Name: Charity Oduro Date: 10 /30/2022
Learning Objectives
At the end of this activity students will be able to:
- Apply observation and assessment skills essential to mental health nursing.
- Describephysical, cognitive, and psychosocial changes related to mental illness.
- Identify risk factors related to mental illness, treatment and rehabilitation.
- Perform a mental status examination on patients with mental illness.
Activity Instructions
- Select a patient from assigned unit.
- Obtain approval from the primary RN and clinical instructor for appropriateness of patient.
- Complete and submit the Mental Status Examination form as scheduled by your clinical instructor.
- Review the Mental Status Examination (MSE) grading rubric.
- Upload completed assignment to Brightspace.
Name: Charity Oduro Date: 10/30/22
| Personal Information/Demographics | ||
|
Patient Name:
A D E |
Admission Date and Unit Admitted to: Patient was admitted to St Joseph hospital behavioral unit on the2nd floor 10/26/22. | Age and Gender: 35 years old male |
| Marital Status: Divorced |
Religious Preference:
Patient believes in God but does not go to church. |
Race: white |
| Ethnic Background:Caucasian | Employment: Unemployed | Living Arrangements: Patient said he is homeless and does not have a place of his own. |
|
Patient’s Reason for Admission/ Chief Complaint:
Patient was admitted to the hospital through emergency with the complaints of depression, substance abuse and suicidal ideation to hang himself. Charts states that patient is A&O*4 and has history of hallucination, decreased energy, insomnia and loss of concentration. |
Co-morbid Conditions
Blindness in the left eye |
|
|
Mental Status Examination
|
||
| What You See (list) | Descriptive example (narrative) | |
|
1. Appearance (observed)
· Grooming/Clothing · Level of hygiene · Pupil dilation or constriction · Facial expression · Height, weight, nutritional status · Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings · Relationship between appearance and age
|
· The patient was clean, well dressed and had neat hair
· Patient worea short-sleeved shirt, blue jeans pant and hospital socks. · Patient was blind in his left eye, but the right eye dilates and constrict. · Patient skin color was pink and usual for ethnicity. · Patient ambulate independently with a steady gait. · Patient has numerous tattoos on his skin. · Patient weighs 160lb and his height was 5”4inches which looksappropriate for his age.
|
The patient is a 35-year-old Caucasian male who looks clean, well-groomed and had no body odor. Patient is average in height and weighs 160lb.Patient was wearing a short-sleeved shirt, blue jeans, and a pair of hospital socks. Patient is blind in his left eye and wears a patch on it. Patients ambulate independently by himself with a steady gait. Patient has pink skin which is usual for ethnicity with numerous tattoos.During the group therapy, he actively participated and drew a dog. |
|
2. Behavior (observed)
· Excessive or reduced body movements · Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness,balance, and gait) · Abnormal movements: (e.g., tardive dyskinesia, tremor/ tics/ abnormal movements) · Level of eye contact (keep cultural differences in mind) · Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia |
-The patient sat quietly in a chair watching Tv with his colleagues.
-No evidence tremors/tics/abnormal movements. -There was no psychomotor retardation observed. – He was able to follow instructions The patient-maintained eye contact throughout the interview stated that: “I feel happy talking to you”. |
Prior to interviewing the patient, I found him sitting quietly in a chair watching TV with other patients at the dining room. Upon questioning, patient was happy and answered all my questions. During the interview, the patient-maintained eye contact, followed instructions appropriately displayed no abnormal movements nor psychomotor retardation.
|
|
3. Attitude (observed)
· Ability to follow commands · Ability to provide reliable information. Possible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian. |
-The Patient was cooperative and followed commands correctly.
-Reliably reported information and remembered clearly the events preceding his admission to the hospital.
|
The patient cooperated and followed commands given correctly. Patient communicated openly about his life and shared how he has been depressed of late and felt nothing was working in his favor. He felt anxious about his future which according to him felt more dim. He felt happy that the hospital was a safe and secure place for him.
|
|
4. Speech
· Rate: slow, rapid, normal · Volume: loud, soft, normal · Disturbances (e.g., articulation problems, slurring, stuttering, mumbling) · Cluttering (e.g., rapid, disorganized, tongue-tied speech) |
-Patient had auditory hallucinations.
-The patient spoke clearly and with a medium volume. – Patient spoke with an even tone and rhythm and communicated information coherently
|
During my conversation with the patient, the patient informed me he previously had intentions of hurting himself but at the time he was feeling happy and had no such thoughts. He reported that the hospital was a good place for him, and he felt comfortable. His speech content had evidence of auditory hallucinations. He informed me that sometimes he could hear his brother talking to him and his voice made him agitated. He fears being discharge from the hospital because has no job and money to rent an apartment and does not want to be a homeless again. |
|
5. Mood and Affect (inquired/observed)
Affect · How the client outwardly is expressing emotion · Appropriateness to situation · Congruency with mood · Congruency with thought o Other descriptors include broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate Mood · How the patient describes what they are feeling o Possible descriptors include labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable |
AFFECT:
Patient affect was appropriate to the situation. He was clear and consistent with his thoughts. MOOD: -I observed the patient was in positive mood as evidenced by patient displaying willingness to talk. -During conversation, he was accommodative and actively participated. He had a pleasant mood but became anxious when he discussed the future and fears associated withthe unknown.
|
During my interaction with the patient, I observed that he was in a positive mood and was pleasant during the entire period. He only appeared angry when he mentioned about his brother’s commanding voice in his head.
Also, I noted that his mood and affect had changed as compared to that on admission which on his chart had been indicated to be irritable. He was a bit anxious and clearly expressed his fears about the future. His affect was congruent with mood. Patient stated that he feels sad anytime he remembers how someone made him loose his left eye.
|
|
6. Thought (inquired/observed)
Process · Describes the rate of thoughts, how they flow and are connected o Possible descriptors: Linear, goal-directed, disorganized, circumstantial, tangential, loose associations, flight of ideas, coherent, incoherent, evasive, racing, thought blocking, perseveration, neologisms. Content: · Refers to the themes that occupy the patient’s thoughts and perceptual disturbances o Possible descriptors: preoccupations, ideas of reference, delusions, obsessions, suicidal/homicidal ideation, rumination |
-Patient had linear thoughts which were purposeful
-Patient provided direct and appropriate answers to questions and conversation. -Patient experiences were realistic except on the aspect of his brother talking to him while in the hospital. –patient had some small memory lapses especially on things that happened 2 to 3 years ago. Chart stated patient has difficultly concentration due to flight of ideas.
|
-The patient’s conversation was goal directed. He provided clear answers to questions asked. The patient had no delusions which were identified during admission in the ED. He however had auditory hallucinations during the interview and stated that sometimes he hears voices to kill himself. Furthermore, the patient reported he could not remember some information especially that happened 2 to 3 years ago. Upon questioning, patient could not reveal the cause of the memory lapses. |
|
7. Perceptual disturbances
· Hallucinations (e.g., auditory, visual) · Illusions |
Patient was experiencing auditory hallucination during the interview. | Patient stated, he sometimes hears voices telling him toharm himself. |
|
8. Cognition
· Orientation: time, place, person · Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose) · Memory: remote, recent, immediate · Attention/concentration: performance on serial sevens, spelling a word backwards · Abstract vs concrete thinking: proverbs, involving similarities Judgment · Good, fair, or poor · Impulse control Insight · Good, fair, partial, poor Adaptive Coping Strategies vs Defense Mechanisms Possible defense mechanisms: Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression |
-Patient was alert and oriented x 4
-patient looked relaxed during first contact -Patient had trouble remembering things that happened several years ago -Patient has good judgement fair insight throughout the interview.
-Patient coping mechanism is suppressionbecause he feels depressed losing the left eye.
|
The patient was able to state why he was at the hospital, what lead him to come there and how he felt at this time. His chart supported that he has A/OX4.
I was able to assess his short- and long-term memory based the answers he gave me during questioning.He also appears to have good judgement and has fair insight. He reports that he avoids thinking about bad things as his life is full of those. However, this time things got really had that why he was contemplating to commit suicide prior to admission. |
|
8. Safety of Self/ Others
Risk of Self/Suicidal/Self-Injury · Fully assessed-no indicators of risk · If yes, then o Suicidal ideation (current, past) o Suicide attempts (hx of) o Plans to attempt (current, past) o Access to means o Family history · Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present? · Unintentional (when delusions, demented, intoxicated, in manic stages) present? Harm to Others/Aggression · Fully assessed- no indication of risk identified · If yes, then o Plan (current, past) to assault Property Destruction · Fully assessed- no indication of risk identified · If yes then o Current admission o Hx of |
-The patient has not displayed any self-harm behaviors or threats to any other person
-Patient stated that he occasionally hasthought of harming himself whenever he gets depressed. -Patient has no history of property destruction butused to steals car parts and money to buy illicit drugs.
Patient also stated that his parent were drug addicts and that influenced him, and his brother to use drugs. Patient stated that he and his brother became homeless after their parents abandoned them.
Patient currently has no thought of harming himself or anyone.
Patient has no history of property destruction but used to steals car parts and money to buy illicit drugs. . |
According to his chart, he was admitted with complaints of depression with suicidal ideations to hang himself. Also, he informed me that he was abandoned by his parents at the age of 13 years when he started to steal cars and anything else he can sell to survive. In the hospital, he has not had any problems with either staff or other patients. He has no history of violence
Patient denial thought of harming himself and others at the hospital.
|
