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I.
PRESENTATION A. General Appearance The Client is awake, conscious, afebrile and not in respiratory distress. Client is well groomed. His nails are well trimmed and clean. He has a fair complexion
B. General Mobility 1. Posture & Gait: ( ) Normal ( / ) Appropriate ( ) Inappropriate He is kyphotic appropriate for a 88 years old patient whom always sitting on the chair.
2. Activity:
( / ) Normoactive ( ) Agitated
( / ) Appropriate
( ) Inappropriate
The Client has an appropriate facial expression according to what he felt. He is also smiling when someone gives him food to eat.
C. Behavior ( / ) Friendly ( ) Embarrassed ( ) Seductive ( ) Impulsive ( ) Dramatic ( ) Indifferent ( ) Sullen ( ) Negativistic ( ) Withdrawn
The Client is friendly but sometimes causes trouble to other client. D. Nurse Patient Interaction ( / ) Cooperative ( ) Initially only ( ) Uncooperative ( / ) Throughout Interview ( ) Later only Quality: ( ) Warm Hostile The Client is cooperative ( ) Distant ( ) Suspicious ( / ) Talkative ( )
II.
The client is always talking, always asking everyone who pass him.
B. Organization of Talk ( / ) Relevant ( ) Perseveration ( ) Tangential ( ) Loose of Association ( ) Circumstantial ( ) Clang Assoc ( ) Neologism
( ) Echopraxia
( ) Echolalia
( ) Flight of Ideas
The answer of the client are relevant and good enough to understand the given information.
III.
The client has a normal mood and not depressed and reasonably positive mood.
He has moderate potential for homicidal, the client sometimes hurt other clients.
IV.
Type: ( ) Thought Control, Broadcasting, Insertion ( ) Influence ( ) Paranoia persecutory, grandiose ( ) Somatic The Client has a good mind set when being assessed.
C. Preoccupation, Rumination ( ) Preoccupied ( ) Intrusive thoughts ( ) Dejavu & Jamais Vu N/A none of the above are noted to the client. ( ) Rumination ( ) Phobias ( ) Rituals
V.
PERCEPTION
A. Illusions
( ) Present
( / ) Absent
The Client has no any illusions when asked with his current situation. B. Hallucinations Type: ( ) Auditory ( ) Gustatory ( ) Olfactory No perceptual hallucinations noted. ( ) Visual ( ) Kinesthetic/Tactile
VI.
The client sleeps well, sometimes felt sleepy when ate a lot.
E. Diurnal Variation The Client changes its mood when felt hungry.
F. Attention Span ( ) Good ( ) Fair (/) poor The Client has a short attention span. He always forgot what has been said just a while ago.
VII.
B. Memory
The client knows the name of his student nurse after doing the activities. C. Calculations (Progressive Subtraction of 7s from 100) ( / ) Good ( ) Fair ( ) Poor The Client was able to count all the crayons and buttons given.
D. General Information The Client was unable to provide information relevant to his
E. Abstract Thinking Ability The Client can able to understand simple short instructions.
The Client was able to compare trash from food and reasons out the need for more food.
VIII.
INSIGHT The client is always showing increase of appetite, does he always ask about food to eat.
IX.
A. Disturbance in: ( ) Presentation ( ) Stream of Talk ( ) Emotional state and reaction ( ) Thought ( ) Perception ( ) Neurovegetative dysfunction ( / ) General Sensorium and intellectual state ( ) Insight ( ) Positive Signs of Organicity
B. Diagnostic Category ( ) Functional ( ) Organic ( ) Psychotic ( ) Non Psychotic ( / ) Both Functional and organic