Mental Health Nursing: The Mental Status Examination and Nursing Care Plan

Running head: MENTAL HEALTH- NURSING
MENTAL HEALTH- NURSING
Name of the Student:
Name of the University:
Author Note:

1MENTAL HEALTH- NURSING
Part 1
The Mental Status Examination
1. Appearance
The patient, Mary appears very clean and tidy. She is seen to wear fashionablet-shirts paired
with jeans. She hasshort and dark hair. However Mary does not wear any makeup. However
often she is also seen sitting wearing her dressing gown.
2. Behaviour
The behaviour of the patient apparently seems normal. However sometimes she has moments
of despair and is tearful on some occasions.
3. Attitude
The patient often feels worthless and hopeless and she thinks that she will not be able to
manage herself and carry on to the next day.
4. Level of Consciousness
The consciousness of the level of the patient is normal.
5. Orientation
6. Speech and Language
Her speech and language does not have any problem however she refuses to talk to others at
times.
7. Mood

2MENTAL HEALTH- NURSING
She suffers from mood swings. At times she is apparently normal, and at times she appears
depressed and tearful. She lacks sleep and suffers from insomnia.
8. Affect
As a result of her mood, Mary often lacks the motivation to carry out simple activities like
eating or dressing.
9. Thought Process/Form
She feels worthless and hopeless. She also suffers from thoughts like she will not be able to
survive anymore and will not be able to make it to the next day.
10. Thought Content
Her thought content of the patient is that she will not be able to manage herself anmore and
will not be able to survive.
11. Suicidality and Homicidality
Mary does not have any suicidal thoughts.
12. Insight and Judgment
Mary likes to spend time in the church and admits that she gets pleasure from her visits to the
church.
13. Attention Span
The attention span of the patient is also reduced as she lacks concentration while doing
simple activities even like eating and dressing.
14. Memory
The memory of the patient is normal as she remembers things from her past.

3MENTAL HEALTH- NURSING
15. Intellectual Functioning
The intellectual functioning of the patient is apparently optimal. She understands that if she is
admitted to the hospital again, she would be trouble her family members. She is now adamant
that she needs to stay at home to take care of her children and her husband.
Clinical Formulation Table 200
Biological Psychological Social
Presenting Acute illness depression Interpersonal
problems
Precipitating Sleeping
disorder
psychosis Social
problems
Predisposing stress Cognitive
problems
Work
problems
Perpetuating fatigue Developmental
problem
Healthcare
factors
Protective Chronic pain Chronic
addition
Cultural
factors
Plan for Nursing Care
The two high priority nursing problems as perceived from the given case comprises of
disturbed thought processes and impaired social interaction.
In order to justify the priority of the problem of disturbed thought processes, it should
be mentioned that this is a symptom of major depression, where the individual is in a state
when he or she experiences a disruption in cognitive operations and activities.