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Mental Status Exam and Psychiatric Nursing Care Plan

Student Name: Morgan Butts Date of Admission: 02/13/2017
Patient’s initials: JS Date of Assessment:02/17/2017

Click on the gray box to type. Put an “x” in all that apply. Tab between boxes.
Identifying Gender: Male Female
Data: Age: 48 Unit: North Legal Status: BA 52 Allergies Tomatoes
Reason for Patient brought himself in for auditory hallucinations of voices telling him to
Admission: kill himself and with dissatisfaction with his current Assisted Living Facility

General Unkempt Unclean Well-groomed Posture: slumped

Appearance: Ht.: 6’ 4” Wt.:95.3 Pulse :74 Blood Pressure:102/63
Respirations:18 Temp: 98.2 F Pain/Other: none; 0 out of 10
Motor Tremors Tics Hyperactivity Restlessness
Activity: Aggressiveness Rigidity Psychomotor Retardation
Agitation Other:
Speech Slow Rapid Pressure of Speech Volume: elevated
Patterns: Stuttering Other:
General Cooperative Uncooperative Friendly Hostile Defensive
Attitude: Disinterested Apathetic Attentive Guarded
Other: Easily distracted
Mood: Sad Depressed Despairing Irritable
Anxious Elated Euphoric Fearful
Guilty Labile Other:
Affect: Congruent with mood Blunted Constricted
Flat Appropriate Fearful Other:
Thought Flight of ideas Associative Looseness Circumstantiality
Processes: Tangentiality Neologisms Concrete Thinking Clang
Word Salad Perseveration Mutism Poverty of Speech
Other: Poor vocabulary
Form: Ability to concentrate Attention span – How Long? Short- 2 minutes
Content: Delusions/type

Obsessions Paranoia Magical Thinking Religiosity

Phobias Poverty of Content Other:

Suicidal: if positive for ideation, state plan: positive; no direct plan

Homicide: if positive for ideation, state plan: negative

What does the patient’s topic of speech tell you about what he or she is
thinking? Patient’s topic of speech tells me that he is focused on discharge
and nothing more. He is not concerned with the current situations. His
thoughts are often short or interrupted by passersby.
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Perceptual Hallucinations/Type: The patient had auditory hallucinations commanding

Disturbances: him to kill himself. He hears them sometimes and is currently not
experiencing these hallucinations.

Illusions Depersonalization Derealization

Were hallucinations present prior to admission? No Yes per chart?

Judgment per patient? Hallucinations were auditory.
and Insight:
(impaired or intact) Ability to solve problems: impaired as evidenced by: need for prompting or
guidance with most tasks- mentally disabled

Ability to make decisions: impaired as evidenced by: Replies “I don’t know”

to most yes or no questions. Needs prompting.

Knowledge about self: intact as evidenced by: Awareness of age, living

arrangement and hallucinations

Memory: Recent Memory: Impaired Intact

Disoriented Confused

Orientation: patient is A&O to person and place but is unsure of time or

timeline of events
Sociocultural Patient volunteers at a soup kitchen at his church, received special education,
Factors: has no relationship to family members, lives in an ALF (Cara House) but
 Work? continually leaves, enjoys fishing and watching movies, and claims to have
 School? one friend living in Tampa and one living in Zephryhills in addition to his
 Family? roommates.
 Legal?
 Spiritual?
 Hobbies?
 Friends?
What medical concerns does your patient have? Sleep concerns?
Patient has been diagnosed with diabetes mellitus type 2, hypertension, experienced seizures, and has
a mild disability. With medication, patient has mild insomnia.
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Psychiatric Disorder(s) Bipolar disorder, Schizophrenia (Schizoaffective disorder)

Identify clinical behaviors that support the psychiatric diagnoses: Patient has poor critical thinking
skills, inability to care for himself, and

Psychiatric Brand Name: Depakote Generic Name: divalproex sodium

Medication:

Dose and Time: 1000 mg tab 1xDaily Date Ordered:02/14/2017

Purpose (for this patient): anti-convulsant for seizures and anti-manic for bipolar

Side Effects/Adverse Effects: drowsiness, thoughts of suicide

Nursing Considerations (include interactions with regular medications/ foods etc.):

Avoid caffeine-containing herbs and changing sodium intake. Monitor CBC and
serum levels. Monitor for signs and symptoms of toxicity.

Medication Effectiveness: Is this medication effective for your patient? Explain

how it is or how it is not. Yes; patient is not experiencing seizures. Mania is
controlled as evidenced by relaxed mood and posture, ability to concentrate,
slowed speech, and low energy.

What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Drowsiness- patient expresses he is still
tired shortly after waking.

Patient Teaching Needs: Do not drive while taking this medication, and talk to your
doctor if you experience thoughts of suicide with this therapy. Educate on signs of
toxicity and need for continual labs to monitor levels of Depakote.

(Vallerand, 2017)
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Medication: Brand Name: Haldol Decanoate Generic Name: haloperidol

Dose and Time: 200 mg IM Q4 weeks due 03/06/2017 Date Ordered: 02/06/2017
Purpose (for this patient): antipsychotic- Positive symptoms of Schizophrenia like
auditory hallucinations

Side Effects/Adverse Effects: seizures, EPS, drowsiness, blurry vision,

hypotension, tachycardia, constipation, dry mouth

Nursing Considerations (include interactions with regular medications/ foods

etc.): Do not give with other CNS depressants, alcohol, kava-kava, or chamomile.
Assess for mental status, positive symptoms, and possible EPS.

Medication Effectiveness: Is this medication effective for your patient? Explain

how it is or how it is not. Yes, patient not states he is not hearing voices any more.
Currently not displaying other positive symptoms of Schizophrenia.

What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Patient experiencing drowsiness and
has history of seizures. No other adverse effects were assessed.

Patient Teaching Needs: Do not drink alcohol, change positions slowly to avoid
orthostatic hypotension, and avoid driving after taking this medication. If signs of
EPS occur like uncontrollable movements, rolling tongue, or tremors, contact
your provider immediately.

(Vallerand, 2017)

Medication: Brand Name: Vistaril Generic Name: Hydroxyzine

Dose and Time: 1 50 mg tab Q6H PRN Date Ordered: 02/14/2017

Purpose (for this patient): PRN Anti-anxiety, sedative

Side Effects/Adverse Effects: drowsiness, headache, nausea, dry mouth, weakness

Nursing Considerations (include interactions with regular medications/ foods etc.):

Do not administer with other CNS depressant, kava-kava, or chamomile. Additive
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anticholinergic effects with antihistamines, antidepressants, and haloperidol.

Medication Effectiveness: Is this medication effective for your patient? Explain

how it is or how it is not. Yes. Patient seems relatively anxious but controlled.

What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Patient experiencing drowsiness but no
headache, nausea, or weakness.

Patient Teaching Needs: Do not drink alcohol, and avoid driving after taking this
medication.

(Vallerand, 2017)

Medication: Brand Name: Restoril Generic Name: temazepam

Dose and Time: 1 30 mg cap PRN Date Ordered: 02/14/2017

Purpose (for this patient): PRN insomnia

Side Effects/Adverse Effects: dizziness, drowsiness, hallucinations, lethargy,

nausea, vomiting, diarrhea, blurred vision

Nursing Considerations (include interactions with regular medications/ foods etc.):

Do not give with other CNS depressants, kava-kava, or chamomile. Rifampin and
smoking decrease effectiveness. Assess mental status, suicidal thoughts, and
physical dependence after long-term use.

Medication Effectiveness: Is this medication effective for your patient? Explain

how it is or how it is not. Patient has not taken medication within 7 days.

What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? No, patient has not taken medication in
7 days.

Patient Teaching Needs: Do not drink alcohol, avoid driving until after familiar
with effects, and complex sleep behaviors like sleep-driving may occur.

(Vallerand, 2017)
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Medication: Brand Name: Cogentine Generic Name: benzotropine

Dose and Time: 1 mg tab Q4H PRN Date Ordered: 02/14/2017

Purpose (for this patient): PRN EPS

Side Effects/Adverse Effects: drowsiness, dizziness, loss of appetite, vision

changes, tremors

Nursing Considerations (include interactions with regular medications/ foods etc.):

Do not administer with antihistamines, phenothiazines, quinidine, disopyramide,
and TCAs for increased anticholinergic effects. Assess EPS, bowel function, pulse,
and BP closely.

Medication Effectiveness: Is this medication effective for your patient? Explain

how it is or how it is not. Yes, patient is not experiencing any EPS.

What are the specific adverse effects your patient is experiencing? What
significant ones are they not experiencing? Patient is experiencing drowsiness but
no loss of appetite or tremor.

Patient Teaching Needs: Report any GI discomfort, do not operate heavy

machinery due to drowsiness effect, and change positions slowly to avoid
orthostatic hypotension.

(Vallerand, 2017)

Lab Values/Diagnostic Hematology

Tests related to psychiatric Test: WBC Value: 3.1 (L)
disorder
Nursing Interventions: reduce risk for infection, teach patient proper
hygiene, assess for signs of infection

Test: RBC Value: 4.48

Nursing Interventions: within normal range

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Test: HGB Value: 13.4 (L)

Nursing Interventions: check for fluid overload, administer iron high

foods if anemia is present, assess if patient smokes cigarettes and
provide smoking cessation tips if so, educate about decreasing dark,
leafy greens

Test: HCT Value:38.3 (L)

Nursing Interventions: administer proteins and irons, check fluid

levels and edema in case of overhydration

Test: MCV Value:85.5

Nursing Interventions: Watch for continual drop. If below 80, this

could indicate anemia.

Test: MCH Value:30.0

Nursing Interventions: within normal range

Test: MCHC Value:35.1

Nursing Interventions: within normal range

Test: RDW Value:14.3

Nursing Interventions: within normal range

Test: PLT Value:158

Nursing Interventions: within normal range

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Test: MPV Value:9.6

Nursing Interventions: within normal range

Test: Segs Value:49.0

Nursing Interventions: within normal range

Test: Lymphs Value:32.4

Nursing Interventions: within normal range

Test: Mono Value:14.7 (H)

Nursing Interventions: assess for signs of infection, teach proper

hygiene to patient

Test: Eos Value:3.2

Nursing Interventions: within normal range

Test: Baso Value:0.7

Nursing Interventions: within normal range

Test: Neutrophil, Abs Value:1.5

Nursing Interventions: within normal range

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Test: Lymph, Abs Value:1.0

Nursing Interventions: within normal range

Test: Monocyte, Abs Value:0.5

Nursing Interventions: within normal range

Test: Eosinophil, Abs Value:0.1

Nursing Interventions: within normal range

Test: Basophil, Abs Value: 0.0

Nursing Interventions: within normal range

Urinalysis
Test: Color Value:Yellow

Nursing Interventions: within normal range

Test: Appearance Value: Clear

Nursing Interventions: within normal range

Test: Sp Gravity Value:1.030

Nursing Interventions: within normal range

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Test: pH Value:7.0

Nursing Interventions: within normal range

Test: Protein Value: Negative

Nursing Interventions: within normal range

Test: Glucose Value: Negative

Nursing Interventions: within normal range

Test: Ketone Value: Negative

Nursing Interventions: within normal range

Test: Bilirubin Value: Negative

Nursing Interventions: within normal range

Test: Blood Value: Negative

Nursing Interventions: within normal range

Test: Urobilinogen Value: 0.2

Nursing Interventions: within normal range

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Test: Leuk Est Value: Negative

Nursing Interventions: within normal range

Test: Nitrite Value: Negative

Nursing Interventions: within normal range

Test: RBC Value:3

Nursing Interventions: within normal range

Test: WBC Value: 0

Nursing Interventions: within normal range

Test: Sq Epith Value: Negative

Nursing Interventions: within normal range

Test: Hyaline Cast Value: Negative

Nursing Interventions: within normal range

Test: Bacteria Value: Negative

Nursing Interventions: within normal range

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General Chem
Test: PC Sodium Value:143

Nursing Interventions: within normal range

Test: PC Potassium Value:4.1

Nursing Interventions: within normal range

Test: PC Chloride Value:106

Nursing Interventions: within normal range

Test: PC tCO2 Value:24

Nursing Interventions: within normal range

Test: PC Glucose Value:107 (H)

Nursing Interventions: slightly elevated due to Depakote but

insignificant considering patient has diabetes. Administer low
carbohydrate foods and glucose controlling medications

Test: PC BUN Value:19

Nursing Interventions: within normal range

Test: PC Creat Value:0.70

Nursing Interventions: within normal range

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Test: Calcium Value:8.5

Nursing Interventions: within normal range

Test: Protein, Tot Value:7.6

Nursing Interventions: within normal range

Test: Albumin Value:3.5

Nursing Interventions: within normal range

Test: Globulin Value:4.1

Nursing Interventions: within normal range

Test: Alb/Glob Value:0.9

Nursing Interventions: within normal range

Test: Bili, Total Value:0.2

Nursing Interventions: within normal range

Test: Alk Pho Value:99

Nursing Interventions: within normal range
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Test: ALT Value:16

Nursing Interventions: within normal range

Test: AST Value:11

Nursing Interventions: within normal range

Test: PC Ion CA Value:2.1

Nursing Interventions: within normal range

Test: Magnesium Value:2.1

Nursing Interventions: within normal range

Lipids
Test: Triglyceride Value:342 (H)

Nursing Interventions: monitor diabetic control, administer low fatty

foods, encourage other lifestyle changes like consistent exercise

Test: Cholesterol Value:213 (H)

Nursing Interventions: monitor diabetic control; give low cholesterol,

carbohydrate, and low fat foods

Drug Levels
Test: Acetaminophen Value:<2.0
Nursing Interventions: within normal range

Test: Ethanol Level Value:<3

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Nursing Interventions: within normal range

Test: Salicylates Value:<2.0

Nursing Interventions: within normal range

Test: Valproic Acid Value:63.4

Nursing Interventions: within normal range

Special Chem
Test: Hgb A1c Value:5.3

Nursing Interventions: within normal range

Test: eAG Value:105

Nursing Interventions: within normal range

Test: TSH Scrn Value:2.150

Nursing Interventions: within normal range

Urine Chemistry
Test: Ur Opiates 300 Value: Neg <300

Nursing Interventions: within normal range

Test: Oxycodone Scr Value: Neg <300

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Nursing Interventions: within normal range

Test: Ur Amph Screen Value: Negative

Nursing Interventions: within normal range

Test: Ur Benzo Screen Value: Neg <200

Nursing Interventions: within normal range

Test: Ur Cann Screen Value: Neg <50

Nursing Interventions: within normal range

Test: Ur Coc Screen Value: Neg <300

Nursing Interventions: within normal range

Test: Methadone Scr Value: Neg <300

Nursing Interventions: within normal range

Test: Ur DAU Note Value:Unknown

Nursing Interventions: None

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Use the following format: nursing diagnosis related to **** as evidenced by (or manifested by)****. (For example: ineffective airway clearance
related to pain, position, and possible complication on affected side as manifested by shortness of breath, shallow respirations, use of accessory
muscles.) OR risk nursing diagnosis: risk factors (For example, Risk for injury: Risk factors unsteady gait, history of previous falls, blood alcohol
>0.20).

For this assignment, please focus on the psych mental health diagnoses. Your textbook and your NCP book provide excellent examples relating to a
variety of PMH diagnoses.

Use nursing assessment, measurable clinical findings, and values to formulate nursing diagnoses, patient goals, nursing interventions based on
evidence-based practice, and applicable evaluations. Evaluation – if they met goals, explain how you know this; If not, why not.

Assessment Nursing Diagnosis Goals Interventions Evaluations

Subjective:
Patient states his facility
made him shower in a
dissatisfied manner.
Self-care deficit related Client will take a 1. Encourage client to Patient did not shower
to perceptual and shower by the end of independently perform by the end of the day.
cognitive impairment as the day. ADLs Patient was more
evidenced by negative 2. Offer positive reinforcement concerned with other
symptoms of for like allowing the patient activities that day.
Schizophrenia and extra television time once he
maintaining appearance has showered.
at a satisfactory level. 3. Intervene when client is
unable to perform ADLs.

Objective:
Patient was odorous,
and his appearance was
unkempt and unclean.
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Assessment Nursing Diagnosis Goals Interventions Evaluations

Ineffective coping Patient will verbalize 1. Identify stressors that Patient did not
related to severe level of understanding the he or precipitate severe anxiety verbalize understanding
anxiety in environment she is employing 2. Have patient identify of his dissociative
as evidence by dissociative behaviors methods of coping with behavior. Patient did
Subjective: inadequate problem in times of psychosocial stress in the past and not verbalize more
Patient explains that he solving. stress. determine whether the adaptive ways of
is dissatisfied with the Patient will verbalize response was adaptive or coping. Patient was
facility he was in, so he more adaptive ways of maladaptive. preoccupied with
left. coping in stressful 3. Help patient define more discharge, the other
situations than resorting adaptive coping strategies patients, and the daily
to dissociation by the activities.
end of the shift.

Objective:
Patient continually
leaves the same ALF
when troubles arise.
Patient fled facility and
was returned ten days
prior to this elopement.
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Long-term Within 1 month, the patient will: have all self-care needs met
Goals: independent of staff and demonstrate ability to cope with stress

Discharge Planning Work with case management and ALF patient will be discharged to
Issues/Considerations determine ways he can better manage himself independently. Ensure
medicine adherence to decrease psychotic episodes and elopement.
Explore other ALFs that may suit the patient, his needs, and insurance
better than his previous facility.