MENTAL STATUS EXAMINATION ANDPSYCHIATRIC NURSING ASSESSMENT A.

Appearance The patient dressed neatly and appropriately for his age but notwith the weather. He sees to it that he is clean, has taken a bath,c h a n g e d h i s c l o t h e s a n d b r u s h e d h i s t e e t h b e f o r e g o i n g o u t NurseClient interaction. He seems always alert and maintainseye contact whenever possible. He maintains a good posture andsteady gait. He experienced shaking of legs as a side effect of haloperidol. Generally he is well-nourished. He appears to be hisstated age. B.Speech H e t a l k s i n m o d e r a t e a n d l o u d , h i s w o r d s a r e c l e a r b u t sometimes stuttered. He skips from 1 topic to another, when hea n s w e r e d t h e q u e s t i o n m a r u n o n g k a n g m a g s u l a t k u y a ? h e answered opo maam, kumakanta at sumasayaw pa ako maamah. He talks non-stop, his responses are not minimal by yes orno, and rather he elaborates answers to questions asked. Most of t h e t i m e t h e c o n t e n t o f h i s w o r d s i s r e l e v a n t . H e d o e s n t manifest neologism. C.Level of Consciousness H e i s r e s p o n s i v e a n d n o t c o n f u s e d . H e w a s a b l e t o s u s t a i n attenti on but sometimes distracted with other patients whenthey talk very loud. He answers questions accurately and canfollow simple instructions such as to sit down and carry the chair. D.Emotional Status Most of the time he is happy but sometimes he cries in silentbecause he always remember her sister E. he verbalized thatsana andito siya, para kunin na niya ako dito. E.Cognitive Functioning He is oriented with person, place and time. He knows his fullname, and his sisters name. He is aware of the present day,month and year. He k n o w s h i s b i r t h d a y . H e w a s a b l e t o s p e l l children, can count 1-100 and can name days of the week andmonths of the year correctly. And also do simple calculation. F.Abstract Thinking When he was asked to interpret the common proverb Kungm a y r o o n g i t i n a g o , M a y m a d u d u k o t h e p r o v i d e s a l i t t l e explanation which is Nu indulin mu ti kwarta, adda maalam. Healso explained Aanhin pa ang damo kung patay na ang kabayow i t h A w a n e n a m a a m , n a t a y m e t d i a y k a b a y o n g a m a n g a n kuma. D u r i n g t h e w o r k i n g p h a s e w e a l s o a s k e d h i m t o e x p l a i n t h e massage of the song kanlungan, he answered Para sa akinpo, ang ibig sabihin ng kantang yan ay, isang buhay lang angmeron tayo at dapat nating pahalagahan ito dahil kapag tayoynamatay, mga ala-ala nalang ang maiiwan.He cant interpretthe meaning thus concrete thinking is present. G.Insight and Judgment

When we asked Nu adda ti mapidut mu nga pera anya tia r a m i d a m ? H e a n s w e r e d i s u b l i k a m a a m n g e m n u s i n g k o haanen panggatung ku latta ti sigarilyo kun. While in the ward,he still engages in smoking and even exchanges his things withcigarette. Hence, he has a poor judgment. He manifests good insight since he accepts the responsibility forhis actions. He verbalized Napabarkada kasi ako noon maam,n a n i n i g a r i l y o a k o a t u m i i , o m a k o ng hard liquor un bang gin m a a m . H e a l s o v e r b a l i z e d B e h a v e n a a k o m a a m , k a p a g nakalab as na ako maam di na ako maninigarilyo at iinom ngalak. H.Memory Recent: when he said nagluto ako ng nilagang saging noonmaam, nung si maam Alona pa ang student nurse ko eh. Immediate: w h e n h e i m m e d i a t e k n e w h i s s t u d e n t n u r s e s name, he stated that s i m a a m A l o n a F o r o n d a a n g s t u d e n t nurse ko maam. Remote: when he said naalala ko maam nung natanggal si Estrada bilang Pangulo, naimpitch pa nga siya eh, ang pumalit siGMA pero nandaya naman siya dahil dun sa Hello Garsi! I.Physiologic and Self Care Considerations The patient stated that he eats 3 times a day with 2 snacks, takesa bath everyday, changes his clothes daily and brushes his teetht h r i c e a d a y . H e u s u a l l y s l e e p s f o r 8 h o u r s a n d t a k e s a n a p a t daytime as a side effect of the drug. He takes his medicine atm o r n i n g a n d n i g h t . T h e p a t i e n t k n o w s p r o p e r h y g i e n e a n d compli es with the medications