12

SAMPLE PROCESS RECORDING

NURSE VERBAL

(NONVERBAL)

CLIENT VERBAL

(NONERBAL)

NURSE’S THOUGHTS AND
FEELINGS CONCERNING
THE INTERACTION

ANALYSIS OF THE INTERACTION

Do you still have thoughts
about harming yourself?
(Sitting facing t
he client;
looking directly at client)

Not really. I still feel sad, but
I don’t want to die. (Looking
at hands in lap.)

Felt a little uncomfortable.
Always a hard question to ask.

Therapeutic.
Asking a direct question
about suicidal intent.

Tell me w
hat you were feeling
before you took all the pills the
other night. (Still using
SOLER techniques of active
listening.)

I was just so angry! To think
that my husband wants a
divorce now that he has a
good job. I worked hard to
put him through college.
(Fists clenched. Face and
neck reddened.)

Beginning to feel more
comfortable. Client seems
willing to talk and I think she
trusts me.

Therapeutic.

Exploring. Delving further
into the experience.

You wanted to hurt him
because you felt betrayed.
(SOL
ER)

Yes! If I died, maybe he’d
realize that he loved me more
than that other woman. (Tears
starting to well up in her
eyes.)

Starting to feel sorry for her.

Therapeutic.

Attempting to translate
words into feelings.

Seems like a pretty drastic way
to g
et your point across.
(Small frown.)

I know. It was a stupid thing
to do. (Wiping eyes.)

Trying hard to remain
objective.

Non therapeutic.

Sounds disapproving.
Better to have pursued her feelings.

How are you feeling about the
situation now? (SOLER)

I don’t know. I still love him.
I want him to come home. I
don’t want him to marry her.
(Starting to cry again.)

Wishing there was an easy way
to help relieve some of her
pain.

Therapeutic.
Focusing on her feelings.

Yes, I can understand that you
w
ould like things to be the way
they were before. (Offer client
a tissue.)

(Silence. Continues to cry
softly.)

I’m starting to feel some anger
toward her husband.
Sometimes it’s so hard to
remain objective!

Therapeutic.
Conveying empathy.

What do you t
hink are the
chances of your getting back
together? (SOLER)

None. He’s refused marriage
counseling. He’s already
moved in with her. He says
it’s over. (Wipes tears.
Looks directly at nurse.)

Relieved to know that she isn’t
using denial about the real
ity of
the situation.

Therapeutic.
Reflecting. Seeking client’s
perception of the situation.

So how are you preparing to
deal with this inevitable
outcome? (SOLER)

I’m going to do the things we
talked about: join a divorced
women’s support group;
incre
ase my job hours to full
-
time; do some volunteer work;
and call the suicide hot line if
I feel like taking pills again.
(Looks directly at nurse.
Smiles.)

Positive feeling to know that
she remembers what we
discussed earlier and plans to
follow through.

Therapeutic.

Formulating a plan of action.

It won’t be easy. But you have
come a long way, and I feel
you have gained strength in
your ability to cope. (Standing.
Looking at client. Smiling.)

Yes, I know I will have hard
times. But I also know I ha
ve
support, and I want to go on
with my life and be happy
again. (Standing, smiling at
nurse.)

Feeling confident that the
session has gone well; hopeful
that the client will succeed in
what she wants to do with her
life.

Therapeutic.

Presenting reality
.

Table from
–

Townsend, M. (2006), Psychiatric mental health nursing (5
th

ed.). (p. 127). Philadelphia, PA: F.A. Davis

SOLER:

S

–

Sit squarely facing the client. This gives the message that the nurse is there to listen and is interested in what the
client has to say.



O

–

Observe an open posture. Posture is considered “open” when arms and legs remain uncrossed. This suggests that the nurse is
“open” to
what the client has to say. With a “closed” position, the nurse can convey



a somewhat defensive stance, possibly invoking a similar response in the client.


L

–

Lean forward toward the client. This conveys to the client that you are involved in the interaction, interested in what is b
eing said, and
making a sincer
e effort to be attentive.


E

–

Establish eye contact. Eye contact, intermittently directed, is another behavior that conveys the nurse’s involvement and wi
llingness to
listen to what the client has to say. The absence of eye contact or the


constant shifting of eye contact elsewhere in the environment gives the message that the nurse is not really interested in wh
at is being said.



NOTE:
Ensure that eye contact conveys warmth and is accompanied by smiling and intermit
tent nodding of the head, and does not come
across as staring or glaring, which can create intense discomfort in the client.


R

–

Relax. Whether sitting or standing during the interaction, the nurse should communicate a sense of being relaxed

and comfortable with the
client. Restlessness and fidgetiness communicate a lack of interest and may convey a feeling of discomfort that is likely to

be transferred to the client.


Disk#9SDH


13






Suffolk County Community College

NUR 13
6 Mental Health Nursing

Process Recording (PR)


Student Name:


Date & Location:


Client Diagnosis:


History RT Diagnosis;
Onset, Duration & Prior
Treatment:




Nurse Communication

(Verbal & Non Verbal)

Client Communication

(Verbal & Non Verbal)

Nurse’s

Thoughts &
Feelings Related to the
Interaction

Analysis of the Interaction

(Effectiveness, Technique,
Name & Rationale)

Alternate or Revised
Response

1.










2.










3.










4.












14


Nurse Communication

(Verbal & Non Verbal)

Client Communication

(Verbal & Non Verbal)

Nurse’s

Thoughts &
Feelings Related to the
Interaction

Analysis of the Interaction

(Effectiveness, Technique,
Name & Rationale)

Alternate or Revised
Response

5.











6.











7.










8.










9.










10.











Disk#Green

15





SUFFOLK COUNTY COMMUNITY COLLEGE


Process Recording Evaluation


Student Name__________________________________

Date _____________


Patient initials_____


Patient Age______

Patient Hx__________
__________



Patient Diagnosis___________________________________________________


Clearly present the highlights in sequential order of a
30

minute therapeutic communication.



1. What is your impression of the patients’ tone of the communication?



Ide
ntify content, themes and emotions expressed.












2. What is your impression of your performance?





Indicate ability to facilitate communication.












Areas of strengths and areas of desired growth.







Disk#9S



16






















































17





SUFFOLK COUNTY COMMUNITY COLLEGE

DEPARTMENT OF NURSING

DAILY NURSING PROCESS PLAN

N
U
R
1
36

Student Name:



Date of Care _______Patient Initials _______ Room # _______ Chronological Age _________Code Status_________________

Weight

_______ Height _______ Diet __________________Isolation__________________Glasses/Lenses_________________

Hearing Aid______Oriented_________Disoriented________Admitting Diagnosis______________________________________

____________________________________
____________________________________________________________________

Surgical Procedure_________________________________________________________________________________________
PMH/PSH_______________________________________________________________________
_________________________

________________________________________________________________________________________________________

_______________________________________________________________________________________________________
Social History/Family

History________________________________________________________________________________

________________________________________________________________________________________________________


Allergy to drugs, food, or environment ______________________
________________Activity____________________________

Vital signs: T______________(route) Pulse: A_______ R _______ RR _______ B/P ______________________ (L, R)

SaO
2
_______________ Pain Scale:_________

IV ______________________________________________
_____________________( Solution, Rate, Site, Gauge, Date, Time)

Intake __________ Output __________ Tubes/ Drains/Appliances _______________________________________


Assessment Data: Place your initials in the box if the descriptors match your client, o
therwise (*) and write a nurses note.

SAFETY:
Call bell within reach. Bed in low position.
Environment clutter free. Fall precautions:___YES ___NO

Restraints:___YES___NO Suicide Risk___YES___NO


INTEGUMENTARY
: Skin color pink. Skin warm,
d
ry and intact. Mucous membranes pink and moist.
No skin breakdown.


HYGIENE: ___
Complete ___Partial ___Self

ORAL CARE
: ___Complete ___Self




WOUND/INCISION
: No redness or increased
temperature in surrounding tissues. No drainage.
Wound edges well a
pproximated. Sutures/staples/steri
strips intact.


PSYCHOSOCIAL:
Stress:__________________________

Ways of Handling Sress:_____________________________

Emotional Status:___________________________________

Problems Related to Illness/Condition_____________
_____




MUSCULOSKELETAL
: No joint swelling or
tenderness. Full ROJM. No muscle weakness.
Surrounding tissue without inflammation. Steady
balance and gait.


NEUROLOGICAL:
A & O X 3. PERRLA. Appropriate
behaviors. Verbalization clear and understandable. No

dysphasia. Active ROJM all extremities. No numbness or
tingling.




SKIN RISK ASSESSMENT:
2 points for each
positive answer:___poor physical condition,
___inactive, ___lethargic, ___poor nutrition,
___incontinent, __poor mobility (over 6 = risk)


RESPIR
ATORY:

Respirations regular and unlabored. No
SOB. No cough. Nailbeds and mucous membranes pink.
Breath sounds clear bilateral. No dyspnea on exertion. No
nightsweats. O2 therapy: specify_______________________

CDB/IS_______ Suction_________




FALL RI
SK ASSESSMENT:

1 point for each
positive answer: ___confused, ___seizure disorder,
___weak, ___sedated, ___poor judgment, ___poor
sight, ___combative, ___unsteady, ___lang.barrier,
___incontinent, ___poor hearing (over 5 = risk)


CARDIOVASCULAR:
No ches
t pain. Pulse regular. No
edema of extremities. Vital Signs Stable.. Extremities warm.
Brisk capillary refill.




PAIN ASSESSMENT:
Pain Intensity (1
-
10)______

Pain tolerable:___yes, ___no

___alert, ___sedated FLACC Score____


GI:
Abdomen soft, non
-
tend
er. Audible bowel sounds.
Passing flatus. Stools within own normal pattern and
consistency.

Tubes___________________Ostomy__________________


INTRAVENOUS LINES:
IV site is clear, without
redness, swelling or pain. PIV___Date Inserted,
___Tubing Change. Ce
ntral Line___Date Inserted,
___Tubing Change, ___Dsg Change.


GU
: Empties bladder independently and without difficulty.
Urine clear and yellow to amber. Catheter____________

Ostomy_______________________________________




ACTIVITY:
BR, OOB, Dangle, BRP,
Ambulate

Independent____Assist______________________

Sleep Pattern______________________________


NUTRITION
: Diet:_______________________

Appetite:__Good>75% of meal__Fair50
-
75%___Poor <50%

___Self___Assist Diet Supplement___________________


CLIENT ED/
DISCHARGE PLANNING:
___Needs Identified

___Client Education Started


18







DAILY NURSING PROCESS PLAN


Complete Drug


Order

Safe Dose?

Classification

Generic/Trade

Major Therapeutic Effect/


Major Adverse Effect

Nursing Responsibilities














Add additional pages as necessary.


Mental Status Assessment

General Appearance and Behavior: (Grooming; Speech; Motor Activity)


Mood and Affect


Perceptual Disturbances:


Thought Process and Content: (Delusions; Self Harm)


Sensorium and Cogn
ition: (Orientation; Memory; Concentration; Abstract Thinking Ability)


Judgment and Insight


Safety




Add additional pages as necessary with interpretation of abnormal values.


Labs, Diagnostic Tests; Procedures; Treatments; Dressings:





Clie
nt/Family Teaching: (include health education/ prevention based on cognition and culture)





DIAGNOSES/COLLABORATIVE PROBLEMS

Nursing Diagnoses

Interventions


Evaluations












Nursing Note: Consider the Subjective and Objective Data that records the Client’s response to the interventions for the
䅣A畡氠l楡g湯s敳⽃e汬l扯牡t楶攠m牯扬bms E䅤搠A摤楴楯na氠灡g敳⁡s

湥捥ssa特)



19





Student Name _______________________________________ Client Initials ____________



LABORATORY AND DIAGNOSTIC TEST INTERPRETATION



Lab Test

Client Values

High (H) / Low(L)

Ex
pected

Values

Significance To Client Care

Etiology & Appropriate Nursing Interventions



































































Diagnostic Test

Result

Significance to Client Care
























20



















































Suffolk County Community College

School of Nursing

Mental Health Nursing Assessment

21






Client History

I. General History of Client



Initials ________

Age_______

Sex______

Marital Status__________________

Racial and ethnic

data______________________________________________________

Siblings and children (specify 1
st

name, relationship, age)_________________________

________________________________________________________________________

Housing ______________________________
__________________________________

Living Arrangements (Name & relationship)____________________________________

Occupation______________________________________________________________

Education_____________________________________________________________
__

Religious affiliation/beliefs_________________________________________________

II. Chief Complaint

A. State in client’s own words (why he /she is hospitalized or seeking help)
________

_____________________________________________________________________
__

B. Stressors (Specify intensity (1
-
10) & effect)

1. Relationships___________________________________________________________

2. Behavior ______________________________________________________________

3. Perceptions or cognitive abilities _______________
____________________________

4. Other (Work, Finances, etc) _______________________________________________

_______________________________________________________________________


C. Identify feelings: (Describe intensity (1
-
10), frequency & duration)

1.
Anger ________________________________________________________________

2. Anxiety _______________________________________________________________

3. Confusion_____________________________________________________________

4. Depression_______________________
______________________________________

5. Hopelessness___________________________________________________________

6. Powerlessness__________________________________________________________

7. Suspiciousness__________________________________________________
_______

8. Other_________________________________________________________________



22





D. Physical Complaints: (Describe severity, frequency & duration)

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. Special Skills___
________________________________________________________

2. Employed ________ Duration_________ Company____________________________

3. Previous Positions & Reasons for leaving____________________________________

4. Military Service (Combat) _______________
_________________________________

D. Support System

1. Family, friends, colleagues, 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 Medications (Prescribed) currently taking (Dose & Frequency)_______________

________________________________________
_______________________________

2. List herbal or OTC medications_________________________________________
__
_

3. Alcohol & Street Drugs (Type, amount, frequency, duration)___________________

_________________________________________________________________
_____

23





4. Recognize use of drugs as a problem & attempt to stop (Prior Rehab
-

In/Out Pt, 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?______________________________________________

4. What did he/she try this time?_____________________________________________


IV. Fa
mily 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 issues.

1. Family history of violence, physical or emotional abuse.________________________

________________________________________________________________________

2. Family member with physical or mental issues (suicide

or attempt, type, duration, treatment) and
effect on family_______________________________________________
________________

________________________________________________________________________
____

E. Any Unusual or Outstanding event_______________
_____
__________________
_____
_

____________________________________________________________________________



Mental Status Assessment

A. Appearance

24





Dress: Appropriate/Inappropriate_____________________________________________

Grooming: Neat_____________________
_ Poor (Area)__________________________

Physical Handicaps________________________________________________________

B. Behavior

Eye Contact ______________ Facial expressions _______________________________


Posture_________________________________ Gait____
________________________

Level of Activity (Lethargic, Restless, Agitated) ________________________________

Gestures/Mannerisms _____________________________________________________

C. Speech

Clear___________________ Mumbled/Slurred______________ Volume___
_________

Rapid/Pressured____________________ Constant____________________ Silent______

Barriers to communication (ESL, Hearing, delusions, confused, withdrawn or verbose)__

________________________________________________________________________

D. Mood

Client self
-
report & any changes_____________________________________________

E. Affect

Describe what the client conveys (appropriate & congruent with mood?) _____________

________________________________________________________________________

F. Thought

Process

1. Characteristics

Flight of Ideas_______________ Loose Associations_______________ Blocking______

Concrete Thinking________________________ Confabulation_____________________

Describe the client’s responses._______________________________________
_______

________________________________________________________________________

2. Cognitive Ability

Orientation to Person_________________ Place _____________ Time______________

Memory (Recent/Remote)__________________________________________________

Con
centration_____________________ Problem solving__________________________

Concrete_______________ Abstract_______________________ Proverbs ___________



G. Thought Content

1. Themes (Describe what is important to client)_________________________________

25





__
______________________________________________________________________

2. Self Concept: How does client view self?____________________________________

________________________________________________________________________

Any areas of desired change? ___
____________________________________________

3. Judgement____________________________________________________________

4. Insight (Realistic assess situation, symptoms and current condition)._______________

__________________________________________________
______________________

5. Suicidal or homicidal ideation_____________________________________________

Lethality/plan/access_______________________________________________________

6. Preoccupations: Describe Hallucinations___________________________________
__

Delusions_____________________________ Illusions___________________________

Obsessions__________________________Rituals_______________________________
Phobias________________________ 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.____________

________________________________________________________________________

V. Discharge Nee
ds

Housing_________________________________________________________________

Medications______________________________________________________________

Follow
-
up (Community/Treatment Program)_____________________________________




26





















































27










DRUG EVALUATION GUIDE



Name:

___________________________


Pt. Initials:
__________
_Date:
___________
______
__





DRUG NAME:
____________________________________________________________________



Generic Name:
___________
________________________________________________________



Classification:
____________________________________________________________________



Action:
__________________________________________________________________________



Indications for use: ___
____________________________________________________________



Pt.Dose/24 hour total:
__
_________________________________________________________


Ro
u
te Prescribed:
__________
Alternate Routes available: _
__________________
___
____


Major Side Effects and Toxicity:







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







Contraindications and Precautions:






Patient Education:






Reason Why This Patient Is Taking Medication









28






CRITICA
L THINKING RUBRIC TO ANALYZE THE APPLICATION OF

NURSING PROCESS IN STUDENT NURSING CARE PLANS



PURPOSE OF THE RUBRIC


This critical thinking rubric is designed to analyze the application of nursing process in student
nursing care plans and can be used by
both faculty and students.


COMPONENTS OF THE RUBRIC


Each criterion contains performance criteria to demonstrate critical thinking for each step of
the nursing process used in the development of a nursing care plan. The performance criteria
describe beha
viors and traits that are linked to a level of performance. There are four levels of
performance. The levels of performance represent the degrees in which critical thinking is
applied to accomplish the step in care planning. Level one is a beginner leve
l of performance
that reflects an absence of critical thinking whereas level four represents well developed
critical thinking skills that reflect the students ability to perform higher
-
ordered learning.


USING THE RUBRIC


Students


Students can use the rub
ric to facilitate nursing care plan preparation and development. The
emphasis on systematicity and truth seeking behaviors will facilitate college level students
progress in critical thinking skills. Prior to submission for faculty review, the student wi
ll be
able to perform a self
-
assessment to identify levels of performance in each of the steps of
nursing process and identify areas for future development. The student's ability to identify
with level three and level four performances will enhance their
self
-
confidence in the
reasoning abilities and develop their disposition to critical thinking.


Grading of Care Plan:


The care plan is only graded in whole numbers. The minimum acceptable score is 28/40. The
student will be asked to resubmit or remediat
e the care plan if any section on the rubric
receives a score of less than 2. The care plan will be remediated until an acceptable score is
achieved.



Rev. 5/05, 6/07


29






CRITICAL THINKING RUBRIC TO ANALYZE THE APPLICATION OF NURSING
PROCESS IN NURSING CAR
E PLANS



ASSESSMENT FORM


4:

All subjective and objective data is collected and is recorded using the appropriate
terminology.

Any data that is not collected is adequately explained in the blank spaces.
Additional data is collected through the use of i
nquiry flawlessly, applying knowledge about
the individual's disease and the patient's circumstances.


3:

Most subjective and objective data is collected and is recorded using the appropriate
terminology. Any data that that is not collected is adequately
explained in the blank spaces.
Additional data is collected through the use of inquiry most of the time, applying basic
knowledge about the individual's disease and the patient's circumstances.


2:

Some subjective and objective data is collected. Blank s
paces in the form are not explained
adequately. There is incomplete use of inquiry to collect information.


1:

Some subjective and objective data is collected. Blank spaces in the form are not explained.
There is an absence of the use of inquiry to coll
ect information relevant to the individual's
disease and circumstances.



MEDICATION SHEET


4:

All current medications are written on a separate piece of paper or index card and contain the
required information. The information is complete. The student i
dentifies potential problems
and teaching needs individualized to the patient being cared for that is incorporated into the
plan of care.


3:

Most or all current medications are written on a separate piece of paper or index card and
contain most or all of
the required. The information is complete. The student identifies some
potential problems/teaching needs.


2:

Some or all current medications are written on a separate piece of paper or index card and
contain most or all of the required information. The

information is incomplete with some
omissions noted.


1:

Some or all current medications are written on a separate piece of paper or index card and
contain most or all of the required information. The information is incomplete with many
omissions noted.


LAB DATA/DIAGNOSTIC TESTS

30






4:

Pertinent lab data and diagnostic test results are recorded. Analysis of data recorded helps to
confirm, clarify and direct patient care and is incorporated into the plan of care.


3:

Most pertinent lab data and diagnostic
test results are recorded. Some data that is irrelevant
may be recorded but does not negatively impact patient outcome. Most data recorded helps
to confirm, clarify and direct patient care.


2:

Some pertinent lab data and diagnostic test results are reco
rded. Most data that is irrelevant
may be recorded but does not negatively impact patient outcome. Absence of pertinent data
is not explained.


1:

Lab data and diagnostic test results may or may not be recorded. Significant omissions are
noted that coul
d lead to a negative impact on patient outcome.


REFERENCES


4:

References are recorded in the appropriate space. Varied and appropriate references reflect
the student's pursuit of the best knowledge in preparing the plan of care for the patient. APA
for
mat is used to list references.


3:

References are recorded in the appropriate space. References reflect the student's pursuit of
the basic knowledge in preparing the plan of care for the patient.


2:

References are recorded in the appropriate space. Ref
erences reflect the student's inability to
identify resources that can provide the appropriate knowledge to guide the plan of care.


1:

References are recorded in the appropriate space. References are omitted/limited or
irrelevant to aid the student's att
ainment of the appropriate knowledge to guide the plan of
care.

PRIORITIZATION


4:

The nursing diagnoses are evaluated individually and are ranked in priority order to best
reflect the coordination of care appropriate to the patient.


3:

The nursing diagno
ses are evaluated individually and are ranked in

priority order and reflect a


significant amount of coordination of care appropriate to the patient.


2:

The nursing diagnoses are evaluated individually and are ranked in a priority order that
indicates fl
awed decision making.


1:

The nursing diagnoses are evaluated individually against a framework that does not facilitate
prioritization of nursing diagnoses.



DIAGNOSES

31






4:

The nursing diagnoses/collaborative problems selected reflect the accurate interpre
tation of
the subjective and objective data analyzed. Subjective and objective data are listed
appropriately as supporting data for the nursing diagnosis. All nursing diagnoses use
NANDA terminology. All
actual

nursing diagnoses use 3 part statements (P
ES format).
Risk nursing diagnosis use 2 part statements and syndrome diagnoses use 1 part statements.


3:

The nursing diagnoses selected reflect the adequate interpretation of the subjective and
objective data analyzed but are not always the best choice
from the possible diagnoses that
could be interpreted from the data. PES format is used correctly.


2:

The nursing diagnoses selected reflect the inadequate interpretation of the subjective and
objective data analyzed and result in a flawed plan of care.

PES format is not always
complete or used correctly.


1:

The nursing diagnoses selected reflect that no effort to interpret information was applied
resulting in a flawed plan of care. PES format is usually not complete or used correctly.


THE FOLLOWING
CRITERIA ARE SUBSETS OF CRITERIA ESTABLISHED IN THE
NURSING DIAGNOSIS OF THE RUBRIC. IF THE CARE PLAN RECEIVES A SCORE OF
"2" OR BELOW, THE NEXT FOUR CRITERIA (OUTCOME CRITERIA,
INTERVENTIONS, RATIONALE, EVALUATION) SHOULD NOT BE SCORED.



OUTCOME CRITERI
A


4:

Measurable criteria are identified all of the time and contain verb and time element. The
criteria identified generally are individualized to the patient and will lead to the control of the
related factors that contribute to the nursing diagnosis.


3:

Most of the outcome criteria are measurable and are identified to achieve goals will lead to
the resolution or control of the related factors that contribute to the nursing diagnosis.


2:

Some of the outcome criteria are measurable and are identified t
o achieve goals will lead to
the resolution or control of the related factors that contribute to the nursing diagnosis but are
poorly developed.


1:

Some of the outcome criteria identified to achieve goals will lead to the resolution or control
of the rela
ted factors that contribute to the nursing diagnosis purely by coincidence.







INTERVENTIONS

32






4:

Specific interventions can easily be linked to specific outcomes. The interventions are
realistic and appropriate to the patient's current status.


3:

Spec
ific interventions can be linked to specific outcomes. The interventions are realistic and
usually appropriate to the patient's current status.


2:

Interventions developed can be linked to specific outcomes but may be independent. The
interventions may n
ot be realistic and appropriate to the patient's current status.


1:

Interventions developed are incomplete. Inappropriate interventions may be included in the
plan of care.

RATIONALE


4:

Rationales for each intervention contain comprehensive scientific
reasoning that succinctly
identifies why the intervention was selected.


3:

Rationales for each intervention usually explain the intervention adequately and justify its
inclusion.


2:

Rationales for each intervention do not explain the intervention adequat
ely and consequently
its inclusion can not be justified.


1:

Rationales for each intervention when included do not attempt to explain the intervention and
consequently its inclusion can not be justified.

EVALUATION


4:

The appropriate subjective and object
ive data is selected through review of the interventions
related to ongoing assessment. The subjective and objective data that measures the outcome
is collected and analyzed correctly.


3:

The appropriate subjective and objective data is selected most of
the time, through review of
the interventions related to ongoing assessment that reflects adequate analysis.


2:

The appropriate subjective and objective data is selected some of the time, perhaps through
review of the interventions related to ongoing asse
ssment or perhaps the data was collected
coincidentally. Subjective and objective data is collected most of the time, but there appears
to be no pattern to the data collection and it is rarely with consideration of the outcomes that
are required to be mea
sured.


1:

Subjective and objective data is selected to reflect evaluation without consideration of the
outcome criteria. Subjective and objective data may or may not be collected. Data collection
is not subjected to analysis.


Disk#3Anderson

Revised 6/
07


33





ANALYSIS OF APPLICATION OF NURSING PROCESS IN STUDENT NURSING CARE PLANS



STUDENT NAME ______________________________________ COURSE ______________________
____
____

ASSESSMENT DATE _____________________________ FACULTY ASSESSOR
_
______________________
__







SCORE:





PLEASE ENTER THE LEVEL OF PERFORMANCE IDENTIFIED IN THE







RUBRIC FOR EACH CRITERION.


STRENGTHS:




DESCRIBE HOW THE PERFORMANCE WAS OF HIGH QUALITY AND


COMMENDABLE. LABEL THE ASSESSMENT, SELECTING FROM


THE LIST OF CRITICAL TH
INKING SKILLS AND BEHAVIORS,


THAT DESCRIBES THE PERFORMANCE.


AREAS OF IMPROVEMENT:

IDENTIFY CHANGES THAT COULD BE MADE TO IMPROVE









PERFORMANCE IN THE FUTURE EMPHASIZING THE CRITICAL









THINKING BEHAVIORS THAT SHOULD BE DEVELOPED.


INSIGHTS:

REFLECT ON "NURSE KNOWING", "INTUITIONS", AND PERSONAL
EXPERIENCE THAT WILL ENHANCE THE STUDENT UNDERSTANDING

O
F
THE PATIENT SCENARIO AND FACILITATE APPLICATION TO

NEW
CONTEXTS.





Revised 5/05, 6/07




34





PERFORMANCE
CRITERIA

SCORE

STRENGTHS

AREAS

FOR IMPROVEMENT

ASSESSMENT
FORM

Include Daily Nursing
Process Plan with a
Nurse’s Note.










MEDICATION
SHEETS

Including IV
solutions/PRN
medications.









LAB/DIAGNOSTIC
TESTS

Include on Daily Nursing
Process Plan and submit
an additional sheet

with
interpretation.









PRIORITY SHEET

List all relevant
diagnoses from
systematic analysis that
incorporates complete
diagnostic statements in
PES format.









REFERENCE LIST

On a separate piece of
paper in APA format.
Minimum of 4 references
p
lus a summary of an
article from a
professional journal that
is relevant to the client.



























35





PERFORMANCE
CRITERIA

SCORE

STRENGTHS

AREAS FOR IMPROVEMENT

NURSING
DIAGNOSES

List pertinent subjective
and object
ive data as
defining characteristics
to support diagnoses.












OUTCOME
IDENTIFICATION

Include short and long
term measurable goals.















INTERVENTIONS

Must be client specific.












RATIONALE

Scientific rationale for
interventions.
Cite
sources in APA format.






EVALUATION

Explain why goals were
met/unmet. Include
specific data on
effectiveness of
interventions.






TOTAL SCORE: __________ INSIGHTS:


36






37







SYMPTOMS OF STRESS INVENTORY



A SELF ASSESSMENT







This questionn
aire measures the different ways people respond to stressful


situations. Included are sets of questions regarding typical physical,


psychological and behavioral responses. We are interested in the frequency



with which you experienced these stress
-
related symptoms during the past week.





CHECK ONE:


[ ] Screen [ ] Exit





[ ] 6 Month [ ] 1 Year FU



STRESS MANAGEMENT CLINIC

DEPARTMENT OF PSYCHOSOCIAL AND COMMUNITY HEALTH

UNIVERSITY OF WASHINGTON

SEATTLE, WASHINGTON 98195
-
7263











38








PLEASE CIRCLE THE MOST APPROPRIAT
E RESPONSE TO EACH QUESTION.


0 = Never














1 = Infrequently

SOMETIMES PEOPLE UNDER STRESS EXPERIENCE






2 = Sometimes

A VARIETY OF PHYSICAL RESPONSES. DURING






3 = Often

THE DESIGNATED PERIOD HAVE YOU BEEN






4 = Very Frequ
ently

BOTHERED BY:





1, Flushing of your face …..........................................


0

1

2

3

4





2, Sweating excessively even in cold weather ….......


0

1

2

3

4





3. Severe itching …......................................
................


0

1

2

3

4






4. Skin rashes …..........................................................


0

1

2

3

4





5. Breaking out in cold sweats …...............................


0

1

2

3

4
.





6. Cold hands or feet …..............
................................


0

1

2

3

4





7. Hot or cold spells …................................................


0

1

2

3

4


HAVE YOU NOTICED ANY OF THE FOLLOWING

SYMPTOMS WHEN NOT EXERCISING:



8. Pains in your heart or chest …...............
...............


0

1

2

3

4



9. Thumping of your heart …....................................


0

1

2

3

4



10. Rapid or racing heart beats …...............................


0

1

2

3

4



11. Irregular heart beats …...............
...........................


0

1

2

3

4



12. Rapid breathing ….................................................


0

1

2

3

4



13. Difficult breathing ….............................................


0

1

2

3

4



14. A dry mout
h …......................................................


0

1

2

3

4




HAVE YOU EXPERIENCED:




15. Having to clear your throat often ….....................


0

1

2

3

4





16. A choking lump in your throat ….........................


0

1

2

3

4





17. Hoarseness ….........................................................


0

1

2

3

4




18. Nasal stuffiness …...................................................


0

1

2

3

4




19. Colds …..........................................
........................


0

1

2

3

4




20 Colds with complications (e.g. bronchitis) ….........


0

1

2

3

4




21. Increased asthma attacks …..................................


0

1

2

3

4




22. Sinus headaches …........................................
........


0

1

2

3

4

39







HAVE YOU EXPERIENCED:




23. Spells of severe dizziness …....................................


0

1

2

3

4




24. Feeling faint …......................................................


0

1

2

3

4




25. Blurring of your vision …...
....................................


0

1

2

3

4




26. Migraine headaches …...........................................


0

1

2

3

4




27. Increased seizures (convulsions) …........................


0

1

2

3

4






HAVE YOU BEEN BOTHERED BY:




28. In
digestion …..........................................................


0

1

2

3

4




29. Nausea …................................................................


0

1

2

3

4





30. Severe pains in your stomach …....................
..........


0

1

2

3

4





31. Increased appetite …................................................


0

1

2

3

4

.





.



.





32. Poor appetite ….........................................................


0

1

2

3

4






33. Loose bowel movements or diarrhea ….....................


0

1

2

3

4





34. Heartburn …...............................................................


0

1

2

3

4





35. Constipation …...........................
..................................


0

1

2

3

4


MUSCLE TENSION IS A COMMON WAY OF

EXPERIENCING STRESS. HAVE YOU NOTICED

EXCESSIVE TENSION, STIFFNESS, SORENESS OR

CRAMPING OF THE MUSCLES IN YOUR:





36. Abdomen or stomach ….................
.............................


0

1

2

3

4





37. Neck ….........................................................................


0

1

2

3

4





38. Jaw …........................................................................
...


0

1

2

3

4





39. Forehead …...................................................................


0

1

2

3

4

.

.


40. Eyes …...........................................................................


0

1

2

3

4





41. Back ….........................................................................


0

1

2

3

4





42. Shoulders …..................................................................


0

1

2

3

4






43. Hands or arms …..........................................................


0

1

2

3

4





44. Legs …...........................................................................


0

1

2

3

4









45. Tension headaches …...................................................


0

1

2

3

4



40







IN YOUR DAY
-
TO
-
DAY ACTIVITIES, HAVE YOU

NOTICED SYMPTOMS OF ANXIETY OR RESTLESSNESS,

SUCH AS:







46. Fidgeting with your hands …...
.....................................


0

1

2

3

4






47. Pacing …........................................................................


0

1

2

3

4





48. Chewing on your lips ….......................
.........................


0

1

2

3

4





49. Difficulty sitting still ….................................................


0

1

2

3

4




50. Increased eating …......................................................


0

1

2

3

4





51. Increased smoking …...................................................


0

1

2

3

4





52. Biting your nails …......................................................


0

1

2

3

4






53. Having to urinate frequently …....................................


0

1

2

3

4





54. Having to get up at night to urinate ….........................


0

1

2

3

4





55. Difficulty in falling asleep ….............
..........................


0

1

2

3

4





56. Difficulty in staying asleep at night …........................


0

1

2

3

4






57. Early morning awakening ….......................................


0

1

2

3

4





58.

Changes in your sexual relationship …........................


0

1

2

3

4





59. Working tires you out completely …............................


0

1

2

3

4



60.


Severe aches and pain make it difficult



fo
r you to do your work …............................................


0

1

2

3

4


STRESS IS OFTEN ACCOMPANIED BY A VARIETY OF




EMOTIONS. DURING THE DESIGNATED PERIOD HAVE

YOU FELT:





61. Alone and sad …................................
..........................


0

1

2

3

4





62. Unhappy and depressed …..........................................


0

1

2

3

4





63. Like crying easily …....................................................


0

1

2

3

4






64. Like life is entirely hopeless …....................................


0

1

2

3

4





65. That you wished you were dead …...............................


0

1

2

3

4





66. That worrying gets you down …...............
...................


0

1

2

3

4



67. You get up tired and exhausted in the morning even