IV.

MENTAL STATUS EXAMINATION

Underline as many criteria under each category as applicable to the client

General Appearance
Cooperative Uncooperative Bored Angry
Unkempt Well-groomed Heavily made-up Younger looking than age
Older looking than age Tense posture Relaxed Underweight
Overweight Bizarre behavior observed (Describe postures or psychomotor activity)
The client acted appropriately on the situation although there were times when she was
quiet and did not interact with the other patience. She only respond when asked.______
______________________________________________________________________

Emotions: Mood/Affect
Happy Sad Anxious Frightened Angry Elated
Euphoric Apathy Flat Blunted Inappropriate Labile
Depressed
Congruity of mood/affect (Describe how manifested) The client’s mood depended on__
what she felt on a certain moment. For example, when she felt happy, she smiled. Or__
when we have a serious discussion, she would also behave seriously. Nonetheless,___
there were also times when she would stare blankly in space._____________________

Speech
Clear Coherent Slurred Speech Incoherent Neologisms
Loose association Flight of ideas Aphasic Perseveration Verbigeration
Rumination Tangential Circumstantial Slow
Impoverished Speech logorrhea
Speech Impediment (Describe if applicable) _no speech impediment_______________
______________________________________________________________________
______________________________________________________________________
Other observations The client’s speech was clear and spontaneous. She_______
delivered them with coherent ideas._________________________________________
______________________________________________________________________
______________________________________________________________________

Thought Content
Delusional Obsessive Homicidal Suicidal
Suspicious Memory - Recent: Loss Intact Memory – Remote: Loss Intact

Other observations The client has a very good thought content. Everything she
shared with me has sense and coherent.____________________________________
____________________________________________________________________
Thought Process
Clear Logical Illogical Easy to follow Relevant Confused
Blocking Rapid flow of thought Loose association Circumstantial
Concrete thought process Capable of abstract thought

Other observations The client’s thought process was clear and relevant. Her____
ideas were appropriate, consistent and coherent._______________________________
______________________________________________________________________

Perceptual Disturbances
Illusions Hallucinations Depersonalization Derealization
Other observations The client claimed that she saw a dark figure back home in__
Leyte. She also claimed that when she was a child, a lady in white appeared before her.
______________________________________________________________________

Impulse Control
Describe client’s ability to delay, modulate, or inhibit the expression of behaviours and
feelings The client weighed her emotions before acting on a certain situation. She_
also acted appropriately on circumstances.____________________________________
______________________________________________________________________

Cognition and Sensorium

After applying appropriate test questions, describe:
Level of consciousness The client was alert, responded immediately to questions___
when asked and to activated prepared._______________________________________
______________________________________________________________________
Memory The client has a good memory. Her remote memories were intact. When I
asked about her childhood days, she could recall them right away. Her recent memories
were also intact. She remembered the things that happened a year ago. Moreover, the_
second day we met, she remembered my complete name._______________________
Concentration Client’s concentration was also good. When there were noises____
during our NPI, she could still talk and continue what she was relating to me. During___
therapies, she did good in focusing on her work._______________________________

Orientation Encircle Y or N (Yes or No).

Oriented to a. Time: Y N b. Person: Y N c. Place: Y N d. Situation: Y N
Describe other significant observations The client was well oriented to dates and day_
as well.________________________________________________________________

Knowledge, Insight, and Judgment

Describe client’s answer to a hypothetical question (What will you do if you find
a fifty peso bill while going around SM?) The client answered she would drop it at
the administration office of the establishment. Even though it was on P50, still it’s not__
hers. Moreover, as a Catholic Christian, taking the money with her was considered____
stealing. The client values her faith so much,__________________________________
V. PSYCHOLOGICAL TESTS
Document results of psychological tests that were administered to the client (If
any)
___________________N/A__________________________________________

VI. COPING AND ADAPTATION RESPONSES

Current resources
Growth and stages of development (Based on Freud’s, Erickson’s, Sullivan’s
Theories- whichever is/are applicable)
Theoretical explanation In Erik Ericson’s developmental task ‘Industry vs. Inferiority’,
adults who reflect mastery has sense of competence, completion of projects, pleasure_
in effort and effectiveness, ability to cooperate and compromise, identification with____
admired objects, joy of involvement in the world and others, and balance of work and__
play. On the other hand, adults who have developmental problems reflect lack of follow-
through on plans, feeling unworthy and inadequate, poor work history ( quitting, being__
fired, lack of promotion, lack of productivity), inadequate problem-solving skills,_______
manipulation of others’ rights, lack of friends of the same sex or overly high__________
achieving/perfectionist, reluctance to try new things for fear of failing, feeling unable to_
gain love or affection unless totally successful and being workaholic._______________

Actual Behaviour
Based on Erikson’s stages of development, I could say that the client has a problem in
the Industry vs. Inferiority stage. She is quiet and doesn’t have a good social________
relationship with other people. She can’t even name friends that were close to her. She
quit teaching because of her illness but prior to that, she also experienced some______
problems regarding her co-teachers. She verbalized that she was ugly that’s why her__
boyfriend broke up with her. She felt she is unable to find new love because of her____
appearance. Her self-esteem is very low._____________________________________

Rationale (Psychodynamics and psychopathology)

Before admitted in the institution, the client was apparently well. She was quiet and___
doesn’t interact or socialize with others. She often argued with her mother and siblings.
She quitted her work as a teacher (she stayed and taught at St. Mary’s for two years)__
and became an encoder for 6 months. After her break up with her boyfriend, she______
became irritable, talkative, had more fights with her siblings and parents. She was also_
aloof, loner and doesn’t have much friends.___________________________________
 A. Previous patterns of coping with grief and stress
Significant losses / changes /grief responses. (Generally, how does the client
respond to loss of significant persons, opportunities, relationships, & etc?)
First significant loss of the client was when her relationship with her boyfriend ended.__
She became irritable and angry all the time. It was a way for her to vent out the_______
emotions she felt inside. When I asked her now about what she felt before, she would__
say it was nothing anymore and she just laughed. ______________________________
Consider the following elements:
• How does the client solve his/her problems?
• Classify each into Adaptive, Palliative, Maladaptive, or Dysfunctional

Mark with a ( ) and Identify: (may be several)

Pattern of Coping with Stress Classification
____ Fight or flight Maladaptive_______
____ Dependence on other’s decision _________________
____ Acceptance of fate or destiny _________________
____ Use of physical illness _________________
____ Blaming others/self Maladaptive_______
____ Use of problem-solving coping skills _________________

B. Situations where and how patterns of coping were applied

When the client knew that she had hyperthyroidism, she engaged herself in a________
reflexology group wherein she shared that she felt good knowing there were people like
her who also have to face problems. Through them, she can freely vent her thoughts__
and feelings.___________________________________________________________
Support systems
Family The client never spoke about her problems to her parents because she__
said they don’t ask her anyway. She went to her older sister when she sick__________
(hyperthyroidism)________________________________________________________
Community The client wasn’t good at socializing but because she joined a group in her
parish, she was able to meet new people and gained their support not just in health but
with personal issues as well (like what she was feeling inside).____________________
Economic security (sources of family income, assistance from relatives) All her__
10 sibling were professional and became a help when she needed financial assistance.
Avenue of productivity/contribution
Current job status
The client has no job at the moment._________________________________________
Role contribution and responsibility for others (family, job, community)
She took care of her niece, Margaux, when the child’s mother wasn’t around. She also
did well as a teacher but resigned because of her illness.________________________
Adaptation responses
A. Psychosocial responses

1. Level of anxiety (Underline particular level and the behaviors that apply to it)

MILD MODERATE SEVERE PANIC

Calm Friendly Passive Alert Perceives environment correctly
Cooperative Impaired attention “Jittery” Unable to concentrate
Hypervigilant Tremors Rapid speech Withdrawn Confused
Disoriented Fearful Hyperventilating
Misinterpreting the environment (hallucinations/delusions) Depersonalization
Obsessions Compulsions Somatic complaints Excessive hyperactivity

Other behaviours (describe): The client acted appropriately according to the____

situation. She was well behaved and cooperative. She followed instructions keenly.____
______________________________________________________________________
______________________________________________________________________

2. Ego defense mechanism (Underline as many as applicable)

Projection Suppression Undoing Displacement
Intellectualization Denial Rationalization Repression
Reaction formation Fantasy Religiosity Sublimation
Compensation Symbolization Introjection Regression
Conversion Denial Fixation Identification
Substitution Isolation Splitting (Dissociation)
Describe how the identified responses were used by the client When I asked the
client the reason she was admitted in the institution, she only said it was because she__
didn’t drink her medications. She didn’t acknowledge the fact that she had an illness.__
She was also a devotee in their church wherein she joined a group she thought could__
heal any ailments, including hers.___________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. Level of self-esteem: (Underline one) LOW MODERATE HIGH

Characteristics that the client likes about self The client didn’t talk about her physical_
features so much but when she was admitted in the hospital, she stated that her______
boyfriend broke up with her because she was ugly. Physical features aside, the client__
loved about herself were her being a person who doesn’t want to be stepped upon. She
said she will fight for what she believed in.____________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Characteristics that the client would want to change about self The client wanted to
have a good social relationship with others. She wanted to be open and share with____
others so that in return, she would gain friends she will truly trust,__________________
______________________________________________________________________
______________________________________________________________________
Objective assessment of self-esteem
Eye contact From time to time, the client would stare blankly in space but she________
established a good eye contact when communicating with me. ____________________
General Appearance The client is clean, neat and well-groomed. She wore clean_____
clothes and tied her hair in a pony tail. She also wore slippers.____ ______________
Participation in group activities and interaction with others (in general) The client was__
cooperative in group activities and therapies. Although she was quiet, she also_______
interacted with the other patients and student nurses, She behaved accordingly too.___
______________________________________________________________________
4. Stage and manifestation of grief over life changes (impaired psychosocial
functioning) Underline one (1) only.

DENIAL ANGER BARGAINING DEPRESSION ACCEPTANCE

Describe client’s behaviors that are associated with this stage of grieving in
response to loss or change
After all the things that happened to her, the client was now ready and accepted_
the fact that there’s no possibility getting together with her boyfriend again. She was___
also aware of her illness and was praying that she will be cured soon so that she could_
come back to her family.__________________________________________________
______________________________________________________________________

B. Physiologic responses

Psychosomatic manifestation
Describe any somatic complaint that may be stress-related; e.g., pain: chest
pain, headache, other anatomical pain or discomfort, etc. (onset, location, quality,
intensity, origin; scale of 1-10: 1-3, mild; 4-6, moderate; 7-10, severe); relieved
by/worsened by use of prescribed/over-the counter drugs)

The client complained of headache when she took her medicine (usually after she took_
them). In a pain scale of 10, she rated it 6. She also complained that her leg sometimes
ache as well. However it was also moderate. She was given medication for pain and___
she said it relieved the headache. In the case of her leg pain, there were no medicine__
given._________________________________________________________________

VII. DIAGNOSIS AND INTERVENTIONS

A. Nursing Diagnosis (Physiological/Behavioral)
CUES ACTUAL POTENTIAL
Subjective
“Hindi ako makatulog” Disturbed sleep pattern r/t Risk for activity intolerance
lack of recognition of r/t lack of sleep for almost
As verbalized by folks:
fatigue/need to sleep every night
“Madala lumabas ng bahay
at gabi na umuwi”
“Mabilis magalit. Irritable
lagi”
Interrupted family process Risk for loneliness r/t
r/t difficulty of family affectional deprivation
Objective: member in coping
Quiet effectively with client’s
maladaptive behaviour.
Alienation of family
Insomnia
Sudden talkativeness
Dark circles under the eyes

VIII. EVALUATION OF PSYCHOTHERAPEUTIC AND OTHER INTERVENTION

Evaluation of NPR
I was able to meet the objectives I have set. The client shared her experiences and was
very cooperative. Throughout our NPI, I paid attention to her behaviour, to her reactions
to some situation and to her answers to my questions. I could tell that her ideas and
response were consistent and clear._____________________________________

Responses of Clients to Different Therapeutic Activities

Music and Arts Therapy through Art Appreciation
The client was cooperative during the therapy. She also behaved correspondingly to our
activity. In the slow music, I noticed that it took her sometime before she started
drawing. She drew scenery where there were mountains and a house. She said the
drawing reminded her of her family and their home in Leyte. On the fast music. She
drew a radio and said that when she heard the music, it was as if there was a party an d
she felt she wanted to dance and have fun.________________________________

Remotivation Therapy
Remotivation therapy was quite long but the client was well-behaved and enduring. She
didn’t complain or make unnecessary during the course of the therapy. She was
participative. When thrown with questions from the therapy, her answers were relevant
yet concise.__________________________________________________________
Occupational Therapy
The client was compliant to occupational therapy. She was able to follow the
instructions, step by step, until she made a bracelet. But then, there were times when
she got confused because the direction wasn’t stated in a manner that is apprehensible
(whether it’s the big pink bead or the small pink bead that she had to put inside the
nylon next). Then again, she asked questions on what’s next and that was how she got
by with the therapy. She was not hesitant enough to ask questions which were unclear
to her._______________________________________________________________

Play Activity
The client enjoyed the play therapy. She said that it was fun and she sweated a lot. It
was some form of exercise for her, aside for their daily dance routine in the morning.
She also displayed sportsmanship and established camaraderie with the group.

Other Activities
Food Preparation
The client was very enthusiastic in making a tuna sandwich primarily because it was her
favourite. She followed the steps/instruction accordingly. Her finished tuna sandwich
was carefully made and she ate it heartily afterwards._______________________

Community Singing
The client participated well during the community singing. She was eager to learn the
song and the action that goes with it. To the questions asked afterwards, her answers
were relevant and related to our activity yet her answer were brief though the thought
was there.____________________________________________________________

Calisthenics
The client said that calisthenics was some sort of exercise and at the same time dance
that made her energized, alive, alert and awake for the rest of the day. She was able to
follow the dance steps, hand movements and dance with music as enthusiastically as
the other patients._____________________________________________________

Newspaper Reading
The client also participated in the newspaper reading although when she was asked,
she answered just a little. I know she had a lot to say since she shared to me her
brother worked on a geothermal plant. All through the therapy, she was quiet but she
listened intently to the piece of news that was read before her and the rest of the
patients._____________________________________________________________
REFERENCE LIST

Keltner, N.L., Schweke, L.H. & Bostrom C.E. Psychiatric Nursing 3rd Edition.
Philadelphia: Mosby.

Soreff, S. & McIness, L. (2006). Bipolar Affective Disorder, retrieved May 27,
2010 from http://emedicine.medscape.com/article/286342-overview.

Who Health Organization (1992). Paranoid Schizophrenia, retrieved May 27,

2010 from http://www.schizophrenia.com/szparanoid.htm.