TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING

Mental Status Examination No. ___

Time stamp: 1:23 – 9:52

Note: Put a check mark in the appropriate box of significant observed descriptor/s.

1. General Description
1.1. Appearance
Descriptors Yes No Remarks
Congruent apparent age      
Appropriate dressing      
Clean / Hygienic      
Good posture      
Good gait      
   He is smiling while
Appropriate facial expression   telling his story.
With eye contact      
With pupil dilatation      
With pupil constriction      
Normal state of health & nutrition      
1.2. Speech
Descriptors Yes No Remarks
Rapid speech      
Slow speech      
Loud volume      
Soft volume      
Minimal speech      
Pressured speech      
Stuttering      
Slurring of words      
Unusual accents      
1.3. Motor Activity
Descriptors Yes No Remarks
Lethargic      
Tensed      
Restless    
    Became agitated
when he
encountered his
visual and auditory
hallucination
during their
Agitated   laboratory class.
With observed tics      
Grimaces      
Tremors      
Compulsive      

1.4. Interaction During Interview

Descriptors Yes No Remarks
Hostile      
Uncooperative      
Irritable      
Guarded      
Apathetic      
Defensive      
Suspicious      
Seductive      

2. Emotional State
2.1. Mood
Descriptors Yes No Remarks
   He was sad about
Sad   his condition.
  Became fearful
when he heard the
voices and saw the
black wind
hallucination
during their
Fearful   laboratory class.
Hopeless      
Euphoric      
   He was anxious
the by his
Anxious   hallucinations.
Happy      

2.2. Affect
 Descriptors Yes No Remarks
   He was smiling
while telling his
Congruent / Appropriate   story.
Flat      
   His mood was
suddenly changing
because of the
sudden
appearance of the
Labile   hallucination.

3. Experiences
3.1. Perceptions
Descriptors Yes No Remarks
   He was hearing
Hallucinations: Auditory   voices
   He was seeing
unreal persons and
Visual   things
Tactile      
Gustatory      
Olfactory      
Illusions      

4. Thinking
4.1. Thought content
Descriptors Yes No Remarks
Delusion: Religious      
Somatic      
Grandiose      
Paranoid      
Thought broadcasting      
Thought insertion      
Depersonalization      
Hypochondriasis      
Ideas of reference      
Magical thinking      
Nihilistic ideas      
Obsession      
Phobia      
4.2. Thought process
Descriptors Yes No Remarks
 Circumstantial      
Flight of ideas      
Loose associations      
Neologisms      
Perseveration      
Tangential      
Thought blocking      
Word salad      

5. Sensorium and Cognition

5.1. Level of consciousness
Descriptors Yes No Remarks
   He was confused
by real or unreal
Confused   voices.
Sedated      
Stuporous      
Oriented to: Time      
Place      
Person      
5.2. Memory
Descriptors Yes No Remarks
Intact remote memory      
Intact recent memory      
Intact immediate memory      

5.3. Level of concentration and calculation

Descriptors Yes No Remarks
   He was easily
distracted by his
hallucinations even
when he was
Easily distracted   sleeping.
With difficulty in simple math      
5.4. Information and Intelligence
Descriptors Yes No Remarks
With learning disability      
With learning difficulty      
Able to interpret simple proverb      
5.5. Judgment
Descriptors Yes No Remarks
Appropriate judgment      
With good relationship to others      
5.6. Insight
 Descriptors Yes No Remarks
Accepts presence of problem      
Blames the problem on others      

Descriptive Analysis:

The patient had an inappropriate facial

expression because he was smiling while telling
his story. He became agitated, fearful, and
anxious when he encountered his hallucination
during their laboratory class. He was having
visual and auditory hallucination. Therefore,
since then, he changed his mood easily because
he was confused what voices was real or unreal
and he was easily distracted by them.
 TODAY’S INSIGHT

Lately, I have been asking myself, how I could understand patients when I do not even

understand myself? I suddenly felt that I did not want to encounter and take care a patient with

mental illness. But when I watched this movie, there was this line said that “I have an illness, but

I am not the illness itself” and it made me realize that they are also human beings. If it is hard for

us to take care them, we never know how hard it was for them having that kind of illness. They

did not want or choose it. They all wanted to be normal and okay, and they do not know what to

do. That was the moment that I finally understand my purpose. Why am I studying at the first

place? This whole studying thing is for them. We have the knowledge, and we are planted here

to help them.

When Adam said “it’s nice to be heard than to be observed”, It means that they wanted us

to listen. Listening can be a big step of reaching them out. So many storms ranging in their minds

and they did not know how to fight it until it swallows them whole. Like the priest said in the

movie, “telling somebody our sins give us an opportunity to admit that we are flawed. Admitting

our flaws that give us the opportunity and the strength to face them. And that’s why we confess.”

We can be their opportunity on building up their strength and face their problem. The purpose of

presenting the reality to a patient experiencing hallucination, delusion, and illusion became clear

for me. We cannot help them to make those unrealistic things to go away but we can help them

to keep reminded that those things are unreal. It could be a great help for them to have their own

coping mechanism and be able to handle those things. It is hard but they are worth it.
 CASE ANALYSIS PRESENTATION

During our case analysis presentation, I learned the three common side effects of

antipsychotic drugs which is the weight gain, hypertension, and hyperglycemia. In doing drug

study, the side effects of the drugs should always be considered on the nursing responsibility. We

also need to consider the signs and symptoms of the patient in prioritizing our nursing diagnosis.

Doing the MSE is one of the critical parts because the diagnosis of the patient relies from it. If

anything in the MSE goes wrong, it can lead to a wrong diagnosis, wrong interventions, and no

prognosis may happen. Therefore, I carefully studied those words in the MSE checklist and

listened carefully to ma’am Princess when she interpreted those words. But I know I have still

long way to go and need to study more.

Being observed by our classmates also challenging. We felt that it was required for us to

find something to question about our works and I think it was the best thing. Because the more

we criticize, the more we ask, and the more we learn. We learned things to each other.