nur-253256-clinical-packet-2-psychiatric-evaluation-care-plan (1) 100 % correct

Demographics Patient’s Age: 73 years Patient’s Gender: Female Date of this Admission: 8/31/2024 Height: 162 cm Weight: 73 kg Allergies: ☐ NKDA ☒ Other: Click or tap here to enter text. Psychosocial and Environmental Problems: Primary support group: Family (Husband and children) Educational: graduated high school Housing: Own house, live with husband Access to health care services: easy access Social Environment: Live with husband, has 3 children living in the area Occupational: she is not working Economic: no issue Interaction with the legal system/crime: denies any legal issue Mental Health Diagnosis/Acute or Chronic Medical Diagnoses: Click or tap here to enter text. Bipolar 1, depressed with psychotic Brief Admission History: (What led up to your patient needing psychiatric hospitalization?): Patient was brought to the ER by the husband. Per chart husband stated she has “manic” behavior. But when she was in the ER, there weren’t accelerated speech, racing thought, non-hyperactive evident. She talked about his son being Jesus Christ. There is no manic symptoms when she was there. Describe any Family History of Psychiatric Issues (if available): Denies family history of psychiatric issue Describe any Substance Abuse History (if available): Denies alcohol used Denies drug used Denies alcohol used Describe any Trauma Abuse History (if available): (Domestic violence, sexual or physical abuse, etc.) Denies history of trauma oaded_by MENTAL STATUS EXAMINATION (MSE) ASSESSMENT OF CLIENT MENTAL STATUS: OBJECTIVE AND SUBJECTIVE DATA YOUR ASSESSMENT AFTER INTERACTING WITH THE CLIENT DESCRIBE GENERAL APPEARANCE: (select all that apply) Eye Contact: Dress: Build: Response to examiner: Absent ☐ Conservative ☐ Thin ☐ Defensive Avoided ☐ Non-conservative ☒ Medium ☐ Trusting Intermittent ☐ Appropriate ☐ Heavy ☒ Cooperative Direct ☐ Inappropriate ☐ Obese ☐ Indifferent Physical Handicaps ☒ Other: only make eye contact when she asked my name Posture: Gait: Hygiene: Facial Expression: Activity: Appropriate ☐ Steady ☒ Clean ☒ Calm ☒ Happy ☐ Hyperactive Slumped ☐ Ataxic ☐ Unkempt ☐ Vacant ☐ Hostile ☐ Hypoactive Rigid ☒ Slow ☐ Neat ☐ Mask-like ☒ Sad ☐ Restless Rapid ☐ Unshaven ☐ Worried ☒ Normal Odorous ☐ Other: Click or tap here to enter text. NOTES REGARDING GENERAL APPEARANCE: Patient with normal appearance, sitting calmly on the chair in the recreation room, make a good eye contact when introduced herself, but no eye contact when talking about herself and family, she has medium build, cooperative to others and examiner, she has slow gait and used a walker, clean hygiene, calm facial expression, sometime smiling, sometime sad expression, most of the time bowed her head, and normal activity, most of the time she was in the tv room want to watch but every time want to change the channel and do not know what she really want to watch. But she was not complaint when another patient watching the movie. DESCRIBE BEHAVIOR, MOOD AND AFFECT: Behavior (select all that apply): Cooperative ☐ Uncooperative ☐ Non-adherent ☐ Compulsions ☐ Posturing Restless ☐ Agitated ☒ Relaxed ☐ Tearful Manipulative ☐ Withdrawn ☐ Catatonic ☐ Seductive Other: Click or tap here to enter text. Mood (select all that apply): Dysthymic ☐ Happy ☐ Elated ☐ Angry ☒ Calm ☐ Suspicious ☐ Anxious ☐ Ashamed ☐ Frightened Consistent with thoughts ☒ Inconsistent with thoughts ☐ Other: Click or tap here to enter text. Affect (select all that apply): Flat ☐ Blunted ☒ Labile ☐ Bright ☐ Fearful ☐ Euphoric ☐ Congruent ☐ Limited Range Full Range ☐ Intense ☐ Other: sometime smiling, sometime looks sad, sometime looks angry