1) Appearance (unkempt, unclean, clothing disheveled, atypical clothing, well-groomed, drab, meticulous, obese, underweight, etc. ) -clothing were disheveled, unshaven-ed beard, unclean, unkempt attire 2) Attitude (resistive, cooperative, complacent, detached, resentful, suspicious, uncooperative, overly compliant, provocative, other symptom) -detached from surrounding environment, seemed to be on guard at all times 3) Mood (sad, melancholy, euphoric, labile, irritable, hostile, apathetic, anxious, other symptom) -anxious.
4) Affect (flat, blunted, appropriate to mood, inappropriate to mood, euphoric, other symptom) -animatedand/or inappropriate affect 5) Behavior (repetitive movements, posturing, waxy flexibility, agitated, impulsive, seductive, anxious, avoids eye contact, psychomotor retardation, hyperactive, violent, restless, other symptom) -anxious, restlessness, pacing back and forth, talking to self, performing defensive moves in hallway, paranoid 6) Speech Content (grandiose, self-depreciative, flight of ideas, loose associations, ideas of reference, hallucinations, delusions, phobias, other symptom) – loose associations 7).
Speech Quality and Quantity (overly talkative, slowed, pressured, mute, stutter, dysarthria, guarded, calm, monotone, soft, loud, relevant, coherent, other) – monotone at times, when speaking to self speech was soft, incoherent on occasion 8) Sensorium and Intellectual Functioning A) Orientation- did not seem oriented to place or time B) Memory (remote, retention, confabulation)- not able to track C) Patient’s store of general information- knew basic information D) Ability to Abstract-not able to assess.
9) Insight (patient’s reaction to problem and assessment of causes) -was not quite able to get an accurate assessment on whether or not he had insight to his disease 10) Judgement (regarding own health and business affairs) -not able to make own decisions about own health and business affairs 11) Suicidal and/or Homicidal Risk -was not able to assess 12) Erikson stages: chronological – Generativity vs. Stagnation actual – Industry vs. Inferiority 13) Defense mechanisms: projection, regression Axis I – schizophrenia, paranoia Axis II Axis III Axis IV.
Axis V Psych. Meds Three top priority nursing diagnoses for this patient: 1- Disturbed personal identity r/t inability to distinguish self and nonself AEB bizarre, regressive behavior, disorganized thought process, and inappropriate affect. 2- Ineffective health maintenance r/t inability to identify, manage, and seek out help in order to maintain health AEB lack of sleep and inability to follow through with ADLs. 3- Ineffective coping r/t maturational and/or situational crises AEB alterations in societal participation and inability to follow rules.