SHREY INSTITUTE OF NURSING

AND ALLIED SCIENCES

SUBJECT: MENTAL HEALTH NURSING

TOPIC : MENTAL HEALTH ASSESSMENT

SUBMITTED TO,
Ms. Daksha Baria
Assistant Professor
SINAS Ahmedabad

SUBMITTED BY,
Ms. Madhuri Jani
F.Y. M.Sc. Nursing
Roll No: 06
SINAS Ahmedabad

SUBMISSION DATE:-

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 Mental status examination

Identification Data :
Name : Mrs. Pinkiben Chandubhai Harvani

Age : 35 years

Sex : Female

Marital status: Married

Ward : General

Indoor no :812112

Religion : Hindu

Language : Hindi, Gujarati

Education : 6th Pass

Occupation: House Wife

Address: Sukhmani Apartment,

Naroda Patiya,

Kubernagar, Ahmedabad.

MO - 97206155965

Date of admission : 27/12/2022

Time doing MSE: 10:00 AM

Diagnosis: Depression

Informant : Mother (Kamlaben)

Information (relevant or not)adequate or not: Information was adequate

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CHIEF COMPLAIN

 Patient was always thinking in negative way.

 Patient was feel that somebody want to kill her.
 Patient was aggressive behaviour since 2 months.
 Patient was suffering fever since 2 days.
 Patient was feel restlessness and discomfort.

A. General appearance and behaviour:

Appearance :Physical deformity

Facial expression: Anxious

Level of grooming: Normal groom

Level of cleanliness: Adequate

Level of consciousness: Fully conscious and alert

Mode of entry: Persuaded

Behaviour : Over friendly

Cooperativeness: Normal

Eye to eye contact : Maintained

Psychomotor activity : Normal

Rapport : Spontaneous

Gesturing: Normal

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Posturing : Normal poster

Other movements: Normal

Other catatonia phenomena: Negativism

Conversion and dissociative signs: No any signs

Compulsive acts ritual or habits: No

Hallucinatory behaviour : Talking to self

B) Speech

Initiation : Spontaneous

Reaction time :Normal

Rate : Normal

Productivity : Elaborate replies

Volume: Normal

Tone : Normal variation

Relevance : sometimes off target

Stream : Verbigeration

Coherence :Fully Coherent

Others : No any Kind of neologism or perseveration

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C) Mood And Affect :-

Subjective :

Nurse -How you feel now?

Client -I feel good but I don’t want to stay here.

Inference - Client mood was good but during interview she look in
anxious.

Objective :
Patient look anxious and streeful

Predominant mood state : Anxious and Depressed

D) Thought :-

1. Stream of thought: Racy thoughts

2. Form of thought / flow of thought :Normal

3. Content of thought :

- Delusion :
Nurse - what are you thinking?
Client – My husband always talking about me. He said to me I am
not good wife and my mind was not working. My family
members are also talking about me.

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 Inference - Delusion of reference

- Ideas : worthlessness, Hopelessness

- Thought alienation phenomena :Normal

- Obsessional and compulsive phenomena : Normal

- Phobia : Not present

- Preoccupations : No

E) Perception :-

Illusion :Nurse - if you see the rope, did you interpret it as snake ?

Client - No

Inference – illusion was not present

Hallucination:Nurse – Can you here voices which is not hear by other person?

Client - No now didn’t hearing but previously I heard voices of

People.

Inference – Hallucination was not present

Somatic passivity :Nurse - Do you eel that someone is making you to do

Activity which you really don’t want to do?

Client - No I never felt like

Inference - Somatic passivity absent

Déjà vu / jamais vu :Nurse - Do you feel that you have met me before this

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day?

Client - No I meet you first time

Inference – Déjà vu and jamais vu are absent

Depersonalization / derealisation: Not present

F) Cognitive Function :-

Consciousness :Fully Conscious

Orientation :

1. Time : Nurse - what is the time now?

Client - 10:15AM

Inference - Client is oriented to time

2. Place : Nurse - Do you know where are you now?

Client - Mental hospital Ahmedabad.

Inference - Client was orient to place

3. Person : Nurse - Who am I ?

Client - Nurse

Inference - Client was orient to person

Attention :

Digit forward :

Nurse - Tell me the digit from 1 to10 forward?

Client - 1,2,3,4,5,6,7,8,9,10

1. Digit backward :
Nurse - Tell me the digit from 10 to 1 backward?

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 Client - 10,9,8,7,6,5,4,3,2,1

Inference - Client attention span was good

Concentration :

1. If we minus 7 from 100 than how many remaining?

Client - 93

2. Then again 7 minus 93 then how many remaining?

Client - 87

Inference – client concentration power was good.

Memory :

1. Immediate memory:
Nurse - what are the five object which I said before?

Client - Banana, Pen, …..

Inference - Client immediate memory was altered because she

recognize only 2 objects out of 5 which I told prior.

2. Recent memory :
Nurse - What you had yesterday night?

Client – Brinjals sabji, Roti, Rice

Inference - Client recent memory was intact.

3. Remote memory :
Nurse - When is your birthday?

Client - 13/1/1982

Nurse - How many members in your family?

Client - Total five member

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 Inference - Client remote memory was intact.

Intelligence :

1. General fund of information:

Nurse - Who is the prime minister of India?

Client - Narendra Modi

Inference - Adequate general fund of information.

2. Arithmetic ability :
Nurse - If you go to the market with 100Rs/ with you and you
purchase fruits worth 60rs then how many rupees
remaining with you.

Client - I have 40rs on my hand

Inference - Client arithmetic ability was good

Abstraction :

1. What is the meaning of “unity is strength”

Client - Means if we are in group then nobody harm us and we feel

secure and we can do anything.

2. What is the similarity between pen and pencil?

Client - In both we can write

3. What is the dissimilarity between pen and pencil?

Client - In pen written we can’t erase but pencil written we can erase.

Inference : Client’s abstraction was good

Judgement :

1. Personal judgement :
Nurse - What are your plan for the future?

Client - Nothing

Inference - Client personal judgement was altered

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 2. Social judgement :
Nurse - How will you celebrate Diwali festival ?

Client - I use diya for lighting, wear new cloths and go for

relatives house, decorate home etc.

Inference – Client social judgement was good

3. Test judgement :
Nurse - If fire is occur near to your home than what will you
do?

Client - I call fire brigade and run away from fire sites.

Inference - Client test judgement was good

Insight :Nurse - Do you know why are you here?

Client - For some lines like fever

Inference -Patient insight was 3 (Awareness of being sick attributed it to external

or physical factors.)

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