Mental Status Exam Form

A. General Appearance

During nurse- patient interaction, the patients grooming was not good prior to morning care but on the later part he
improves and shows good grooming. Most of the time, he exhibited appropriate facial expressions and posture during
interactions. At first, he cannot display eye contact which may show lack of focused and interest on the topic. As time
passes he was having an hallucination losing more focused unto the interaction.

B. General Mobility
Posture and Gait

The patient still slouches when seated but holds himself erect when standing and walking. His mannerisms are still
present and evident throughout the interview.

Activity
During the interview, the patient was able to sit straight and focus on answering the questions asked to him. There was
no overactivity or under activity nor impulsiveness noted. He was very calm and composed along the interview.

Facial Expression
The patient wasn't able to exhibit appropriate facial expression towards a certain topics.

C. Nurse-Patient Interaction

The patient was cooperative but for initial time only as he has his own world. He only answered few of the questions
but he was friendly and follow all the nurses command. However, his eye contact was poor. He often looks side.

Stream of Talk

A. Characteristic of Talk

During the conversation with the patient, I noticed that he was spontaneous most of the time. However, there are times

in which blocking was evident in between his speech. His articulation words were clear but the content were slightly

vague.

B. Organisation of Talk

The patient tries to answer some question however, in his answers, apparently I observed succession of circumstantiality

and tangentiality. He provides an excessive amount of irrelevant detail before finally arriving at the answer, or at times,

he doesnt arrive at the answer at all.

Emotional state and reaction

A. Mood

The patients mood was euthymic. His feelings were appropriate to the situations. His mood was appropriate and basing

from his gestures and other nonverbal cues, his mood is fitting to the situation.

B. Affect

The patients affect is inappropriate. There is a marked disharmony between thought content, emotional response, and

expressiveness.
Thought Control

A. Perceptions

Throughout the interaction, I observed manifestations of illusions and hallucinations specifically auditory and visual

hallucinations.

B. Delusions

ABSENT

Neurovegetative Dysfunction

A. Appetite

The patient has normal appetite he eats what ever food there is available.

B. Weight

Increased since the day of the admission.

D. Attention span

The patient has poor attention span.

General Sensorium and Intellectual status

A.Orientation

The patient is unimpaired of the time, place and person. When asked during the interview if what date and time was it,

he did not answer.

B.Memory

The patient has difficulty recalling remote memories.

C. Calculation

The patient was given simple mathematical tasks like 1+1, 2-1, and the like. He was able to answer all of them.

D. General information

The patient does not know the basic general information like the current president of the Philippines and etc.

E. Abstract Thinking, Judgement and Reasoning

Patient cannot explain or even give an proper answer.

Insights

The patient does not have an the concrete understanding of what his illness is. Hallucination are more evident on the

second day. With these statements, we can say that he has a poor insight.
 FIRST NURSE-PATIENT INTERACTION

NURSE PATIENT
INTERPRETATION ANALYSIS
Nonver
Verbal Verbal Nonverbal
bal
M a a y o n g G r e e t s L o o k s a t Nurse: Gives the patient Greetings acknowledge
buntag! Ako t h e the student warm greeting to create clients presence as well
diay s i patient nurses and a positive atmosphere as creating a good start
maam Aya with a smirk. and establish a good and knowing clients
estudyanten s m i l e rapport disposition.
g nurse sa a n d Patient: Didn't
Ateneo de u s e s acknowledges the nurses Fundamentals of Nursing
D a v a o h a n d and didn't shows any by Kozier, B. p. 430
University. gestures interest and curiosity
t o
introdu
ce the
group
member
s
K u m u s t a L o o k s .. Scratches N: Tries to open up a Broad openings make
m a n k a ? at the head and conversation by using explicit that the client has
U n s a m a n patient l o o k s questions t h a t the lead in the interaction.
i m o n g a n d down. encourages patient to For the client who is
f e e l i n g smiles talk and share hesitant about talking,
k a r o n g Starts P: Exhibits boredom b r o a d o p e n i n g s m a y
adlawa? t o over his mental hospital stimulate him or her to
establis stay take the initiative.
h a Psychiatric Mental Health
g o o d Nursing by Frisch p 185
rapport
Kanus-a pa L o o k s .. C h a n g e s N: Asks a question to Seeking information is
man diay ka a t t h e into a seek viable information used to know more about
diri Arnel? patient comfortabl P : H i s c h a n g e o f clients feelings, thoughts
e s i t t i n g position communicates and ideas. It is also used
p o s i t i o n h i s i n t e r e s t t o n o t to make clear that which
then look p a r t i c i p a t e i n t h e is not meaningful or
to the side conversation vague.
l i k e Psychiatric Mental Health
someone Nursing by Frisch p 185
was there.
 FIRST NURSE-PATIENT INTERACTION

Kabalo pod Continu . Makes an N: Attempt to evaluate Exploring is delving

ka why naa e s to eye contact patients understanding further into a subject or
ka dire? maintai w i t h t h e and perception of his idea. This can help patient
n eye nurse own illness examine the issue
contact morefully. Any problem
or concern can be better
understood if explored. If
patient expresses
unwillingness to share,
the nurse must respect his
or her wishes.
Mental Health and
Psychiatric Nursing by
Ann Isaacs p.197
Auditory hallucinations
are false sensory
impression heard by the
p a t i e n t , u s u a l l y,
commanding in nature.
Mental Health and
Psychiatric Nursing by
Ann Isaacs p.197
P a n a n - a w Contin Looks at N: Tries to stimulate Seeking information is
n i m u , ues eye the nurse the patient to recall past used to know more about
n g a n o n g cotact f o r events of his life that c l i e n t s f e e l i n g s ,
nasakit man s e c o n d s could have contributed thoughts and ideas. It is
ka Arnel? a n d to his present illness. also used to make clear
Naay ba l o o k e d P: Patient cannot that which is not
k a y a w a y , remember a n y meaningful or vague.
mahinumdu talked to significant event which P s y c h i a t r i c M e n t a l
man ngano himself. he thinks is a Health Nursing by Frisch
nagka ingon contributing factor. p 185
ana ka?
 FIRST NURSE-PATIENT INTERACTION

Dire lang sa T a p s S m i l e s N : Te r m i n a t e s t h e T h e n u r s e g i v e s
mi kutob sa patient a n d conversation and r e c o g n i t i o n i n a
akong mga s back f o l l o w e d orients patient on the nonjudgmental way. The
pagpanguta t h e scheduled meeting nurse then terminates the
na. Sugod instruction Recognizes effort of the interaction by thanking
k a r o n s given by p a t i e n t w h o w a s t h e c l i e n t f o r h i s
bisitahun ka the nurse accommodating to the p a r t i c i p a t i o n a n d
nakuadlaw group throughout the cooperation during the
adlaw para conversation whole interview.
magstorya Shows gratitude to F u n d a m e n t a l s o f
na pud ta. patient for the time he Nursing by Kozier, B. p
Ayos ba na? and his family spared 470
Salamat sa for us.
i m u n g P: Shows
panahon understanding and
A r n e l . cooperation by
TIndog na. responding positively
to nurses statement
 Anecdotal

Day 1 (February 21, 2017 Tuesday)

"It's not what you say, it's how you say it. This popular saying really got into me
when I had my encounter with my patient. Throughout my childhood, my mother
reminded me of this concept continuously as I spoke to her with an "attitude." I have
always associated this saying with the tone of voice being used until recently. In
clinical, I realised that this could mean more than just the tone of voice one uses
when saying something. Meeting with my patient was a bit heart racing I didn't know
what he would be like, my was just heart pounding like a drum boom boom boom.
So our C.I started to gather us up to get ready for our ADL I got really nervous but I
just kept my positiveness in me and said this is it, Aya what ever and whoever are
you I will try my very best . As we head to the far corner of the ward the warden
called my patient last name Negros Arnel, Hoy magmata na.After a couple of
minutes a guy walked out the door looking sleepy with no expression on his face. I
was a bit confused I honestly didn't know what or how to handle him at first. I was
also confident as he looks a bit better than the other patients my classmates have. I
offered him slippers and walked all the was to the shower area. He followed my
instructions , he was really cooperative but he doesn't talk at all. No words came out
on his mouth. But I just kept my positiveness within me thinking that he just woke up
and etc. As we arrived in the shower area I instructed him to go to shower but he just
standing looking so confused. I asked him and he acted the brushing of the teeth. I
smiled and rushed to hand him his toothbrush. I observed him and god he brushes his
teeth really well more than I do. He even brushed his tongue. I was shocked. After
brushing he teeth he went near to the pale and wet himself. I offered him the toiletries
and after a couple minutes he dried himself really really well. He suddenly look at the
other patient and then looked at me and again acted that he want to shave his
moustache. At first I was hesitant to give him the shave and offered to do it. I told
him to sit, applied lotion and then shaved. And finally ADL done. As we were
walking to the solarium I explained to him what will be my agenda for today. But still
no words came out to his mouth. To be honest I was really worried but I kept thinking
myself that I can do this. After spending my half day with my patient I was just
reading him by his body language. I learnt that body language, just that, the language
of the body. You may think that you only show your emotions through your face, but
that is quite literally only the tip of the iceberg. Your entire body participates in the
business of either showing or hiding your mental state. I also learnt that he has an
chronic hallucination he talks only to himself and he wont talked or reply to my
questions. But how come he follows my commands. Hmmmm very confusing but I
think I have a chance of really knowing him. As the day comes to an end we say our
goodbyes and told my patient that I will be coming back. He smiled making my heart
melt and left me feeling exited for tomorrows encounter.
Psychiatric Nursing Requirements

Submitted to:
Melba Irene Gabuya, RN , MN

Submitted by:
[Group 1]
Aya Basilio

Date:
February 20, 2017