RLE 117 Prelim - Mental Status Examination (MSE) PDF

MENTAL STATUS EXAMINATION (MSE) A – Appearance, Behavior S – Speech ASSESSMENT OF MENTAL HEALTH STATUS E – Emotions (Mood, Affect) STRUCTURED assessment of behavioral...

MENTAL STATUS EXAMINATION (MSE) A – Appearance, Behavior S – Speech ASSESSMENT OF MENTAL HEALTH STATUS E – Emotions (Mood, Affect) STRUCTURED assessment of behavioral P – Perceptual Disturbances and cognitive functioning of the patient T – Thought Process and Content CURRENT state of patients thoughts, I – Insight, Judgment, Knowledge, Impulse feelings, and emotions Control Usually limited to the time of interview C – Cognition and Sensorium An expert observation or assessment CRITERIA FOR ADMISSION IN A MENTAL A – APPEARANCE AND BEHAVIOR HEALTH FACILITY Grooming A threat to hang oneself Kempt / Unkempt A threat to others Poorly groomed, disheveled A threat to property (e.g., Arson) Excessively made up PURPOSES: Posture To construct a clear picture of the client’s Relaxed, slouched, stiff emotional state, mental capacity and Catatonic behavioral functions GENERAL APPEARANCE It serves as a basis for planning care to meet the client’s needs Posture Use to evaluate the effectiveness of Poise treatment and interventions of the client’s Clothing progress Hair and grooming COMPONENTS OF MSE Motor Activity Cognition and Sensorium Hyperactive, hypoactive, normoactive Behavior and General Appearance Psychomotor Retardation Emotions (Mood, Affect) Psychomotor Agitation Speech Waxy Thought Content Disorganized Thought Process Presence of mannerisms, tics, fidgeting, Perceptual Disturbances echopraxia, automatisms Knowledge Insight Attitude / Behavior towards Interviewer Judgment Cooperative / Uncooperative Manipulative, Evasive, Hostile, Passive / Aggressive, Demanding Attention span (good, short) Eye contact (poor, good, avoiding, piercing) Negativistic MOTOR BEHAVIOR ✓ Hyperactivity - Abnormally excessive, almost Mannerisms, tics, gestures, twitches, destructive activity stereotyped behavior, echopraxia, ✓ Hypoactivity hyperactivity, agitation, combativeness, - Visible slowing of thought, speech, and flexibility, rigidity, gait and agility movement Take note of movements which can result ✓ Tic due to drug side effects - Involuntary, repetitious, jerky movement e.g., TD or EPS or tremors ✓ Compulsive Describe restlessness, wringing of hands, - Uncontrollable impulse to perform an pacing and other physical manifestations act repetitively Note psychomotor retardation or ✓ Aggression generalized slowing of body movements - Motor form of hostility or anger Describe any aimless, purposeless activity ATTITUDE TOWARD EXAMINER ❖ Gestures Cooperative ❖ Stereotyped behavior Frank ❖ Pacing Seductive ❖ Any purposeful activity should be Defensive described Hostile Apathetic ✓ Catatonia Playful - Lack of will to talk or move ✓ Echopraxia ❖ Cooperative, friendly, attentive, interested, - Pathological imitation of movements of frank, seductive, defensive, contemptuous, a person perplexed, apathetic, hostile, playful, ✓ Negativism ingratiating, evasive or guarded; any - Indifference or resistance to all number of other adjectives can be used instructions ❖ Record the level of rapport established ✓ Mannerism - Habitual involuntary movement ✓ Mutism - Voicelessness without structural abnormalities S – SPEECH ✓ Pressured speech - Rapid speech, increased amount and Rate difficult to interrupt Increased / decreased ✓ Poverty of speech (alogia) Pressured - Restricted amount, usually Prodded to respond monosyllabic No verbal output ✓ Stuttering - Frequent repetition of prolonged sound Volume syllable Loud / soft ✓ Clang association Whispered - Rhyming of words ✓ Neologism Quality / Quantity - Creating new words Spontaneous / non-spontaneous ✓ Word salad Incoherent - Incoherent mixture of words and Hyperproductive / hypoproductive phrases Word salad, neologisms ✓ Circumstantiality Echolalia - Indirect speech that is delayed in Perseveration, Verbigeration reaching the point but eventually gets Stilled language to desired point Clang association ✓ Tangentiality SPEECH CHARACTERISTICS - Inability to have goal-directed association of thoughts; never gets to Speech can be described in terms of its desires point quantity, rate of production, and quality ✓ Incoherence Such as: talkative, voluble, taciturn (saying - Disorganized, incomprehensive thought very little), unspontaneous, or normally ✓ Perseveration responsive to cues from the interviewer. - Persisting response to a prior stimulus There is alogia or poverty of speech in even if stimulus has been changed Schizophrenia ✓ Verbigeration Speech can be rapid or slow, pressured - Meaningless repetition of specific (hard to interrupt the patient), hesitant, words or phrases emotional, dramatic, monotonous, loud, ✓ Echolalia whispered, slurred, staccato, or mumbled - Psychopathological repeating of words Speech impairments, such as stuttering, or phrases of another person are included in this section Any unusual rhythms (termed dysprosody) or accent should be noted. E – EMOTIONS Range: Affect can be described as within normal range, constricted, blunted, or flat. Mood In the normal range of affect can be variation in Pervasive subjective emotional state facial expression, tone of voice, use of hands, - Ask patient directly how they feel and body movements. Affect When affect is constricted, the range and Visible expression of emotional state intensity of expression are reduced. In blunted - Type, rage, and congruency of affect affect, emotional expression is further reduced. To diagnose flat affect, virtually no signs of MOOD affective expression should be present; the Euthymic > Expansive patient's voice should be monotonous and the face should be immobile. Note the patient's Depressed > Anxious difficulty in initiating, sustaining, or terminating Elated > Labile an emotional response. Irritable ✓ Appropriateness Of Affect ✓ Euthymic - Considered in context of what patient is - Normal range of mood discussing ✓ Irritable ✓ Appropriate - Easily annoyed and provoked by anger - Emotion is in harmony with thought and ✓ Elated speech - More cheerful than normal with air of ✓ Inappropriate confidence and joy - Disharmony with emotion and thought / ✓ Euphoria speech - Intense elation with feelings of ✓ Normal, broad, or full grandeur - Variation and full range of emotions is ✓ Ecstasy expressed in tone of voice, expression, - Feelings of intense rapture and movement ✓ Depression ✓ Constricted - Psychopathological feeling of sadness - Clear, decreased in range and intensity ✓ Labile mood of movement - Mood swings ✓ Blunted ✓ Anhedonia - Emotional expression further reduced - Loss of interest and withdrawal from ✓ Flat pleasurable activities - No affective expressive, monotonous AFFECT voice ✓ Bizarre Patient's present emotional responsiveness, - Odd, illogical, grossly inappropriate, or inferred from the patient's facial expression, unfounded; includes grimacing and including the amount and the range of giggling expressive behavior. Quality: Dysphoric in depression, Euthymic AFFECT (normal) or Elevated/Euphoric in mania, Flat in Schizophrenia or labile (all over the place), or Blunted * Flat irritable Broad * Restricted Congruency: Affect may or may not be Broad > Restricted > Blunted > Flat congruent with mood. Look into type, range, and congruency P – PERCEPTUAL DISTURBANCES A. DISTURBANCE OF PERCEPTION ✓ Hallucination – false sensory Perception perception NOT based on reality Perceptual disturbances, such as Types: hallucinations and illusions, can be Auditory – could hear voices or experienced in reference to the self or the sounds environment. Visual – seeing things or persons This can be sometimes inferred also when Tactile – feeling bodily sensations; the patient clearly responds to internal complaints something is crawling stimuli (and can be described as such) Olfactory – smelling odor The sensory system involved (e.g., Gustatory – experiencing tastes; auditory, visual, taste, olfactory, or tactile) constant metallic taste and the content of the illusion or the hallucinatory experience should be Command hallucination: voices may described. command the person to hurt self or Feelings of depersonalization and others; for example, telling a patient derealization (extreme feelings of to “jump out of the window” or “hit detachment from the self or the that nurse”. environment) are also part of this section. Illusion: misperceptions of actual PERCEPTUAL DISTURBANCES environmental stimuli Directly ask for presence of hallucinations. Depersonalization: feelings of being Note type and content (but focus on disconnected from their behavior feelings!) Derealization: sensing that things Common: auditory hallucinations are not real Visual: second most common, possibly organic in nature Olfactory: common in dementia, seizures, CVA Tactile: rare in schizophrenia, more common in alcohol withdrawal, drug- use disorders Gustatory, Cenesthetic (involve viceral organs), Kinesthetic Note command auditory hallucinations If patient denies, observe for hallucinatory gesture THOUGHT ----------------------------------------------- T – THOUGHT PROCESS AND CONTENT Thought can be divided into process (or Thought Process form) and content Flight of ideas Process refers to the way in which a Tangentiality, Circumstantiality person puts together ideas and Looseness of association associations, the form in which a person Thought blocking, Thought broadcasting thinks (thinking that one’s thoughts are being Process or form of thought can be logical broadcasted to the outside world) and coherent or completely illogical and Thought withdrawal (someone is removing even incomprehensible ideas or thoughts), Thought insertion Content refers to what a person is actually (belief that someone is putting ideas or thinking about: ideas, beliefs, thoughts into their mind) preoccupations, obsessions Alogia (Poverty of content) THOUGHT PROCESS Thought Content The patient may have either an Delusions: Persecutory / Paranoid; overabundance or a poverty of ideas. Grandiose; Religious (demons or There may be rapid thinking, which, if goddess), Somatic; Bizarre delusions; carried to the extreme, is called a flight of Erotomanic delusions (assuming ideas. something/love/ stalking); Delusions of A patient may exhibit slow or hesitant Infidelity; Nihilistic (hopelessness) thinking. Ideas of reference (belief that things in the Thought can be vague or empty. environment refers to them, whey they do Do the patient’s replies really answer the not) questions asked? Suicidal / Homicidal / Escape / Assaultive Does the patient have the capacity for thoughts goal-directed thinking? Preoccupations Are the responses relevant or THOUGHT PROCESS AND CONTENT irrelevant? Is there a clear cause-and effect relation FLIGHT OF IDEAS Frequently changing topics in the patient's explanations? TANGENTIAL Going away from a topic Does the patient have loose and not returning associations (e.g., do the ideas CIRCUMSTANTIAL Provides unnecessary expressed seem unrelated and detail, but eventually gets to the point. idiosyncratically connected)? NEOLOGISMS Making up new words Disturbances of thought continuity include LOOSENESS OF Illogically shifting between statements that are: ASSOCIATION topics Tangential, circumstantial, rambling, WORD SALAD Non-sensical responses evasive, or perseverative CLANG Rhyming words, speech ASSOCIATION makes no sense THOUGHT Stops speaking suddenly BLOCKING in the middle of a sentence ✓ Process or form of thought B. Content of thought - General disturbance in form of thought What person is actually thinking about ✓ Psychosis beliefs, ideas, obsessions, - inability to distinguish reality from preoccupations fantasy ✓ Delusion ✓ Illogical thinking - fixed, false belief based on incorrect - thinking that has erroneous conclusions inference about reality or internal contradictions - Types: ✓ Autistic thinking Grandiose - thinking that gratifies unfulfilled desires Paranoid / Persecutory with no regard for reality Reference ✓ Magical thinking Alien control - thinking in which thoughts, words or Somatic action assumes power Nihilistic ✓ Looseness of associations Religious - ideas shift from one subject to another TYPES OF DELUSIONS in an unrelated or idiosyncratically Grandiose a belief that the related way person is someone of ✓ Flight of Ideas extreme importance - rapid, continuous verbalization with Persecutory a belief that the constant shifting person is being ✓ Clang association followed, is under surveillance, being - Association of words similar in sound ridiculed, or treated but not in meaning unfairly ✓ Thought Blocking Infidelity A belief that the - interruption of train of thought before individual’s sexual completion partner is unfaithful Religious belief containing a THOUGHT CONTENT religious being and concepts Disturbances in content of thought include Somatic belief that there is a delusions, preoccupations (which may physical defect or involve the patient’s illness), obsessions, medical condition compulsions, phobias, plans, intentions, when none exists hypochondriacal symptoms, and specific Ideas of reference Belief that things in antisocial urges the environment refers to them, when does the patient have thoughts of doing they do not self-harm? Is there a plan? Thought insertion Belief that someone Note homicidal ideation, intent or plan is putting ideas or thoughts into their mind Thought Thinking that one’s broadcasting thoughts are being broadcasted to the outside world THOUGHT CONTENT ✓ Bizarre Delusion - out of reality ✓ Erotomanic delusion - someone is so in love with you ✓ Nihilistic delusion - belief that it is the end of the world ✓ Poverty of Content - thought that gives little information because of vagueness, empty repetition, or obscure phrases ✓ Obsession - persistence of an irreversible thought or feeling in spite of conscious attempts to remove it ✓ Compulsion - irresistible impulse to do something against the will of the individual, usually stemming form obsession ✓ Hypochondria - exaggerated concern over one’s health I – INSIGHT, JUDGEMENT, KNOWLEDGE LEVEL OF INSIGHT INSIGHT JUDGMENT KNOWLEDG A summary of six levels of insight follows: E 1. Complete denial of illness Assess Good, Fair, Good/Poor 2. Slight awareness of being sick and awareness Poor fund of of illness Assess if knowledge needing help, but denying it at the and patient is able Client’s same time behavior to understand basic 3. Awareness of being sick but blaming it Level I: the potential knowledge on others, on external factors, or on complete consequence and organic factors denial s of their awareness Level II: behavior 4. Awareness that illness is caused by slight Ask the patient of social events something unknown in the patient awareness about a Ask 5. Intellectual insight: admission that the , but hypothetical denying situation common patient is ill and that symptoms or Level III: requiring good knowledge failures in social adjustment are caused aware, but judgement questions by the patient’s own particular irrational blaming it feelings or disturbances without to others Level IV: applying this knowledge to future illness experiences unknown 6. True emotional insight: emotional to client awareness of the motives and feelings Level V: intellectual within the patient and the important insight persons in his or her life, which can Level VI: lead to basic changes in behavior true emotional JUDGMENT – ability to assess a situation insight correctly and act appropriately within the situation IMPULSE CONTROL The ability to delay, modulate or inhibit the expression of behaviors and feelings Assess how patient handled stressful situations in the past (drug use, uncontrolled aggressive behaviour, frustration tolerance) Important part of determining potential for acting on suicidal and violent thoughts C – COGNITION AND SENSORIUM D. Concentration and Attention simple calculations, spelling backwards Orientation Short-term memory ✓ Distractibility Long-term memory - inability to concentrate attention - Concentration attention drawn to unimportant Naming objects ✓ Selective Inattention Important in assessing dementia and intellectual - blocking out only things that generate disability anxiety ✓ Hypervigilance CONSCIOUSNESS, SENSORIUM, AND - excessive attention and focus on all COGNITION internal and external stimuli secondary A. Alertness and level of consciousness to paranoid stance disturbance of consciousness indicate organic brain impairment E. Capacity to read and write patient is asked to read a sentence and do ✓ Disorientation as it says - disturbance of orientation in time, place to write a simple sentence or person ✓ Clouding F. Visuospatial ability - overall decreased awareness with patient asked to copy a figure disturbance in perception and attitudes G. Abstract thinking B. Orientation ability to deal with concepts refers to the ability of the person to grasp ideas, the significance of the environment C. Principles and Techniques of Psychiatric and the existing condition or the clearness Nursing Interview of the conscious process 1. Basic Principles recognition of time, place, and person a. Do not reinforce or argue on patient’s hallucinations or delusions C. Memory b. Orient patient to time, person, and place ✓ Remote memory c. Do not touch patients without warning - childhood data, important events before them illness occurred d. Avoid whispering or laughing when - last to be impaired patients are unable to hear all of the ✓ Recent past conversations - past few months e. Reinforce positive behaviors ✓ Recent f. Avoid competitive activities with some - Past few days patients - what patient had for lunch g. Do not embarrass patients ✓ Immediate retention h. For withdrawn patients, start with one- - repeat 6 digits forward / backward; to-one interactions repeat 3 words immediately then i. Allow and encourage verbalization of 3-5 mins. later feelings ✓ Confabulation - filling of gaps in memory by imagined or false experiences  THERAPEUTIC COMMUNICATION SOCIAL DISTANCE Communication 4 to 12 feet characterized by a clear perception of the any means of exchanging information or whole person feelings between two or more people body heat & odor are imperceptible, eye basic component of human relationship contact in increased, and vocalizations are loud enough to be overheard COMMUNICATION PROCESS by others SENDER PUBLIC DISTANCE a group of people who wishes to convey a 12 to 15 feet message to another; encoder requires loud, clear vocalizations w/ careful enunciations MESSAGE what is actually said or written, the body ACTIVE LISTENING language that accompanies the words, and how the message is transmitted being attentive to what the client is saying both verbally and nonverbally RECEIVER Five aspects of Physical Attending the listener, who must listen, observe and - S – Sit squarely facing the client attend; decoder - O – Observe an open posture - L – lean forward toward the client RESPONSE - E – establish eye contact is the message that the receiver return to - R – relax sender; feedback THERAPEUTIC NURSE-PATIENT RELATIONSHIP PERSONAL SPACES is a helping relationship between a Nurse distance between people prefer in and the Patient based on mutual interactions w/ others trust and respect, nurturing of faith and hope INTIMATE DISTANCE touching to 1 ½ feet it is being sensitive to self and other, and assisting w/ the gratification of your characterized by body contact, heightened patient’s physical, emotional, and spiritual sensations of body heat and smell and needs through your knowledge and skill. vocalizations that are low; vision is intense, restricted to a small body part, and may be distorted effective verbal and nonverbal communication is an important part of the frequently used by nurses nurse - patient interaction PERSONAL DISTANCE providing care in a manner that enables your 1 ½ to 4 feet patient to be an equal partner in less overwhelming than intimate distance achieving wellness voices tones are moderate, and body heat and smell are noticed less THERAPEUTIC COMMUNICATION TECHNIQUES On 1st contact, introduce yourself and use her Restating name while talking to her - let’s client know whether an expressed Observe PRIVACY during care provision statement has or has not been understood ACTIVELY LISTEN to your patient. Make sure you understand her concern by restating what Reflecting she has verbalized - directs questions or feelings back to client so that they may be recognized Maintain eye contact and accepted - smile, nod, speak calmly Focusing Maintain professional boundaries - taking notice of a single idea or even a single - respect culture/be careful w/ touch word Use Silence Exploring - allows client to take control of - delving further into a subject, idea, the discussion, if he or she so desires experience, or relationship Accepting Seeking clarification and validation - conveys positive regard - striving to explain what is vague and searching for mutual understanding Giving recognition - acknowledging, indicating awareness Presenting reality - clarifying misconceptions that client may be expressing Offering self - making oneself available Voicing doubt - expressing uncertainty as to the reality of Giving broad openings client’s perception - allows the client to select the topic Verbalizing the implied Offering general leads - putting into words what client has - encourages the client to continue only implied Placing the event in time or sequence Attempting to translate words into feelings - clarifies the relationship of events in time - putting into words the feelings the client has expressed only indirectly Making observation - verbalizing what is observed or perceived Formulating plan of action - striving to prevent anger or anxiety Encouraging description of perceptions escalating to unmanageable level when - asking client to verbalize what is stressor recurs being perceived Encouraging comparison - asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships NON-THERAPEUTIC COMMUNICATION Making Stereotyped Comments, and Trite TECHNIQUES Expressions - these are meaningless in a nurse- Giving reassurance client relationship - may discourage client from further ***Mga lumang kasabihan. Meaningless expression of feelings if client believes for us pero sa kanila meron the feelings will only be downplayed or ridiculed Using Denial - blocks discussion with client and avoids Rejecting helping client identify and explore areas - refusing to consider client’s ideas of difficulty or behavior ***Ayaw pag usapan kapag hindi naintind ihan Approving or disapproving - implies that the nurse has the right to Interpreting pass judgment on the “goodness” or - results in the therapists telling client the “badness” of client’s behavior meaning of his or her experience ***Interpret yung mga sinasabi nya - Agreeing or disagreeing “may binabangit ka kania na masama an - implies that the nurse has the right to g pakiramdam mo” pass judgment on whether client’s ideas or opinions are “right” or “wrong” Introducing Unrelated Topics - causes the nurse to take over the Giving advice direction of the discussion - implies that the nurse knows what is best ***Let the client choose the topic for the client and that client is incapable of any self – direction GOOD COMMUNICATION IN HEALTHCARE It means approaching every patient Probing interaction with the intention to understand - pushing for answers to issues the client the patient's concerns, experiences, and does not wish to discuss causes client to opinions. feel used and valued only for what is An important communication skill for shared w/ the nurse psychiatric nurses involves their ability: Ask the right questions Defending Analyze information communicated back - to defend what client has criticized Come up with solutions implies that client has no right to express LISTEN ideas, opinion, or feelings - w/ compassion by using your: Asking “why” 1. EYES - implies that client must defend his or her giving the person your undivided behavior or feelings attention 2. EARS Indicating the existence of an external hearing carefully their concerns source of power 3. HEART - encourages client to project blame for his w/ caring and showing respect or her thoughts or behaviors on others Requirement for Therapeutic Relationship: Belittling feelings expressed 1. Rapport - causes client to feel insignificant 2. Trust or unimportant 3. Respect 4. Genuineness 5. Empathy PHASES OF NURSE-PATIENT RELATIONSHIP 4. Summary and Closure / Termination phase 1. Initial or pre-interaction phase - summarize information obtained during - the nurse should prepare to meet with a the working phase and validate problems particular client and goals with the client - interaction phase - you may discuss the plans to resolve - interpersonal communication phase the problem - establish rapport - allow the client time to express feelings, - You can never be effective in healing the concerns, and questions wounds of others if you cannot heal your - preparation for the phase starts as the own, if yourself need to be healed. beginning of the relationship with - self-awareness clarification of how long the relationship will continue 2. Introductory or orientation phase - hardest part of nurse-pt relationship - introduce yourself and describe your role - address the client with their surname The termination phase may begin due to: - explain the purpose of the interview - explain the purpose of 1. Achieving goals set by the nurse and the patient note-taking (this is discouraged on psychiatric patients) 2. Patient's discharge from the hospital 3. Nurse has finished work in the station - provide comfort, privacy, and confidentiality TRANSFERENCE Steps to follow when meeting the patient for the first time: Transference is the technical term used to describe an unconscious transferring of introduce yourself and explain the purpose of the interview (duty, why are you there?) experiences from one interpersonal situation to another. ask the patient how they would like to According to psychoanalytic theory, be addressed transference evolves from unresolved or sit at a comfortable distance from the patient unsatisfactory childhood experiences in and give them undivided attention, while relationships with parents or other important maintaining a professional but friendly figures (Wilson & Kneisl, 1996) attitude In psychoanalytic theory: speak in a calm, non-threatening tone to - Transference – occurs when a client encourage the patient to be candid unconsciously redirects feelings associated with an important figure from 3. Working phase their life (often early life), onto the - elicits the client's comments about major therapist biological data, reason for seeking - Countertransferase – occurs when a healthcare, history of present concerns, client triggers an emotional reaction in lifestyle, health practices, and the therapist, which may be related to developmental skills the therapist’s own unresolved issues - use of critical thinking skills - collaborate with the client and identify problems and goals - discuss the time frame of your working relationship SELF-AWARENESS is the mental ability to recognize who and what you are namely that you are distinctly separate from other people and your environment. it enables you to realize your own personality, feelings, action, beliefs, emotion, thoughts, and desires It allows you to have abstract thoughts about who you are, and things you have done in the past or will do in the future. PROCESS RECORDINGS written reports of verbal interactions with clients they are written by the nurse or student as a tool for improving communication techniques FORMAT OF PROCESS RECORDING Student's name: Patient's initial: Identifying data: - Age - Sex - Marital Status - Address - Religion - Education - Attending Physician - Information source Chief Complaint Admitting Diagnosis I. Purpose or Objective of the Nurse-Patient Interaction a. Student Nurse b. Patient II. Setting of the Interaction (Description of the Environment) III. Observation of the Patient (Use MSE) (SOMETEAMS) IV. Process Recording V. Conclusion