VISION Republic of the Philippines MISSION

A premier university in CAVITE STATE UNIVERSITY Cavite State University shall provide
historic Cavite recognized for excellent, equitable and relevant
excellence in the Don Severino Delas Alas Campus educational opportunities in the arts,
development of morally Indang, Cavite science and technology through
upright and globally quality instruction and relevant
competitive individuals. research and development activities.
It shall produce professional, skilled
and morally upright individuals for
College of Nursing global competitiveness.

ASSESSMENT FOR PSYCHIATRIC NURSING

Submitted by:

Callada, Corrine Ivy S.

Submitted to:

Nenita B. Panalingan, RN, MAN, PhD

Date:

March 16, 2022

In Partial Fulfilment of the Requirement in NURS 70B for the Degree Bachelor of Science in
Nursing
I. DEMOGRAPHIC DATA
A. Initials of Clients’ Name: Z.J.R
B. Address: Monterey, General Trias Cavite
C. Age: 23 yrs. old
D. Birth Date: May 21, 1999 Date of Interview: March 15, 2022
E. Birth Place: Singapore Primary Informant: Z.J.R (client)
F. Gender: Female
G. Civil Status: Single
H. Religion: Catholic
I. Highest Educational Attainment: College
J. Occupation: Student
K. Monthly Income / Budget : 6000 php

II. REASON FOR SEEKING HEALTH CARE

During the interview, the client stated that she had a cough a few days after

receiving the covid-19 booster dose. Apart from the cough, she seemed to be in good

health, as she stated.

III. HISTORY OF PRESENT ILLNESS

The client said that at first it felt like a fever, then it subsided and then, after a few

days, the cough and illness returned. She also said that she feels somewhat queasy

after the covid-19 booster dose but is not in discomfort. Additionally, the client

mentioned that she is using over-the-counter medications such as biogesic and

robittusin.

IV. PAST MEDICAL HISTORY

Client ZJR said verbally that she had a childhood asthma attack when she was

around 6-7 years old but that it had passed her by. She also took certain drugs and

inhalers before to each attack of asthma. She stated that she had no record of any

surgical operations in the client for the past 22 years

 . Additionally, the client said that she has an allergy to alcoholic beverages but

continues to consume them, at which point she will take an antihistamine

medication..

There is no record of any surgical operations in the client for the past 22 years

V. HEREDO-FAMILIAL HISTORY
A. Genogram

Interpretation:
 According to client ZPR’s genogram, both her grandparents on her father's side

are already dead due to diabetes and cervix cancer, while on her mother's side, her

grandfather died due to hypertension and her grandmother had asthma. Her father also

died due to liver cancer, which is a complication of hepatitis-B, and on the maternal side,

her mother has adult immune thrombocytopenia and her uncle is hypertensive. She only

has one sibling, who is a 17-year-old boy who has G6PD (glucose-6-phosphate

dehydrogenase). This shows that client ZJR is prone to some diseases like diabetes,

hypertension, cervical cancer, and adult immune thrombocytopenia since it runs in their

genes.

VI. DEVELOPMENTAL HISTORY (Determine the exact stage based on client’s age and

his milestone and provide some justifications that would be most applicable to the

specified developmental stage)

A. J. Piaget’s Cognitive Development

Stage Specific Task(s) Evidences of Milestone Achievement
The Formal At this stage, the adolescent Client ZJR is able to think abstractly and
Operational or young adult begins to reason about hypothetical problems. She is
Stage think abstractly and reason able to answer questions that are given to
Ages: 12 about hypothetical problems her during the interview.
and up Abstract thought emerges
Teens begin to think more When asked a math question, she was able
about moral, philosophical, to answer properly.
ethical, social, and political
issues that require
theoretical and abstract
reasoning
Begin to use deductive
logic, or reasoning from a
general principle to specific
information

B. E. Erikson’s Psychosocial Development

Stage Specific Task(s) Evidences of Milestone Achievement
Intimacy Building Intimate Client ZJR stated that she is in a
 vs relationship relationship with her boyfriend. They
Isolation have known each other for 5 years and
Young adults need to form are together for already a year.
intimate, loving
relationships with other Client ZJR also stated that she has a few
people. Success leads to small groups of friends that she spends
strong relationships, while time with. Some of her friends are in
failure results in loneliness Philippines while the others are in
and isolation. This stage Malaysia.
covers the period of early
adulthood when people
are exploring personal
relationships.

Erikson believed it was

vital that people develop
close, committed
relationships with other
people. Those who are
successful at this step will
form relationships that are
enduring and secure.

C. S. Freud’s Psychosexual Development

Stage Specific Task(s) Evidences of Milestone Achievement
Genital The genital stage is the Client ZJR is aware that her and her
Stage last stage of Freud's boyfriend are in their reproductive age
(puberty to psychosexual theory of but they’d prefer to wait till marriage
adult) personality development, before engaging in sexual intercourse.
and begins in puberty.  It
is a time of adolescent
sexual experimentation,
the successful resolution
of which is settling down
in a loving one-to-one
relationship with another
person in our 20's.

Sexual instinct is directed

to heterosexual pleasure,
rather than self-pleasure
like during the phallic
stage. 

For Freud, the proper

outlet of the sexual
instinct in adults was
through heterosexual
intercourse.  Fixation and
conflict may prevent this
with the consequence that
 sexual perversions may
develop. 

For example, fixation at

the oral stage may result
in a person gaining sexual
pleasure primarily from
kissing and oral sex,
rather than sexual
intercourse.

D. J. Fowler’s Spiritual Development

Stage Specific Task(s) Evidences of Milestone Achievement
Conjunctiv “Conjunctive” Faith (Mid- Client ZJR stated that she is a Roman
e Faith Life Crisis). Catholic and states that she has a strong
A person at this stage faith in God. She believes in the
acknowledges paradoxes existence of God, the Angels, and even
and the mysteries the devil. She knows that there are other
attendant on transcendent religions other than her own and she
values. This causes the respects their existence as well.
person to move beyond
the conventional religious
traditions or beliefs he
may have inherited from
previous stages of
development. A resolution
of the conflicts of this
stage occurs when the
person is able to hold a
multi-dimensional
perspective that
acknowledges” truth’ as
something that cannot be
articulated through any
particular statement of
faith.

E. L. Kholberg’s Moral Development

Stage Specific Task(s) Evidences of Milestone Achievement
Level 3 - Postconventional morality is Client ZJR has reached postconventional
Postconven the third stage of moral morality as evidenced by her strong sense
tional development, and is of respect towards other people with
morality characterized by an different religions. “No matter what their
individuals’ understanding of religion is, it’s important that we respect
universal ethical principles. them because by the end of the day, every
These are abstract and ill- religion is there to teach us to be good to
defined, but might include: one another.”
the preservation of life at all
costs, and the importance of
human dignity.
 Individual judgment is based
on self-chosen principles,
and moral reasoning is
based on individual rights
and justice. According to
Kohlberg this level of moral
reasoning is as far as most
people get.

F. R. Havighurst’s Developmental Task

Stage Specific Task(s) Evidences of Milestone Achievement
Middle For Havighurst, Client ZJR stated that one of her long-
Age lasts developmental tasks term goal is to find a stable job that she
from age derived from physical enjoys to earn good money and to stay
30 to age maturation, personal with her boyfriend. She states that
60 and is values and the pressures nursing was not entirely her dream
the time of society. course so she plans to finish nursing,
when graduate and see where her life takes her
most Developmental Tasks of when she searches for a job in the future.
people Middle Age
start a
family and 1. Achieving adult civic
settle into and social
their adult responsibility
lives. 2. Establishing and
maintaining an
economic standard of
living
3. Assisting teenage
children to become
responsible and happy
adults
4. Developing adult
leisure-time activities
5. Relating oneself to
one’s spouse as a
person
6. Accepting and
adjusting to the
physiologic changes
or middle age
7. Adjusting to aging
parents.
VII. GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception – Health Management

According to customer ZJR, although she perceives her health to be fine,

she nevertheless becomes unwell quickly if she does not take proper care of

herself. Additionally, she said that she makes an effort to eat properly and sleep

sufficiently. She mentioned that she does not smoke but does take alcohol in

moderation owing to an allergy to it. Additionally, she does not undergo annual

physical examinations and does not use herbs or traditional medicines unless no

drugs are available.

B. Nutritional – Metabolic

When queried about her nutritional-metabolic condition, the client said

that she feels underweight but she is trying her best to gain weight by eating

more food especially rice and breads or foods that are high in carbohydrates.

She is also taking vitamin C, and she said verbally that she has no difficulty

eating or swallowing and is not on any special diet.

*3-day Diet Recall

MEALS March 13, 2022 March 14, 2022 March 15,

2022
Milo and Milo and
Breakfast (time) Milo and oatmeal
oatmeal oatmeal
Snacks (if any) N/A N/A N/A
2 cups of
1½ cups of rice 2 cups of rice
fried rice
Lunch (time) 2 servings of 3 sausages
1 canned
squid eggplant
sardine
N/A Strawberry milk 1 chocolate
Snacks (if any)
bar
Dinner (time) 2 cups of rice 2 cups of rice 1½ cups of
3 pieces of 3 pieces of rice
 chicken Sushi
spicy chicken
mushroom Isaw
Snacks (if any) N/A N/A N/A
Total Fluid Intake 2000 ml 2000 ml 2000 ml

According to client ZJR's 3-day diet meal plan, she often takes milo and

oatmeal for breakfast, which is presumably helps her to enhance her metabolism.

Due to the fact that oatmeal is a complete grain and high in fiber, eating it in the

morning may assist enhance metabolism, allowing your body to process meals

more efficiently. Oatmeal is one of the meals that may assist in increasing your

energy levels and metabolic performance (National Library of Medicine). Typically,

she drinks 1-2 cups of rice and nibbles on strawberry milk and chocolate bars. The

National Academies of Sciences, Engineering, and Medicine of the United States

decided that an acceptable daily fluid consumption for males is around 15.5 cups

(3.7 liters) of fluids. Women should drink around 11.5 cups (2.7 liters) of fluids every

day. As a result, customer ZJR is not drinking enough water each day, as she often

drinks just 2 liters.

C. Elimination

According to client ZJR, she usually defecates 3-4 times a week before

taking her bath in the morning. She said that she used to be constipated and would

defecate once a week but is now taking oatmeal to help her defecate more. A 2010

study published in the Scandinavian Journal of Gastroenterology found that 98

percent of its participants pooped between 3 times per week to 3 times daily. So the

frequency of defecating of client ZJR is considered normal. She also verbalized that

her poop was normal, brown in color, and soft but firm in appearance. Furthermore,

she stated that she usually urinates around 5 to 7 times per day as she drinks a lot

of water and never encountered problems in urinating.

D. Activity – Exercise
 According to patient ZJR, she seldom exercises or does so only when she is free

or in the mood, but most of the time she only does stretching for a couple of minutes and

likes to exercise at home when no one is observing. When she has free time, she

generally spends it reading novels in bed, and when asked to assess her fitness level on

a scale of 1-10, she chose 6, since, although she is not overweight, she feels sluggish

due to her lack of exercise.

7-Day Activity Table

Days of the Week & Date
Time WED THURS FRI SAT SUN MON TUE
3/9 3/10 3/11 3/12 3/13 3/14 3/15
1 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
2 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
3 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
4 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
5 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
6 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
7 am Sleep Sleep Sleep Sleep Sleep Sleep Sleep
Online Online Online Online Online
8 am Class Class Class
Sleep Sleep
Class Class
Online Online Online Online Online
9 am Class Class Class
Sleep Sleep
Class Class
Online Online Online Breakfas Breakfas Online Online
10 am Class Class Class t t Class Class
Online Online Online Breakfas Breakfas Online Online
11 am Class Class Class t t Class Class
12 nn Lunch Lunch Lunch Lunch Lunch Lunch Lunch
Online Online Online Online Online
1 pm Class Class Class
Relax Laundry
Class Class
Online Online Online Online Online
2 pm Class Class Class
Relax Laundry
Class Class
Online Online Online Online Online
3 pm Class Class Class
Work Laundry
Class Class
Online Online Online Travel to Online Online
4 pm Class Class Class
Work
dorm Class Class
Online Online Online Travel Online Online
5 pm Class Class Class home
Work
Class Class
Online Online Online Online Online
6 pm Class Class Class
Relax Work
Class Class
7 pm Dinner Dinner Dinner Dinner Dinner Dinner Dinner
Assignment Assignment Assignment Relax Relax Assignment Assignment
8 pm s s s s s
9 pm Work Work Work Relax Relax Work Work
10 Relax Relax
Work Work Work Work Work
pm
11
Sleep Sleep Sleep Sleep Sleep Sleep Sleep
pm
12
Sleep Sleep Sleep Sleep Sleep Sleep Sleep
mn

Legends:
Sleep Assignments

Breakfast Online class

Lunch Work

Dinner Laundry

Relax Travel to dorm

Travel home

Interpretation:

According to client ZJR’s 7-day activity table, she usually sleeps from 11pm to

7am to prepare for her online class. She is having her lunch at noon and dinner at 7 p.m.

She is also playing Axie Infinity to earn some money for her allowance. She is also either

reading or relaxing when she have a spare time. She is not also doing any form of

exercise. This shows that client ZPR’s are having a sedentary lifestyle, which is a

lifestyle type in which little to or no physical activity and exercise is done, as opposed to

an active lifestyle. Since the client has a family history of hypertension and diabetes,

having this lifestyle without doing any exercise might be a risk factor

E. Sleep – Rest

Client ZPR described her usual sleep pattern. She stated that she usually needs

the fan facing her feet when she is sleeping and she also uses 3 pillows to keep herself

comfortable. She said that she feels comfortable after sleeping if she is getting enough

sleep and experiences headaches upon waking up if the weather is hot. She also had
insomnia before but was able to pass through it by reading and watching videos on how

to overcome insomnia. She also verbalized that schoolwork can make her awake late at

night, and she usually goes to bed at 11–12 pm. She also tends to be moody when she

does not get enough sleep and used to take melatonin pills to help her sleep well.

F. Cognitive – Perceptual

Client ZJR said that she has no vision or reading difficulties and never

uses glasses or contact lenses. Despite the fact that her mother and brother

both have visual difficulties, she has normal eyesight. She often has difficulty

focusing or concentrating when she is sleep deprived or agitated.

G. Self-Perception – Self-Concept

When asked to describe herself as a person, client ZJR verbalized that

she is a 22-year-old who is mostly quiet around people and that she feels her

strength is being able to work on tasks alone, while her weakness is being a

perfectionist, as she usually takes her time on a task when she tries to perfect it.

She also feels particularly alright with her achievements in life so far and she

feels like her performance in life is average because she is not giving her 100%

effort in some things that she does. She also stated that she usually gets

anxious being around people that she does not know or whenever she needs to

start a conversation. Whenever she feels annoyed or angry, she calms herself

by sleeping, reading webtoon comics, or playing games. And at a certain point,

she feels depressed, and to overcome it, she has started having a conversation

with her trusted friend whenever she needs someone to talk to. Sleepy and

happy are her common moods, according to her.

H. Role-Relationship
 Client ZJR is currently living with her family in General Trias Cavite but

she now stays in Indang and comes home only every Saturday and Sunday. Her

grandparent’s on her father’s side lives in Manila while her grandparents on her

mother’s side lives in Iloilo so she is not really close with her. As for her siblings,

she only has one little brother. She stated that she only opens to her family about

certain things.

I. Sexuality – Reproductive

Client ZJR stated that she is not active in sex and that she does not have

any reproductive issues that interferes her daily activities. Her menstruation is also

normal and has a 28 days cycle and lasts for 7 days.

J. Coping-Stress

Client ZJR stated that the primary stressor she has been feeling recently

is not being able o tgraduate on time, that she has been thinking about it a lot and

has been emotionally affected to the point that it has affected her everyday

activities. The sudden pandemic also had an effect on her mental health, since

she spent the most of her time at home and had minimal engagement with other

people. Her method of relieving stress is to engage in an activity she enjoys,

whether it's drawing, painting, or playing her favorite game. Additionally, she

stated that she had not participated in any treatment or psychological sessions.

K. Value-Belief

Although the client was born in Singapore and raised in Malaysia, she is

fully Filipino because both of her parents are Filipino. She stated that if a

disease is present, she believes that health care and prayer are the only ways to

heal. She is Roman Catholic and believes in the existence of a God who
 watches over us, as well as the value of prayer. She expressed comfort with

modes of communication such as silence, close closeness, touch, gestures, and

eye contact, but only with individuals who are close to her and have no malice

toward her. Family and friends are the most important things in her life.

COMPREHENSIVE PHYSICAL EXAMINATION

A. Anthropometric Data

Height = 5’2ft.. BMI = 17.6 kg/m

Weight = 44kg

General Appearance

ZJR. is a 22-year-old woman who appears to be her age. She has a good

posture and gait, her hair is neatly styled. Due to her bmi of 17.6 kg/m, she is

considered underweight. If your BMI is less than 18.5, you are considered to be

underweight. If your BMI is between 18.5 and 24.9, you are considered to be

within the normal or healthy weight range. If your BMI is between 25.0 and 29.9,

you are considered overweight. (From the Centers for Disease Control and

Prevention) The client appears to be in good health and in a comfortable state of

mind. Additionally, she is well-organized and keeps a cheerful attitude throughout

the interview. Client ZJR was able to reply adequately to the interviewer's

queries. There is also relevancy and structure of thoughts in the client's

verbalization.

REVIEW OF SYSTEM (include only those that are significant to the case under study)
A. Eyes /Vision According to client ZJR, she does not have any vision difficulties.

She stated that she prefers to protect her eyes by using anti-

radiation glasses when using her laptop or phone.

B. Head and Neck Client ZJR stated that she never had any history of head injury and

neck problems.

C. Integumentary Client ZJR verbalized that she has no existing skin lesions or hair

loss, but she does have a few hyperpigmentedations from her acne

before. She also noticed a mole that looked like it was growing on

her right arm and says that it is nothing unusual.

D. Cardiovascular Client ZJR denied she has no history of cardiovascular diseases.

But she is at risk of being hypertensive since it runs in their blood.

E. Gastrointestinal Client ZJR stated that She has experienced diarrhea and

constipation before. She has also experienced having blood in her

stools a few times when she had a hard time defecating.

Sometimes when she has migraines, she is prone to vomiting

especially when she tries to ingest food.

F. Genito-Urinary The client stated that she urinates just the right amount, about 5 to

7 times a day. She only feels pain or a burning sensation when she

has an UTI. She gets UTIs when she doesn’t drink enough water.

She also had a history of hematuria when she had a urinary tract

infection. Her period usually lasts for 7 days at most and usually

has a strong flow starting on the second day. She also experiences

dysmenorrhea. She first got her period when she was 11 years old.

She is also experiencing dysmenorrhea whenever she has her

period. She rates the pain at least 8 out of 10.

G. Neurological According to the client, she has experienced the sensation of

 fainting and backing out a few times especially when she is on her

menstruation or when she is feeling unwell. There are also a few

times where she experienced her leg numbing only because she

sat in the wrong position. She has also experienced a lot of

headaches especially migraines when she is on her menstruation

or when the weather is too hot.

H. Endocrine Client ZJR mentioned that she has does not experience: polyuria,

polydipsia, polyphagia, fatigue and sudden weight loss and weight

gain.

I. Musculoskeletal ZJR stated that she believes that she has scoliosis as she

sometimes feels pain on her back when she stands for too long.

She rates the pain a 3 out of 10.

J. Pulmonary According to client ZJR, as of right now, she is experiencing

coughs and colds due to the booster shot of covid-19 vaccine that

she got last March 4, 2022..

K. Hematology As stated by client ZJR, she has not had any problems with her

blood before, but she feels like she has low iron in her blood since

she sometimes feels like fainting, especially on days where she is

menstruating.

L. Immunologic The client verbalized that she feels like she is prone to infections

since she gets sick easily when she does not take care of herself.
 She also has an existing allergy to alcohol and gets urticaria when

she ingests it. She is also a little allergic to dog fur and dust as she

experiences sneezing when it comes into contact with her nose,

she stated.

MENTAL HEALTH AND PSYCHIATRIC NURSING EVALUATION

I. Chief Complaints/presenting complaints

The client stated that she is currently stressed and anxious as a result of

the pandemic that we are facing. She stated that it was OK at first since, as an

introvert, you wanted to stay at home and relax, but it got really stressful after

she had been at home for too long because she felt deprived of physical

communication with friends and other loved ones. She also stated that she also

feel depressed at the time due to the risks and restrictions of going out.

II. Present psychiatric history / nature of the current episode

Client ZJR considered herself an introvert since she liked to have her own

space and to stay at home most of the time. She also stated that she loves to

remain in the background while people are conversing, such as when her friends

are talking; she simply listens to them, not because she does not want to engage,

but because she enjoys listening to them and does not like speaking too much.

And, as a student nurse, she is required to communicate with others, which

causes her social anxiety because she is not used to dealing with individuals she

does not know much about. ZJR verbalized that she also experienced being

stressed and anxious when she was in high school especially when they had to

do an oral exam where you need to stand in front and talk to people or to the
 examiner and sometimes even though she already memorized it at home, she

always tends to forget when she is at the front already.

ZJR also stated that not being able to do hospital duties and graduate

on time caused her great stress. However, returning to face-to-face classes

made her anxious because she believed she was not ready to communicate with

people again due to her tendency to become very timid. It somehow affected her

daily life because she always feels lazy to do something and use her time

overthinking about the situation.

III. Past Psychiatric history:

ZJR has never been diagnosed or treated for psychiatric conditions. But

she always feels anxious in many circumstances, like, for example, standing in

front of many people and talking to them. She also gets easily stressed whenever

new problems arrive. She also considered herself a perfectionist, which

sometimes becomes a problem because it takes her time to finish one task..

IV. Family History

Client ZJR verbalized that no one in their family have been diagnosed with

mental health disorder but her mother usually tends to get stressed and got

depressed when her father passed away.

V. Personal History

She studied elementary while she was in Malaysia in Sekolah Rendah Sri

Mawar from 2006-2011. And as a child, she considered herself very naughty

because she always do not listen to her parents and always fought with other

kids back then. She also almost got expelled when she bit one of her classmates
on her shoulder, and after that incident, she started to become an introvert

because the whole class started to ignore her.

ZJR also stated that she studied high school also in Malaysia in Riam

Road Secondary School from 2012-2016. According to her she felt depressed

when she was in high school due to her ex-boyfriend's being possessive

and refusing to allow her to make friends with other people. She felt excluded

and alone as a result of it. To alleviate her sadness, she would draw or paint as a

way to escape reality and communicate her feelings. She also stated that she

has not sought professional assistance, but instead studied and watched videos

to better understand how she is feeling and that was extremely beneficial to her.

Having very strict parents affected her when she was growing up. It made

her a perfectionist, and she tried not to make any mistakes in anything she did

because her parents would always scold her for even just one mistake. She

verbalized that it is becoming a problem for her because sometimes she tends to

become too much of a perfectionist and it always takes her a long time to do a

single task.

ZJR also stated that she felt depressed when she was in high school due

to her ex-boyfriend's being possessive and refusing to allow her to make friends

with other people. She felt excluded and alone as a result of it. To alleviate her

sadness, she would draw or paint as a way to escape reality and communicate

her feelings. She also stated that she has not sought professional assistance, but

instead studied and watched videos to better understand how she is feeling and

that was extremely beneficial to her.

ZJR is not yet engaged in sexual activities since she believes that people

can only have sex when they are married.

VI. Premorbid Personality

When asked about her interactions with others and the people in her

immediate environment, client ZJR stated that she has close friends at school on

whom she can rely and call anytime she is in need. She added that she is close

to her mother and brother, but not nearly as close to her father. She noted that

while both her mother and father were strict, her father was more so, and she

was always afraid of him. Her connection with her brother is strong, yet they

frequently disagree. When her father died of a sickness, it took her a time to

process the news. It affected her not only emotionally, but also physically, as she

became ill as a result of the stress and was bedridden for about two weeks.

Client ZJR identified herself as a Roman Catholic who believes in

the existence of a God who cares for us and the value of prayer. She is not a

churchgoer, but she makes it a point daily to pray and communicate with God.

She believes that people should respect one another's beliefs since, at the end of

the day, we all worship the same God.

She remarked that her current state of mind is perpetually tired

and cheerful. She is drowsy the majority of the time and readily becomes

cheerful when something positive happens. She frequently spends her leisure

time drawing, painting, and reading books. She is typically an imaginative type of

person; she vividly imagines several events in her mind and is adept at drawing

and inventing stories in her thoughts. Whenever she is stressed, she attempts to

de-stress through drawing and painting, as these mediums allow her to convey

what she cannot express verbally. Additionally, she reads and watches

encouraging films to assist her in overcoming her stress.

 MENTAL STATUS EXAMINATION

I. General Appearance and Behavior (GAAB):

ZJR appears to be a 22-year-old woman. She has a good posture

and gait. Her hair is groomed impeccably. The consumer appears to be in

good health and has a pleasant personality wearing her white uniform and

sitting comfortably in front of her laptop. Additionally, she is organized and

maintains a positive demeanor during the interview. Client ZJR provided

satisfactory responses to the interviewer's questions. Additionally, there is

relevance and structure to the client's verbalization. Client ZJR is unable to

maintain constant eye contact and frequently looks sideways when speaking.

Because my client and I are already acquainted, it is easy for us to establish

rapport.

II. Psychomotor Activity

Throughout the session, the client sits comfortably in front of her

laptop but is unable to sustain eye contact with me. Every time she speaks,

she always looks sideways and up and down, but she still communicates

effectively.

III. Speech

“Since the pandemic has been going on for like 2 years was it? At

first it was fine because as an introvert you want to stay at home and just

relax. But then once you stayed at home for really too long it becomes really

stressing because you are deprived of physical communications,

communication with friends and your loved ones” as verbalized by client

ZJR. This demonstrates that she is coherent, as she is presenting her

 thoughts in a clear and calm manner that I can comprehend. Her responses

are also pertinent to my inquiry, and she speaks in a soft tone with a low

pitch. Throughout the conversation, she appears cool and composed and

maintains the way she reacts on each question.

IV. Thought

ZJR's responses to each topic I posed are succinct and direct, and

she avoids word salad. There are moments when her words become

jumbled, but she will pause for a moment and reassemble them.

V. Mood (subjective) and Affect (objective):

Client ZJR appeared to be at ease and capable of answering the

questions during the interview. She occasionally stops for a bit, particularly

when the question is more personal. She is trying to formulate it in her mind

before speaking it. She remains emotionally stable, even when we talk about

her past and how she deals with problems.

She mentioned that she experiences social anxiety anytime she

speaks with someone about whom she knows little and is unable to open out

freely. The fact that the two of us were acquainted aided her in opening up

easily and feeling at ease during the interview.

VI. Disorders Perception:

ZJR does not show any signs of perception disorders such as

illusions, delusions, hallucinations etc.

VII. Cognitive Function

 During the interview, I gave various tests and asked some

questions to ascertain client ZJR's cognitive functions. I initially asked her to

list the months of the year aloud and then backwards. The client was capable

of completing the work and also answering several mathematics problems. I

then gave her an address and asked her to repeat it back to me to test her

recall. She made a few errors due to the omission of one letter. I also asked

her to recall her activities over the previous 24 hours, which she was able to

do. I inquired as to whether she remembered certain dates, such as when we

resumed our restricted face-to-face lessons and when the epidemic began,

and she responded properly. Then I assessed her abstract reasoning by

presenting her with a proverb and asking her to explain how she understood it.

"You catch more flies with honey than with vinegar," I stated. She put it this

way: "you can catch or perform a particular task using a particular method

rather than another type of technique, and that method should be appropriate

for that particular work." It demonstrates that the client was capable of abstract

thought and comprehension. When asked about her future intentions to

assess her judgment, she stated that she intended to graduate first and then,

while nursing is not her first choice, work for a few years in nursing before

pursuing a career in the art sector, specifically graphic and fashion design.

Finally, I questioned her about her perceptions of the people around her and

the state of society at the time. She stated that she is not a political person

and so does not know much about it. However, as she can see on social

media, some people do not respect the right to choose, while others are

reluctant to express their thoughts out of fear that others would quarrel or

discuss with them.

 This demonstrates that client ZJR is capable of thinking,

reasoning, having a good memory, and exercising sound judgment, and that

she does not have cognitive difficulties.

VIII. General Observations

Client ZJR overall is in good condition physically as she is sitting

comfortably in front of her laptop while she we were talking and she also was

able to convey well, think, and reason properly. Emotionally, she is stressed

because of the current situation and that she tends to always feel anxious but

she do things to relieve her stress, however client ZJR still needs more ways

to help her relieve from stress and anxiety.