Name: Sex: Religion: Occupation:

R.N F Born Again None

Christian

Address:

Educational Status Chief Complaint: Contact

Attainment: Number:
Single Irritability, behavioral changes, suspiciousness,
High School wandering aimlessly N/A
graduate

Admitting Diagnosis:

Bipolar Disorder (Manic Phase)

Nursing Diagnosis:

Insomnia related to excessive hyperactivity as evidenced by difficulty falling asleep and sleeping only
short periods at a time.

Brief History of patient:

1. General Appearance (Manner of dressing, grooming and observance of hygiene etc.)

- Client is a 22 year old female who appears her stated age.

- Client’s appearance is remarkable for wearing revealing clothes.

- Client’s hair was not neatly combed and tied.

- Client has taken a bath.

2. Behavior (Presence of unusual movement and psychomotor changes

- Client was hyperactive and agitated

- Client initiated eye contact and started talking

- Client was agitated and restless

- No movement disorder was noted

 3. Communication (Coherent, tone, rate, volume, character ect.)

- Increased speech tone, rate, and volume.

- Classic grandiose delusions was noted.

- Client was spontaneous and comprehensible.

- Client respond promptly.

- Client was elated, at times irritable, and reactive.

Mental Status Examination