Mental Health and Psychiatric Nursing

Comprehensive Mental Health Assessment

Psychosocial Assessment:
Name (Initials): ECL
Age: 18 years old
Gender: Male
Marital status: Child
Birthdate: November 24, 2004

Admission data
Date of admission: May 27, 2023

(1) Reason for Admission

As perceived by patient: Patient stated that a barangay deputy brought him there after being admitted to
a hospital. He also used to believe that an enchanted woman took a liking to him.
According to third-party source: The patient’s mother reported that the patient usually mess things
inside their house and patient also ran away from home. The patient is diagnosed with undifferentiated
schizophrenia.

(2) Previous psychiatric history (if any)

Dates: ____________________________________________________________________________
Reasons / diagnosis: No reported history
Type of treatment received: ___________________________________________________________

(3) Family Psychiatric History

Client reported no family psychiatric history

(4) Social and Developmental History

According to patient, he has no friends but blurted out names he recognized who were once nice to him
and people who gave opportunity for him to earn a little bit of money. During one on one interaction
with the student nurse, the patient showed exceptional understanding and analyzing skills by answering
simple math questions and understanding the content of the story in one activity. Additionally, the chart
said that he excels in his studies. However, he tends to be alone due to his experience being bullied by
his peers.

(5) Drug and Alcohol use / abuse

Type: Patient denied use/abuse of any type of alcohol and drugs
Amount: ______________________________________________________________________
Frequency: ____________________________________________________________________
Duration of past and present use: __________________________________________________
Date of last use: ________________________________________________________________
(6) Disturbances in patterns of daily living
Sleep: PTA, client stated that he used to sleep 12 hours every night. However, the chart denied that and
has a record where patient have no sleep at all. In the mean time, client revealed that his usual time of
sleep inside the ward starts at 8 in the evening and he usually wakes up at 5 to 5:30 in the morning with
a total of 9 hours of sleep every night. Client also denied any disturbances in his sleep at night.
Intake: PTA, client admitted to eating lizards, cockroaches, and small insects because the voices told
him to do so.
Elimination: Client stated to eliminate wastes daily.
Sexual activity: No response was recorded regarding client’s sexual activity.
Leisure: PTA, client’s leisure time is spent with playing computer games and scrolling through
Facebook. Once admitted, client stated that his leisure time only revolves in thinking and sleeping.
Self-care and hygiene: Client stated that he showers everyday.

(7) Spirituality
Religion: Client reported that he is a Born Again, although chart stated that he is a Catholic.
Beliefs and practices: Client stated that he prays everyday. He also stated that in order to stop the
voices telling him what to do, he just starts praying.

(8) Support system

According to client, his mother was with him when he was first admitted to the facility. However, as f
now the client stated that his mother has not visited him again.

Mental Status Examination`

(9) General appearance: Type and condition of clothing, cleanliness, physical condition, posture, gait,
facial expression, eye contact, general state of health and nutrition
Patient is wearing the pavilion’s uniform. During activity and interaction with the client, he has already
showered and changed to new pair of clothes. Client’s posture is usually stooped with slow gait. His
usual facial expression looked dissociated but hold eye contact during conversations. Client verbally
stated that he is starting to get healthier because he is thin. His overall health status and nutrition is
undetermined.

(10) Behavior during the interview:

Expression of anger: covert, overt, physical
Degree of cooperation, resistance, or evasiveness
Social skills: positive / unpleasant habits, shyness, withdrawal
Client refused to share his way of expressing his anger. During daily activities, the client was
completely cooperative but gets shy whenever he is trying to share something with the group.

(11) Amount / type of motor activity: Level of Activity

☐Psychomotor retardation: ______________________________________________________
_____________________________________________________________________________
☐Agitated: During first day of nurse-patient interaction, client seems nervous when interacting with
the student nurse by saying wrong answersto the given questions.
☐Restlessness: _______________________________________________________________
☐Tensed: ____________________________________________________________________
______________________________________________________________________________
☐Hypervigilance: ______________________________________________________________
______________________________________________________________________________
☐Others: No notable motor activity._______________________________
______________________________________________________________________________
Type of activity
☐Tics: _______________________________________________________________________
☐Grimaces: ___________________________________________________________________
☐Tremors: ____________________________________________________________________
☐Compulsions: ________________________________________________________________
☐Unusual gestures / mannerisms: __________________________________________________
☐Others: No remarkable findings noted.

(12) Speech Patterns

Amount: (muteness, paucity, loquacious): During first day of interaction, client speak in a slow
manner. After the next days, his speech gradually increased.
Rate: _________________________________________________________________________
Volume: Client speak in a soft low tone manner.
Characteristics: ☐Slurring ☐Stuttering: No stuttering or slurring noted.
Others: (Describe any unusual speech pattern) Client used to answer differently from the questions
asked to him during first day of nurse-client interaction. This got better as days goes by with different
activities that involve his cooperation.

(13) Degree of Concentration, Attention Span and Calculation:

(Count from 1-20 rapidly, odd/even numbers, serially/alternately subtract or add from 100)
Client can count 1-20 and back rapidly and without any pause, as well for odd and even numbers. He
showed exceptional knowledge related to serially/alternately subtract and add numbers from 100.
Orientation:
☐Time (What is today's date?) “Ngayon ay Miyerkules, ng July, 2023”.
☐Place (Where are you today?) “Nasa Mandaluyong.”
☐Person (What is your name?) Patient stated his full name

(14) Memory:
Remote (Recall events/information from distant past)
Client verbalized that he cannot recall when his last graduation happened.
Recent (Recall events of the past 24 hours or past week)
Can recall what the weather was from yesterday and their activity every morning o the past week.
Immediate (Repeat a series of numbers either forward or backward within a 10-second interval)
Client was able to recall few numbers but forgot the rest and remember to tell false numbers.
Others: ☐Blackout ☐Confabulation ☐Amnesia
Thought Clarity: ☐Coherence ☐Confusion ☐Vaguenes
(15) Thought Processes reflected in speech:
☐Blocking ☐Flight of Ideas ☐Perseveration ☐Ambivalence ☐Circumstantiality ☐Loose
associations ☐Verbigeration ☐Neologism ☐Echolalia ☐Word Salad ☐Tangential Ideas
The client used to only talk about the people who were once kind to him, and when the student nurse
would try to ask or open another topic he would go back to the topic he want to talk about again.
Moreover, client used to answer unrelated topic to the topic asked by the student nurse.

(16) Thought Content:

☐Feelings of hopelessness, ☐Compulsions helplessness worthlessness, guilt ☐Preoccupations
☐Suicidal ideas / plans ☐Antisocial attitude ☐Homicidal ideas / plans ☐Blaming of others
☐Suspiciousness ☐Poverty of content ☐Phobia ☐Denial ☐Obsessions
There are times when the client is pre-occupied to answer some questions. Just staring either on air or
on student nurse’ eyes.

(17) Hallucinations
☐None ☐Auditory ☐Visual ☐Others (specify): __________________________________
Remarks: Client verbalized that he hears some voices telling him to eat lizards, cockroaches, and small
insects.

(18) Delusions
☐Grandeur ☐Influence ☐Religious ☐Persecution ☐Reference ☐Somatic ☐None
Remarks: No delusions noted about the patient.

(19) Information and Intelligence

Educational level: Client stated his last education was ALS. Chart noted that he finished high school.
(Ask to list similarities, interpret a proverb or assess general information knowledge)
Habang maikli ang kumot matutuong mamaluktot. “Baka po kasi masakit ang tyan nila kaya naka
baluktot.”

(20) Mood / Affect

Mood: (prevailing emotional state) ☐Euthymic ☐Elevated ☐Depressed ☐Labile Affect:
(statement of emotion) ☐Appropriate ☐Inappropriate ☐Adequate ☐Restricted
☐Blunted ☐Flat ☐Labile
Remarks: Client expression looks neutral whenever engaged to conversations.
Anxiety level: ☐Mild ☐Moderate ☐Severe ☐Panic ☐None

(21) Insight: (degree of awareness / understanding of problems and their causes) ☐Poor ☐Good
Client is not aware of the purpose of the drugs being given to him and verbally asked the student nurse
whether they are vitamins. Client also believed that the cause of his illness is because of enchanted
creatures.
(22) Judgment: Soundness of problem solving and decisions
In a situation where an old woman, pregnant woman, and a mother with a child enter afully packed
train car, client chose to offer his seat to the old woman just because he is an old woman and gave no
further explanation.