Mental Status Examination PDF

PSYCHIATRIC AND MENTAL HEALTH NURSING (NUR 441) 481 MENTAL HEALTH & THE NURSING PROCESS & MENTAL STATUS ASSESSMENT  Objectives Up on the end of the lecture the student will be able to : - Identify the...

PSYCHIATRIC AND MENTAL HEALTH NURSING (NUR 441) 481 MENTAL HEALTH & THE NURSING PROCESS & MENTAL STATUS ASSESSMENT  Objectives Up on the end of the lecture the student will be able to : - Identify the concept of the followings related to mental health: A. Mental Health/Mental Illness B. Historical and Theoretical Concepts C. Cultural and Spiritual Concepts Relevant to Psychiatric/ D. Mental Health Nursing. Identify six steps of the nursing process and describe nursing actions associated with each. Identify the components that are considered critical in the assessment of a client’s mental status. Mental health Mental Health/Mental Illness  Historical and Theoretical Concepts  Cultural and Spiritual Concepts Relevant to Psychiatric/ Mental Health Nursing Dr. A A  For many years, the nursing process has provided a systematic framework for the delivery of nursing care. It is nursing’s means of fulfilling the requirement for a scientific methodology in order to be considered a profession.  The focus of the nursing process is goal-directed and based on a decision-making or problem-solving model, consisting of six steps: Assessment Assessment is a systematic, dynamic process by which the nurse, through interaction with the client, significant others, and healthcare providers, collects and analyzes data about the client. The nurses can use specific assessment tools (an example, the MSE tool: APPENDIX K: P, 622 Townsend, 2018) Diagnosis Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems/life processes. Diagnoses are congruent with available and accepted classification systems (e.g., NANDA International Nursing Diagnosis Classification [see Appendix E,P891]). Outcome identification Outcomes are measurable, expected, patient-focused goals that translate into observable behaviors. Planning The care plan is individualized to the client’s mental health problems, or needs and is developed in collaboration with the client, significant others, and interdisciplinary team members, if possible. For each diagnosis identified, the most appropriate interventions based on current psychiatric/mental health nursing practice and research, are selected. Implementation Interventions selected during the planning stage are executed. Several specific interventions are included among the standards of psychiatric/mental health clinical nursing practice as: Coordination of Care, Health Teaching: Milieu Therapy :Pharmacological, Biological ,and Integrative Therapies: Psychotherapy : Consultation Evaluation. Evaluation is the process of determining both the client’s progress toward the attainment of expected outcomes and the effectiveness of nursing care. MENTAL STATUS ASSESSMENT MSE TOOL: APPENDIX K: P, 622 TOWNSEND, 2018)  Gathering the correct information about the client’s mental status is essential to the development of an appropriate plan of care. The mental status examination is a description of all the areas of the client’s mental functioning. The following are the components that are considered critical in the assessment of a client’s mental status.  Identifying Data: 1. Name 9. Religious preference 2. Gender 10. Allergies 3. Age 11. Special diet considerations 4. Race/culture 12. Chief complaint 5. Occupational/financial status a. For what reason did you come 6. Educational level for help today? 7. Significant other b. What seems to be the a. Are you married? problem? b. Do you have a significant 13. Medical diagnosis relationship with another person? 8. Living arrangements a. Do you live alone? b. With whom do you share your home?  General Description : Appearance: 1- Grooming and dress : a. Note unusual modes of dress/ b. Evidence of soiled clothing?/c. Use of makeup?/ d. Neat; unkempt? 2. Hygiene : a. Note evidence of body or breath odor./ b. Skin condition, fingernails 3. Posture: a. Note if standing upright, rigid, slumped over. 4. Height and weight: a. Perform accurate measurements.  continuation… General Description : Appearance: 5. Level of eye contact: a. Intermittent?/ b. Occasional and fleeting? c. Sustained and intense? / d. No eye contact? 6. Hair color and texture: a. Is hair clean and healthy- looking? /b. Greasy, matted? 7. Evidence of scars, tattoos, or other distinguishing skin marks: a. Note any evidence of swelling or bruises. b. Birth marks? c. Rashes? 8. Evaluation of client’s appearance compared with chronological age:  General Description : Motor Activity: 1. Tremors. 2. Tics or other stereotypical movements: a. Any evidence of facial tics? / b. Jerking movements? 3. Mannerisms and gestures: a. Specific facial or body movements during conversation / b. Nail biting / c. Covering face with hands? / d. Grimacing? 4. Hyperactivity. 5. Restlessness or agitation 6. Aggressiveness. continuation… General Description : motor activity 7. Rigidity : Sits or stands in a rigid position. /b. Arms and legs appear stiff and unyielding. 8. Gait patterns : a. Any evidence of limping? /b. Limitation of range of motion?/ c. Ataxia? 9. Echopraxia : Evidence of imitating the actions of others? 10. Psychomotor retardation :a. Movements are very slow. /b Posture is slumped. 11- Anergia : A chronic state of lethargy and low energy, commonly characterized by the inability to complete normal tasks. Often associated with depression. 12- Akathisia: Subjective feeling of motor restlessness manifested by a compelling need to be in constant movement. 13- Apraxia: Inability to perform a voluntary purposeful motor activity despite being able to demonstrate normal muscle function. continuation… General Description : motor activity 11. Freedom of movement : (range of motion) a. Note any limitation in ability to move. 12. Waxy Flexibility: the client allows body parts to be placed in bizarre or uncomfortable positions. Once placed in position, the arm, leg, or head remains in that position for long periods, regardless of how uncomfortable it is for the client. E.g: the nurse may position the client’s arm in an outward position to take a blood pressure measurement. When the cuff is removed, the client may maintain the arm in the position in which it was placed to take the reading. 13. Posturing :voluntary assumption of inappropriate or bizarre postures  General Description : Speech Patterns 1. Slowness or rapidity of speech : a. Note whether speech seems very rapid or slower than normal. 2. Pressure of speech : a. Note whether speech seems frenzied. /b. Unable to be interrupted? 3. Intonation : a. Are words spoken with appropriate emphasis? b. Are words spoken in monotone, without emphasis? 4. Volume : a. Is speech very loud? Soft? /b. Is speech low-pitched? High-pitched? 5. Stuttering or other speech impairments: a. Hoarseness? b. Slurred speech? 6. Aphasia: a. Difficulty forming words /b. Use of incorrect words /c. Difficulty thinking of specific words /d. Making up words (neologisms)  General Description : General Attitude 1. Cooperative/uncooperative: a. Answers questions willingly or not. 2. Friendly/hostile/defensive: a. Is sociable and responsive. /b. Is sarcastic and irritable. 3. Uninterested/apathetic: a. Refuses to participate in interview process. 4. Attentive/interested: a. Actively participates in interview process. 5. Guarded/suspicious: a. Continuously scans the environment. /b. Questions motives of interviewer. /c. Refuses to answer questions.  Emotions : Mood 1. Depressed; despairing: a. An overwhelming feeling of sadness/ b. Loss of interest in regular activities 2. Irritable : a. Easily annoyed and provoked to anger. 3. Anxious : a. Demonstrates or verbalizes feeling of apprehension. 4. Elated : a. Expresses feelings of joy and intense pleasure. /b. Is intensely optimistic.  continuation… Emotions : Mood 5. Euphoric : a. Demonstrates a heightened sense of elation. /b. Expresses feelings of grandeur (“Everything is wonderful!”). 6. Fearful : a. Demonstrates or verbalizes feeling of apprehension associated with real or perceived danger. 7. Guilty : a. Expresses a feeling of discomfort associated with real or perceived wrongdoing. / b. May be associated with feelings of sadness and despair. 8. Labile : a. Exhibits mood swings that range from euphoria to depression or anxiety  Emotions : Affect 1. Congruence with mood: a. Outward emotional expression is consistent with mood (e.g., if depressed, emotional expression is sadness, eyes downcast, maybe crying). 2- Constricted or restricted affect : Reduction in intensity of feeling tone that is less severe than blunted affect. 3- Blunted affect: Severe reduction in the intensity of externalized feeling tone 4- Flat affect: Absence or near absence of any signs of affective expression. 5- Inappropriate affect: Emotional tone out of harmony with the idea, thought, or speech accompanying it. Seen in schizophrenia. Thought Processes : Form of Thought 1. Flight of ideas :Verbalizations are continuous and rapid, and flow from one to another. 2. Associative looseness :Verbalizations shift from one unrelated topic to another. NB. With associative looseness, the individual is unaware that the topics are unconnected. When the condition is severe, speech may be incoherent (e.g., “We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere. continuation… Thought Processes : Form of Thought 3. Circumstantiality: Verbalizations are lengthy and tedious, and because of numerous details, are delayed reaching the intended point. 4. Tangentiality: Verbalizations that are lengthy and tedious, and never reach an intended point 5. Neologisms: The individual is making up nonsensical sounding words, which only have meaning to him or her. 6. Concrete thinking: Thinking is literal; elemental. Absence of ability to think abstractly. Unable to translate simple proverbs. continuation… Thought Processes : Form of Thought 7. Clang associations: Speaking in puns or rhymes; using words that sound alike but have different meanings. “e.g., It is very cold. I am cold and bold. The gold has been sold.” 8. Word salad: Using a mixture of words that have no meaning together; sounding incoherent. 9. Perseveration: Persistently repeating the last word of a sentence spoken to the client. (e.g., Ns: “George, it’s time to go to lunch.” George: “lunch, lunch, lunch”). Or persistently repeats the same word or idea in response to different questions. continuation… Thought Processes : Form of Thought 10. Echolalia: Persistently repeating what another person says. (For instance, the nurse says, “John, it’s time for lunch.” The client may respond, “It’s time for lunch, it’s time for lunch” or sometimes, “Lunch, lunch, lunch, lunch”). 11. Mutism: Does not speak (either cannot or will not). 12. Poverty of speech: Speaks very little; may respond in monosyllables. 13. Ability to concentrate and disturbance of attention: a. Does the person hold attention to the topic at hand? b. Is the person easily distractible? 14- Blocking: Abrupt interruption in the train of thinking before a thought or idea is finished; Blocking after a brief pause, the person indicates no recall of what was being said or what was going to be said continuation… Thought Processes: Content of Thought 1. Delusions : False belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence, and despite the fact that other members of the culture do not: its types are: A- Persecutory: False belief of being harassed or persecuted. e.g., “The FBI will be here at any time to take me away.” (e.g., “I can’t take a shower in this bathroom; the nurses have put a camera in there so that they can watch everything I do”). b. Grandiose: An idea that he or she is all-powerful or of great importance (e.g., “I am the king...and this is my kingdom! I can do anything!”). continuation… Thought Processes: Content of Thought c. Reference: An idea that whatever is happening in the environment is about him or her (e.g., “Just watch the movie on TV tonight. It is about my life.”) (e.g., “Someone is trying to get a message to me through the articles in this magazine [or newspaper or TV program]; I must break the code so that I can receive the message”).. d. Control or influence: A belief that his or her behavior and thoughts are being controlled by external forces (e.g., “I get my orders from Channel 27. I do only what the forces dictate.”). e. Somatic: A belief that he or she has a dysfunctional body part (e.g., “My heart is at a standstill. It is no longer beating.”). f. Nihilistic: A belief that he or she, or a part of the body, or even the world does not exist or has been destroyed (e.g., “I am no longer alive.”) continuation… Thought Processes: Content of Thought 2. Suicidal or homicidal ideas a. Is the individual expressing ideas of harming self or others? 3. Obsessions a. Is the person verbalizing about a persistent thought or feeling that he or she is unable to eliminate from their consciousness? 4. Paranoia/suspiciousness:(Individuals with paranoia have extreme suspiciousness of others and of their actions or perceived Intentions/ “I won’t eat this food. I know it has been poisoned.”)) a. Continuously scans the environment. /b. Questions motives of interviewer. /c. Refuses to answer questions. NB. Someone can be paranoid but not have persecutory delusions, while someone who has persecutory delusions will always be a paranoid by default. continuation… Thought Processes: Content of Thought 5. Magical thinking a. Is the person speaking in a way that indicates his or her words or actions have power? (e.g., “If you step on a crack, you break your mother’s back!”/“It’s raining; the sky is sad.” ) 6. Religiosity a. Is the individual demonstrating obsession with religious ideas and behavior? 7. Phobias a. Is there evidence of irrational fears (of a specific object, or a social situation)? 8. Poverty of content a. Is little information conveyed by the client because of vagueness or stereotypical statements or clichés?  Perceptual Disturbances 1. Hallucinations Is the person experiencing unrealistic sensory perceptions? a. Auditory :Is the individual hearing voices or other sounds that do not exist? b. Visual : Is the individual seeing images that do not exist? c. Tactile : Does the individual feel unrealistic sensations on the skin? d. Olfactory :Does the individual smell odors that do not exist? e. Gustatory :Does the individual have a false perception of an unpleasant taste?  --Perceptual Disturbances 2. Illusions: Does the individual misperceive or misinterpret real stimuli within the environment? (Sees something and thinks it is something else?) 3. Depersonalization : (altered perception of the self) The individual verbalizes feeling “outside the body;” visualizing him- or herself from afar. 4. Derealization : (altered perception of the environment) The individual verbalizes that the environment feels “strange or unreal.” A feeling that the surroundings have changed.  Sensorium and Cognitive Ability 1. Level of alertness/consciousness: a. Is the individual clear-minded and attentive to the environment? Or is there disturbance in perception and awareness of the surroundings? 2. Orientation: Is the person oriented to the following? a. Time b. Place c. Person d. Circumstances  Sensorium and Cognitive Ability 3. Memory: a. Recent (Is the individual able to remember occurrences of the past few days?) b. Remote (Is the individual able to remember occurrences of the distant past?) c. Confabulation (Does the individual fill in memory gaps with experiences that have no basis in fact?) 4. Capacity for abstract thought a. Can the individual interpret proverbs correctly? “What does ‘no use crying over spilled milk’ mean?” (Concrete Thinking is characterized by actual things, events, and immediate experience, thinking rather than by abstractions)  Impulse Control 1. Ability to control impulses: (Does psychosocial history reveal problems with any of the following?) a. Aggression b. Hostility c. Fear d. Guilt e. Affection f. Sexual feelings  Judgment and Insight 1. Ability to solve problems and make decisions: a. What are your plans for the future? b. What do you plan to do to reach your goals? 2. Knowledge about self: a. Awareness of limitations b. Awareness of consequences of actions c. Awareness of illness “Do you think you have a problem?” “Do you think you need treatment?” 3. Adaptive/maladaptive use of coping strategies and ego defense mechanisms: (e.g., rationalizing maladaptive behaviors, projection of blame, displacement of anger)  References Townsend M., Morgan K (2018): Pocket Guide to Psychiatric Nursing. 10th ed, Davis Company, Philadelphia. Bernstein K. and Kaplan R :( 2023)Psychiatric Mental Health Assessment and Diagnosis of Adults for Advanced Practice Mental Health Nurses, Routledge, New York.