Mental status exam

Assessment is the first step of Nursing Process and involves the collection, organization and

analysis of the information about the client’s health. In Psychiatric Mental Health Nursing, this is

often referred to as Psychosocial Assessment which includes mental Status Exam.

Psychosocial Assessment’s purpose is to conduct a picture of the client’s emotional state,

mental capacity, and behavioral function. Mental Status Exam focuses on the client’s Cognitive

abilities. The fewer the task the client completes accurately, the greater cognitive deficit.

A. Presentation

i. General appearance

Ms. SD had been living in this world for 45 years and been in such psychological

condition for 39 years already. She was wearing the appropriate clothes for her

age. She wore t-shirt and pants. She looks tidy. There were no unnecessary

things worn and found in her body. She does not wear any jewelry. The client’s

skin was dry; the group was able to notice some skin problems such as scars

and lesion. Her sclera was white in color. She does not have any hearing

difficulties. She looked and appears older than her age. She even looked alder

than her older sisters. She has a lot of white hair strands already
ii. General motility

During the group’s entire visitation, Ms. SD preferred to slouch most of the time.

She always fails to sit up straight and prefers to stay at one corner in their house.

Sometimes she walks with her head turns at one side. The group was able to

noticed evident mannerisms like rubbing her hands when she talks and even

after talking. Unusual tics were observed. She scratches her fingernails when

she thinks something. She kept on moving her legs and tapped her foot on the

ground. She does not follow certain commands and do it correctly. She was also

able to pick unnecessary things on the floor and places them in its proper place.

Ms. SD should do the bathing and dressing herself alone. She does not

disarrange things in the house. Any unusual gestures that may cause commotion

was not observed by the group. Her facial expressions do responds to her

thought content. Most of the time, she prefers to bow down her head, looking at

the floor. Her eye contact was not consistent. She would smile back if you smile

at her.

iii. Behavior

The client seemed to be very aloof during the group’s initial visitation. Ms. SD

tends to sit silently at one corner of the house. She had been observant and

seemed to listen to the group’s discussion with her family. She kept on looking

and focuses at one corner thinking something we don’t know because when the

group would ask what she thinks, she sometimes repeats the same sentence

“labad ako ulo”. Ms SD started to feel comfortable with the group during the third

visitation. She had shown her friendliness and warmth. She behaves well. She
 only talks whenever the group would raise certain questions. But whenever she

talks, she sometimes elaborates what she meant to say. Ms SD had a blunted

affect which means showing little or slow-to-respond facial expression. Her mood

depends on the topic of the discussion.

iv. Patient-nurse Interaction

Ms. SD was not talkative. She only talks whenever the group had to open up a

certain topic. She was able to show her warmness to the group during our

second day of visit. Her eye contact was inconsistent. She answers back

whenever she’s asked about something. She smiles back also whenever you

give her a smile.