Hali Saucier

Mental Status Assessment, DSM-IV Comparison & Nursing Care Plan

Part I. Mental Status Assessment:

1. Identifying Data (include age and sex only):
- Sex: Female
- Age: 34
2. General Description:
- Appearance: Patient is well-groomed with appropriate application of make-up and
dressed in comfortable street clothes. She displays a fair amount of eye contact when
interacting with others. Her hair is clean and pulled back. She is at an appropriate weight
for her height.
- Motor Activity: steady gait with coordinated movements. Client is sitting with one leg
crossed over the other slightly slouched back in the chair. She appears relaxed with no
signs of agitation and no fidgeting behaviors. Motor activity is within normal limits.
- Speech Patterns: speech is at a moderate pace with varying tone and pitch. At times the
volume of speech volume is slightly raised when patient is attempting to be heard or
make a point. Client is eager to speak and offer her opinion in group. She occasionally
loses her train of thought when speaking.
- General Attitude: patient is cooperative, friendly, attentive, and interested with a
generally pleasant attitude.
3. Emotions:
- Mood: patient reports sadness, depression, hopelessness, worthlessness, and struggles
with irritability and anger. She is fearful when experiencing hallucinations. She appears
interested and attentive.
- Affect: patient’s affect seems incongruent with mood. She appears calm and less sad
then what she reports. She smiles frequently and displays a generally pleasant attitude
toward others.
4. Thought Process:
- Form of thought: patient is motivated, interested, engaged, and insightful. She displays
linear thought processes. She can be superficial at times and stares off into space for short
periods during group.
- Content of thought: patient denies any delusions, feelings of grandiosity, or racing
thoughts. She does admit to having suicidal ideation but agreed to contract with the
hospital for safety.
5. Perceptual Disturbance: patient complains of transient auditory hallucinations in which
she hears her father’s voice belittling her. She says that this reflects how he used to speak
to her when she was younger. When she was 5 years old, her father told her that she
would not receive a birthday present because she did not deserve one, and she continues
to hear this sort of verbal abuse when she is experiencing high stress. She also reports
seeing a vision in the emergency room of a knife and a rope and thinking about suicide
by cutting or hanging.
6. Sensorium & Cognitive Ability: patient is alert and oriented to person, place, time, and
circumstance. She has some difficulty with short-term memory. She is intelligent, holds a
bachelor’s degree, and is capable of abstract thought as evidenced by her understanding
and explanation of a metaphor she learned in goal-setting group.
Hali Saucier

7. Impulse Control: patient is able to control impulses fairly well. She shows no display of
aggression or hostility. She shows dramatic displays of affection toward other females
and is inappropriately flirtatious with one other male on the unit. She tends to try to
rescue other patients by answering questions for them or speaking on their behalf. (This
is a borderline trait.)
8. Judgment and Insight: patient displays insightful ability to solve problems and provides
helpful suggestions to others. She struggles with decision making skills. She is aware of
her symptoms and is knowledgeable about her medical and psychiatric diagnoses
although she tends to have a somatic focus at times. She is aware of her own limitations
and can identify her maladaptive coping strategies.
9. Additional Relevant Information from the Medical Record:
10. DSM-IV Diagnosis: Axis I, II, III, IV, IV. Justify the GAF score
Axis I: Recurrent major depression, premenstrual dysphoric disorder. Rule out bipolar
disorder type 2. Rule out posttraumatic stress disorder.
Axis II: Borderline personality traits
Axis III: Endometriosis, ovarian cysts, scoliosis, acid reflux
Axis IV: Living with chronic pain, recent loss of job and home due to pain problems,
recent estrangement from parents.
Axis V: GAF currently 20, past year 60.
I think 20 is accurate due to the client’s suicidal ideation and near suicide attempt.
She is in moderate danger to hurting herself and suffers at times from auditory
hallucinations. 60 is accurate for her previous level of functioning when she suffered
from symptoms of depression and experienced dysphoria and decreased functioning at
times due to her premenstrual dysphoric disorder.
11. Two Nursing Diagnoses:
1. Risk for suicide related to increased depressive symptoms, feelings of hopelessness
and worthlessness, chronic pain, history of suicide attempts, and expressed suicidal
ideation.
2. Chronic pain related to dysmenorrhea, repressed anxiety, and maladaptive coping skills
as evidenced by verbal reports of pain, clutching abdomen, depression, and requests for
analgesics.
12. Current Psychiatric Medications:
Note: I have provided detailed information on two psychiatric medications under Part I to meet
the criteria for both the mental status assessment and the nursing care plan (since mine is all on
the same patient).
• aripiprazole (Abilify)
• citalopram (Celexa)
• lithium (Lithobid)
• clonazepam (Klonopin)
• quetiapine (Seroquel)

Name: aripiprazole (Abilify)

Classification: antipsychotic
Action: Psychotropic activity may be due to agonist activity at the dopamine D-2 and serotonin
5-HT1A receptors and antagonist activity at the 5-HT2A receptor. Also has α-adrenergic blocking
Hali Saucier

activity. This mixed agonist/antagonist decreases manifestations of schizophrenia and decreases

mania in bipolar patients.
Indications: Schizophrenia, acute bipolar mania (manic/mixed episodes). In this particular case,
the patient is probably on Abilify to treat suspected bipolar disorder and reduce auditory/visual
hallucinations.
Route/Dosage: 15 mg PO daily for this particular patient.
Adverse Reactions/Side Effects: confusion, depression, drowsiness, extra-pyramidal reactions,
nervousness, restlessness, suicidal thoughts, tardive dyskinesia. Dyspnea. Chest pain,
bradycardia, hypertension, orthostatic hypotension, tachycardia, constipation, anemia, anorexia,
n/v, neuroleptic malignant syndrome.
Client Teaching:
- inform patient of possible EPS and tardive dyskinesia and instruct the patient to report
symptoms immediately.
- Teach patient to change positions slowly to minimize orthostatic hypotension and risk for
falls due to drowsiness.
- Advise patient to avoid extreme cold and hot environments because this drug impairs
body temperature regulation.

Name: citalopram (Celexa)

Classification: antidepressant. Selective serotonin reuptake inhibitor.
Action: Selectively inhibits the reuptake of serotonin in the CNS. Produces an antidepressant
effect by making more serotonin available.
Indications: Treatment of depression
Route/Dosage: 60 mg orally daily in this particular patient.
Adverse Reactions/Side Effects: apathy, confusion, drowsiness, insomnia, weakness, abd pain,
anorexia, diarrhea, dry mouth, dyspepsia, flatulence, cough, increased saliva, nausea, tremor,
increased sweating, dysmenorrhea, photosensitivity.
Client Teaching:
- Change positions slowly to minimize dizziness.
- Advise patient to wear sunscreen and protective clothing outside to prevent
photosensitivity reactions.
- Avoid alcohol or other CNS depressants while on Celexa.
- Side effects such as drowsiness, dizziness, impaired concentration, and blurred vision
may make it unsafe to drive a car or operate other heavy machinery.
- To alleviate or minimize dry mouth symptoms: rinse mouth frequently, have good oral
hygiene, and chew sugarless gum.
- Inform patient that it may take anywhere from 1-4 weeks of therapy to obtain an
antidepressant effect and so they must be patient and hopeful.
(Deglin & Vallerand, 2007).

This client has undergone trials of several antidepressants such as Prozac, Paxil, Zoloft,
Effexor, Cymbalta, Wellbutrin, and Lexapro. There was no mania induced by any of these
medications. However, the patient is currently on a trial of Lithium due to the concern that she
may be bipolar. The patient feels that Lithium is helpful for her, which points toward the
possibility that she may indeed be bipolar.
Hali Saucier
Part II. Comparison of Patient’s Symptoms and DSM-IV Diagnostic Criteria:
DSM-IV Diagnoses:
Axis I: Recurrent major depression, premenstrual dysphoric disorder
Axis II: borderline personality traits
RECURRENT MAJOR DEPRESSION
DSM-IV Criteria (Symptoms)
A. Presence of two or more
Major Depressive Episodes.
DSM Criteria for a Major Depressive Episode:
A) Five (or more) of the following symptoms
have been present during the same 2-week period
and represent a change from previous functioning;
at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure
Note: Do not include symptoms that are clearly
due to a general medical condition, or mood-
incongruent delusions or hallucinations
1) depressed mood most of the day, nearly every
day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by others
(e.g., appears tearful). Note: In children and
adolescents, can be irritable mood.
2) markedly diminished interest or pleasure in all,
or almost all, activities most of the day, nearly
every day (as indicated by either subjective
account or observation made by others)
3) significant weight loss when not dieting or
weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase
in appetite nearly every day. Note: In children,
consider failure to make expected weight gains.
4) insomnia or hypersomnia nearly every day
5) psychomotor agitation or retardation nearly
every day (observable by others, not merely
subjective feelings of restlessness or being slowed
down)
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or
guilt about being sick)
8) diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by
subjective account or as observed by others)
Patient Behaviors/Symptoms
Yes, the client has had multiple major
depressive episodes.
Yes, the client meets the criteria of having 5
or more of these symptoms during the same
week period. She displays at least 8 of these.
She has been in psychiatric hospitalization
four times in her life, each time due to
depressive symptoms.
Yes, the patient reports being depressed.
She has been treated for depression for the
past 5 years. She appeared tearful upon
admission and also when talking about her
symptoms.
When the client is depressed, she feels she
can no longer carry out activities of the day
and is unable to care for herself. She also
has a decreased interest level.
Yes, the patient reports a loss of appetite.
Yes, the client reports struggling with
insomnia for most of her life and usually
only sleeps about 4 hours per night.
Yes, the client reports fatigue and a lack of
energy.
Yes, the client states she feels worthless,
hopeless, and sad.
The client reports a decrease in
concentration. She appears distracted in
Hali Saucier
9) recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific
plan for committing suicide
B) The symptoms do not meet criteria for a Mixed This is accurate. The client denies ever
Episode
C) The symptoms cause clinically significant
distress or impairment in social, occupational, or function or take care of herself when she is
other important areas of functioning.
D) The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical
condition (e.g., hypothyroidism)
E) The symptoms are not better accounted for by
Bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months or
are characterized by marked functional
impairment, morbid preoccupation with
worthlessness, suicidal ideation, psychotic
symptoms, or psychomotor retardation.
B. The Major Depressive Episodes are not
better accounted for by Schizoaffective
Disorder and are not superimposed on
Schizophrenia, Schizophreniform
Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise
Specified.
C. There has never been a Manic Episode, a
Mixed Episode, or a Hypomanic Episode.
group at times and sometimes loses her train
of thought.
Yes, the client has attempted suicide twice
by overdose and came close to suicide prior
to her most recent hospitalization. She
admits to having suicidal ideation.
experiencing full mania. She does not recall
any period of markedly elevated mood.
Yes, the client feels that she is unable to
experiencing depression.
It is possible that some of the patient’s
symptoms could be related to her
premenstrual dysphoric disorder—however,
the depression is pervasive and the timing is
not restricted to her menstrual cycle.
No, the client has not experienced any major
losses that could better describe her
symptoms as Bereavement. Yes the
symptoms have persisted for longer than 2
months (at least 5 years). Yes, she is
functionally impaired. She also is
preoccupied with worthlessness and has
suicidal ideation. She also experiences
psychotic symptoms such as auditory and
visual hallucinations.
No, the client’s symptoms do not fit as well
with Schizoaffective disorder because she
does not display psychomotor retardation,
and does not show symptoms of grandiosity,
euphoria, or hyperactivity. Her psychosis is
typically only under high stress situations
and is not a defining characteristic of her
mental illness.
No. From the medical record and from the
patient’s report, there has never been a
manic episode, a mixed episode, or a
hypomanic episode. The client denies any
history of grandiosity, being hyperverbal,
having racing thoughts, displaying
diminished judgment, or having any period
of markedly elevated mood. However, she
Hali Saucier

does have problems with irritability and

anger. These symptoms can be a
manifestation of mania in some cases. This
is probably part of the reason why her Axis I
diagnosis includes a rule out of Bipolar
Disorder type II.
(American Psychiatric Association, 1994).

Part III. Nursing Care Plan:

Nursing Diagnosis: Risk for suicide related to depression, feelings of hopelessness and
worthlessness, recent suicidal behavior, history of previous suicide attempts, auditory and visual
hallucinations, and history of childhood abuse.
Long Term Goal (Discharge Goal): client will remain free from harm and experience a
decrease in depressive symptoms by time of discharge.
Short Term Goals:
1. Client will not harm self during the duration of hospitalization.
1. Nurse will ask the client directly: “Have you thought about hurting yourself? Do you
have a plan? If so, will you be able to carry out this plan?” Rationale: the risk of suicide
is greatly increased if the client has a plan and particularly if they have the means to
execute the plan (Townsend, 2007)
2. Nurse will obtain a verbal short-term contract for safety from the client and secure the
promise that the client will seek out a staff member if she feels like harming herself.
Rationale: Discussing suicidal feelings with a trusted person provides relief, gets the
subject out in the open, and places some of the responsibility for safety with the client
(Ackley & Ladwig, 2006).
3. Nurse will ensure a safe environment for the client by removing all harmful objects
from the client’s access such as shoelaces, belts, sharp objects, chemical substances,
medications, etc. Rationale: safety is a priority, and the suicidal client with intent may
take any opportunity to harm themselves. A safe environment reduces the opportunity for
self-harm (Ackley & Ladwig, 2006).
2. Client will experience a decrease in depressive symptoms within 7 days.
1. Nurse will collaborate with the physician to ensure that the patient receives her
prescribed Celexa medication. Rationale: Celexa selectively inhibits the reuptake of
serotonin in the CNS, which produces an antidepressant effect (Deglin & Vallerand,
2007). Note: Celexa may take 1-4 weeks to produce an antidepressant effect so other
interventions are crucial for decreasing depressive symptoms.
2. Nurse will spend one-on-one time with the client, using empathy, actively listening,
and attempting to understand the client. Rationale: Physical presence and active listening
inspire hope in the hopeless client. As a person experiences the understanding of
another, she may explore possibilities in her life with the nurse. A therapeutic
relationship is an essential component of interventions to address hopelessness (Ackley
& Ladwig, 2006).
3. Nurse will assess for pain and provide appropriate pain relief. Rationale: fear of pain
and inability to cope with pain are significant risk factors for hopelessness (Ackley &
Ladwig, 2006). Chronic pain is often linked with depression (Lewis, 2007).
3. Client will learn and be able to verbalize 2 adaptive coping strategies within 10 days.
Hali Saucier

1. Nurse will encourage the client to participate in group sessions. Rationale: group
activities provide social support and help the client identify alternative ways to problem
solve (Ackley & Ladwig, 2006)
2. Nurse will help client identify coping behaviors previously used and the client’s
perception of effectiveness. Rationale: it is important to identify strengths and
encouraging their use in crisis situations (Townsend, 2007). Recounting previous
experiences that were perceived by the client as having been dealt with successfully
strengthens effective coping and helps eliminate ineffective coping mechanisms (Ackley
& Ladwig, 2006).
3. Nurse will collaborate with the milieu to help the client learn adaptive coping
strategies such as awareness, relaxation, meditation, and problem solving. Rationale:
Awareness is the first step to effective management of stress. Problem solving skills are
an extremely adaptive coping strategy. Meditation and relaxation have been proven to
significantly reduce stress and anxiety (Townsend, 2007).
Hali Saucier

References

Ackley B.J. & Ladwig G.B. (2006). Nursing diagnosis handbook: A guide to planning care (7th
ed.). St. Louis: Mosby Elsevier.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author

Deglin J.H., & Vallerand A.H. (2007). Davis’s drug guide for nurses (10th ed.). Philadelphia:
F.A. Davis Company.

Townsend M.C. (2006). Psychiatric mental health nursing: Concepts of care in evidence-based
practice (5th ed.). Philadelphia: F.A. Davis Company.