Mental Status Exam Essay Example

Mental Status Exam Essay Example Mental Status Exam Essay Mental Status Exam Essay Thuy Huynh November 16, 2012 Mental Status Exam 1) Appearance (unkempt, unclean, clothing disheveled, atypical clothing, well-groomed, drab, meticulous, obese, underweight, etc. ) -clothing were disheveled, unshaven-ed beard, unclean, unkempt attire 2) Attitude (resistive, cooperative, complacent, detached, resentful, suspicious, uncooperative, overly compliant, provocative, other symptom) -detached from surrounding environment, seemed to be on guard at all times 3) Mood (sad, melancholy, euphoric, labile, irritable, hostile, apathetic, anxious, other symptom) -anxious ) Affect (flat, blunted, appropriate to mood, inappropriate to mood, euphoric, other symptom) -animatedand/or inappropriate affect 5) Behavior (repetitive movements, posturing, waxy flexibility, agitated, impulsive, seductive, anxious, avoids eye contact, psychomotor retardation, hyperactive, violent, restless, other symptom) -anxious, restlessness, pacing back and forth, talking to self, performing defensive moves in hallway, paranoid 6) Speech Content (grandiose, self-depreciative, flight of ideas, loose associations, ideas of reference, hallucinations, delusions, phobias, other ymptom) loose associations 7) Speech Quality and Quantity (overly talkative, slowed, pressured, mute, stutter, dysarthria, guarded, calm, monotone, soft, loud, relevant, coherent, other) monotone at times, when speaking to self speech was soft, incoherent on occasion 8) Sensorium and Intellectual Functioning A) Orientation- did not seem oriented to place or time B) Memory (remote, retention, confabulation)- not able to track C) Patient’s store of general information- knew basic information D) Ability to Abstract-not able to assess ) Insight (patient’s reaction to problem and assessment of causes) -was not quite able to get an accurate assessment on whether or not he had insight to his disease 10) Judgement (regarding own health and business affairs) -not able to make own decisions about own health and business affairs 11) Suicidal and/or Homicidal Risk -was not able to assess 12) Erikson stages: chronological Generativity vs. Stagnation actual – Industry vs. Inferiority 13) Defense mecha nisms: projection, regression Axis I – schizophrenia, paranoia Axis II Axis III Axis IV Axis V Psych. Meds Three top priority nursing diagnoses for this patient: 1- Disturbed personal identity r/t inability to distinguish self and nonself AEB bizarre, regressive behavior, disorganized thought process, and inappropriate affect. 2- Ineffective health maintenance r/t inability to identify, manage, and seek out help in order to maintain health AEB lack of sleep and inability to follow through with ADLs. 3- Ineffective coping r/t maturational and/or situational crises AEB alterations in societal participation and inability to follow rules.