General Observations

Appearance

 Hygiene: has a body odor

 Dress: clean, dirty, neat, ragged, climate appropriate — stained and crumpled clothing

 Makeup: too much makeup

 Other: tattoo on her right arm

Speech

 General: clarity, stuttering

 Rate: Rapid, ‘can’t get a word in’

 Latency (pauses between questions and answers): increased

 Volume: loud

 Intonations: decreased (monotone)

Behavior

 General: increased activity

 Eye Contact: excessive

 Mannerisms

Cooperativeness

 friendly

Thinking

Thought Processes

 flight of ideas

Thought Content

 ruminative ideas

Perceptions

 Delusions (paranoid)

Emotion

Mood

 (Patient describes in own words and rates on a scale 1-10)

7
Affect

 Type: anxious

 Range: full range

Cognition

 Consciousness:
Confusion – Muddled thinking, can be: Acute (Delirium)
 Orientation : Awareness of person, place and time – Who are you / where are ?
 Attention: Serial Sevens not able to sustain focus
 Memory: Immediate- was able to repeat the words
 Language: She was able to name common objects and can right and verbalize instructions
 Visio-Spatial Functioning: Ask the patient to draw an old fashioned clock, showing 14:50

Was able to draw

  a.  Government

If you having trouble about your mental health consult a psychiatrist for counselling to help you
understand and manage your situation.

   b.  Academe (Nurse Educators)

as a educator you must understand what they are coming from and try to support, help and
educate them to manage their condition

   c.  Parents

support of parents through out the medication and treatment are very important. The patient feel
that they are not alone and lessen their anxiety 

   d.  Client

seek for medical attention to avoid the situation become worst