Mental Status Assessment & Nursing Care Plan

Part 1: Mental Status Assessment

1. Identifying Data
a. Name: -------------
b. Sex: F
c. Age: 38 Y
d. Race/Culture: Hispanic, Argentina
e. Occupational/financial status: housewife
f. Education Level: equivalent high school in Argentina
g. Significant other: husband
h. Living arrangements: lives with husband and two daughters, 4Y and 14Y.
i. Religious preference: no preference
j. Allergies: No allergies
k. Special diet considerations: No
l. Chief Complaint: “I always feel sad, lonely, and I have no purpose in life.”
Claims her “four year old daughter has been acting like a 20 year old
woman”. Accuses husband of having sexual feelings for their 4Y daughter
and tried to forcefully take children from home. States she “could see
handprints all over her daughter’s body”. Also states that her daughter
cannot wake up in the mornings and often finds her dead. Loss of appetite.
2. General Description
a. Appearance: Wears clinic gown with unlaced sneakers. Face is
expressionless and shows no sign of interest. Sits with head bent and arms
crossed. Height is appropriate. Weight is appropriate to height. Eye
contact is avoidant and stares at the floor. Hair is tied back but uncombed.
Hair is coarse and thick. Appearance correlates with chronological age.
Hygiene is well maintained. No makeup.
b. Motor Activity: Slow body motions. Walks slowly. Keeps arms crossed
when walking.
c. Speech Patterns: Speech is monosyllabic and slow. Speech is accented in
English, but fluent in Spanish. Falling intonation.
d. General Attitude: Passive, guarded, and withdrawn. When spoken to she is
friendly.
3. Emotions
a. Mood: Depressed and fearful. Preoccupied.
b. Affect: Blunted affect that is congruent and appropriate.
4. Thought Process
a. Form of thought: Circumstantial. Flight of ideas and disorganized.
b. Content of thought: Delusional; mixed persecutory and jealous type.
Suspiciousness. Denies suicidal or homicidal ideation.
5. Perceptual Disturbance: Visual hallucinations. “I often find my daughter dead and
she cannot wake up.” “My daughter acts and talks like a 20 year old.”
 6. Sensorium & Cognitive Ability: Is alert and oriented to person, place,
circumstance and time. Appears fatigued. Short and long term memory intact.
Unable to think abstractly.
7. Impulse Control: Able to control impulses of fear.
8. Judgment and Insight: patient denies problem and has no insight into need for
treatment. Lack of coping strategies.
9. DSM-IV Diagnosis:
a. Axis 1 298.9 Psychosis NOS
b. Axis II No diagnosed disorders.
c. Axis III No active medical problems.
d. Axis IV Relationship Stress
Recent move across country
Possible child abuse of her daughter
e. Axis V Current GAF= 35.
Has impairment in reality testing. Hallucinates that her
daughter is speaking to her as a 20 year-old woman. Her
speech is often obscure.
Has major impairment in family relations and mood.
Children are scared of her and she avoids interacting with
husband.
Delusions and hallucinations influence her behavior. Does
not seek out new friendships although she ‘had many
friends in North Carolina’ and misses them.

Part II: Nursing Care Plan

1. Nursing Diagnosis: Social isolation related to delusional thinking as evidenced by

flat affect, uncommunicative, withdrawn, preoccupation with own thoughts,
‘always feeling sad’ and dysfunctional interaction with family.
2. Long-term goal: patient will voluntarily spend time with other patients and staff in
groups and during activities by time of discharge.
a. Pt. will willingly attend goal-setting group accompanied by trusted staff
member within 2 days.
i. Intervention: Verbally acknowledge pt’s absence from any group
activity. This encourages pt’s self-worth and importance of being
at group activities.
ii. Intervention: Establish therapeutic relationship by being attentive
and accepting. By being emotionally present the nurse fosters
growth in relationships and decreases the patients feeling of
aloneness. (Ackley, B.J., & Ladwig, G. B., 2006).
iii. Intervention: Offer to accompany pt. to group ahead of time. The
presence of a trusted individual provides emotional security for
the patient.
b. Pt. will identify the reasons for her feelings of isolation within 1 week.
 i. Intervention: Encourage patient to verbalize feelings during
groups. (Ackley, B.J., & Ladwig, G. B., 2006) This increases
communication level with peers and others.
ii. Intervention: Discuss causes of perceived isolation. . (Townsend,
M. C., 2004). Allows for exploration of causes of isolation and
gives nurse information and history to better identify areas to
focus on.
iii. Intervention: Music therapy to support the expression of feelings.
Music can play a role in retrieving emotions and enhances
relaxation so patient can feel more at ease. (Ackley, B.J., &
Ladwig, G. B., 2006)
c. Pt. will initiate interactions with others within 3 days.
i. Intervention: Observe for barriers to social interactions. (Ackley,
B.J., & Ladwig, G. B., 2006) Knowing exactly what causes social
isolation helps evaluate if further interventions are needed and
allows an opportunity for both nurse and patient to achieve
outcome.
ii. Intervention: Provide positive reinforcement when the pt seeks out
others. (Ackley, B.J., & Ladwig, G. B., 2006). This type of social
support contributes to a higher self-esteem and encourages
repetition of acceptable behaviors. (Townsend, M. C., 2004).
iii. Intervention: Help the pt. identify appropriate diversional activities
to encourage socialization through activities in creative
expressions. (Ackley, B.J., & Ladwig, G. B., 2006) Active
participation by the patient is fundamental for producing
behavioral changes.

Part III

1. Medications:
a. Acetaminophen, 650 mg for pain.
b. Loperamide (Imodium)
c. Lorazepam, 1 mg for anxiety, agitation, or restlessness.
d. Magnesium hydroxide suspension.
e. Nicotine polarilex gum 2 mg.
f. Promethazine (Phenergan) 25 mg.
g. Trazodone (desyrel) 50mg.
h. Aripiprazole (abilify) 15 mg.
i. Classification: antipsychotics
ii. Indications: Schizophrenia. Acute bipolar mania.
iii. Contraindications: hypersensitivity. Use cautiously in: conditions
that cause hypotension. Known cardiovascular or cerebrovascular
disease.
iv. Side effects: constipation, confusion, depression, restlessness.
v. Patient Teaching: advise patient to make position changes slowly
to minimize orthostatic hypotension. Advise pt that extremes in
temperature should be avoided.
 References

Ackley, B.J., & Ladwig, G. B. (2006). Nursing Diagnosis Handbook: A Guide to

Planning Care. (7th ed.). St. Louis: Mosby Elsevier.

(Townsend, M. C., 2004). Nursing Diagnoses in Psychiatric Nursing; care plans and
psychotropic medications. (6th ed.). Philadelphia: F.A. Davis Company.