CHAPTER II MENTAL STATUS ASSESSMENT LEGEND: O- Present X- Absent 1.

GENERAL APPERANCE CRITERIA Good Grooming Appropriate Facial Expression Appropriate Posture Maintains Eye Contact NORMS Grooming- the patient should be clean and well-groomed, and should wear appropriate clothing for age, weather and socio-economic. Facial expression- patients facial expression should be appropriate to the content of the conversation and should be symmetrical. Posture- the patient should exhibit erect posture, a smooth gait and symmetrical body movements. The patient should maintain good eye contact. (Health and Physical Assessment, Janet Weber) ANALYSIS Based from the observations made, the clients attire was in good condition and is in good grooming. On the first day, she wasnt able to show appropriate facial expressions regarding to certain topics. Her eye contact denotes that she was able to listen and participate to the conversation. DAY 1 o x x x DAY 2 DAY 3 o o o o o o o o

2. MOTOR BEHAVIOR CRITERIA Automatism Hyperkinesthesia Waxy flexibility Cataplexy catalepsy Sterotype Compulsion Psychomotor retardation Echopraxia Catatonic stupor Catatonic excitement Tics and spasms Impulsiveness Choreiform movements NORMS Patients weight is relevant to the coordination of motor behaviour of an individual; and it must be evenly distributed to the body/ able to stand out right/left heels, toes, Posture must be erect, stride must be equal both sides, arms swing opposite with each other. (Health and Physical Assessment, Janet Weber) ANALYSIS based from the observation above, the client did not manifest any unusual motor behaviour. DAY 1 x x x x x x x x x x x x x x DAY 2 DAY 3 x X x X x X x X x X x X x X x X x X x X x X x X x X x X

3. SENSORIUM AND COGNITIVE ABILITY CRITERIA Orientation: Time Place Person Concentration Memory: Remote Recent Immediate Retention NORMS Concentration- the patient should be able to correctly repeat the series of numbers upon series of five numbers. Memory- the patient should be able to correctly respond to questions and to identify all the objects as requested. The patient should be oriented with the date, person and the place where she is. Psychotropic drugs and abusive substances can be altering clients concentration and perceptions.(Health and Physical Assessment, Janet Weber) ANALYSIS Based from the data above, it shows that during the first day he has difficulty in remembering things that were told to him a while ago. He was not able to memorize the names of his new student nurses. Its because he is not yet familiar with the names. DAY 1 O O O O O O X DAY 2 DAY 3 o o o o o o o o o o o o o o

7. AFFECTIVE STATE

CRITERIA Euphoria

DAY 1 X

DAY 2 X

DAY 3 X

Flat Affect Blunting Elation Ecstatic Anxious Fearful Ambivalent

X X X X X X X

X X X X X X X X X X X X

X X X X X X X X X X X X

Depersonalized X Irritable Rage Labile Depressed X X X X

NORMS The appropriateness and degree of affect should value the topics and the patients cultural norms and be reasonable for eurythmic (normal). (Health and Physical Assesstment; Estes) ANALYSIS The client did not elicit any unusual effects. Though he remember and longs for his family, he just talks to his friends to ease his longing for them.

8. SPEECH CRITERIA Verbigeration Rhyming Punning Mutism Aphasia Unusual Rate of Speech Unusual Volume of Speech Unusual Intonation Unusual Modulation DAY 1 X X X X X X X X X DAY 2 X X X X X X X X X DAY 3 X X X X X X X X X

NORMS The patient should be able to produce spontaneous, coherent speech. The speech should have an effortless flow with normal inflections, volume, pitch, articulation, rate, and rhythm. Content of the message should make sense. Comprehension of language should intact. (Health Physical Assessment; Estes) ANALYSIS The client did not elicit any unusual characteristics of speech. It means that he was aware about the way he delivers his answers. 9. THOUGHT PROCESS AND CONTENT

CRITERIA Blocking Flight f Ideas Word Salad Perseveration Neologism

DAY 1 X X X X X

DAY 2 X X X X X X X X X X X X

DAY 3 X X X X X X X X X X X X

Circumstantiality X Echolalia Condensation Delusion Phobia Obsession Hypochondriac X X X X X X

NORMS The thought process should be logical, coherent, and goal oriented. Thought content should be based on reality. (Health Physical Assessment; Estes)

ANALYSIS The client did not show any unusual characteristics regarding to his thought process. He was able to be logical with his verbal responses and able to act what is acceptable to the norms of the society and in line with reality.

PND CUES

NSG. DX

PSYCHODYN AMICS

OBJECTIV E

THERAPEUTIC APPROACH

RATIONALE

S: Gusto kong lumabas at makapagtra boho O: -glance at times -smile -able to shake hands -nods and maintains eye contact -looks down and smile -calm and speaks softly

Ineffecti ve role perform ance related to inadequ ate role socializat ion

Existence therapy; believe that the person is avoiding personal responsibility in giving in to the wishes or demands of others

Within 4 meetings with the client he will be able to state knowledg e of change in responsib ility and new behavior associate d with the responsib ility.

Observ e clients knowle dge of behavi ors associa ted with role.

Ability to perfor m perceiv ed role is easily hamper ed by illness. This theme consist of the sub themes control, balanci ng emotio ns, subjecti ve well being, being open or not toward the family In setting valued goals, people adapt their world to self

Allow client to expres s feeling s regardi ng role change .

EVALUATIO N AND JUSTIFICATI ON Within the shift the client will be able to state knowledge of change in responsibilit y and new behavior associated with the responsibilit y as evidenced by: Able to state what his perception about his role/respons ibility

Have the client make a list of strengt hs that are neede d for the

new role

. Have the client list his proble ms associa ted with the new role and identif y the ways of overco ming them Reinfo rce the client strengt h have the client identif y past coping skills and suppor t the contin ued of these skills

generat ed needs and project s rather than adaptin g themse lves to a given word. Help the client recogni zed these and make the approp riate accom modati on

Behavio ral change is facilitat ed by a person al sense of control.

PND CUES

NSG. DX

PSYCHODYN AMICS

OBJECT IVE

THERAPEUTIC APPROACH

RATIONALE

S: Pag may problema ako, tinatawanan ko na lang o kaya nakikipagusap ako sa mga akibigan ko O: Calm Tries to maint ain eye conta ct A little bit confu sed Speak s softly Glanc es at times Smile

Readin ess for enhan ce coping

Sigmund Freuds Ego Defense Mechanism: Freud belie ved that the self or ego uses ego defen se mech anis m, whic h are meth ods of atte mpti ng to prote ct the self and cope with basic drive s or emoti onall y

Within the 2 meetin gs with the client he will be able to verbaliz e and negotia te with others to meet needs.

Help the client set realistic goals an identify personal skills and knowled ge

Encoura ge expressi on of positive thoughts and emotion s.

Providi ng validati on of actual stressor s and availabl e coping resourc es or strategi es aids in a positive adaptat ion to stress. Positive emotio ns initiate upward spiritual s toward enhanc ed emotio nal well being. Relaxati on training has been

EVALUATION AND JUSTIFICATI ON Within the 2 meetings with the client he will be able to verbalized and negotiate with others to meet needs as evidenced by: a) Verb al expr essio n of hid feeli ngs towa rds his probl em. b) Be able to plan actio ns regar ding on how to cope

Encoura ged the used of cognitive behavior al relaxatio n

painf ul thoug hts, feelin gs or event s.

demons trated to improv e

with certa in circu msta nces.