8/4/2019 for mse

1/8

INFORMANTS:

MSE

Orientation Phase Working PhaseA.General Apperance

This is my 1st

assessment to rosalie

> She is 24 years old and looks accordingly to her

age

> She has a mesomorphic body

> She has a fair complexion

> Her lips were pinkish in color and her set of teeth

was yellow with some tar.

> She has a long hair

> She was wearing a Brown t-shirt, a blue pants and

a pair of black slippers

> She said that she took a bath and no unpleasant

smell was noted

> Her fingers and toenails were trimmed

> She seems to have a good and neat appearance

because of the way she carries herself

> She maintains eye contact as we talk and no

difficulty in speaking noted

A.General Apperance

This is our 2nd

assessment to jek-jek

> She still established and maintained good eye

contact during our conversations

>She was wearing a white t-shirt, a pants and a pair

of slippers

>We noticed that she does her ADL properly

> Fouled odor not noted

>Have enough rest

B. General Mobility

1.Posture and Gait

Partner jek-jek projects a semi-slouching posture.As she walks, she walks with a slow movement

notice. She was able to move and does things by

herself. She walks in a slow pace and careful

movements.

B. General Mobility

1.Posture and Gait

Partner jek-jek projects a semi-slouching posture.As she walks, she walks with a slow movement

notice. She was able to move and does things by

herself.

2. Activity

( ) normoactive

( ) underactive

2. Activity

( ) normoactive

( ) underactive

8/4/2019 for mse

2/8

( ) hyperactive

( ) agitated

( ) psychomotor retardation

( ) compulsive/ ritualistic

( ) stereotyping retardation

Our client on the first week especially on the first

day was underactive. She was participative in the

activities and games. She does not need assistance

in performing. However still some of clients

movement were delayed somtimes

( ) hyperactive

( ) agitated

( ) psychomotor retardation

( ) compulsive/ ritualistic

( ) stereotyping retardation

Still on this phase she shows normoactive in activity.

She was participative in any activities and games.

She does not need assistance in performing.

3. Facial Expression

jek-jek facial expressions were with congruence

to her emotions or reactions. She was quite most of

the times. When having our activity she participates

with showed happiness on her face. When she feels

happy she smiles.

3. Facial Expression

jek-jek facial expressions were with congruence to

her emotions or reactions. She was quite most of

the times. When having our activity she participates

with showed happiness on her face. When she feels

happy she smiles.C. Behavior

() friendly

( ) impulsive

( ) angry

( ) embarrassed

( ) negativistic

( ) evasive

( ) seductive

( ) indifferent

( ) withdrawn

The manner of behaviour Jek-Jek has was

friendly. She was friendly to the assigned student

nurse and as well as to the other student nurses.

C. Behavior

() friendly

( ) impulsive

( ) angry

( ) embarrassed

( ) negativistic

( ) evasive

( ) seductive

( ) indifferent

( ) withdrawn

All of us student nurse notice that Jek-Jek was

friendly. She smiles to a student when talked.

D. Nurse-Patient Interaction

( ) cooperative

( ) uncooperative

( ) initially

( ) all throughout

Quality:

() warm

( ) distant

( ) dependent

( ) hostile

( ) suspicious

( ) talkative

Jek-Jek was very cooperative, well responsive and

very vocal. She was able to answer questions asked

to her. The quality of interaction that she has

D. Nurse-Patient Interaction

() cooperative

( ) uncooperative

( ) initially

( ) all throughout

Quality:

( ) warm

( ) distant

( ) dependent

( ) hostile

( ) suspicious

( ) talkative

Since the orientation phase up to now, Jek-Jek

showed the same attitude, she was still cooperative

and the quality was very warm.

8/4/2019 for mse

3/8

shown us was very warm. She gets to talk a lot and

share her experiences whether be good or bad.

I. Stream of Talk

A. Character

( ) spontaneous

( ) deliberate

( ) blocking

( ) pressured

We consider the character of talk that Jek-Jek has

a spontaneous and in a right pace. She talks clearly

and comprehensively. Sometimes she talks fast. She

was able to speak Bisaya, Tagalog and English.

II. Stream of Talk

A. Character

() spontaneous

( ) deliberate

( ) blocking

( ) pressured

We consider the character of talk that Jek-Jek has

a spontaneous and in a right pace. She talks clearly

and comprehensively. Sometimes she talks fast. She

was able to speak Bisaya, Tagalog and English.

B. Organization of Talk

( ) relevant

( ) loose of associations

( ) tangentiality() irrelevant

( ) flight of ideas

( ) neologism

() incorrect

( ) circumstantialities

( ) others

Jek-Jek organizations of talk were irrelevant and

some are incorrect because she still believes in the

presence of her delusions.

B. Organization of Talk

( ) relevant

( ) loose of associations

( ) tangentiality( ) irrelevant

( ) flight of ideas

( ) neologism

( ) incorrect

( ) circumstantialities

( ) others

Jek-Jek organizations of talk were relevant. She

answers most of the questions correctly and

appropriately. She answers directly with no any

flight of ideas or circumstantialities

C. Accessibility

( ) good

( ) self- absorbed

( ) defensive

() fair

( ) mute

( ) inaccessible

Fair accessibility means that the client was able to

be involved in a conversation whenever the student

nurse initiates the conversation. It was different

from good because it was still our first week of

interaction with our client

C. Accessibility

( ) good

( ) self- absorbed

( ) defensive

( ) fair

( ) mute

( ) inaccessible

We could say that we were able to establish a good

trusting relationship with our client. There was a

good accessibility between us and Jek-Jek,

especially to the assigned student nurse. She

communicate very well with us

III. Emotional State and Reactions

A.Mood

() euthymic

III. Emotional State and Reactions

A.Mood

() euthymic

8/4/2019 for mse

4/8

( ) depression

( ) euphoria

Jek-Jek was euthymic in such way that when the

situation calls for being active and happy, she was

happy and active. She appears to have initiative and

focus to the activities

( ) depression

( ) euphoria

Jek-Jek was euthymic in such way that when the

situation calls for being active and happy, she was

happy and active. She appears to have initiative and

focus to the activities

B. Affect

( ) appropriate

() inappropriate

Quality:

() flat

( ) elated

( ) histrionic

() blunted

( ) labile

( ) angry( ) hostile

( ) anxious

( ) others

Upon the observation of the student nurses, Jek-

Jek affect was inappropriate. Her facial expressions

were with flat and blunted. She shows seriousness

most of the time when no one is conversing with

her.

B. Affect

() appropriate

( ) inappropriate

Quality:

( ) flat

( ) elated

( ) histrionic

( ) blunted

( ) labile

( ) angry( ) hostile

( ) anxious

( ) others

Upon the observation of the student nurses, Jek-

Jek affect was appropriate. Her facial expressions

were with congruence to her feelings and verbal

cues. She shows seriousness most of the time when

no one is conversing her.

C. Depersonalization andDerealization

( ) present

() absent

Our client was not detached from herself to reality.

She was able to understand that she was a human

being with multiple functions and feelings. She was

also aware of her environment. With this we can

say that depersonalization and derealisation were

not present

C. Depersonalization andDerealization

( ) present

( ) absent

Our client was not detached from herself to reality.

She was able to understand that she was a human

being with multiple functions and feelings. She was

also aware of her environment. With this we can say

that depersonalization and derealisation were not

present

D. Suicidal Potential

( ) present

() absent

The chart of our client says that she does not have a

suicidal or homicidal potential. Jek-Jek was

already excited about whats her life would be after

she will be discharged

D. Suicidal Potential

( ) present

( ) absent

The chart of our client says that she does not have a

suicidal or homicidal potential. Jek-Jek was

already excited about whats her life would be after

she will be discharged

8/4/2019 for mse

5/8

IV. Thought Control

A,Perception

( ) present

( ) absent

There was absent of neither hallucination nor

illusions. Her thoughts are relevant. Jek-Jek

perceived through her senses and well interpreted

by her brain.

IV. Thought Control

A,Perception

( ) present

() absent

There was absent of neither hallucination nor

illusions. Her thoughts are relevant. Jek-Jek

perceived through her senses and well interpreted

by her brain.

B. Delusions

() present

( ) absent

There were persecutory delusions noted because

our client still thinks that someone is following her

and would kill her. She has suspicious belief of

others.

B. Delusions

( ) present

( ) absent

No any type of delusions was observed. She has self-

control and she was oriented to reality.

C. Ideas of Reference

( ) present

( ) absent

Jek-Jek does not associate herself to an external

event. She knows the things or happenings that she

was not involved with.

C. Ideas of Reference

( ) present

() absent

Jek-Jek does not associate herself to an external

event. She knows the things or happenings that she

was not involved with.

D. Preoccupations and Ruminations

( ) present

() absent

There was no over centering of thought content on

particular ideas observed to Jek-Jek. She does not

repetitively say things of what was in her mind.

D. Preoccupations and Ruminations

( ) present

() absent

There was no over centering of thought content on

particular ideas observed to Jek-Jek. She does not

repetitively say things of what was in her mind.

Jek-Jek feels protected when she is inside the New

Day Recovery Center

E. Deja vu and Jamais Vu

( ) present

( ) absent

There was never a time in which our client shared

or talked about certain events that have not yet

occurred that she find familiar nor the other way

around.

E. Deja vu and Jamais Vu

( ) present

() absent

There was never a time in which our client shared or

talked about certain events that have not yet

occurred that she find familiar nor the other way

around.

V. Neurovegetative state

Dysfunction

A.Sleep

( ) normal

V. Neurovegetative state

Dysfunction

A.Sleep

() normal

8/4/2019 for mse

6/8

( ) MNA

( ) DFA

( ) hypersomia

( ) EMA

() interrupted sleep

According to Jek-Jek on the first 3 days upon

being admitted to NDRC she cant sleep at night.

But as days goes by Jek-Jek has a normal sleeping

pattern. She sleeps more than 7 hours.

( ) MNA

( ) DFA

( ) hypersomia

( ) EMA

( ) interrupted sleep

In this phase our client Jek-Jek sleeping pattern

was normal.

B. Appetite

Our client has a fair appetite. She cant eat well and

consume her meals during the first days of

admission because of her depression and the onset

of her condition was still at its peak.

B. Appetite

Our client has a good appetite. She was able to

consume the entire foods served every meal of the

day. She can immediately finish eating her food and

drink right away. She was not anorexic nor did

experience volemia

C. Diurnal Variation

Jek-Jek follows and participates on the schedule

of activities that the institution provided for them.

She does always her actual daily living activities.

She also participates in our daily activities and

program.

C. Diurnal Variation

Jek-Jek follows and participates on the schedule of

activities that the institution provided for them. She

does always her actual daily living activities. She also

participates in our daily activities and program.

D. Weight

Jek-Jek initial weight was 46 kg.

D. Weight

The weight of our client was increase to 48 kg.

E. Libido

We would consider her libido as normal. She was

not sexually preoccupied.

E. Libido

We would consider her libido as normal. She was

not sexually preoccupied.

VI.General Sensorium and Intellectual Status

A.Orientation

Jek-Jek was well oriented to time, place and

persons around her. She was oriented to every time

of the day

VI.General Sensorium and Intellectual Status

A.Orientation

Jek-Jek was well oriented to time, place and

persons around her. She was oriented to every time

of the day. She also asks of when will be our next

visit or to what will be our therapy for the next

activity.

B. Memory

In terms of remote memory, Jek-Jek was able to

recall certain important events from her past. She

has a good memory as she was able to recall even

the dates and years of her lifes happenings. She

also has a good and recent memory.

B. Memory

In terms of remote memory, Jek-Jek was able to

recall certain important events from her past. She

has a good memory as she was able to recall even

the dates and years of her lifes happenings. She also

has a good and recent memory. Before we start our

8/4/2019 for mse

7/8

activity we always asked her of what did she do

before we went to her and she answered that she

ate her lunch and then sleep.

C. Attention Span

Jek-Jek has a good attention span. She does not

easily get bored. During our programs, she just

stayed in her seat and enjoyed each of the

happenings or activities. She participates very well

and listens attentively.

C. Attention Span

Jek-Jek has a good attention span. She does not

easily get bored. During our programs, she just

stayed in her seat and enjoyed each of the

happenings or activities. She participates very well

and listens attentively.

D. General Information

Jek-Jek was not aware of the latest news because

they cannot watch TV frequently. But we the

student nurse render latest news Jek-Jek can

always recall the news of what we have said.

D. General Information

Jek-Jek was not aware of the latest news because

they cannot watch TV frequently. But we the

student nurse render latest news Jek-Jek can

always recall the news of what we have said.

E. Abstract Thinking Ability

Jek-Jek abstract thinking ability was good. When

we ask her what she can say about our daily motto

her answers were relevant to the motto.

E. Abstract Thinking Ability

Jek-Jek abstract thinking ability was good. When

we ask her what she can say about our daily motto

her answers were relevant to the motto.

F. Judgement and Reasoning

( ) unimpaired

() impaired

Her judgement and reasoning were impaired. She

manifests those signs of delusions.

F. Judgement and Reasoning

( ) unimpaired

( ) impaired

Her judgement and reasoning were impaired. She

manifests those signs of delusions.

VII.Insight

() unimpaired

() impaired

( ) intellectual

( ) true

Clients insight was impaired because she talks

much of the delusions she experienced and she

believes that her delusions really exist.

VII.Insight

() unimpaired

( ) impaired

( ) intellectual

( ) true

Clients insight was impaired because she talks much

of the delusions she experienced and she believes

that her delusions really exist.

VIII.Summary of MENTAL STATUS EXAMINATION

A.Disturbances

( ) presentation

()stream of talk

( ) thought of control

( ) insight

( ) neurovegetative dysfunction

( ) general sensorium and intellectual status

VIII.Summary of MENTAL STATUS EXAMINATION

A.Disturbances

( ) presentation

( ) stream of talk

( ) thought of control

( ) insight

( ) neurovegetative dysfunction

( ) general sensorium and intellectual status

8/4/2019 for mse

8/8

( ) emotional state and reaction

Our client looks according to her age. She does not

have any difficulty in uttering words. Her thought

were relevant. She expresses her feelings and

emotions in an appropriate manner.

( ) emotional state and reaction

Our client looks according to her age. She does not

have any difficulty in uttering words. Her thought

were relevant. She expresses her feelings and

emotions in an appropriate manner.

B. Diagnosis Category

() functional

( ) organic

( ) psychotic

( ) non-psychotic

Jek-Jek disorder is considered functional. There

were no organic or anatomical abnormalities or

disorder that Jek-Jek has.

B. Diagnosis Category

() functional

( ) organic

( ) psychotic

( ) non-psychotic

Jek-Jek disorder is considered functional. There

were no organic or anatomical abnormalities or

disorder that Jek-Jek has.

C. DSM IV-R Diagnosis

Axis I- None

Axis II- Persecutory type

Axis III- None

Axis IV- Psychosocial Problem

Jek-Jek was lack of trust to other people due to

the experienced delusions. By this our client tens to

isolate herself from the society. Our client was

introvert she does not express her feeling.

Axis V- GAF is 92 (90-95) absent or minimal

symptom (e.g mild anxiety); good functioning in all

areas, interested and involved in a wide range of

activities; socially effective; generally satisfied with;

no more than everyday problems or concerns. She

has much contact with her family.

C. DSM IV-R Diagnosis

Axis I- None

Axis II- Persecutory type

Axis III- None

Axis IV- Psychosocial Problem

Jek-Jek was lack of trust to other people due to

the experienced delusions. By this our client tens to

isolate herself from the society. Our client was

introvert she does not express her feeling.

Axis V- GAF is 92 (90-95) absent or minimal

symptom (e.g mild anxiety); good functioning in all

areas, interested and involved in a wide range of

activities; socially effective; generally satisfied with;

no more than everyday problems or concerns. She

has much contact with her family.