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Nursing - Assessment - (Mse) (Josol)

The nursing assessment summarizes Nathalie Grace M. Elajas' medical history and current mental status. She is a 21-year-old female who presents with depressed mood and affect, and reports experiencing auditory hallucinations telling her to leave where she is for her safety. She has a diagnosis of schizophrenia from 2 years ago and is currently undergoing treatment. The patient expresses suicidal ideations in the past but no longer feels that way and is grateful to be alive. She is oriented and cooperative during the assessment.

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131 views5 pages

Nursing - Assessment - (Mse) (Josol)

The nursing assessment summarizes Nathalie Grace M. Elajas' medical history and current mental status. She is a 21-year-old female who presents with depressed mood and affect, and reports experiencing auditory hallucinations telling her to leave where she is for her safety. She has a diagnosis of schizophrenia from 2 years ago and is currently undergoing treatment. The patient expresses suicidal ideations in the past but no longer feels that way and is grateful to be alive. She is oriented and cooperative during the assessment.

Uploaded by

kuro hanabusa
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSING ASSESSMENT

Date: June 29, 2021


I. General Information
Name of Patient: Nathalie Grace M. Elajas Height: 146 cm Weight: 45 kg
Address: Magallanes, Agusan Del Norte Age: 21 Gender: Female
Marital Status: Single Name of Spouse: N/A
Number of and ages of children/siblings:
Lyra Lynn M. Elajas 24 y.o. (sibling)
Parent’s name and ages (if still living):
Jocelyn M. Elajas 54 y.o. (mother)
Eddie R. Elajas 57 y.o. (father)
Occupation of Patient: N/A
Include and specify past occupation and reason of change of occupation: N/A
Educational Attainment: High School Graduate Religion: Roman Catholic
Arrests, Court Dates, Probation: N/A

II. Initial Parameters


Vital signs: BP 120/80 mmHg Temp: 37.5 PR: 96 bpm RR: 18 bpm
Allergies to food, drug, etc. (Please specify in RED ink) N/A
Use of street drugs: N/A
Use of alcohol (Specify the amount, when it started, how it started and history of
blackouts: N/A

III. Current Status


A. Physical characteristics (Describe the apparent age, manner of dress, hygiene,
posture, gait, gestures, facial expression, mannerisms, behavior during
interaction) ¨The patient is a 21 year old female who appears her age. There is
no poor grooming and personal hygiene evidenced by absence of body odor and
well kempt hair. The patient’s expression was more like depress and presenting
a worried presence and expression to her face. The patient sat slouchly. Also,
the patient has no eye contact.
B. Speech
Soft: ____ Hesitant: ____ Pressured: _____ Mumbled: _____Loud: ____
Slurred: ____Rapid: ____ Whispered: ____ Others:
(Please Specify): The patient was able to talk in an appropriate manner.
Does his/her style of vocabulary convey:
Coyness: __ Arrogance:___ Superiority: ___ Pretentiousness:___
Suspiciousness: ____Secretiveness: ____ Humor: ____
Others (Please specify): The patient was able to talk in an appropriate manner.

Does he/she use speech to:


Plead:____Command:____Shock:____Frighten:____Seduce:____Intimidate:___
Others (Please specify): N/A
C. Stream of Talk
Spontaneous: ✓ Deliberation of talk: The patient was able to coherently and
clearly deliver her thoughts.
(Please write the actual statement)
Organization of Talk:
Relevant: SN: “Naa bay times maam nga naka sinati ka nga down ka kayo og
kanang murag hopeless jud na imong pamati, like sigi rakag hilak, depress na
kayo ka?”
Pt: “oo, naa jud toy semana nga naa rako sa akong selda. Dili gyud ko mo
gawas, sigi rako og hilak unya wa ko kasayud sa rason ngano.”
Irrelevant: N/A
Incoherent:N/A
Looseness of association: N/A
Flight of Ideas: N/A
Tangential: N/A
Circumstantial: N/A
Perseveration: N/A
Clang Association: N/A
Neologism: N/A
Echolalia: N/A
Echopraxia: N/A
Others, specify: ___________________________________________________

IV. Mood and Affect


Mood
Euthymic:____ Euphoric: ____ Anxious: ____ Angry: ____ Depressed: ✓
Irritable: _____ Terrified: _____ Empty: ____ Guilty: ____
Others (Specify) ___________________________________________________
Affect
Blunt: ____ Flat: ✓ Depressed: ✓ Fearful: ____ Angry: ___ Elated: ____
Others (Specify)___________________________________________________
Range of affective expression?
Consistent: ✓ Anhedonic: ____________Labile:__________________
Appropriate to the situation and feelings verbalized There is appropriateness of
emotions though patient seemed to be worried.
Others (Specify) ___________________________________________________

V. Perception
(Please write the actual statement)
Hallucination (Auditory hallucination): SN: “Sa imo pang giingon maam naa kay
madungog, tama ba? Pwede ba nimo ma ingon kung unsa na mga tingog ang
iong nadungog og kung familiar bana cla nga mga tingog sa imoha maam?”
Pt: “o maam naa koy mga madungog lagi. Ang ilang iingon kay dapat daw ko mo
lakaw kay dili ko safe dinhi. Sa akong madungog mura siya og lalaki og tingog
maam pero wa ko kaila kinsa.”
Delusion (Somatic delusion): SN: “Nganong naka ingon man ka maam na
controlon ka sa imong family?”
Pt: “Nag tuo man gyud jud ko maam nga naa nay device diri sa akong utok. Mao
nang ma control jud ko nila.”
Illusion: N/A
Derealization: N/A
Depersonalization: N/A
Identification: N/A
Thought broadcasting: SN: “So imong pasabot maam usa sa imong gi
kahadlukan kay naka sayud ang mga tao sa imong gi huna-huna?”
Pt: “oo maam. Kung unsa akong huna hunaon maka sayud jud sila.”
De ja vu: N/A
Jamais vu: N/A

VI. Orientation and Memory


(Please write the actual statement)
Orientation
1. Does the client identify the date correctly?SN: “Kasayud baka unsa ta nga petsa ron
maam?”
Pt: “o maam, June 29, 2021.”
Can he/she estimate the time of the day? SN: “Kasayud kas oras ron maam?”
Pt: “Basta kay udto ron maam.”
The month and year? SN: “Kasayud baka unsa ta nga petsa ron maam?”
Pt: “o maam, June 29, 2021.”
2. Does the client know where he/she is? SN: “Kasayud baka as aka karon maam?”
Pt: “Nasa mental.”
3. Does the client know who the examiner is? SN: “Kaila baka nako maam?”
Pt: “Wala.”
Is he aware of the roles or names of the people with whom he/she is in contact with?
N/A
Memory
Recall of remote past experience: SN: “Kadumdum baka kanus-a ka na tawo maam?”
Pt: “O maam adto lang nangaging duh aka tuig.”
Recall of recent past memory: SN: “Kadumdum baka kanus-a ka na anhi sa mental
maam?”
Pt: “September 18, 1999.”
Recall of recent memory/present events: SN: “Unsa may imong gi sud-an gaining udto
maam?”
Pt: “Gulay nga sinabaw maam.”

VII. Content of Thought


(Please write the actual statement or describe the situation/circumstances that will
support your assessment)
Preoccupation with illness: SN: “Pwede baka maghisgut bahin sa imong kaugalingon
maam?”
Pt: “Kuan maam gi diagnosed ko og schizophrenia adtong nangaging 2 ka tuig pero sa
karon medyo ok ok na ko maam kay naa man koy treatment. Pero lagi nay usahay nga
maka sinati kog mga pangdungog dungog.”
Compulsions/Obsessions: N/A
Phobias: N/A
Homicidal ideation: SN: “Nganong maka huna huna man kag suicide?”
Pt: “Kay adto nga panahuna maam kay pamati nako wa najud koy pag asa.”
Suicidal Ideation: SN: “Unya maam naka huna huna jud ka og suicide?”
Pt: “O maam. Para sa ako adto nga time mao nalang gyud akong solusyon. Para nako
ang suicide maoy makaayu ra sa ako.”
Specific Antisocial Urges: N/A
Concentration (Is the client able to sustain attention over an extended period of time?
The patient was able to have the attention during the interview though sometimes has
no eye contact.
Judgement (Is the client aware of the probable consequences of his social behavior?
Test judgement by asking the client what he would do in an imaginary situation) SN:
“Maam kung naa kay Makita nga kutsilyo sa salog unsa man ang imong buhatin adto na
kutsilyo?”
Pt: “Akong puniton maam og iuli sa butanganan kay maka disgrasya man to kung naa
ra sa salog.”

VIII. Awareness
(Please write the actual statement or describe the situation/circumstances that will
support your assessment)
Client perception or meaning of current mental illness and causes: SN: “Unsa man
imong ika ingon maam nga naa kay schizophrenia?”
Pt: “Sa una maam nahadlok jud k okay wala man ko kasayud gud basig unsa ko labi na
nga naa koy ingon ani nga sakit. Para sa ako maam pasalamat lang ko nga nakatabang
jud ning treatment sa akoa.”
______________________________________________________________________
Beliefs about illness and health: N/A
Client’s attitude or beliefs towards hospitalization and health care personnel: SN: “Unya
maam unsa man imong ika sulti bahin nia sa mental?”
Pt: “Ok raman nuon maam kay kasayud ko sa ako raman sab ning kaayuhan.”
Client expectation and goals for current hospitalization: SN: “So nag pasalamat ka
maam nga nga nay kabag uhan karon imong pamati?”
Pt: “Kaayo gyud maam kay ako jung aim na ma maayo gyud ko.”
Coping skills used: SN: “So unsa man imong ginabuhat dri maam nga ok ok naman
kaha imong pamati. Unsa may dugang nimong ginabuhat arn mas mamaayo imong
pamati?”
Pt: “Kuan maam naga follow ko kanunay sa among mga activities diri.”
Frequency and types of physical complaints: N/A
Client’s opinion of himself (who he/she is, value of own life): SN: “So diba naka hisgut
ka maam na nag attempt ka og suicide. Unsa may imong ika sulti adto?”
Pt: “O maam. Sa karon pasalamat jud ko na wa ko nagpadayun adto na butang kay
para nako importante jud akong kinabuhi maam. Nag tuo ko nga naa juy rason ang
tanan nakong gi again maam.”

Submitted by:
Kathleen P. Josol

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