Mindanao State University – Iligan Institute of Technology

COLLEGE OF NURSING

Psychiatric Mental Health Nursing

MENTAL HEALTH STATUS ASSESSMENT

Patient: Maricel A. Doquiles Student: Hasnor G. |Ditingki

8 Group: K
I. GENERAL DESCRIPTION
a. Appearance
Assessment Justification Psychobiological Rationale
Grooming and Dress
[/ ] Well groomed Maricel is a well- groomed patient. In the manic phase, bipolar patient
[] Inappropriate use of clothing She takes a bath everyday using may wear clothes that reflect the
[] Evidence of soiled clothing Head N’ Shoulder shampoo and elevated mood: brightly colored,
[/] Use of make-up Shield soap. It’s also evident by flamboyant, attention-getting and
[] Unkempt wearing clean and brightly colored perhaps sexually suggestive. For
clothing. She wears lipstick on her woman with bipolar disorder, they
lips and put some of it on her upper may wear garnish or heavy makeup.
eyelid.
Hygiene
[ ] Any body odor No foul body odor noted in every Mostly, patients with bipolar 1
[/ ] Condition of skin, fingernails nurse- patient interaction. disorder can perform activities of
Fingernails and toenails are clean daily living such as taking a bath,
and short. going to school or even having a job
as long as compliant to medications.
Posture (note of standing)
[/] Upright Maricel stands in an upright posture. Most bipolar 1 disorder patients had
[ ] Rigid great postural sway and weaker
[] Slumped over balance.
Height* 4’8”
Weight* 48 Kg
Level of Eye Contact
[/ ] Intermittent Maricel, when she is conversing, can Eye movement analysis can be used
[ ] Occasional and fleeting maintain eye contact intermittently to discriminate patients with
[] Sustained and intense but there are episodes of sustained. depressive disorders from controls,
[ ] No eye contact The sustained eye contact is broken as well as patients with unipolar
when her name is addressed. depression.
Hair Color and Textures
[ /] Clean and healthy-looking Patient’s hair is healthy and clean Psychotic symptoms are also part of
[] Greasy with no foul odor this disorder, which can severely
[ ] Matted impact a person ability to function.
[ ] Tangled

Evidence of Scars, Tattoos, or Other Distinguishing Skin Marks

[/ ] Swelling/bruises Patient have minimal scars on upper
[ ] Birth marks and lower extremities. During
[ ] Rashes inspection, there was a round newly
healed scar approximately a half
inch at the left elbow. The patient
said it was hit on the floor.
Evaluate client’s appearance Clients can still look their age but the

Psychiatric Mental-Health Nursing | Mental Status Assessment


relative to chronological age
*Indicate accurate measurements in feet.
b. Motor Activity
Assessment
Tremors (trembling hands of legs)
[ ] continuous
[ ] at specific times
Tics or Other Stereotypical Movements
[ ] Facial tics
[ ] Jerking or spastic moments
Mannerisms and Gestures
[/ ] Specific facial or body
movements during conversation
[ ] Nail biting
[] Covering face with hands
[ ] Grimacing
Hyperactivity
[/ ] Gets up and down out of chair
[ ] Paces
[/ ] Unable to sit still
Restlessness or Agitation
[ ] Lots of fidgeting
[ ] Clenching hands
Aggressiveness
[ ] Overtly angry and hostile
[ ] Threatening
[ ] Uses sarcasm
Client appearance is just as her age
Justification
8
Patient does not manifest tremors.
Patient does not manifest facial tics,
jerking or spastic movements.
Patient frequently removes hair ties,
next is combing her hair, then ties
hair again. She does this cycle with
an interval of approximately every 30
minutes
Patient gets up and down out of
chair and at times goes to the
hallway and talk to other students
and clinical instructor. She comes
back when called by the student
nurse assigned. She can’t remain
sitting for a long time.
Patient did not demonstrate fidgeting
of the hands.
Patient did not exhibit clenching of
hands.
Patient did not exhibit
aggressiveness and hostility.
Psychiatric Mental-Health Nursing | Mental Status Assessment
grooming; mood and affect,
movements and speech can be
affected.
Psychobiological Rationale
Drugs that treat bipolar disorder may
cause muscle stiffness cramping,
and tremors.
Automatisms, repeated purposeless
behaviors are often indicative of
anxiety.
During manic phase, patients with
bipolar disorder experience
psychomotor agitation and seem to
be in perpetual motion sitting still is
difficult. This continual movement
has many ramifications: clients can
become exhausted or injure
themselves.
Excessive agitation expressed in
meaningless repetitive motion is
common, but most patients with
bipolar disorder does not manifest
these.
Excessive agitation may lead the
client to exhibit overt cues and also
some clients exhibit actions opposite
to what he actually feels or is
incongruent.
Psychotic symptoms such as
delusions and hallucinations, with
subsequent suspiciousness and
hostility may result in aggressive
behavior. It may be precipitated by
emotional triggers and can be more
aggressive and violent during acute
episodes.
Rigidity
[ ] Sits or stands in a rigid position Patient did not demonstrate rigidity. Dopamine function include
[ ] Arms and legs appear stiff and regulations of movements and
unyielding coordination, emotions and voluntary
decision-making ability.
Gait Patterns
[ ] Any evidence of limping Patient had a normal gait. Side effects of medications can
8
[ ] Limitation of ROM affect the musculoskeletal
[ ] Ataxia functioning of the client that can be
[ ] Shuffling exhibited by how the client moves
about.
Echopraxia (Mimicking the actions of others)
[ ] Present Patient does not mimic the actions of The frontal lobe controls the
[/ ] Absent others. organization of thought, body
movement, memories, emotions and
moral behaviour. This part of the
brain contains areas with mirror
neurons, which are never cells that
fire when we performed an action
and when we witness someone
perform the same action.
Psychomotor Retardation
[ ] Waxy flexibility Patient did not demonstrate waxy People with psychosis often have
[ ] Thinking and speech are very flexibility. Patient also does not irrational thoughts. Their speech
slow speak and think slow. maybe rapid and hard to follow and
[ ] Posture is slumped they may move from subject to
[ ] Immobile subject, losing tract of their train of
thought.
Freedom of Movement
Note any limitation in ability to move. Limitation of movement not noted. Antipsychotic medications and the
disease process itself can limit the
client’s movement.
c. Speech Patterns
Quantity
[/ ] Talkative The patient is very talkative. She Patients with bipolar disorder may
[/ ] Spontaneous talks spontaneously and answers to have impaired thought process and
[ /] Expansive questions but at times exhibit flight content that is brought about by the
[ ] Paucity of ideas, loose associations and disease process.
[ ] Poverty circumstantial thinking.
Rate
[ ] Fast She speaks rapidly Patients with bipolar disorder can
[ ] Slow sometimes speak in a rapid and
[ ] Normal disorganized way.
[/ ] Pressured/Rapid
Intonation
[/ ] with appropriate emphasis Patient’s intonation is with Some patients are monotone,
[ ] monotone, without emphasis appropriate emphasis. without emphasis that can
sometimes lead into confusion for
the listener as to what the client
feels.

Psychiatric Mental-Health Nursing | Mental Status Assessment

 Volume (Tone)
[/ ] Loud Patient speaks in a loud voice Bipolar 1 disorder patients may
[ ] Soft speak in whispers or hushed tones
[ ] Monotone or talk loudly or yell.
[ ] Weak
[ ] Strong
Fluency and Rhythm 8
[ ] Slurred speech Patient speaks rapidly but can Bipolar 1 disorder patients may
[/ ] Clear articulate words clearly and fluently exhibit unusual speech pattern that
[ ] Hesitant which enables the listener to sometimes can be indicative of
[ /] Articulate understand what the patient say. aggression or anxiety.
[ ] Stuttering
[ ] Aphasic (describe fully)
d.General Attitude
Assessment Justification Psychobiological Rationale
General
[/ ] Cooperative (describe fully) Patient is very cooperative. When During a depressive episode patient
[ ] Uncooperative (describe fully) asked to perform self-care activities, may feel drained, in deep despair,
[/ ] Friendly/Sociable the client willingly follows (unless guilty for no reason, worthless and
[ ] Hostile (Sarcastic and irritable) she is agitated), answers questions irritable. Activities you normally
[ ] Defensive and follows simple instructions. She enjoy will hold no interest. You may
is also participative in the activities experience sudden weight loss or
conducted. gain and uncontrollable crying
spells. At your lowest moment you
may even have thoughts of suicide.
Uninterested/Apathetic* Apathy and disinterested not noted. Disruptions of the regulation of the
neurotransmitters cause the patient
to change mood, cognition and
movement suddenly.
Attentive/Interested* Patient is attentive and seems to be Bipolar disorder symptoms include
interested when we were talking. manic episodes followed by hypo
manic episodes, or extreme highs
and extreme lows and loss of
pleasure in activities.
Guarded/Suspicious* Patient did not exhibit guarding or If bipolar psychosis occurs during a
suspicious behaviour. low period or a depressive episode,
the individual may believe that
someone is trying to harm them, or
that they themselves have done
something wrong.
* Please specify assessment then explain further under justification.
II. EMOTIONS
A. Mood
Assessment Justification Psychobiological Rationale
[ ] Depressed; despairing Patient is in euphoric state Bipolar 1 disorder requires that an
[ ] Irritable individual has at least one manic
[ ] Anxious episode. These manic episodes can
[ ] Elated cause abnormally elevated mood
[ /] Euphoric and odd behaviour that can disrupt

Psychiatric Mental-Health Nursing | Mental Status Assessment

[ ] Fearful daily life. Individual with bipolar 1
[ ] Guilty often cycle between mania and
[] Labile depression, but may experience
relatively normal state in between.
b. Affect
Assessment Justification Psychobiological Rationale
Congruence with Mood 8
Affect is congruent with mood. She Bipolar 1 disorder requires that an
laughs when she says/hears individual has at least one manic
something funny. episode. These manic episodes can
cause abnormally elevated mood
and odd behaviour that can disrupt
daily life. Individual with bipolar 1
often cycle between mania and
depression, but may experience
relatively normal state in between.
Consistency with Mood Patient is consistently happy and is Mood fluctuations can be evident
congruent with her facial expression according to the levels of the
neurotransmitters and their activity in
the brain.
Intensity
[ ] Flat/Blank Patient’s affect is normal. She knows While some patients are congruent,
[ ] Blunt/Constricted how to react. She laughs when she others may exhibit inappropriate
[/] Normal/Regular says/hears something funny. expression or emotions incongruent
within the context of the situation
that rages from mild to grossly
inappropriate.
Compatibility of Emotions to Certain Situations
[/ ] Appropriate Most of the time, the patient’s affect The client may exhibit inappropriate
[ ] Inappropriate is compatible to the situation, expressions of emotions or
appears sad when she talks about incongruent with situation that
her family. ranges from mild to grossly
inappropriate that depends on the
play of the neurotransmitters that
affect brain activity.
Fluctuations
[ ] Labile Patient exhibit even mood but on the Mood fluctuation depends on several
th
[/ ] Even 5 day of duty has been labile and factors including the
had shifted from normal to neurotransmitter levels, brain activity
depressed and back again. or environmental triggers.
Range
[/ ] Broad Patient exhibited broad affect with Some clients display full range of
[ ] Restricted facial expressions that match the emotional expressions that is
emotions. consistent others have restricted or
are mask-like.
Quality
[ ] Sad Most of the time, the patient is Manic behaviour: for the bipolar
[ ] Angry euthymic- is cooperative and can go subtype, people can experience
[ ] Hostile along well with the interaction but feelings of euphoria, racing
[/ ] Indifferent there are episodes of indifference thoughts, risky behaviour (sexual
[/ ] Euthymic and irritability followed by secluding financial) or sudden increase in

Psychiatric Mental-Health Nursing | Mental Status Assessment

[ ] Dysphoric self in the corner then sleeping. energy or behaviour that’s out
[ ] Detached character.
[ ] Elated
[ ] Euphoric
[ ] Anxious
[ ] Animated
8
[/ ] Irritable
III. THOUGHT PROCESS
a. Form of Thought
Assessment Justification Psychobiological Rationale
[ ] Though blocking Patient manifests flight of ideas. She The individual may jump quickly
[ ] Though broadcasting tends to jump from one topic to from one topic to another (flight of
[ ] Though withdrawal another topic. The patient ability to ideas), making it hard for others to
[ ] Though insertion concentrate during a conversation. understand.
[/] Flight of ideas
[/] Associative looseness
[/] Circumstantiality
[ ] Tangentiality/Tangential thinking
[ ] Neologisms
[ ] Concrete thinking
[ ] Clang association
[ ] Word Salad
[ ] Perseveration
[ ] Echolalia
[ ] Verbigeration
[ ] Stilted language
[ ] Poverty of speech
[ ] Alogia
[ ] Latency of response
[ ] Mutism
[/] Ability to concentrate and
disturbance of attention
b. Content of Thought
Assessment Justification Psychobiological Rationale
Delusions
[ ] Jealous During inclusive dates if care, the In bipolar disorder, psychosis
[ ] Control or influence patient did not experience any typically occur during a manic
[ ] Sexual delusion. episode but it can occur during a
[ ] Somatic depressive episode as well.
[ ] Persecutory
[ ] Religious
[ ] Referential
[ ] Erotomanic
[ ] Nihilistic
[ ] Grandiose
[/ ] None
[ ] Suicidal Patient does not manifest The individual thinks about death a

Psychiatric Mental-Health Nursing | Mental Status Assessment

 [ ] Homicidal suicidal/homicidal thoughts. great deal and many contemplate or
[ ] None even attempt suicide. Depression is
highly associated with suicide.
Obsessions* Patient is not obsessed with Obsessive thinking is fairly common
anything. but rarely discussed symptom of
bipolar.
Paranoia/Suspiciousness* Patient did not
8 exhibit paranoia. Some patients have paranoid
delusions, believing that they are not
safe or that others want to hurt them.
Magical Thinking* Patient did no manifest any. Odd beliefs or magical thinking that
influences behavior and is
inconsistent with subcultural norms
can sometimes be the result of
delusions and hallucinations.
Religiosity* Patient believes in God but with no Some patients turn their faith in their
delusions. She prays when she has God into delusions for example they
problems. will believe that they are a saint or
are pregnant with the messiah.

Phobias* The patient verbalized “ginahadlok
ko ni mama nga naa dao wakwak
basta mag study ko busa mahadlok
nako mugawas.”
Phobias can be a minor part of some
disorders such as depression,
obsessive neurosis, anxiety state,
personality disorder, or
schizophrenic disorders.

Poverty of Content* Patient did not demonstrate poverty The individual says very little, or
of content. when he or she talks, there does not
seem to be much information being
conveyed.
* Please specify assessment then explain further under justification.
IV. PERCEPTUAL DISTURBANCES
Assessment Justification Psychobiological Rationale
Hallucinations
[ ] Visual Patient does not manifest any of Hallucination is a false sensory
[ ] Auditory these. perception or perceptual
[ ] Gustatory experiences that do not exist in
[ ] Tactile reality. Initially, the client perceives
[ ] Olfactory hallucinations as real, but later in the
[ ] Cenesthetic illness, he may recognize them as
[ ] Kinesthetic hallucinations. Visual hallucination is
[ ] Illusions seeing images that do not exist at
[ ] Depersonalization all.
[ ] Derealization
Illusions* Patient did not manifest this. Hallucinations are distinguished from
illusions, which are misperceptions
of actual environmental stimuli.
Depersonalization* Patient did not manifest this. During episodes of psychosis,
clients are commonly disoriented to
time and place. The most extreme

Psychiatric Mental-Health Nursing | Mental Status Assessment


8
Derealization* Patient did not manifest this.
* Please specify assessment then explain further under justification.
V. SENSORIUM AND COGNITIVE ABILITY
Assessment Justification
Level of Alertness/Consciousness
[/ ] Clear-minded/attentive Patient is clear-minded, attentive
[ ] Disturbed and can focus.
Orientation
[/ ] Oriented Patient is oriented to person, place
[ ] Not oriented and time. Patient is well-aware that
she is in Vicente Sotto Memorial
Medical Center- Center for
Behavioral Sciences, Cebu City.
Memory
Patient can remember the therapy
Recent performed the day prior.
Patient can recall who brought her to
Remote* VSMMC – CBS.
Patient can remember the name of
Immediate* the student nurse.
Patient can read, write, can count 1-
Intellectual* 100 and can memorize song lyrics
easily
Patient can remember her parents
Confabulation* and brothers.
Intellectual
Patient knows how to speak English
and Tagalog, knows who the current
president is and sing her favorite
Information and vocabulary*
songs with correct lyrics.
Vocabulary* Patient knows how to speak English
and tagalog
Psychiatric Mental-Health Nursing | Mental Status Assessment
form of disorientation is
depersonalization, in which the client
feels detached from her or his
behavior. Although he knows his
name correctly, he or she feels as if
his body belongs to someone else or
his spirit is detached from his body.
Derealization is often see coexisting
with depersonalization.
Psychobiological Rationale
A deeper understanding of memory
function and brain system has
served to refine and expand the
classification of short and long-term
memory.
Orientation refers to the client’s
recognition of person, place and
time that is known and where she is
and the correct day and year.
The nurse directly assesses
memory, birth recent and remote by
asking verifiable answers.
The nurse directly assesses
memory, birth recent and remote by
asking verifiable answers.
The nurse directly assesses
memory, birth recent and remote by
asking verifiable answers.
Some clients have impaired
cognitive functions and others do not
exhibit this kind of dysfunction.
Some clients have impaired
cognitive functions and others do not
exhibit this kind of dysfunction.
When assessing intellectual
functioning, the client’s level of
formal education must be taken into
consideration. Lack of formal
education could hinder performance
in many tasks.
Client’s level of formal education
must be taken into consideration.
 Lack of formal education could
hinder performance in many tasks.
Can explain “if there is a will, there is Some client’s still has the ability to
a way” use abstract thinking which is to
make associations or interpretations
about a situation or comment and
8 other continually gives literal
Abstraction* translations of has evidenced
concrete thinking. Client’s level of
formal education must be taken into
consideration. Lack of formal
education could hinder performance
in this task.
* Please specify assessment then explain further under justification.
VI. IMPULSE
Assessment Justification Psychobiological Rationale
Ability to Control Impulses
[ ] Aggression The patient can control her Patients with schizophrenia may
[ ] Hostility impulses, but shows suggested show dysfunctional impulsivity and
[ ] Fear provocative behavior and calms aggression. Although
[ ] Guilt down when reprimanded and when neurobiological aspects of
[ ] Affection boundaries are restated. aggression in patients with
[ ] Sexual feelings schizophrenia are still not well
understood, impulsivity, and
aggression may correlate with frontal
and temporal brain abnormalities.
VII. JUDGMENT AND INSIGHT
Assessment Justification Psychogiological Rationale
Ability to Solve Problems and When asked about her plans or how Judgment is frequently impaired in
Make Decisions* to solve problems, the client always clients with schizophrenia because
says when you pray there’s always a judgment is based on the ability to
solution. interpret the environment correctly, it
follows that the client with disordered
thought processes and
environmental misinterpretations will
have great difficulties in judging.
Knowledge About Self
[/ ] Awareness of limitations Patient is well-aware of her Increased self-knowledge and
[/ ] Awareness of consequences of limitations and consequences of awareness leads to more effective
actions actions. management of the illness.
[] Awareness of illness
Adaptive/Maladaptive Use of Coping Strategies and Ego Defense Mechanisms
Please specify here. When asked about her current Failure to acknowledge an
1. Denial condition, she does not accept that unbearable condition, failure to
she have a psychiatric problem admit reality of a situation or how
which is bipolar disorder due to her one enables the problem to
chronic depression. continue.
2.Resistance She perceives that real psychiatric Overt or covert antagonism towards
patients are those on the street remembering or processing anxiety-

Psychiatric Mental-Health Nursing | Mental Status Assessment

 without wearing clothes producing information.
* Please specify assessment then explain further under justification.
VIII. ATTENTION
Assessment Justification Psychobiological Rationale
Attend, Concentration, Distractibility
Patient can count 1-100 Impairment inattention is greatly

8 derived from the impairment in the

Digit Span*
patient can spell the word “Maricel”
backwards
Spelling Backwards*
Patient can solve basic calculations
such as addition, subtraction,
multiplication and division.
Calculations*
* Please specify assessment then explain further under justification.
thought processing, content and
clarity of the patient. It is further
aggravated by the difficulty in
concentration and intellectual
functioning which precipitates into
nearly basic primitive and superficial
manner of interpretations. When
problems are let down for the client’s
analysis.
Impairment inattention is greatly
derived from the impairment in the
thought processing, content and
clarity of the patient. It is further
aggravated by the difficulty in
concentration and intellectual
functioning which precipitates into
nearly basic primitive and superficial
manner of interpretations. When
problems are let down for the client’s
analysis.
Impairment inattention is greatly
derived from the impairment in the
thought processing, content and
clarity of the patient. It is further
aggravated by the difficulty in
concentration and intellectual
functioning which precipitates into
nearly basic primitive and superficial
manner of interpretations. When
problems are let down for the client’s
analysis.

Psychiatric Mental-Health Nursing | Mental Status Assessment