MENTAL STATUS

EXAMINATIO
N CHARLES Z. ARIOLA JR., MSN, LPT.
I. GENERAL APPEARANCE AND BEHAVIOUR (GAAB):

a) Facial expression (Eg. Anxiety, pleasure, confidence,

blunted, pleasant)
b) Posture (stooped, stiff, guarded, normal)
c) Mannerisms (stereotype, negativism, tics, normal)
d) Eye to eye contact (maintained or not)
e) Rapport (build easily or not built or built with
difficulty)
f) Consciousness (conscious or drowsy or
unconscious)
g) Behaviour (include social behaviour. Eg. Overfriendly,
disinhibited, preoccupied, aggressive, normal)
h) Dressing and grooming – well dressed / appropriate (to
season and situation) / neat and tidy / dirty.
i) Physical features:- look older / younger than his or her age /
II. PSYCHOMOTOR ACTIVITY:

(Increased / Decreased), Compulsive / echopraxia,

Stereotype, negativism, Automatic obedience
 III. SPEECH:

 One sample of speech (verbatim in 2 or 3 sentences)

a) Coherence – coherent / incoherent
b) Relevance (answer the questions appropriately) – relevant
/ irrelevant.
c) Volume (soft, loud or normal)
d) Tone (high pitch, low pitch or normal / monotonous)
e) Manner – Excessive formal / relaxed / inappropriately familiar.

f) Reaction time (time taken to answer the question) – increased,

decreased or normal
IV. THOUGHT:
a) Form of Thought / formal thought disorder – (not understandable /
normal / circumstantiality /
tangentiality / neologism / word salad / perseveration /
ambivalence)
b) Stream of thought / flow of thought – (pressure of speech / flight of ideas /
thought retardation / mutism / aphnoia / thought block / clang association.)
c) Content of thought
a)delusion – specify type and give example – Persecutory / delusion of reference /
delusions of influence or passivity / hypochondracal delusions / delusions of
grandeur / nihilistic- Derealization / depersonalization / delusions of infidelity.
b) Obsession
c) Phobia
d) Preoccupation
e) Fantasy – Creative day dreaming.

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V. MOOD (Subjective) AND AFFECT
(Objective):-
a) Appropriate / inappropriate (Relevance to situation and
thought congruent).
b) Pleasurable affect – Euphoria / Elation / Exaltation /
Ecstasy
c) Unpleasurable affect – Grief / mourning /
depression.
d) Other affects – Anxiety / fear / panic / free floating
anxiety / apathy / aggression / moods swing / emotional
liability.
VI. DISORDERS PERCEPTION:

a) Illusion
b) Hallucinations – (specify type and give example) –
auditory / visual / olfactory / gustatory / tactile
 VII.COGNITIVE FUNCTION:
a) Attention and Concentration:
 Method of testing (asking to list the months of the year forward and
backward)
b) Memory :
a. Immediate (Teach an address & after 5 mts. Asking for recall)
b. Recent memory – 24 hrs recall
c. Remote – asking for dates of birth or events which are
occurred long back
i) Amnesia / paramnesia / retrograde amnesia / anterograde amnesia
ii) Confabulation
iii) ‘Déjà vu’ / Jamaes Vu
iv) Hypermnesia

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 Count…
c) Orientation:
1. Time - approximately without looking at the watch, what
time is it?
2. Place – where he / she is now?
3. Person – who has accompanied him or her
d) Abstraction: Give a proverb and ask the inner meaning
(Eg. Feathers of a bird flock together / rolling stones
gather no mass)
e) Intelligence & General Information: Test by carry over
sums / similarities and differences / and general
information / digit score test.
 Count…
f) Judgment :-
-Personal (future plans)
-Social (Perception of the society)
-Test (presents a situation and ask their response to the
situation)
g) Insight
I. Complete denial of illness.
II. Slight awareness of being sick.
III. Awareness of being sick attributes it to external / physical factor.
IV. Awareness of being sick, but due to something unknown in himself.
V. Intellectual insight
VI. True emotional insight
VIII.General Observation:
a) Sleep
i. Insomnia – temporary / persistent
ii. Hypersomnia – temporary / persistent
iii. Non-organic sleep –wake cycle disturbance
iv. EMA – Early Morning Awakening

b) Episodic disturbances – epilepsy / hysterical / impulsive

behaviour / aggressive behaviour / destructive behaviour.

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Gordon’s
Functional
Health Pattern
A. Health Perception and Management
Prior to admission:
•Can only recall being immunized with BCG and DPT
•Rarely visits a doctor to have a check-up and seek for
medical assistance
•Uses herbal medicines such as oregano, guava, bitter
gourd, and ginger
•Buys and takes over the counter drugs such as Solmux,
Neozep, Biogesic, Mefenamic acid, Diatabs, and
Loperamide.
•Stopped taking multivitamins Enervon
•When sick, goes to the manghihilot or just waits for
the sickness to heal
•Practices healthy lifestyle and depends on fruits and
vegetables
•No vices since young such as drinking
alcoholic beverages and smoking cigarette
•After experiencing difficulty in defecating,
she decided to see a physician
During hospitalization:
•Oriented
•Conscious and coherent
•Concerns for her surgical site after incision and repair
•Willing to accept and listen to health teachings
•Shows interest to recover easily and fast
•Always prays to God
B. Nutrition/ Metabolism
Prior:
•Eats more of fruits and vegetables
•Eats her meals 3x a day with snack in between
•Can drink up to 1.5L of water or 4-5 glasses a day
•Drinks coffee in the morning and in the afternoon
•Claimed to be allergic on shrimps and claimed to have
good appetite
During:
•Weight: 41 kg
•Height: 4 ft and 10 in
•Normal Body Mass Index; BMI = 18.89 kg/m2
•Average Body Temperature is 360 C
•Able to fast in preparation for surgical procedure
•Before operation, being infused with an IVF of D5NM 1L x
160 hooked at her left cephalic vein
•After operation, being infused with an IVF of PLR 1L x 8
hours as main line hooked at her left cephalic vein with a
side drip of PNSS 500mL + 2 ampules Voltaren at 20cc/hr
and an IVF of PNSS 1L x KVO hooked at her right cephalic
vein with a side drip of 2units PRBC
•On NPO
C. Elimination
Prior:
•She voids 4-5 times a day
•Her urine color is yellow which is dark most of the times
•There is no burning sensation/ pain felt during urination
•She usually moves her bowel every morning
•With brown and formed stools. But recently, she is having
difficulty in defecating
•The impression to the result of the ultrasound of her whole
abdomen is to consider ileus; partial obstruction and fecal
stasis
During:
•No pain or burning sensation during
•urination
Before she experienced vomiting
operation,
yellowish with andhasn’t move her
throughout
vomitus the 8 hour
bowel
shiftall
•After undergoing the surgical procedure, a nasogastric
tube is used which is attached to a drainage bottle; a
colostomy is present attached to a colostomy bag
•After operation, a foley catheter was used which is
attached to the uro bag draining well with dark yellow
urine with an output of 175 cc was taken after the shift
D. Activity/Exercise
Prior:
•The patient ambulates within the house
•She does household chores
•She takes a walk at their subdivision to visit
the neighbors and buy at the store
•She does simple exercises on the upper and
lower extremities by means of shaking and stretching
•Able to bathe herself
During:
•Reaction to stimuli are slower
•Decreased strength; becomes weak in prolonged activities
•Decreased speed of movement
•Limited range of motion
•Radial pulse rate easily palpable and heard
•PR: 70 bpm
•RR:18 cpm
•BP: 110/80 mmHg
•Before operation, patient can turn to sides with
slight discomfort and can ambulate with assistance
•After operation, patient is on bed rest; flat on bed
and shows evidence of weakness
•Steady and in deep sleep for 4 hours
E. Sexuality/ Reproductive
•Married
•A mother of 4 children
•Menarche was on the year 1938 when she was 11 years
old
•On her menopausal stage
•She has no history of Sexually Transmitted Disease or
any disease affecting her genitals
F. Cognitive/Perceptual
Prior:
•No sensory deficits but functions are diminished due to
age
•Oriented to people, time, and place
•Responds to stimuli verbally and physically
•Pain felt radiating on the abdomen

During:
•Pre-operative Phase
•Before operation, she verbalized, “Sakit kaayo akong tiyan
tapos butod ko. Magbalik-balik ang sakit.”
•She rated pain as 8, from a pain scale of 1-10, 10 as
the highest possible pain perceived
•She claimed that pain starts at the right upper quadrant
and radiates all throughout the abdomen
•Claimed pain to be intermittent
•In normal thought process
Post-operative Phase
•“Akong tahi, nagasakit
pa.”, as verbalized
•Felt pain around the
surgical site
•Slight facial grimacing
•Can respond to stimuli verbally and physically
with weakness noted
•Believes that pain felt is due to post-operative experience
G. Roles/Relationship
Prior:
•Married
•With 4 children
•Lives with the youngest child
•Close to her grandchildren
•Loves her family so much
•Well – supported and loved by her family with
close
relationship
During:
•Well – supported by the family
•Still plays the role of a mother despite condition by means
of reminding important matters to her children
H. Self-Perception/Self-Concept
Prior:
•Manages to practice healthy lifestyle so as not to seek
medical assistance
•Recently, she believed that admission will be helpful to assist her in her
needs, to alleviate the pain she felt, and to correct her bowel
•Hopeful to be relieved and treated

During:
•Though weak, she still manages to appear calm and relaxed
•Agreed to be operated and undergo surgery and gives her trust to the
surgical team
•Hopeful and positive to have a successful operation
•Before operation, she prays all the time
•She desires that no complications will arise after the surgery
•Major concern is her recovery
I. Value/Belief
Prior:
•A Roman Catholic
•Have strong faith in God
•She always brings with her the rosary and always prays at
night
•She goes to the church with her youngest child and
her grandchildren to attend the mass every Sunday

During:
•No restrictions in the procedure brought by religion
•The admission and surgery don’t interfere with
spiritual
practices
J. Coping/Stress
Prior:
•Copes up with stress by doing household chores and
by taking a nap or sleep
•Copes up with problems by talking about it with the family
and finds ways to resolve it together
•No traumatic events experienced before
•Reason for admission is to alleviate the pain and correct
her bowel
•Went to hospital and sought for medical assistance after
experiencing inability of defecating

During:
•Takes a nap and rests when tired
•Verbalizes desires to recover
•Able to accept situation by cooperating with the medical
advices and procedures
K. Sleep/Rest
Prior:
•Can sleep for 7-9 hours per night
•Straight hours of sleep
•Her earliest time in going to sleep is at 9:30 PM
•Latest time in waking up is at 6:30 AM
•She sometimes takes a nap at noon for about 1-3 hours
•No difficulties in going to sleep
•Doesn’t uses any medication to promote sleep

During:
•Sleeps at 8:00 PM
•Wakes up at 6:00 AM
•Can consume 10 hours of sleep
•Sometimes, she is distracted and sleep is interrupted due
to pain, administration of medication and visitors
•With rest intervals, usually naps for 4 hours
L. Medication History
Prior:
•Took Bentyl and Loperamide

During:
•Pre-operative Phase
•IVF of D5NM 1L x 160
•Completed 6 doses of Kalium Durule 1 tab TID
•Completed 3 doses of Senokot Forte 2 tabs
BID
•Administered with Motillium 10 mg 1 tab TID
•Nexium 40 mg 1 tab OD
•Lactulose 30 cc
Post-operative Phase
•IVF of PLR 1L x 8 hours as main line with a side drip of
PNSS 500mL + 2 ampules Voltaren at 20cc/hr
•PNSS 1L x KVO with a side drip of 2units PRBC
•On NPO
•Administered with Cefuroxime 750 mg q80 IVTT
•Metronidazole 500 mg q80 @ am
•Omepron OD 40 mg IVTT
•Voltaren 20 cc/hr
•2nd dose of 12 doses Nalbuphine 5 mg q60 IVTT
•Nebulized with Convibent q80