Week 2: Lecture Proper (RLE) Flashcards
(42 cards)
a state of well-being where there is the ability to deal with
the typical stresses of life, works productively, and
contribute to their community.
MENTAL HEALTH
may modify reality, influence daily living, or harm
judgment
MENTAL ILLNESS
the main reason the patient is presenting, in their own
words
CHIEF COMPLAINT
the chronological account of what led up to the chief
complaint
HISTORY OF PRESENT ILLNESS
the history of all psychiatric or psychological concerns in
the past
PSYCHIATRIC HISTORY
listing all medical illnesses and listing all surgeries and
dates
MEDICAL OR SURGICAL HISTORY
All current and past medications, including the dose and
frequency
MEDICATION LIST
Any substances currently used and used in the past
● Method of use (oral, inhalation, injection, intranasal)
HISTORY OF ALCOHOL AND DRUG USE
under VIOLENCE RISK ASSESSMENT
Suicidal Ideation
Homicidal Risk
Abuse
ABUSE ASSESSMENT
In the past year, have you been hit, kicked, or physically
hurt by another person?
provides clues as to how the person interacts with others
SOCIAL HISTORY
important because many mental illnesses are hereditary
FAMILY HISTORY
Commonly genetic mental illnesses include
depression, bipolar disease, schizophrenia, and
attention deficit disorder.
Record the patient’s current employment status and
occupation
OCCUPATIONAL HISTORY
will help the nurse understand the best way to interact with
the patient
EDUCATIONAL HISTORY
Determine if the patient has legal trouble, probation,
parole, pending charges, or incarcerated.
LEGAL HISTORY
will provide insight into the origins of behavior, help
diagnose and manage some conditions
DEVELOPMENTAL HISTORY
Patient’s religious background
● the degree of involvement within the religious community
and any spiritual practices
SPIRITUAL ASSESSMENT
any critical issues regarding the patient’s ethnic and
cultural background
CULTURAL ASSESSMENT
a morbid fear along with extreme anxiety
Phobia
the obsession with the idea of having a serious or
life-threatening disease which is not diagnosed
Hypochondriasis
are unwelcome idea, impulse, or emotion that is
continually forced into the conscious mind
Obsessive thoughts
are something that the patient perceives but is
not rea
Hallucinations
a belief that is clearly false and that indicates an
abnormality in the affected person’s content of
though
Delusion