Running Head: Mental Status Exam

RosalynArdoin
MentalHealthStatusExam
April19,2015

MENTAL HEALTH STATUS EXAM

PatientwasafiftyeightyearoldCaucasian/partHawaiianwidowedmale.
Hewasadmittedwithgangrenetohisrightgreatertoesthatleadtoosteomyelitis.March
3rdthepatienthadhisrightlegamputatedbelowtheknee.Hishealthhistoryincluded
CHF,alcoholiclivercirrhosis,DMII,HTNanddrugusethatincluded
methamphetamine,heroinandmarijuana.
Basedonthepatientshealthhistory,druguse,andamountoftime
hospitalizedwithlossofalimb;Ichoosetoaskthepatientquestionsbasedoffofthe
BurnsDepressionChecklist.Itwasnotaneasytask,thepatientwasnotveryopento
discussionbutafterbuildingaprofessionalrelationshipandestablishingtrust,thepatient
openedupaboutlifegrowingup,hischildren,hisrelationshipsandhisgoalsforthe
future.Thepatientscoreda16thatresultedinBoarderlinetomilddepression.
SSelfEsteem:Thepatientsseemedtohavegoodhumorwhenitcametohis
personalhygiene.Hemadejokesabouthisbeardstatingthathewasnotgoingtoshaveit
tillhegetsdischargedbecauseitsthenewthingandhewantedtolookgoodforthe
nurses.Hisselfcarewasperformedatbedside,hemaintainedhisownoralhygienebut
neededassistanceinhisdailybathing.Hehadthirdspacinginhisscrotalandabdomen
areasecondarytohislivercirrhosisthatmadeselfcaredifficult.Hewasverygoodabout
marinatingeyecontactandwasvocalabouthisdiscomfort.Hedidcontinuetomention
howmuchweighthehasgainedandoftenkepthishandsinhispantsaroundhisswollen
scrotum.

MENTAL HEALTH STATUS EXAM

EEnergyLevel:Thepatientwasfatiguedeasy;thiswasmostlikelyrelatedto
hisillnessesincludingdepression.Hewasdeterminedtobeverballystrong,Ithinkthis
washiswasofreassuringhimself.Hisouterdemeanorspokeawholeotherlanguage.I
hadtheopportunitytogetclosewiththepatientandseehowmuchhereallywas
strugglingwithlifeinthehospitalandwhatwastocome.Heoftensatonthesideofbed,
withhishandsonhiskneeshunchedoverstaringblanklyatthefloor.
LLifestyle:Thepatientdidnothaveanaddressoutsideofthehospital.He
statedthathehadburnedbridgeswithfamilyandwouldnotwanttoburdenthemwithhis
care.Hegrewupinthehousingwithfivesiblings,hewatchedhismotherandfather
struggleandsufferuntilherealizedthathecouldhustleandprovideforthefamily.His
hustlingincludeddealingdrugs,tradingfoodstampsforcash,andbuyingcarsfrom
chronicsfixingthemandresellingthem.Heonlyspokeofthethingshewasstill
currentlytakingpartin,hestatedthathewasluckythathecouldstilldoallofthisfrom
hishospitalbedotherwisehewouldnotknowhowtoprovideforhisyoungestdaughter.
Hemadeitveryclearthathisfamilydoesnotseehimtakepartinanythingillegalandhe
heldhiskidstoahigherexpectationthanheheldhimselfto.Heknewwhathedidwas
againstthelawandhesaidhehadpaidhisdueswith12yearsinjail,butitisallhe
knowsandcouldnotimaginealifewithouthustling.Ithinkthepatientfearednotbeing
abletocontinuehislifeoutsideofthehospital.
FFamilySystem:Thepatientwasnotopentotalkingabouthiswife,shewasin
factstillalive,butsheisadrugaddictprostituteandhedidnotwanttotalkabouther.He

MENTAL HEALTH STATUS EXAM

hadmultiplekidsfromdifferentwomen.Thepatientsmostimmediateandimportant
contactswerehisfriends.Twoofthemhadvisitedhimeverysingledaysincehewas
admitted.HehadquiteafewboutsofangerandfrustrationwhileIwaswithhimand
eachtimehereachedforhisphoneanddecompressedtoafriend.Whenaskedhowhe
generallycopeswithstressfulsituationsherespondedwiththeoceanandsmokinga
blunt,bothofwhichhestatedhehadgivenup.Ienquiredaboutthethoughtbehind
givinguponthethingsthatrelaxhimandbroughthimhappiness.Hestated,Mobetta
Inosmokedope,sowhenIswimwithoneprosthesisIcanbreath.Thetransitioninto
findinganothercopingmechanismwashardforthepatient.Hehadlimitedresourcedthat
werefamiliartohiminthehospital,andtherecoursesthathewouldbeexposedtoafter
dischargedwereharmfultohishealth;hishealthwasbecomingmoreofapriority.
PPhysiological:Physiologicallythepatientwasorientedtoperson,place,time
andsituation.Patienthadrightlegbelowthekneeamputation,withdecreasedsensation
toleftlegwithpulsesheardonlybydoppler.Patientrespiratoryrate,depth,rhythm
normal,andnonlabored.PatienthadanAICDwithanirregularheartbeat.Hewasa
perviouspackadaysmokerwithmethamphetamineandmarijuanausesinceteenage
years.PatienthadweighttakenonadmissionFebruary15,2015,whichwastwohundred
fifteenpounds,herelatedhislackofmobilitytotheamountofextraweightgainedin
hospital.Idecidedtoweighhimforthefirsttimesinceadmission;thepatientsweight
wasonehundredeightytwopounds.Hewasextremelydistraughtbyhisweight,notonly
washenolongeroverweight,buthewasbelowhisnormalbaselineweight.Itwashard

MENTAL HEALTH STATUS EXAM

forhimtocomprehendwhyhisweightwasless,yethisbodywasfluidfilled.Thereality
ofmusclewastingandliverdiseasewashardforhim.
AAffect:Patientsexternalrangeofexpressionwasverymixed.Attimeshe
wasintensewithdeterminationandwillpower.Hespokeofhavingastrongmindand
beingabletoovercomementallywhathashappenedphysicallywithhisbody.Onthe
otherhandhewasdistressedandquiet.Externallyhelookedsadandwithdrawn,buthe
wasalsogoodatmaskinghisemotions.
CCulture:ForcultureIfocusedonhishomelessness.Thepatientwasliving
withafriendpriortohospitalization,heandhisfriendhadanagreementtoworktogether
repairingcarsandsplitthecostofrent.Returningtohisfriendshousewasnotaoption,
heknewthathewouldneedassistancewithADLsanddidnotwanttoburdenhis
friendoranyfamilymembers.Hewasadamantaboutalwaysbeingindependent,he
statedthatthemomenthewasunabletocareforhimself,eitherhimorfriendwould
injectagramheroineinhisarm,whichwouldstophisheart.Thiswassomethingthatthe
patienthadclearlytalkedaboutandthoughtthrough.Icouldnthelpbutwonder,ifhedid
notfindaplacetostay,ifoverdosingwasanoption.Iaskedhim,hesaidhehadtoo
muchtolivefor,butIwasnotconvincedbyhisanswer.Healsostatedthathehadthe
cashtopayforaSNF,buthedidnotwanttothrowupanyredflagsandriskthelossof
hisbenefits.
IInterests:Thepatientexpressedinterestandpassionforfamily.Hehadadeep
senseofneedtoprovideforhisyoungestdaughterwhowaslivedwithhissister.He

MENTAL HEALTH STATUS EXAM

seemedtotalkaboutwhatheknewbestandthatwashustling.Iaskedhimhowhis
childrenseehim;herespondedthattheyseehimasanoutdoorsmanwhohasapassion
forrepairingcars.Whenraisinghiskidstheyfocusedondiving,fishing,andbeachtime.
Heconsideredhimselfanaviddiver.Also,hehasgrowntolovecars,hementionednever
havinganinterestincars,butonceherealizedthattherewasmoneytobemadehe
learnedtolovethem.
NNeeds:Whenaskedabouthispersonalneedsoutsideofthehospitalhestated
thatheneededtonotdependonanyone.Hereveredbacktogrowingupinthehousing
andeverythingheevergotwaswithouttheassistancefromanotherperson.Herefusesto
thinkofhislegasadisability.Heisadamantaboutstayinginthehospitaltillheiswell
enoughtocareforhimself.Itriedmultipletimestodiverttheconversationawayfrom
hishospitalstay;Iattemptedtofocusonwhathemightneedtoimprovehisstay
emotionally.Hesaid,IneednothingmorethanwhatIgot.Thewholetimehetalked
abouthisneeds,hisheadwasdown,shouldersslumpedandheoftenclosedhiseyesand
shookhishead.Asstrongashiswordswherehewasclearlystrugglingwithbelievingthe
wordsthatcamefromhismouth.
GGoals:Hisgoalswereaboutthesameashisinterests.Someothergoalshe
expressedwhereensuringhisdaughterhadbracesbeforehergraduation,shehadacarto
drivewhensheturned16andimprovinghishealthsowewontloosehisotherleg.
Mentalillnessisdifficult.IfIwerenotlookingforanyunderlyingillnessand
strictlylisteningtowhatthepatientwassaying,Iprobablywouldnothavepickedupon

MENTAL HEALTH STATUS EXAM

thepatientsdepressionandwithdrawalfromreality.Heseemedtojustifyhisactionsof
illegalactivitybyplacingblameonhisupbringing,eventhoughheknewtheactionsare
unlawfulandmorallywrong.Honestly,Iwouldliketofindawaytohelpguidethis
patient.Ifindhissituationverycomplicatedanddontknowifhewillgetthedirectionor
helpheneeds,eitherfromhislackofparticipationorlackofresources.Ifeelheis
functionalyetunpredictableandsuffersfromdepression,delusionandmildmental
illness.

General appearance and behavior:

1. Affect: Patients external range of motion was hosilte at first AEB refusing to have a nursing student
provide care. Patients perception changed to engaging aeb willingness to allow me to participate in care and
opening up about personal feeling after a trust was established
10. Psychotropic Medications: NONE
2. Mood: Internal emotional tone was distant yet open aeb his openness to talk but he was still guarding his
emotion
3. Thought Process: Tangentially aeb his diverging of personal feelings and emotions related to his illness.
4. Thought Content: perceptual disturbances, illusions and misinterpretations of reality aeb his justification
for staying in his unhealthy relationship with self, regardless of the outcome.
5. Cognitive Evaluation: LOC. Orientation to person, place and date. Short-term memory intact aeb abilty to
verbalize hospital, date and myself
6. Insight: Able to show understand of current problems and situations aeb attempting to establish care
outside of the hospital.
7. Judgment: Patients judgment seemed to impaired aeb long term drug use and lack of knowledge of
alternative option.
8. Level of Function: patients level function was slightly limited aeb the decreased movement and below the
knee amputation of his right leg
9. Psychiatric status: the psychiatric status of the patient was deemed normal by the hospital.

MENTAL HEALTH STATUS EXAM

Psychosocial assessment:
1.Housing: Patients current housing is the hospital. He does not have an address outside the hospital
2. Transport: Patient does not drive and does not have a car. He does have friends that are willing to take
him to and from his appointment and therapy.
3. Financial: Financially the patient is dependent on the resell of cars and selling drugs. He is on Quest and
Snap benefits
4. Support: Patients immediate support is friends, he is not planning on getting support from his family.
5. Follow-up: This patient is planning on eating healthy, improving mobility, and working with friends to
establish a facility where he can be discharged.

0
Not at All
1. Sadness: Do you feel sad or down in
the dumps?
2. Discouragement: Does the future look
hopeless?
3. Low self-esteem: Do you feel
worthless?
4. Inferiority: Do you feel inadequate or
inferior to others?
5. Guilt: Do you get self-critical and
blame yourself?
6. Indecisiveness: Is it hard to make
decisions?
7. Irritability: Do you frequently feel
angry or resentful?
8. Loss of interest in life: Have you lost
interest in your career, hobbies, family,
or friends?
9. Loss of motivation: Do you have to
push yourself hard to do things?
10. Poor self-image: Do you feel old or
unattractive?
11. Appetite changes: Have you lost
your appetite? Do you overeat or
binge compulsively?
12. Sleep changes: Is it hard to get a good
nights sleep? Are you excessively
tired and sleeping too much?

1
Somewhat

2
Moderately
2

3
A Lot

1
1
0
0
0
2
0
1
0
2
3

MENTAL HEALTH STATUS EXAM

13. Loss of sex drive: Have you lost your

interest in sex?
14. Concerns about health: Do you
worry excessively about your health?
15. Suicidal impulses: Do you have
thoughts that life is not worth living or
think youd be better off dead?

2
2
0

Total Score on items 1-15

16

Total Score

Degree of Depression

0-4

Minimal or No Depression

5 - 10

Normal but Unhappy

11 - 20

Borderline to Mild Depression

21 - 30

Moderate Depression

31 - 45

Severe Depression

Available Points
Grading Rubric Psych- Social Assessment:
Add/fill in to CIS a box titled Mental Status Exam (MSE) - using your
MSE handout. Be sure to include descriptions of clients mood, affect,
thought process, behavior, feelings and so on.
Add to CIS a box titled Psychosocial Assessment be sure to include
those factors relevant to your client- Living situation, support or lack of,
level of function, employment or unemployment, money, after hospital
care needs, issues of mental illness/ substance abuse or history of.
What is this clients situation? How does their illness, this
hospitalization impact their life and ability to function? See Self Pacing
guideline above.
Include one or more standardized assessment tools as appropriate to
the client and is sure to include the total score and the implications of

MENTAL HEALTH STATUS EXAM

10

that score. Assessment Tools are posted in Laulima Resource.

Write a 2 page assessment regarding your assessment decisions and
why you choice it, Your own feelings of doing the assessment and
implications to your nursing care, what your plan of nursing care was
post psychosocial assessment and why. Please use APA 6th edition
format- 12 point font, double spaced.
No use of patient names or identifiers and no use of staff names.

Turned in on time using a labeled folder.

Total Assignment Points = 10= 100
9=90
8=80
7=70