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NUR 1212C Mental Status Exam template $11.99   Add to cart

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NUR 1212C Mental Status Exam template

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This is a comprehensive and detailed Mental Status exam template for NUR 1212C.

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  • October 16, 2024
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  • 2022/2023
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anyiamgeorge19
Student Name: _____________________________________________________________
Patient initials: ______________________________________________________________
Bipolar disorder, with manic depression
Diagnosis: _________________________________________________________________


MENTAL STATUS ASSESSMENT:Mental Health Examination include these four main sections:
Appearance (5 points), Behavior (5 points), Cognition (5 points) and Thought Processes (5
points) (A, B, C, T). Mental Status Examinations are important to complete when patients have
abnormal affects or behaviors in certain situations. Must complete all sections with resource
tools attached to form to identify your ratings for depression, anxiety, suicidal tendencies, mood
and cognitive issues.
------------------
APPEARANCE AND BEHAVIOR:(Attach depression scale.)
 Agitated
 cooperative and reasonable
 disheveled
 grooming appropriate
 psychomotor retardation
 hostile/threatening
 unusual/bizarre
Rationale for Findings: Dominic knows that he is depressed and needs medical attention. He
feel like a burden to his wife and children. He is alert and oriented despite his diagnosis/
condition. He has had bizarre/ unusual behaviors such as walking in a public place shouting and
singing along with skipping. He wants to get the help that is needed to ensure he is alive to
watch his children grow.

ORIENTATION AND CONSCIOUSNESS: (Attach mini mental exam)
 alert and attentive
 lethargic
 obtunded
 oriented x3
 disoriented to place
 disoriented to time
Rationale for Findings: Dominic knows what is happening around him and is coherent/ aware
of the fact that he has mental health problems. He is cooperative with the treatment that the
doctor has recommended for him and is able to think for himself/ is not cognitively impaired
despite his condition.
SPEECH:
 normal rate/rhythm
 dysarthric
 increased latency of response
 mute
 poverty of speech
 pressured/pushed speech
 slow
 Slurred
Rationale for Findings: Dominic can hold a stable and relatively calm/ composed conversation.
He speaks clearly and coherently.
LANGUAGE:
 intact
 expressive aphasia
 partially aphasic
 receptive aphasia



Dr. Hetzel | FLORIDA STATE COLLEGE AT JACKSONVILLE UPDATED 10/2019

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