St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

SCHOOL OF HEALTH SCIENCES

MENTAL HEALTH AND PSYCHIATRIC NURSING ASSESSMENT

A. General Information

Name: ____Carl Stephen Dulin___________________

Age: __21_ Gender: Male_____ Marital Status: _Single___
Address:___#25 Batang St. Caggay, Tuguegarao City______________

The client’s name is Carl Stephen Dulin. He is 21 years old, single and currently living in
Caggay Tuguegarao City.

Chief Complaint/s:
When asked if how he is today, he said that “I am good thanks for asking.” He
described his mental health as good but in the past few weeks he is not so well. He said that he is
experiencing anxiety lately because of his upcoming subjects in school.

B. Psychiatric Nursing History

For the psychiatric nursing history, the client has not been clinically diagnosed
with any mental health illnesses or disorder. But the client shared that he experienced
depression last 2017. When asked to describe it, he said “I like to stay in bed. Every time
I wake up in the morning, I feel empty, sometimes it would be better if I would just end
myself. Outside the interview the client also personally shared that he coped up with his
depression by entertaining his self with learning how to play guitar. The client does not
have any problem with his social relationships.

1. Developmental History:
a. Prenatal History:
The client was not sure if he was planned or unplanned but he said that maybe he
was an unexpected baby. In addition, the client does not have any birth defects.

b. Toddler or early childhood

When sharing about his toddler or early childhood stage, he said that he was
bottle-fed when he was a baby. And he said that he hates eating vegetables when he was
in his early childhood, he stated “I hate eating vegetables when I was a kid, I always gag
every time I eat okra. I am not a picky eater; I just hate vegetables.” He starts walking at
1 year old and start talking and teething at 9 months. The client said that he felt safe as a
child. He shared that he finds his self-seeking approval of others and having a hard time
saying “no”. When asked to describe his relationship with his parents as a child he just
said “It’s good.” He lived with his grandparents when he was a kid because his parents
are both in abroad that time. When asked how does he feel when his parents left him for
work, he said “ Wala kasi di ko naman sila gaano ka close kaya okay lang saakin.” He
 said that sometimes his parents get angry to him and he said that he felt bad about it he
stated “I feel bad about myself bakit kasi hindi ako ganito yung hindi ko maimprove sarili
ko.” He also experienced temper tantrums he said “yes, kapag di napag bibigyan yung
gusto ko ganun.” The client also personally shared outside the interview that “kapag
napapagalitan ako ganun nag wawala ako.” He sometimes have night terrors or
nightmares. He also shared having visual hallucinations he said “nakakakita ako ng mga
ganun mga gumagalaw ganun kasi malakas rin imahinasyon ko nung bata ako.
Nakakakita ako ng mga small people parang may activities sila na ginagawa nag lalaro
sila ganun” He said that he was afraid of frogs as a child. The client does not experienced
head banging, rocking and tics. He said that he is overactive when he was in his early
childhood.

c. Middle Childhood:
He said that he was excited going to school when he was in his elementary, he
said “Excited ako nun kasi I’m about to learn new things, hanggang sa unti unting
bumaba yung confidence ko dahil sa mga teachers ko.” He considered himself as a male.
The client said that he developed his conscience after his childhood. He experienced
punishments during childhood he said “Tamad kasi ako mag sulat, tapos ginagaya yung
mga classmate ko na di nila tinatapos mga sinusulat sa blackboard, ayun nalalaman ni
mama ko na di ko tinatapos mga sinusulat ganun kaya yun napapalo.” Outside the
interview the client also personally shared that he was bullied and to cope up with
bullying he is befriending the ones who are bullying him. His phobia in his middle
childhood is to approach his teachers. The client love animals when asked if he is cruel to
animals he said, “not all the time. Minsan pasaway kasi sila ganun napapalo ko.” He also
experienced bed wetting.

d. Later Adulthood:
When asked how is his relationship with other people he said “okay naman,
mabilis ako makipag kaibigan ganun” He also shared that he likes to socialize to other
people. When asked about his relationship to his sibling he said “minsan pangit minsan
okay naman.” When asked about his relationship with his playmates, the client said
“Madalas rin yung tampuhan.” and when asked about the reason he said “Dahil hinid nag
papahiraman ng laruan ganun. He has four close friends as of now but in the past he has
many friends he said that things got complicated with his past friends. He consider his
self as a follower rather than a leader. When asked if he is idealizing popularity he said
“Oo dati” He also said that sometimes he is experiencing anti-social behavior. When
asked about how is his relationship with his teacher, he said “Hindi ako masyadong
nakikipag ano kasi sa mga teacher, ayaw ko maging sipsip.” He said that his interest is to
play video games. He shared that he does not involve his self in extracurricular activities
 in his school. When asked if he is having a hard time learning skills, he said “ may time
na nahihirapan ako ganun kasi madali akong madistract.” He is also finding hard time
assimilating lessons taught in school, he said “Kailangan pang ulit ultin bago ko magets.”
Adolescent problems:
He said that he used to smoke during his adolescent stage and also drinking
alcohol, he first tasted alcohol when he was six. He said that he used to drink a lot of alcohol in
his adolescent stage. He does not have any eating problems and weight problems, also he does
not engage in drug use or abuse. He also personally shared that sometimes he is suffering from
nightmares.

Psychosexual History:
The client said that he has a sexual partner as of now. But he does not remember
how he acquired his sexual knowledge. His puberty started when he was 13. When asked
about his attitude toward sex, he said “Okay I’m shy at the start but when things get more
intense, yun” He said that he is comfortable to share and talk about sex with his partner.
He also do not engage in multiple sexual partners.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500

SCHOOL OF HEALTH SCIENCES

MENTAL STATUS EXAMINATION

A. History
The client said that he experienced depression last 2017 but is not clinically
diagnosed with it, he also shared that he also had episodes of anxiety in the past years.
When asked if there are family history of alcoholism he said that there is, when asked
who in his family engaged in drinking alcohol he said “My grandfather, my father, my
uncle and my grand father’s brothers, almost all of us.” When asked if he has suicide
attempts he said “Yes” but he does not recall how many times.

B. GENERAL APPERANCE AND MOTOR BEHAVIOR:

The client is properly dressed and groomed. There are no evidence of physical
retardation and automatisms. And he appears to be the age he stated

C. SPEECH
For speech, the client has a nice exchange of conversations though there are some
answers that he does not want or comfortable to elaborate. His voice is also audible and does
not change the topic that being talked about. He does not also used any neologism throughout
the conversation. He does not also stutter during the exchange of conversation.

D. MOOD AND AFFECT:

Throughout the conversation the mood and affect of the patient depends on the topic
that was talked about. When talking about private things like suicide and his feelings toward
others his affect seems to be flat and blunt. But there are also times that he laughs
appropriately when talking about some topics about his past.

E. THOUGHT PROCESS AND CONTENT:

Throughout the conversation the client does not portray in illogical thinking,
delusions, thought broadcasting, insertion, withdrawal and word salad. Overall, the client
possesses a logical thought and thinking.

F. ASSESSMENT OF SUICIDE OR HARM TOWARDS OTHERS

The client shared that he has thoughts of suicide or killing his self. When asked about
what way we would want to do it, he said “I’ve always wanted to stab myself in the chest or
slit my wrist.” He plans to kill his elf in their house during the night.

G. SENSORIUM AND INTELLECTUAL PROCESS:

1. MEMORY (testing the client’s memory both recent and remote)

 When asked what did he do yesterday he said “I woke up late and it’s raining so when
I woke up, I just had a good mood then all of a sudden I became anxious once I start thinking
about my requirements in school.” When asked about the names of his parents he said “My
mother’s name is Arlena M. Dulin and my father’s name is Julius R. Dulin.” When asked
when is his birthday he said “November 23, 1999”

2. ABILITY TO CONCENTRATE:
The client can state his name backwards and can count from 30 to 1. He also been
able to state the days of the week

3. ABSTRACT AND INTELLECTUAL ABILITIES:

When asked to explain a proverb “Kung ano ang puno ay cya ang bunga” he said
“So parang ganun, kung ano yung mga actions na gagawin mo ngayon may consequences na
mang yayari.” In the client’s answer there is an abstract thinking because he came out of a
thought that was not merely a literal thought of the proverb.

4. SENSORY/ PERCEPTUAL ALTERATIONS:

Hallucinations
The client shared that he is having hallucinations when he was a kid but now he is not
experiencing it anymore.

5. JUDGMENT AND INSIGHT:

When asked what he will do if he found a wallet on the ground, what will be the next
thing/s he will do, He said “It depends, either if I take it or return it to the owner.”. When
asked what does he think about his anxiety he said “I do not want to experience it
anymore.” The client is not clinically diagnosed with it but he wants to seek medical help
about it.
6. SELF CONCEPT:
When asked what does he think of his self, he said “I am a shy type boy; a boy
with many ambitions but destroyed by self-doubt.”

7. ROLES AND RELATIONSHIPS:

The client said the he feels close to his family, when asked to describe he said
“There are times na may misunderstanding siyempre hindi naman maiiwasan yung ganun
pero okay lang”. He is currently in a relationship with someone, when asked how was it
he said “I am very happy about it.” He also meet his sexual needs satisfactorily. He also
does not engage in an abusive relationship in the past and his past relationship does not
affect his current relationship.

8. PHYSIOLOGIC AND HEALTH CARE

 When asked if he can eat well, he said “Yes” and sometimes he does not have
appetite, when asked for the reason he said “Kapag madami akong ginagawa ganun
kapag busy ako.” When asked if he sleeps well, he said no. He has trouble sleeping he
said “may time na hindi ako makatulog kahit inaantok na ako may time na madaming
pumapasok sa isip ko”

General Comments:
There are parts that the client seems not comfortable to talk about, the facial expression is
somewhat blunt on the other parts but he possesses logical thinking. He is experiencing
anxiety and repeated twice that it is because of his requirements in school. After the
interview he said that he was okay during and after the exchange of conversation

Assessed by: Chriszanie Cruz (student nurse)