Mental Health Critical Thinking Map
| Psychiatric Diagnosis(s): Chief Complaint (subjective, patient’s own words): Hyperactivity Admission Status: Voluntary or Involuntary History of Present Illness: Psychiatric History: Past : | Pathophysiology (In your own words): Risk Assessment: Does patient have thoughts of hurting themselves? Yes or No Does patient have thoughts of hurting others? Yes or No Suicide risk factors: Protective factors: | Complications/Potential Complications (Physiologic Adaptation(s)/Reduction of Risk Potential): **Include substance use/abuse history | Psychosocial Concerns (Psychosocial Integrity): **Include psychosocial history |
| Assessment (Physiological Adaptation) **performed by the student **include age/sex **MSE, MMSE, CIWA, COW, if applicable) | |
| Labs and Diagnostics (Reduction of Risk Potential) ** Must include therapeutic drug levels, tox screen and pregnancy test. | |
| Planning and Goals (short term and long term goals) **Actual priority problems with prioritized goals | |
| Nursing Interventions (Basic Care and Comfort, Safety and Infection Control) **What did the student/nurse perform throughout the day **Include rationale | |
| Evaluation of Interventions |
| Medication Name (Generic) and Drug class | Patient’s Dose, Route, and Frequency | Why is patient receiving this medication? | Nursing considerations (labs, assessment, etc.) | Side effects and Major adverse effects | Patient Teaching |
| Alternative Treatments with benefits and risk: For example, if patient is currently being treated with SSRI’s for depression what other options for treatment are available? |
| Patient Teaching (Health Promotion, Safety and Infection Control, and of Care): |
| Patient Summary (SBAR Format): S- B- A- R- |
