Running Head: MENTAL STATUS EXAMINATION AND CARE PLAN
Mental Status Examination and Care Plan
Lindsey M. Gamrat
Indiana University
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MENTAL STATUS EXAMINATION AND CARE PLAN
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Diagnoses
Axis I: Bipolar Disorder –manic state with psychosis
Axis II: Deferred
Axis III: Hypothyroidism, Hypertension
Axis IV: Problems with son (who she also lives with), financial stress
Axis V: Admission- GAF 5-10, Current – GAF 22
Patient is dressed appropriately in hospital attire. She took initiative to request hygiene
items for a shower this morning and asked for new hospital scrubs, socks, and a jacket because
she stated she gets cold. Patient showered, appropriately re-dressed self and proceeded to spend
a lot of time combing her hair. No psychomotor retardation or agitation noted but patient
appeared restless at times when pacing halls. The only abnormal movements were occasional
exaggerated gestures. Patient was pleasant and cooperative when speaking to nurse. Speech was
normal volume and rate when conversing with others. Some muttering and rambling to self and
possible hallucinations were noted at times. Patient oriented to person, place, and time. Mood is
labile, going between elevated/pleasant to anxious and angry while hallucinating. Patient states
she “is feeling great” when asked and was observed smiling and singing “Oh Happy Day.” When
the patient was alone and appeared to be hallucinating and muttering to herself, her tone and
expression became angry. Affect is labile but congruent to her mood at the time. Thought clarity
varies between coherent and oriented when speaking to staff to vague and confused when
speaking to hallucinations. Patient speaks to hallucinations who may be real people (i.e.: “I am
talking to (states name) from Chicago.” Patient states that she speaks her thoughts out loud to get
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rid of internal stress. Hallucinations appear to be both auditory and visual. Content is frightening
and stressful to the patient as stated by her and observed by behavior during these hallucinations.
She is experiencing some paranoid delusions such as someone stealing her purse when it is
locked up in security. Patient appears to have lack of insight into her illness and hospitalization.
She has been off of her medications for a few months and developed a psychosis for which she
was brought in to the emergency department on a 72-hour hold. She stated that people were
coming in to her house to rape her and force her son to rape her. Admission notes state that she
had a labile affect, angry mood, anxiety, impulsivity, fragmented thought content,
bizarre/paranoid/persecutory delusions, and auditory/visual hallucinations. Patient has not
attempted suicide and does not state or appear to want to harm herself.
Reflection on Interaction
Overall, I feel that my interaction with this patient went fairly well. She was
difficult to interact with due to the nature of her illness. Being in a manic state as well as
psychosis, she had trouble focusing very long to converse. She also wanted to remain very busy
all morning so there was not a lot of time to interact in between showering, visiting the doctor,
breakfast, group, etc. I would have appreciated spending more time with her to hear more from
her about her situation and gain insight into her illness.
One of my strengths of this interaction with the patient was maintaining a positive
attitude. Even though she was bipolar, she was pleasant, cooperative, and smiling every time she
conversed with me. This was not the case when she was alone and hallucinating or with other
students who reported back to me after they attended group. I always try to maintain a kind,
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trustworthy demeanor and I hope I was successful at this since she was kind to me in return.
Another personal strength of mine was my willingness to interact with her. When you see her
diagnosis on paper, it can be intimidating. A bipolar manic with psychosis does not sound like
the pleasant older woman that I saw in the patient. Although I knew she was mentally ill and
hallucinating and could potentially snap at any moment, I was not hesitant to interact with her. I
am beginning to feel much more comfortable with these types of patients and that is a great
personal success for me.
Just as I had strengths in my interaction, there are also ways in which I could have
improved. I could have been more firm in my request to sit down and talk to her. I think that I
was sort of “walking on eggshells” because I did not want to upset her or cause her to snap.
Because of this, I did not get a whole lot out of her. It would have been interesting for me to talk
to her more and hear more about her story and what was going on in her mind. I also wish that I
would have been able to attend group with her. She was very excited about the arts and crafts
group and was gone there for a while. I would have gotten to interact with her a lot more if I had
been able to attend group.
MENTAL STATUS EXAMINATION AND CARE PLAN
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Concept Map
Hallucinations
Racing
Thoughts/Hyperactivity
Cues: Conversing with
people who do not
exist, seeing bugs in
the sky, pointing at
thin air
Cues: Easily distracted,
inattentive, antsy/always
on the move
Bipolar Disorder:
Mania with
Psychosis
Impaired Relationships
Insomnia
Cues: Son does not
appear interested in her
care, patient claims son
rapes her, patient does
not have support system
Cues: Patient has not been
sleeping through the night,
requires medication to
sleep, racing thoughts
Client Strengths
Other Problems
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Medication Noncompliance
Anxiety
Labile Mood
Family Conflicts
Financial struggles
Hypertension
Thyroid hormone imbalance
Inability to care for self
Smokes ½ pack per day
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Sense of purpose by religion
Willingness to participate in
activities
No drug or alcohol use
Generally pleasant and
cooperative with staff
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Care Plan One
Nursing Diagnosis: Insomnia related to racing thoughts and hyperactivity as evidenced by patient
not sleeping through the night.
Outcome:
Patient will sleep a minimum of 6 hours straight on Tuesday night
Intervention
Rationale
Evaluation
Provide a quiet, low
stimulation environment for
sleep
Decreasing stimulation can help
reduce racing thoughts and
hallucinations while promoting
relaxation (Keltner, Schwecke &
Bostrom, 2007).
Allow patient an outlet for
excess energy
If a patient has a lot of pent up
energy left when it is bedtime, it
will be more difficult to sleep
(Keltner, Schwecke & Bostrom,
2007).
Patient walked halls throughout
the day, participated in group,
did not return to room to rest
until bedtime
Allow time for patient to
“wind down” before bed
(encourage low key activities
as it gets closer to bedtime)
Reducing stimuli can help
control racing thoughts and
begin to allow the body to relax
(Keltner, Schwecke & Bostrom,
2007)
Patient reads book before
bedtime
Administer PRN medications
to assist with sleep (i.e.
Benzodiazepines)
Benzodiazepines reduce anxiety,
relax muscles, and promote sleep
as they are CNS depressants
(Keltner, Schwecke & Bostrom,
p. 268).
Patient shut door at night and
turned off lights. Staff tried to
keep other patients on the unit
quiet
Patient will recognize the need
for sleep and comply with
medications
Outcome Evaluation: Unable to assess because I only have clinical from 7am-12pm
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Care Plan Two
Nursing Diagnosis: Hallucinations related to psychosis as evidenced by muttering to non-existent
people, pointing at thin air, and describing hallucinations
Outcome:
Patient will report no voices or hallucinations by lunchtime.
Intervention
After assessing content of
hallucinations, do not focus
on hallucinations but reorient to reality
Assess orientation to person,
place and time. Keep patient
engaged in environment and
grounded by reality
Administer anti-psychotic
medications as prescribed
Rationale
Evaluation
After content is known, focusing
on hallucinations is unnecessary
and may reinforce the
hallucination (Keltner, Schwecke
& Bostrom, p.105).
Patient stated that she was just
talking to herself out loud and
recognized that she was not
actually conversing with a real
person. Changed subject
If the patient’s hallucinations are
ignored, they can be distracted
from them by engaging in
productive activities. Eventually
they learn to ignore the
hallucinations (Keltner,
Schwecke & Bostrom, p. 105).
Patient appropriately answered
reality-based questions about
her day, hobbies, and activities.
Showed interest and
excitement to participate in
group.
Alterations in perceptions such
as hallucinations and delusions
can be reduced with these drugs
(Keltner, Schwecke & Bostrom,
p. 217).
Patient compliant with
medication. Hallucinations
have improved since admission
Outcome Evaluation: Patient was still hearing voices and experiencing hallucinations, although
they did not interfere with her self-care activities or participation in group
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Data Collection Form
Date Admitted _________3/22/13____________
Hospital Unit or agency_CRS____
Age: __72___
How admitted and accompanied by: _Direct Admit from Johnson Memorial Hospital__
Type of admission:
72 hr hold ________
Sex _F__ Height _5’2”__ Weight ____ BP_121/60 T _97.6_ P _83_ R 19 __
Allergies to food/medicine ___Lithium________________________________
Vision _Glasses___ Hearing _______ Teeth _______ Prostheses _______
Education: High school __X___ GED ______ Other_____
Work history _____Unable to assess_______________________________________
Socio-economic status (estimate) ___________________________________________
Special interests (ex: music, sports, hobbies) __TV, church, “gospel”_______________
Spirituality (what gives life meaning & purpose?) __Religious - Christian___________
Marital Status _Widowed__ Lives with __Son___in city & county __Frankilin, IN
(Johnson Co.)_________
Type of housing ___Single level home with son ___________________________
Parents ____Deceased__________ Siblings __3 brothers, 2 sisters__
Children _Son –age 50________
Significant other ___Deceased___________________________________
Smoking history _Has smoked every day for 40 years; smokes ½ pack per day__
Alcohol/drug history ____denies_____ last drink _____________ drug use ________
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Amount used (ex: drink a pint/day, six pack?) _____NA____________________
Age began _________ History of blackouts _____________ DWI ______________
Past Detox or Tx. _____________________________________________________
Health history:
Head Problems:
migraines ___headaches _____ seizures ______ other _______
Skin Condition:
rashes _____ bruises _____ scars _____ scratches _____ other _
Breathing Problems: asthma _____ pneumonia _____ bronchitis _____ SOB ______
Emphysema _________ sinus problems ________ other ___________________
Heart Problems: chest pain _____ angina _____ high blood pressure _X__ other __
Musculoskeletal: sprains _____ strains ________ fractures _____ other __________
Gastrointestinal: ulcers _____ gastritis _____ nausea _____ vomiting ____________
Bloody stool _____ diarrhea ______ constipation _______ other _____________
Miscellaneous: any other problems ____Hypothyroidism__________________
Family History: mental illness ________ drug abuse ________ alcoholism _____
Significant medical problems _____2 siblings died from cancer_______________
Client’s past hospitalizations:
Medical: reasons ___bipolar mania____________
Surgeries _hysterectomy, tonsillectomy and adenoidectomy, breast lumpectomy______
Psychiatric: age at first admission _unknown__ number of admissions __
Types of facilities __________________________________________________
Outpatient therapy __None____________ Use of social services ___________
Support Groups: AA ________________ ACOA _____________ other _______
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Mental Status
General Appearance: dress _X grooming_X_ hygiene _X affect _X_posture X_
Orientation: Time ___X____ Date ___X____ Place _____X_____ Person ___X____
All appropriate
Thought Patterns:
Hallucinations: auditory X visual _X__ tactile ____ olfactory ___ gustatory___
Talking to invisible people, pointing at nonexistent things
Delusions: _Believed someone stole her purse__________________________
Behavior: _Varied; Cooperative and pleasant when conversing with staff this
morning, excited for group, angry and anxious when hallucinating
Eye Contact : ___Appropriate_____________
Body Movements: _Some slightly exaggerated gestures______________
Suicidal: ____No reports_________ Homicidal: ___No reports_______
Is client at risk to harm self or others now? _Does not appear to be currently_
Other? __________________________________________________________
Has client experienced losses (ex: deaths, illness, job loss, pending divorce, loss of child
custody, etc.)? ______Loss of significant other, loss of parents and siblings, appears to have
some strife with 50 year old some whom she lives with__________________________
Reason for hospitalization: (from client’s perception and staff) __Manic episode of
bipolar disorder, non-compliance with meds_________________________
Client’s expectation of hospital stay: _Unable to assess___________________
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Medications: (medication, dose, route, frequency)
Quetapine XR (Seroquel) 200mg PO HS
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Antipsychotic, Dibenzodiazepine
Lisinopril (Zestril) 5mg PO daily
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Antihypertensive, ACE inhibitor
Levothyroxine (Synthroid) 88mcg PO daily
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Thyroid hormone
Significant lab reports: __Platelets 154 (low)___________ x-rays ___________________
EEG ___________ MRI _____________ other ____________________________
History of hormones, cortisone, BCP: ______
Psychiatrist: ________________________ Therapist: ________________________
Psychiatric Diagnosis:
Axis I: Bipolar Disorder –manic state with psychosis
Axis II: Deferred
Axis III: Hypothyroidism, Hypertension
Axis IV: Problems with son (who she also lives with), financial stress
Axis V: GAF 22
Relationship or other problems __Social services consult to investigate situation with
son_________
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References
Keltner, N. L., Schwecke, L. H., & Bostrom, C. E. (2007).Psychiatric nursing. (5th ed.). St.
Louis: Mosby Elsevier.