Republic of the Philippines

Cebu Normal University Osmeña

Blvd., Cebu City, 6000, Philippines

College of Nursing
Telephone No.: (+63 32) 254 4837
Email: cn@cnu.edu.ph Website: www.cnu.edu.ph

MENTAL HEALTH ASSESSMENT FORM

Name of student: _Canazares, Chariemae N. ___Date of Exposure: _March 09, 2023___________
Yr Level & Section: _____BSN 3A____________ Area of Exposure: __Online_________________
Client Initials: E.S. Date of submission: __March 09, 2023_________
Diagnosis: _Chronic Paranoid Schizophrenia with Acute Exacerbation

PSYCHIATRIC EVALUATION

I. DEMOGRAPHICS
Client’s Initials: ___E.S.___ Age: 67_Birth Date: _1956 (Month and Day undisclosed)
______________
Marital Status: __Married Number of children: Undisclosed____Ethnicity: _____White______________
Religion: Undisclosed Occupation: Graphic Novelist, Cartoonist, Author, Public Speaker, Educator and
Visual Artist
Handicaps: _None_________________________________________________________
Referral source (how did the client get referred to the center/institution)
__The client was a student at the hospital’s affiliated academic institution. __________________
Identification of informant (if not Client; note mood and apparent biases and reliability of
informants):
The informant was the client’s college professor who witnessed the client’s unusual behavior and speech at
school and at the informant’s house during dinner.

II. CHIEF COMPLAINT (Verbatim statement from Client)

Client was involuntarily brought to the psychiatric hospital due to her inability to finish her assignments
secondary to psychosis as evidenced by signs of hallucinations, delusions, and disorganized speech, while
in university. Client’s verbalizations are as follows:

• "'The memo materials have been infiltrated,"

• "They're jumping around. I used to be good at the broad jump, because I'm tall. I fall. People put things
in and then say it's my fault. I used to be God, but I got demoted."
• "People are trying to kill me,"
• "They've killed me many times today already. Be careful, it might spread to you."

III. PRESENTING PROBLEM/ILLNESS/SITUATION (Chronological order of symptoms and treatments, life

changes, stressors or conflicts, past psychiatric diagnosis (severity of illness, treatments, drug abuse).
• Client was diagnosed with chronic schizophrenia at 28 years old while attending law school.
• 7-8 years old: Exhibited signs of obsessive-compulsive disorder as the client needed to do things a
little differently than her parents would have wished her to do them as she developed certain
behaviors, such as being unable to leave her room unless her shoes were all lined up in the closet
and was also unable to sleep until her books were organized in the shelf. She also developed urges
to washing her hands at a particular number of times before stopping.
• 7-8 years old: Developed signs of delusions as she developed thoughts, such as thinking that
someone is outside there house waiting for her parents to sleep and abduct them followed by fear
and inability to sleep because of such thoughts
• 8-10 years old: Experience disorganization from reality with another delusional episodes when left
alone at home
• 16-18 years old: Tried marijuana and mescaline and eventually started smoking
• 16-18 years old: Experienced episodes of hallucinations where she saw changes and alterations
from reality, saw letters and words dancing and being jumbled, and felt that houses were starting to
communicate with her and that they were sending her messages when she walked home from school,
which was 5 miles apart.
• 21 years old: Started exhibiting symptoms indicative of depression and mild paranoia with intense
and frequent delusions and exhibition of chaotic and disorganized thinking
 • Postdiagnosis: Entered a state of debilitating psychosis and underwent analytic treatment, but was
not on medication
• Note: Refused medications for 10 years postdiagnosis, however, has not become compliant to
medications and other forms of therapy and has been stable for a decade and is under Zyprexa
therapy.

IV. PERSONAL HISTORY (use extra sheet if necessary)

A. Birth and Early Development (pregnancy, complications, psychophysiological)
No history of complications during pregnancy and birth. Signs of delusions, hallucinations, and
disorganization during early development are undisclosed.

B. Childhood (personality traits, behavior problems, social/family relationships, school

adjustment)
During childhood, exhibited signs of obsessive-compulsive disorder as the client needed to do things
a little differently than her parents would have wished her to do them and developed certain
behaviors, such as being unable to leave her room unless her shoes were all lined up in the closet
and was also unable to sleep until her books were organized in the shelf. She also developed urges
to washing her hands at a particular number of times before being able to stop.

C. Adolescence
During teenage years, tried marijuana and mescaline for the first time, the reason she was sent to
an addiction center, and eventually started smoking in the center. Along with delusions and
disorganization from reality, the client started to experience episodes of hallucinations where she
saw changes and alterations from reality, saw letters and words dancing and being jumbled, and felt
that houses were starting to communicate with her and that they were sending her messages when
she walked home from school, which was 5 miles apart.

D. Marriage (age, times, current relationship, children) if applicable

Client married at 40 years old, but has no children.

E. Education (highest attained, academic/success, behavior/social)

Client obtained a B.A. in undergraduate studies and M.Litt. in graduate studies. She also obtained
J.D. degree, has a Ph.D. in Psychoanalytic Science, and was awarded an Honorary Doctor of
Laws degree and an Honorary Doctor of Humane Letters.

F. Occupational History (current job, previous job, relationships, aspirations)

Client spent most of her years confined in a psychiatric hospital and was unable to work in law firms.
She is now currently an Orrin B. Evans distinguished Professor of Law, Psychology, Psychiatry and
the Behavioral Sciences, Faculty at a Psychoanalysis Educational institution, and the founder and
faculty director of the Saks Institute for Mental Health Law, Policy, and Ethics. She is also currently
a notable author and speaker.

G. Sexual History (feelings, performance, desire, deviant behavior, fantasy)

Client expressed unsatisfaction of intimate and sexual relationship from the past.

H. Social History (interpersonal relationships, group activities, follower/leader, premorbid

personality)
Client is currently married and describes marriage as “healthy”. She currently has multiple
engagements as a faculty member, speaker, and author. She also claims that she has a strong
support system with her husband, parents, brothers, friends and psychiatrist. Client has been on
therapy and has also been able to join social gatherings and events where the main topic is mental
health law, policy, and ethics, and mainly psychiatry. Before the disease, during childhood, the client
has always been self-conscious, curious, and passionate to her interest.

I. Forensic history (trouble with law)

Client has no disclosed historical data of trouble with law.

J. Current social situation (living arrangements, income, social environment, risk behavior,
 stability)

Client is living with her husband in one house and is constantly immersed with colleagues, students,
and generally with people with the same interest in law, mental health, and psychiatry. Client has
been stable for a decade due to therapy, medications, and a strong support system. Risky behaviors
would be being in a stressful environment in line with work and social events, which may have
several triggers.

K. Assets (list attributes of the client, include voluntary acceptance of treatment, verbal skills,
above average intelligence, other assets)
- Voluntary acceptance of treatment
- Has above average intelligence
- Having a high educational level with an excellent educational background, including a background
in psychiatry
- Active involvement in her care
- Ability to ask for help from husband, friends, families, and psychiatrist when things become too
stressful
- Has great communication skills, especially through creative writing and storytelling
- Is able to express emotions, experiences, and insights through creative writing and journaling
-Is passionate in promoting mental health laws, policy, and ethics and is an empath

V. FAMILY HISTORY

A. Who lives at home, relationships, role in family, etc.

- Client currently lives together with her husband.

B. Psychiatric history of family and relatives

- Undisclosed

VI. MEDICAL/SURGICAL HISTORY

A. Medical/illnesses/Diagnosis:
Client has a history of breast cancer.

B. Medication, dosages:
Medications are undisclosed.

C. Surgical Procedures/Diagnosis:
Breast Cancer Surgery – Unilateral Total Mastectomy

D. History of drug misuse/abuse (street drugs, illicit drugs, over-the-counter preparations,

nicotine, caffeine and alcohol use)
Cannabis, Mescaline, Nicotine

VII. COLLATERAL INFORMATION (from family, chart, physician, social worker, other sources)
- Has maintained stability for 10 years through individualized therapy, including talk therapy,
medications- Zyprexa, and through a strong support system.

MENTAL STATUS EXAMINATION

I. APPEARANCE (use separate paper if necessary)

A. Apparent and chronological age and gender: Client looks according to chronological age and
gender at the age of 68years old with minimal accessories, gray hair, and wrinkles.
B. Ethnicity The client’s nationality is American and ethnicity is White.
C. Apparent height and weight: The client appear to have a normal BMI with her height, weight,
and body type via inspection. The client also appears fit with no overt signs of excess fat.
D. Physical deformities: No physical deformities noted.
E. Basic grooming and hygiene: The client is clean and groomed appropriately for occasion.
F. Dress: Dress is appropriate for occasion and weather with neutral color of clothes and
minimal use of accessories.
 G. Accessories, prosthesis, personal aids: Wearing minimal accessories, including a
necklace and a ring.
H. Gait and motor coordination: Gait is rhythmic and coordinated with stable standing
posture and balance.
I. Posture: The client appears to be relaxed, with shoulders and back erect when standing
and sitting.
J. Work Speed: The client works and speaks at a moderately pace, enough for others to catch
up and understand her actions and words in a well-paced and organized manner.
K. Mannerisms or gestures: The client expresses words and expressions well through facial
expressions and physical gestures in a controlled and organized manner. Client is able to maintain eye
contact.

L. II. MANNER AND APPROACH (use separate paper if necessary)

A. Interpersonal characteristics and approach to evaluation (attitude towards examiner,
sociability, sexual attitude, physical sexuality, hostility: verbal, physical, attitude):
Client maintains a cooperative, calm, and open attitude and responds to questions and
statements in an appropriate manner, while ensuring to choose and use words that are
appropriate and both socially and culturally acceptable. Client did not exhibit any inappropriate
behaviors in a sexual and hostile manner. However, it appears that client’s affect during speech
was flat with less expression of emotions.

B. Behavioral approach (self – esteem, emotional warmth, ambition, flexibility, guilt)

Client approached the interaction with adequate amount of self-esteem as she takes pride in her
accomplishments in maintaining stability as a person with schizophrenia and showed emotional
warmth and flexibility by becoming sentimental of her previous experiences, specially struggles,
with the disorder.

C. Speech (rate and speed, volume, enunciation quality, tone, flow of words, form, content):
Speech is in a moderate tone, clear, with moderate pace, and culturally appropriate.

D. Eye contact: Client maintains appropriate eye contact with easiness with no signs of anxiety,
guilt, and hesitation

E. Expressive language: Client maintains a cooperative and calm attitude and expresses feelings
appropriate to situation, verbalizes positive feelings regarding others and the future, expresses
positive coping mechanisms. Client expresses full, free-flowing thoughts; follows directions
accurately; expresses realistic perceptions; is easy to understand and makes sense; does not
voice suicidal thoughts. However, client appears to have a flat affect an has showed less
emotions.

F. Receptive language: Client listens well, answer and respond to questions appropriately,
follows a conversation with ease, and can follow directions without difficulty.

G. RECALL AND MEMORY

1. Immediate Client recalls immediate memory and information with ease and accuracy after -,
10-, an 30-minute period.
2. Recent Client recalls recent events without difficulty.
3. Remote Client recalls past events correctly.

III. ORIENTATION, ALERTNESS AND THOUGHT PROCESS

A. Orientation (time, place, presidents, events, situation, name of examiner)
Client is aware of self, others, time, home address, current location, current location and events, and
the name of the examiner.
B. Alertness Client is alert and oriented to what is happening at the time of the interview and physical
assessment. Responds to questions and interacts appropriately.
C. Coherence Client names familiar objects without difficulty and reads age-appropriate written
print. Client writes and speaks a coherent and organized sentence with correct spelling and grammar.
D. Concentration and attention _Client listens and can follow directions without difficulty.
 E. Thought processes Client expresses full, free-flowing thoughts; follows directions accurately;
expresses realistic perceptions; is easy to understand and makes sense; does not voice suicidal
thoughts.
F. Thought content _Client expresses thoughts in a well-organized, well-planned, and well-thought
manner, arriving at a senseful and meaningful message.
G. Judgment Provide answers to questions that are based on sound rationale.
H. Insight Client expresses insights in a clear manner and provides insights based on previous
experiences and events, accompanied with sound rationale.
I. Intellectual ability Client is able to exhibit skills in active listening and has good turn-taking skills.
Client also portrayed good communication skills and is demonstrated sound and good analytical and
critical thinking skills.
J. Abstraction skills: Client explains similarities and differences between objects and proverbs correctly
and uses puns correctly and appropriately while choosing the right words and phrases according to what
is socially acceptable and culturally appropriate.

IV. MOOD AND AFFECT

A. Mood (how client feel most days): Client has been experiencing stability of emotions for the past
few days and have been feeling positive and satisfied about self lately with mild fluctuations of mood
with external stimuli (encounters with others, songs, and movies). Cooperative and friendly, expresses
feelings appropriate to situation, verbalizes positive feelings regarding others and the future, expresses
positive coping mechanisms
B. Affect (how client feels at this moment): Client is cooperative and purposeful in her interactions
with others. Affect is appropriate for the client’s situation, however, it can be perceived as too flat, and
is currently feeling good about herself as she is able to share her journey with others in the hopes of
touching lives.
C. Rapport: Client maintains a friendly and harmonious approach towards the examiner, while showing
trust, agreement, and mutual understanding with the examiner as partner in her care.
D. Facial and emotional expressions: Client maintains eye contact, smiles, and frowns appropriately
E. Suicidal and homicidal ideations: Does not voice suicidal thoughts and verbalizes positive,
healthy thoughts about the future and self
F. Risk for violence: Tendency to experience a relapse of exacerbated psychotic episode secondary
to schizophrenia.
G. Response to failure on test items: Accept failures and see them as great turning points in turning
something great and eventually achieving success. Also sees failures as an integral part of life and an
important stepping stone to growth.
H. Impulsivity: Client is careful with monitoring impulsive behaviors as these can be onset of
psychotic episodes, such as client’s reaction to hallucinations, delusions, and disorganization from
reality, including disorganized speech and unusual behaviors.
I. Anxiety Maintains an adequate amount of anxiety to be able to explore and learn,
J. Defense mechanisms
- Humor: thoughts that tend to retain a portion of innate distress are skirted round by the client by
witticism with overt expression of ideas and feelings that gives pleasure to others, especially during
sessions as a public TED talk speaker, a professor, and as an authot
- Anticipation: Has developed a personalized system to plan for future discomfort, such as
hallucinations, delusions, and psychotic episodes.
- Identification: Modeled one’s self upon other person’s character and behavior through memoirs of
other inspirational people, through writing a memoir and books about self being the character with
schizophrenia, and by becoming a mental health professor.
-Sublimation: Transforming negative emotions and experiences into positive actions, behavior, or
emotion that the self and others can learn and benefit from.

K. Coping mechanisms
- Communication: Communicating with support systems: (1) friends, (2) family; (3) and psychiatrist
- Creating a Story: Creating her experiences as a person with schizophrenia into a story that herself
and others can learn from while being entertained.
- Entertainment: As a speaker, the client found a way to share her experience in a witty and
entertaining manner to be able to express her emotions and struggles while keeping others
 entertained.
-Developing a System: The client’s creativity allowed her to create a system in a unique and
creative manner in order to deal with her symptoms and manage her disorder
-Teaching: Client shares her story as a person with schizophrenia through educating others
interested about mental health, law, and psychiatry and becoming an instrument in helping her
students get through in their psychological struggles.

V. OTHER AREAS OF CONCERN

A. Sleeping patterns (falling, staying asleep, waking up)
- Maintains 6-8 hours of sleep and develops an intact sleep-wake routine by waking up 6:00 AM in the
morning and going to bed not beyond 10:00 in the evening. Verbalized to falling smoothly and faster
with dimmed lights, comfortable room temperature, comfortable bed and blanket, and with less noise
stimuli. Expressed that waking up with no alarm clock is better and promotes peaceful awakening.
B. Energy level throughout the day
- Remains adequately active throughout the day with sleepy hours between 2:00 PM-3:00 PM and with
no reports of fatigue and sleepiness during active hours.
C. Appetite and food intake
- Expressed good appetite and eats 3 proper meals and 2 snack meals a day with preference on
healthy and clean foods, such as fruits, vegetables, lean meats, and fish as client believes that food
affects mood and affect greatly.
D. Feelings of anxiety, vague feelings, feeling of impending doom
- No reports of feelings of impending doom; however, client expressed that she still experiences
transient symptoms of hallucinations and delusions, which are sometimes causes of her anxiety and
vagueness in feelings.
E. Compulsions and obsessions
- No compulsions and obsessions noted.
F. Phobia
- Has social anxiety and cannot keep up with a large crowd for an extended time.
G. Traumatic life experiences
- Going through debilitating psychotic episodes, being physically abused in mental health facilities, an
being physically restrained.
H. Recent difficulties (ADL, IPR, getting things done, etc)
- Client has not reported experiences of recent difficulties that has affected her daily life as she has
maintained stability.

PSYCHIATRIC NURSING REPORT

I. SUMMARY OF PERTINENT DATA

- Client was diagnosed with Chronic Paranoid Schizophrenia with Acute Exacerbations
- Client showed signs of paranoid schizophrenia during childhood, however, was only diagnosed in college.
- Client has a history of smoking cannabis and regular cigarettes with nicotine and was sent to an addiction
center.
- Client has a history of being involuntarily hospitalized in mental health facilities with restraints and isolation
orders due to acute exacerbation of paranoid schizophrenic episodes.
- Client was previously diagnosed with breast cancer, which she had to go through surgery, and was also
diagnose with subarachnoid hemorrhage with unknown cause.
- 10 years post-diagnosis, the Client refused to take anti-psychotic medications; however, exhibited
compliance afterwards and is under Zyprexa as an antipsychotic medication.
- Client has been stable for a decade with episodes of mild and controllable hallucinations and delusions.
- Client has showed significant compliance to antipsychotic and antidepressant medications and has been
doing well with talk therapy and extensive support from husband, friends, families, colleagues, students,
readers, and her private psychiatrist.
 II. PSYCHIATRIC NURSING IMPRESSION

- Client has Chronic Paranoid Schizophrenia with Acute Exacerbations and has been stable for a decade
with episodes of mild hallucinations and delusions when triggered with stress.
- Client has been compliant with medication and therapy and has a strong support system.
- Client is capable of accomplishing day-to-day activities independently, while fulfilling varying social roles
at home and work without being limited by chronic disorder.

III. PSYCHIATRIC NURSING DIAGNOSIS (5 – 10 diagnoses in priority) based on NANDA

Nursing Care Plan during Onset of Episodes

: Disturbed sensory perception of touch and hearing related to psychological stress as evidenced by
disorientation to space, hallucinations, and change in behavior patterns.
: Impaired verbal communication related to altered perception, alteration in self-concept, and psychosis as
evidenced by inappropriate verbalizations and difficulty in comprehending usual communication pattern

Nursing Care Plan for Current Stability and Concurrent Symptomatology:

: Risk for self-directed violence related to the presence of risk factors of disturbances of thinking and feeling,
including depression and paranoia, and toxic reactions to current medications, including antidepressants
and antipsychotic
: Risk for Injury related to the presence risk factors of long-term therapy and biochemical and neurologic
processes and imbalances secondary to the disease process of Chronic Paranoid Schizophrenia with
episodes of mild hallucinations and delusions triggered by stress
: Readiness for enhanced communication as evidence by verbalization of desire and willingness to
communicate in a more effective manner
: Readiness for enhanced coping as evidenced by verbalization of desire to enhance knowledge of stress
management strategies, management of stressors; enhance use of emotion-oriented and problem-oriented
strategies; enhance social support; and develop awareness of environmental change through developing
an individualized coping and management system
: Readiness for enhanced decision-making as evidenced by expression of desires to enhance
understanding of choice for decision-making; enhance congruency of decisions with values and goal; and
enhance use of reliable evidence for decision-making and risk-benefit analysis of decisions
: Readiness for enhanced health literacy as evidenced by expression of desire to obtain sufficient
information to navigate the healthcare system, verbalized desire to enhance and participate in health
communication with healthcare providers, and enhance ability to make more informed personal healthcare
decision-making.
 MENTAL HEALTH ASSESSMENT RUBRICS

Criteria Competent Advance Beginner Novice

Completeness All sections of the There are 3-5 There are more than
(10%) mental health missing details or 5 missing details or
assessment form were information (7) information (3)
properly filled out. (10)

Comprehensivene Provides descriptions of Missed to elaborate Missed to elaborate 6

ss of Content the mental assessment 3-5 mental or more mental
(10%) findings (not just limited assessment assessment findings
to documenting normal, findings (3)
abnormal, present, (7)
absent etc.) as
applicable
(10)

Accuracy (25%) Documents the Committed 3-5 errors Committed 6 or more

correct mental in documenting the errors in
assessment mental assessment documenting the
findings or health data findings of the mental assessment
of the client/case. client/case. (18) findings of the
(25) client/case. (10)

Clarity of All data presented is Documented data Documented data

information (25%) clear and easily includes 3-5 includes 6 or more
understood. (25) ambiguous and/or ambiguous and/or
non-specific non specific
information. information
(18) (10)

Relevance (25%) All data in the Documented Documented

psychiatric nursing psychiatric nursing psychiatric nursing
diagnoses are diagnoses diagnoses
appropriate and related include 3-5 health include 6 or more
to the Client’s case or data that are health data that are
case scenario as inappropriate and inappropriate and
supported by the unrelated to the unrelated to the
documented Client’s case or Client’s case or case
assessment findings case scenario. The scenario. The
(25) information is not information is not
supported by supported by
assessment assessment
findings. (18) findings (10)

Timeliness (5%) Submits the completed Submits the Submits the

mental health completed mental completed mental
assessment form on health health
the agreed date and assessment form assessment form
time of submission (5) within the agreed after the agreed
date, beyond the date of
specific time of submission
submission (2)
(4)

Total Score ___/100 points

_____________________________________
Name and Signature of Faculty