CHAPTER VII

NURSING MANAGEMENT

INITIAL MENTAL STATUS EXAMINATION

1. PRESENTATION

A. General Appearance

Upon NPI, patient is wearing ward gown, the patient appears clean and tidy. She has a
shaved head, eyes is symmetrical in movement and her lips are pale. Patient has a complete set of
teeth. Her fingers are well-trimmed and clean. The patient has bad odor. She is slim and has a
normal posture.

B. General Mobility

1. Posture and Gait

( ) Normal ( ) Appropriate ( ) inappropriate

Describe: Patient is straight in posture with normal gait.

2. Activity

( ) Normoactive ( ) Hyperactive ( ) Psychomotor Retardation ( ) Agitated

Describe: Patient has slow movement.

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3. Facial Expression

Quantity:

( ) Smiling ( ) Worried ( ) Happy ( ) Tense ( ) Ecstasy ( ) Sad ( ) Fearful ( ) Angry ( ) Suspicious

( ) Frightened ( ) Distant

Describe: Since it was our first meeting with the patient seemed distant and doesn’t seem interested
with the conversation.

C. Behavior:

The patient appears shy and quiet. She gives only limited answers to the question.

D. Nurse – Patient Interaction

( ) Cooperative ( ) Initially only ( ) Uncooperative ( ) Throughout Interview

Quality:

( ) Warm ( ) Distant ( ) Suspicious ( ) Talkative ( ) Hostile ( ) Others

II. STREAM OF TALK

A. Character of Talk

( ) Spontaneous ( ) Deliberate

B. Organization of Talk

( ) Relevant ( ) Tangential ( ) Flight of Ideas ( ) Irrelevant ( ) Incoherent

( ) Loose Association ( ) Others:

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C. Accessibility

( ) Good ( ) Poor ( ) Self – absorbed ( ) Fair ( ) Inaccessible ( ) Mute ( ) Defensive

Describe: The patient takes long before she responds to questions being asked to her.

III. Emotional State and Reaction

A. Mood

( ) Euthymic ( ) Depression ( ) Euphoria ( ) Others:

Describe: throughout our initial NPI, the patient appears empty.

B. Affect

( ) Appropriate ( ) Inappropriate

Quality:

( ) Flat ( ) Blunted ( ) Labile ( ) Hostile ( ) Elated ( ) Others:

Describe: The patient doesn’t have any facial expressions that would indicate emotion as mood

C. Depersonalization and Derealization

( ) Present ( ) Absent

D. Suicidal Potential

( ) Present ( ) Absent

E. Homicidal

( ) Present ( ) Absent

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IV. Thought Control

A. Perception: Hallucination

( ) Present ( ) Absent

Type: Visual

Describe: during our NPI we noticed that the patient’s eyes was wandering around so we asked
her if she is seeing someone aside from us. The patient stated that she is seeing 15 dancing girls.

B. Delusions

( ) Present ( ) Absent

Type:

Describe:

C. Ideas of Reference

( ) Present ( ) Absent

Type:

Describe:

D. Déjà vu and Jamais vu

( ) Present ( ) Absent

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V. NEUROVEGETATIVE DYSFUNCTIONS

A. Sleep

( ) Normal ( ) Hypersomnia ( ) Late Insomnia ( ) Mixed

B. Appetite

( ) Normal ( ) Increased ( ) Decreased

C. Weight: 41 kg.

D. Diurnal Variation

( ) Present ( ) Absent

E. Libido

( ) Present ( ) Absent

Describe: The patient didn’t show sexual desire.

F. Attention Span

( ) Present ( ) Absent

Describe: After 5 minutes talking the patient, she was uncooperative to the interview.

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VI. GENERAL SENSORIUM AND INTELLECTUAL STATUS

A. Orientation

( ) Time ( ) Person ( ) Place ( ) Situation

Describe: The Patient is oriented to time, name of the persons and the place but was silent when
asked the reason why she was taken to the hospital.

B. Memory

( ) Remote ( Immediate ( ) Recent ( ) Impaired ( ) Situation

Describe: The patient remember the schools she attended and our names when asked again after
the interview.

C. Calculation

Describe: The patient was able to perform mathematical operation but takes long before she
answers and got only one mistake when asked with serial seven test; 100-7=93; 93-7=86; 86-7=78;
78-7=71; 71-7=64.

D. General Information

Unimpaired:

Nurse: kaila ka kinsa atong President karon?

Patient: Duterte

Patient was able to answer the question appropriately.

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E. Abstract Information

Describe: The patient’s abstract thinking is poor when asked about her interpretation with the
saying “aanhin pa ang damo Kung patay na ang kabayo” the patient answered “wala nay
katubuan”.

F. Judgment and Reasoning

Describe: The patient’s judgment and reasoning is good when asked “unsa imo buhaton kong naay
sunog?” the patient answered “palungon gamit ang tubig.”

G. Comprehension

Describe: The patient was able to understand the questions being asked to her but she appears to
have thought blocking because whenever we ask her she looked like she understood the question
but chooses not to answer us.

VII. INSIGHT

Describe: The patient’s insight is impaired when asked for the reason why she was taken in the
hospital, the patient answered “ambot lang.”

VIII. SUMMARY OF MENTAL STATUS EXAMINATION

A. Disturbance in

( ) Presentation ( ) Stream of Talk ( ) Emotional State and Reaction

( ) General Sensorium and Intellectual Status ( ) Thought Control

( ) Neurovegetative dysfunction

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B. Diagnostic Category

( ) Functional ( ) Psychotic ( ) Organic ( ) Non-Psychotic ( ) Both Functional and Organic

IX. DEVELOPMENTAL TASK (Ideal)

Intimacy vs. Isolation

Occurring in young adulthood (ages 18 to 40 yrs), we begin to share ourselves more

intimately with others. We explore relationships leading toward longer-term commitments with
someone other than a family member.

Successful completion of this stage can result in happy relationships and a sense of
commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and
relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will
lead to the virtue of love.

Reference: SimplyPsychology.Org

DEVELOPMENTAL TASK (Actual)

The patient was not able to form an intimate relationship with anyone. She didn’t mention
being in a romantic relationship or having a very close friend whom she trusts and shares her
secrets.

TEN IDENTIFIED NURSING PROBLEMS

1. Self-care deficit

2. Disturbed thought process

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3. Ineffective coping

4. Impaired verbal communication

5. Impaired social interaction

6. Low self esteem

7. Disturbed sensory perception

8. Decreased attention span

9. Risk for injury

10. Risk for harming others

FIVE PRIORITY NURSING PROBLEMS (STATE IN NURSING DIAGNOSIS)

1. Disturbed thought process related to cognitive impairment secondary to schizophrenia

2. Self-care deficit related to perceptual or cognitive impairment secondary to schizophrenia

3. Impaired verbal communication related to disordered thinking secondary to schizophrenia

4. Impaired social interaction related to cognitive impairment secondary to schizophrenia

5. Social isolation related to low self-esteem secondary to schizophrenia

Diagnostic and Statistical Manual of Mental Disorders (DSM)

AXIS I – Schizophrenia

AXIS II – Schizotypal personality disorder

AXIS III – Seborrheic Dermatitis

AXIS IV – Socio economic status

AXIS V – 21-30 Positive Hallucination

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DIFFRENTIAL DIAGNOSIS

5 / 6 x 100 = 83.33 % Residual Schizophrenia

A form of schizophrenia that is characterized by a previous diagnoses of schizophrenia,

but no longer having any of the prominent psychotic symptoms. There are some remaining
symptoms of the disorder however, such as eccentric behavior, emotional blunting, illogical
thinking, or social withdrawal.

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FINAL MENTAL STATUS EXAMINATION

1. PRESENTATION

A. General Appearance

Patient appears sleepy. She is wearing stripes shirt and leggings. She has a shaved head,
eyes are symmetrical in movement and her lips appears cyanotic. Patient has a complete set of
teeth. Her fingers are well-trimmed and clean. The patient has bad odor. She is slim and has a
normal posture.

B. General Mobility

1. Posture and Gait

( ) Normal ( ) Appropriate ( ) inappropriate

Describe: The patient walks normally with coordination. She is able to sit on chair in an
appropriate and normal manner.

2. Activity

( ) Normoactive ( ) Hyperactive ( ) Psychomotor Retardation ( ) Agitated

Describe:

The patient has a slow movement.

3. Facial Expression

Quantity:

( ) Smiling ( ) Worried ( ) Happy ( ) Tense ( ) Ecstasy ( ) Sad ( ) Fearful ( ) Angry ( ) Suspicious

( ) Frightened ( ) Distant

Describe: The patient looked distant and seems disinterested with the conversation.

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C. Behavior

The patient looked tired and sleepy. She seems more focused on the television than to us.

D. Nurse – Patient Interaction

( ) Cooperative ( ) Initially only ( ) Uncooperative ( ) Throughout Interview

Quality:

( ) Warm ( ) Distant ( ) Suspicious ( ) Talkative ( ) Hostile ( ) Others

II. STREAM OF TALK

A. Character of Talk

( ) Spontaneous ( ) Deliberate

B. Organization of Talk

( ) Relevant ( ) Tangential ( ) Flight of Ideas ( ) Irrelevant ( ) Incoherent

( ) Loose Association ( ) Others :

C. Accessibility

( ) Good ( ) Poor ( ) Self – absorbed ( ) Fair ( ) Inaccessible ( ) Mute ( ) Defensive

Describe:

The patient stares blankly at times and would give limited answer to our questions.

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III. Emotional State and Reaction

A. Mood

( ) Euthymic ( ) Depression ( ) Euphoria ( ) Others:

Describe:

The patient looked empty and indifferent.

B. Affect

( ) Appropriate ( ) Inappropriate

Quality:

( ) Flat ( ) Blunted ( ) Labile ( ) Hostile ( ) Elated ( ) Others:

Describe:

During our final NPI, the patient was lacking emotional expressiveness.

C. Depersonalization and Derealization

( ) Present ( ) Absent

D. Suicidal Potential

( ) Present ( ) Absent

E. Homicidal

( ) Present ( ) Absent

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IV. Thought Control

A. Perception: Hallucination

( ) Present ( ) Absent

Type:

Describe: During our final NPI we asked the patient if she still see the girls she mentioned in
our initial NPI, she said she doesn’t see them anymore.

B. Delusions

( ) Present ( ) Absent

Type:

Describe:

C. Ideas of Reference

( ) Present ( ) Absent

Type:

Describe:

D. Déjà vu and Jamais vu

( ) Present ( ) Absent

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V. NEUROVEGETATIVE DYSFUNCTIONS

A. Sleep

( ) Normal ( ) Hypersomnia ( ) Late Insomnia ( ) Mixed

B. Appetite

( ) Normal ( ) Increased ( ) Decreased

C. Weight: 41 kg

D. Diurnal Variation

( ) Present ( ) Absent

E. Libido

( ) Present ( ) Absent

Describe:

The patient doesn’t show sexual desire.

F. Attention Span

( ) Present ( ) Absent

Describe: The patient’s attention span is good only for 10 minutes.

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VI. GENERAL SENSORIUM AND INTELLECTUAL STATUS

A. Orientation

( ) Time ( ) Person ( ) Place ( ) Situation

Describe:

The patient is oriented to time, name of persons and place but still doesn’t understand her
condition.

B. Memory

( ) Remote ( ) Immediate ( ) Recent ( ) Impaired ( ) Situation

Describe:

She was able to remember the schools she attended and her 4th year of high school adviser.
She was also able to recite the words we gave her ( orange, apple, mango) and was able to recite
it backwards. The patient was also able to recall what we did last week which was the interview.

C. Calculation

Describe:

The patient was able to answer the serial sevens test correctly but takes long pause before
she answers it.

100 – 7 = 93; 93 – 7 = 86; 86 -7 = 79; 79 – 7 = 72; 72 – 7 = 65

D. General Information

Unimpaired:

Nurse: kaila ka kinsa atong president karon?

Patient: Duterte

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Nurse: ang mayor sa davao?

Patient: Inday Sara.

The patient was able to answer the question appropriately.

E. Abstract Information

Good:

Nurse: Unsa man ang kalahian sa barko ug eroplano?

Patient: ang barko sa dagat, ang eroplano molupad.

Describe:

The patient was able to give relevant answer.

F. Judgment and Reasoning

Good:

Nurse: Unsa may buhaton nimo kung makakita kag pitaka?

Patient: Iuli.

Describe:

The patient was able to answer the question appropriately.

G. Comprehension

Describe: The patient can understand the question but can’t elaborate thought.

VII. INSIGHT

Describe:

The patient still doesn’t understand her situation.

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VIII. SUMMARY OF MENTAL STATUS EXAMINATION

A.Disturbance in

( ) Presentation ( ) Stream of Talk ( ) Emotional State and Reaction

( ) General Sensorium and Intellectual Status ( ) Thought Control

( ) Neurovegetative dysfunction

B. Diagnostic Category

( ) Functional ( ) Psychotic ( ) Organic ( ) Non-Psychotic ( ) Both Functional and Organic

Intimacy vs. Isolation

Occurring in young adulthood (ages 18 to 40 yrs), we begin to share ourselves more

intimately with others. We explore relationships leading toward longer-term commitments with
someone other than a family member.

Successful completion of this stage can result in happy relationships and a sense of
commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and
relationships can lead to isolation, loneliness, and sometimes depression. Success in this stage will
lead to the virtue of love.

Reference: SimplyPsychology.Org

DEVELOPMENTAL TASK (Actual)

The patient was not able to form an intimate relationship with anyone. She didn’t mention being
in a romantic relationship or having a very close friend whom she trusts and shares her secret.

76
TEN IDENTIFIED NURSING PROBLEMS

1. Self-care deficit

2. Disturbed thought process

3. Ineffective coping

4. Impaired verbal communication

5. Impaired social interaction

6. Low self esteem

7. Disturbed sensory perception

8. Decreased attention span

9. Risk for injury

10. Risk for harming others

FIVE PRIORITY NURSING PROBLEMS (STATE IN NURSING DIAGNOSIS)

1. Disturbed thought process related to cognitive impairment secondary to schizophrenia

2. Self-care deficit related to perceptual or cognitive impairment secondary to schizophrenia

3. Impaired verbal communication related to disordered thinking secondary to schizophrenia

4. Impaired social interaction related to cognitive impairment secondary to schizophrenia

5. Social isolation related to low self-esteem secondary to schizophrenia

77
Diagnostic and Statistical Manual of Mental Disorders (DSM)

AXIS I – Schizophrenia

AXIS II – Schizotypal personality disorder

AXIS III – Seborrheic Dermatitis

AXIS IV – Socio economic status

AXIS V – 21-30 positive hallucination

DIFFRENTIAL DIAGNOSIS

5 / 6 x 100 = 83.33 % Residual Schizophrenia

A form of schizophrenia that is characterized by a previous diagnoses of schizophrenia, but no

longer having any of the prominent psychotic symptoms. There are some remaining symptoms of
the disorder however, such as eccentric behavior, emotional blunting, illogical thinking, or social
withdrawal.

78