Scribd Logo
Upload

Welcome to Scribd!

  • 40 views

    MENTAL STATUS ASSESSMENT Form

    Uploaded by

    Liza Soberano
    The document provides a mental status assessment of a 21-year-old female student named Arfa Binasing Kamad. The summary includes: 1) The patient cooperates actively during the assessment and appears calm with proper posture, gait, and station. Her affect is congruent with her mood and speech is normal. 2) The patient reports feeling good and her mood appears normal and positive. Her thinking is goal-directed and responses are relevant and coherent with no evidence of perceptual disturbances. 3) The patient is fully oriented with intact memory and intellectual functioning. She demonstrates insight into her stress and coping mechanisms. Her judgment appears normal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    MENTAL STATUS ASSESSMENT Form

    Uploaded by

    Liza Soberano
    40 views6 pages
    The document provides a mental status assessment of a 21-year-old female student named Arfa Binasing Kamad. The summary includes: 1) The patient cooperates actively during the assessment and appears calm with proper posture, gait, and station. Her affect is congruent with her mood and speech is normal. 2) The patient reports feeling good and her mood appears normal and positive. Her thinking is goal-directed and responses are relevant and coherent with no evidence of perceptual disturbances. 3) The patient is fully oriented with intact memory and intellectual functioning. She demonstrates insight into her stress and coping mechanisms. Her judgment appears normal.

    Original Title

    MENTAL-STATUS-ASSESSMENT-Form

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document provides a mental status assessment of a 21-year-old female student named Arfa Binasing Kamad. The summary includes: 1) The patient cooperates actively during the assessment and appears calm with proper posture, gait, and station. Her affect is congruent with her mood and speech is normal. 2) The patient reports feeling good and her mood appears normal and positive. Her thinking is goal-directed and responses are relevant and coherent with no evidence of perceptual disturbances. 3) The patient is fully oriented with intact memory and intellectual functioning. She demonstrates insight into her stress and coping mechanisms. Her judgment appears normal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    40 views6 pages

    MENTAL STATUS ASSESSMENT Form

    Uploaded by

    Liza Soberano
    The document provides a mental status assessment of a 21-year-old female student named Arfa Binasing Kamad. The summary includes: 1) The patient cooperates actively during the assessment and appears calm with proper posture, gait, and station. Her affect is congruent with her mood and speech is normal. 2) The patient reports feeling good and her mood appears normal and positive. Her thinking is goal-directed and responses are relevant and coherent with no evidence of perceptual disturbances. 3) The patient is fully oriented with intact memory and intellectual functioning. She demonstrates insight into her stress and coping mechanisms. Her judgment appears normal.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 6

    KASIM, FAISHA M.

    January 31, 2022


    GROUP A2 Prof. Jeory B. Gutigulao

    MENTAL STATUS ASSESSMENT


    I. GENERAL INFORMATION

    Name of Patient: ____Arfa Binasing Kamad_________________


    Address:__RH8 Cotabato City______________________________________
    Age: __21_____ Sex: _F______ Height: __5’3_______ Weight: __65kg_________
    Civil Status: _S_____ Occupation: __Student_______ Religion: _Islam___________
    Educational Assessment: _______________________________________________
    Name of Spouse: ______________________________________________________
    Age: ________ Religion: ______________________________________________
    Educational Attainment: ________________________________________________
    Occupation: ____________________________ Number of Children: ____________

    Date of Admission: _________________ Type of Admission: _________________


    Number of Admissions: ___________________
    Chief Complaints upon admission: ________________________________________
    ____________________________________________________________________
    ____________________________________________________________________
    ____________________________________________________________________

    Diagnosis: ( Multiaxial System)


    Axis I.

    Axis II.

    Axis III.

    Axis IV.

    Axis V.

    1
    II. GENERAL DESCRIPTION
    APPEARANCE
    A. Dress (situation and age appropriate?)
    1. Appropriate (/) 2. Inappropriate

    B. Grooming, Hygiene (situation and age appropriate?)


    1. Appropriate (/) 2. Inappropriate

    C. Age Appearance
    1. Stated (/) 2. Younger 3. Older

    III. BEHAVIOR
    A. Manner of Relating
    1. Cooperative (/)
    2. Indifferent
    3. Withdrawn
    4. Defensive

    Remarks: _My patient cooperates actively when being asked

    B. Psychomotor activity
    1. Appropriate to Situation (/)
    2. Hyperactivity
    3. Retardation
    4. Tremor
    5. Purposeless activity
    6. Posture
    (1) normal (/) (2) abnormal
    7. Gait and station
    (1) Normal (/) (2) abnormal
    8. Repetitive behaviors

    Remarks: _The patient normally responds appropriate to the situation, appears calm, with proper
    posture, gait and station

    C. Speech, Language
    1. Intensity
    (1) normal (/) (2) loud (3) soft

    2. Pitch
    (1) Normal (/) (2) monotone (3) wide swings

    3. Rate
    (1) Normal (/) (2) pressured (3) slow (4) halting

    2
    4. Spontaneity, productivity
    (1) normal (/) (2) intrusive (3) decreased

    5. Relevance, coherence
    (1) Normal (/) (2) incoherent (3) irrelevant

    6. Deviations
    (1) None (/)
    (2) Aphasia
    (3) Neologisms
    (4) Echolalia
    (5) Stammering
    (6) Clanging
    (7) Verbigeration
    (8) Perseveration
    Others, specify _________________________
    7. Vocabulary, diction, syntax
    (1) Appropriate to socio-educational background (/)
    (2) Not appropriate to socio-educational background
    Remarks: _The patient is normally responsive to cues during interview. No stuttering being
    observed.

    IV. AFFECT
    A. Appropriate to content (/)

    B. Apathetic

    C. Inappropriate
    D. Shallow

    E. Blunted
    F. Flat
    Remarks: _Patient present responsiveness, appropriate facial expression, not irritable, affect is
    congruent to her mood, range is within normal range

    V. MOOD
    A. Normal (/)
    B. Anxious
    C. Sad, depressed
    D. Happy, elated
    E. Worried, perplexed
    F. Labile
    Remarks: _The patient states she feels good, normal and positive mood was observed

    3
    VI. THINKING

    A. THOUGHT
    1. Form
    (1) normal (/) (3) referential (5) scattered
    (2) concrete (4) illogical

    2. Progression
    (1) normal (/) (3) tangential (4) flight of ideas
    (2) circumstantial (4) loose association (6) blocking

    3. Content
    a. Normal appropriate (/)
    b. Persecutory treads
    c. Paranoia, delusions
    d. Hypochondriacal trends
    e. Grandiosity
    f. Obsessive thoughts
    g. Phobias
    h. Depressive trends
    i. Poverty of thoughts

    Remarks: _the patient replies really the answer being askes, has a goal-directed thinking.
    Responses are relevant and coherent. The patient doesn’t have thought of doing self-harm or
    harming others.

    B. PERCEPTION
    1. Normal (/)
    2. Hallucinations
    a. Olfactory
    b. Visual
    c. Gustatory
    d. Auditory
    e. Tactile
    f. Others, specify ___________
    Remarks: _there are no perceptual disturbances being experienced and observed by the patient.

    C. GENERAL KNOWLEDGE AND INFORMATION

    1. Tests: What planet do we live on?

    2. Conclusion:
    a. Normal for socio-educational background (/)
    b. Not normal for socio-economic background

    Remarks: Patient answered the question correctly and socio-educational background is normal.

    D. SENSORIUM AND INTELLECTUAL FUNCTION


    1. Orientation
    a. Time – oriented
    b. Place – oriented
    c. Person – oriented

    4
    d. Situation – oriented
    2. Memory
    a. Immediate (1) Normal (/) (2) Impaired
    Test: The medication ticket in NDH are TID – PINK, QID – BLUE, BID –
    YELLOW, OD –WHITE. I will ask you after 3 mins.

    b. Recent (1) Normal (/) (2) Impaired


    Test: “who is the level 3 coordinator?”

    c. Remote (1) Normal (/) (2) Impaired


    Test: “What ncm subjects we took during our second year second
    semester?”

    d. Specific abnormalities
    □ Amnesia
    □ Hypermnesia
    □ Confabulation
    3. Abstract Reasoning
    Test: What is the similarities between metzenbaum and mayo scissors?

    Remarks: _The patient is oriented to time, place, person, and situation. Patient has sharp memory
    and can recall things and events. Patient ihas abstract ideas

    4. Calculations and concentration


    Test: How many ml in one liter? If 1kg is equivalent to 1000g, how many g do 5
    kg have?

    Remarks: The patient understood immediately the question and respond appropriately with
    correct answers.

    E. INSIGHT
    1. Normal (/) 2. Impaired
    Test: What is the purpose of our interview today?; For you what is the difficult subject
    you have in this semester?; What are the usual challenges you experienced in nursing and
    what are your coping mechanisms?

    Remarks: _The patient states that she usually experience stress and stress eating is her coping
    mechanism. The patient express her insights freely. Patient is capable for social judgment

    5
    F. JUDGMENT
    1. Normal (/) 2. Impaired
    Test: What is the purpose of our interview today?; For you what is the difficult
    subject you have in this semester?; What are the usual challenges you experienced in
    nursing and what are your coping mechanisms?

    Remarks: The patient states that she usually experiences stress and stress eating is her coping
    mechanism. The patient express her insights freely

    VII. IDEATION
    There is no suicidal or homicidal ideation.

    VIII. ADDICTIVE AND COPING HABITS

    IX. SEXUAL FUNCTIONING


    X. NEED LEVEL

    XI. DEVELOPMENTAL LEVEL

    XII. COPING DEVICES/DEFENSE MECHANISMS


    (Cite instances)

    XIII. ASSETS, RESOURCES AND INTERESTS

    XIV. IMPRESSION

    XV. NURSING DIAGNOSIS/ES

    *****************

    You might also like