mental status examination in details_psychiatry nursing

MSE_MENTAL HELATH NURSING

1. MENTAL STATUS EXAMINATION PRESENTED BY SRABANI JANA 1 st YEAR M.Sc. NURSUNG

2. The mental status examination (MSE) is used to determine whether a patient is experiencing abnormalities in thinking and reasoning ability, feelings or behavior. DEFINITION

3. A mental status examination is an assessment of a patient’s level of cognitive ability, appearance, emotional mood, speech pattern at the time of evaluation

4. To check the current mental health status of client To record the data collected To identify the nursing needs of patient To allow us to make a diagnosis To plan and give the nursing care based on priority PURPOSE

5. Identification Data General Appearance and behavior Speech Mood and affect Thought Perception Cognitive functions COMPONENT

6. Name Gender Age Race/culture Occupational / financial status IDENTIFICATION DATA

7. Educational level Significant other Living arrangements Religious preference Allergies

8. Special diet consideration Chief complaint Medical Diagnosis

9. Grooming and dress -Note unusual modes of dress -Evidence of soiled clothing? -Use of makeup? -Neat ; unkempt GENERAL APPEARANCE & BEHAVIOUR

10. Hygiene - Note evidence of body or breath odor - Note condition of skin, fingernails

11. Posture - Note if standing upright, rigid, slumped over

12. Height and weight - Perform accurate measurements

13. - Intermittent? - Occasional and fleeting? - Sustained and intense? - No eye contacts? Level of eye contact

14. - Is hair clean and healthy looking? - Greasy, matted, tangled? Hair colour and texture

15. Evidence of scars, tattoos or other distinguishing skin marks - Note any evidence of swelling or bruises? - Birth marks? - Rashes?

16. Evaluation of clients’ appearance compared with chronological age

17. Motor activity is a summation of other impulses like desires and emotions in human being. These responses are synchronized and any abnormality in schronization will cause abnormal motor activity MOTOR ACTIVITY

18. Tremors Do hands or legs tremble? Continuously? At specific times?

19. Mannerisms and gestures Specific facial or body movements during conversion? Nail biting? Covering face with hands? Grimacing?

20. Tics or other stereotypical movement? Any evidence of facial tics? Jerking or spastic movements?

21. Hyperactivity Gets up and down out of chair Paces Unable to sit still

22. Restlessness or agitation - Clenching hands

23. Aggressiveness Overly angry and hostile Threatening Uses sarcasm

24. Rigidity - Sits or stands in a rigid position. - Arms and legs appear stiff and unyielding

25. Gait patterns Any evidence of limping? Limitation of range of motion? Ataxia? Shuffling?

26. Echopraxia - Evidence of mimicking the actions of others?

27. Psychomotor retardation Movements are very slow Thinking and speech very slow Purpose is slumped

28. Slowness or rapidity of speech - Note whether speech seems very rapid or slower than normal Pressure of speech - Note whether speech seems frenzied - Unable to be interrupted SPEECH PATTERN

29. Intonation - Are words spoken with appropriate emphasis? - Are words spoken in monotone, without emphasis? Volume - Is speech very loud? soft? - Is speech low-pitched? High-pitched

30. Stuttering or other speech impairments - Hoarseness? - Slurred speech?

31. Aphasia - Difficulty forming words. - Use of incorrect words. - Difficulty thinking of specific words. - Making up words (neologisms)

32. Samole of speech - What happened to you? - Tell me little about your childhood.

33.  Cooperative / uncooperative - Answers questions willingly - Refuses to answer questions Friendly/ hostile/ defensive - Is sociable and responsive - Is sarcastic and irritable GENERAL ATTITUDE

34. Uninterested/ apathetic - Refuses to participate in interview process Attentive/ interested - Actively participates in interview process Guarded/ suspicious - Continuously scans the environment - Refuses to answer questions

35. Depressed, despairing - An overwhelming feeling of sadness - Loss of interest in regular activities MOOD or AFFECT

36. Irritable - Easily annoyed and provoked to anger

37. Anxious - Demonstrates or verbalizes feeling of apprehension

38. Euphoric - Expresses feelings of joy and intense pleasure

39. Elation -Demonstrates a heightened sense of elation

40. Exhaltation - Express felling of grandeur along with elation symptoms

41. Fearful - Demonstrates or verbalizes feeling of apprehension associated with real or perceived danger

42. Guilty - Expresses a feeling of discomfort associated with real or perceived wrongdoing - May be associated with feelings of sadness and despair

43. Labile - Exhibits mood swings that range from euphoria to depression or anxiety

44. Congruence with mood - Outward emotional expression is consistent with mood

45. Constricted or blunted -Minimal outward emotional expression is observed Flat -There is an absence of outward emotional expression

46. Appropriate -The outward emotional expression is what would be expected in a certain situation Inappropriate -The outward emotional expression is incompatible with the situation

47. Questions regarding mood or affect? Ask the patient directly how he/she feels? How do you generally feel most of the time? What’s your mood like? How would you say you feel generally- happy, sad, frightened, angry?

48. Normal thought process involves imagination, coordination and inferring, resulting in the formation of thought As the ideas are connected with other ideas, there is progression of thought The subject, importance, value and feeling tone attached to an idea is the content of thought THOUGHT PROCESS

49. Flight of ideas -Verbalization are continuous and rapid, and flow from one to another.

50. WHO BROUGHT YOU HERE My father sent me here He drove me in a car The car is yellow in color Yellow color looks good on me.

51. Associative looseness - Verbalization shift from one unrelated topic to another

52. I like to dance, all people have hands. I like to play games because the river is flowing down a mountain.” The weather is sunny, the monkey has a long tail.”

53. Circumstantiality - Verbalization are lengthy and tedious and because of numerous details, are delayed reaching the intended point

54. I went to bed at 9 pm Upto 11 pm, I read a book After reading sometime I switched of the light In morning , I think at 7 am got up

55. Tangentiality - Verbalization are lengthy and tedious, but never reach an intended point

56. Neologisms -The individual is making up nonsensical sounding words, which only have meaning to him or her

57. Concrete thinking -Thinking is literal, elemental -Absence of ability to think abstractly -Unable to translate simple proverbs

58. Clang Associations - Speaking in rhymes, using words that sound alike but different meanings

59. Word salad - Using a mixture of words that have no meaning together, sounding incoherent

60. Preservation - Persistently repeating the last word of a sentence spoken to the client

61. Echolalia - Persistently repeating what another person says

62. Mutism Does not speak (either cannot or will not)

63. Poverty of speech - Speaks very little, may respond in monosyllables

64. Ability to concentrate or disturbance of attention - Does the person hold attention to the topic at hand? - Is the person easily destructible? -Is there selective attention? (e.g.- blocks out topics that create anxiety)?

65. Question regarding thought form Who all are there in your home?

66. Delusions Persecutory : - A belief that someone is out to get him or her in some way, has false beleifs that her family member, freinds etc. are trying to kill him/her Grandiose : - An idea that he or she is all powerful or of great importance Reference : - An idea that whatever is happening in the environment is about him or her, feels that he is being talked about by others CONTENT OF THOUGHT

67. Control of influence : - A belief that his or her behavior and thoughts are being controlled by external forces Somatic: - A belief that he or she has dysfunctional body part. Nihilistic: -A belief that he or she, or a part of body or even the world does not exist or has been destroyed

68. Question regarding delusion - Do you think anyone is planning against you? - Do you think anyone is controlling you? - Do you feel that you can do something which cannot be done by anyone? - Do you feel that you are responsible for what is happening? - Do you feel that some body parts missing for that you canot work? - Doyou feel that a small cut can change into a big problem?

69. Suicidal or homicidal ideas - Is the individual expressing ideas of harming self or others? - Does the individual express plans and intentions to die? Or plans and intentions to harm another?

70. Obsessions - Is the person verbalizing about a persistent thought or feeling that he or she is unable to eliminate from their consciousness?

71. Paranoia? Suspiciousness? - Continuously scans the environment - Questions motives of interviewer - Refuses to answer question

72. Magical thinking - Is the person speaking in a way that indicates his or her words or actions have power?

73. Religiosity - Is the individual demonstrating obsession with religious ideas and behavior?

74. Phobias -Is there evidence of irrational fears?

75. Poverty of content - Is little information conveyed by the client because of vagueness or stereotypical statements

76. Thought Alienation - Thought insertion - Thought withdrawal - Thought broadcasting

77. Hallucination (Is the person experiencing unrealistic sensory perceptions?) Auditory Visual Tactile Olfactory Gustatory

78. Questions regarding hallucinations? - Can you see someone who cannot be seen by anyone? - Can you hear anything which cannot be heard by any of us? - Can you smell something which is unusual? - Can you feel the taste of something without eating anything? - Do you feel something is crawling on your skin? - Do you feel you don’t have your legs or hands so you could not do you regular activities?

79. Illusions - Does the individual misperceive or misinterpret real stimuli within the environment? (Sees something and thinks it is something else?)

80. Depersonalization (altered perception of self) - The individual verbalizes feeling “outside the body”’ visualizing him or herself from afar

81. Derealization (altered perception of the environment) - The individual verbalizes that the environment feels “strange or unreal”. A feeling that the surroundings have changed

82. Level of alertness - Is the individual clear minded and attentive to the environment? - Or is there disturbance in perception and awareness of surroundings? SENSORIUM AND COGNITIVE ABILITY

83. Orientation . - Is the person oriented to the time, place, person and circumstances? - Time- time, date, day, month, year, season, time spent in hospital - Where is he, location, where does he stay? - Person- His own name, can he identify people around him and their role in setting

84. Attention - Is the attention easily aroused and sustained. - Ask the client to repeat digits forwards and backwards 71504 284936

85. Concentration -Can the patient concentrate? -Ask the subtract serial sevens from hundreds (100-7) or serial threes from forty (40-3 test) or count backwards from 20 -Enumerate the names of the months or days of the week in the reverse order -Note down the answer and the time take perform the test

86. Memory - Immediate -Recent (Is the individual able to remember occurrence of the past few days? -Remote (Is the individual able to remember occurrence of the distance past)

87. Intelligence - General fund of information - Arithmatic ability

88. Capacity for abstract thought (similarily/desimilarity) Can the individual interpret proverbs correctly?

89. Judgement - Personal (One’s perception of realistic self -overvalued or undervalued) - Social ( One’s perception of the society and environment that is realistic or impaired) - Test ( It is assessed by giving one situation)

90. INSIGHT: It is rated on a 6-point scale from 1 to 6 Complete denial of illness Slight awareness being sick Awareness of being sick attributed to external or physical factor Awareness of being sick but due to something unknown in himself Intellectual insight True emotional insight

91. Theodore D. Dorothy, Textbook of Mental Health Nursing, Volume 1, ELSEVIER, Page No-218-227 Sreevani R, AGuide to Mental Health & Psychiatric Nursing, 4th Edition, JAYPEE, Page No.- 91-92, 408-409 Kapoor Dr. Bimla, A Textbook of Psychiatric Nursing Vol-I, KUMAR PUBLISHING HOUSE Page No-152-156 Townsend Mary C., Morgan Karyn I., Psychiatric Mental Health Nursing Concept of care in Evidence-Based Practice, JAYPEE , Page No.- Appendix-6 REFERENCE S

92. THANK YOU