Mental Status Exam

Exam 1 - sem 3

Assessment in Psychiatric Nursing

• Uses the nursing process (recognize cues, analyze cues, prioritize hypothesis, generate solutions, take actions, evaluate outcomes) and a holistic approach to care for clients

• Each encounter with a client involves on-going assessment

• Assessment includes

  • Physical assessment: VS, lung assessment etc, medical/surgical hx

  • Psychosocial history: supports, interests, coping abilities, substance use etc, family psychiatric hx

  • Cultural beliefs and practices: health care beliefs, practices, values

  • Spiritual and religious beliefs

  • Current medication list and previous trials of medications

  • Mental Status Exam (MSE): assesses client’s current state of mind

Mental Status Exam

• Integrated into the nursing assessment

• Structured way of assessing and describing

  • Client’s current state of mind

• Gathers objective data 

  • Etiology (causes)

  • Diagnosis  & prognosis

  • Treatment

  • Risk of harm to self or others

General elements of MSE

General Appearance 

Psychomotor Behavior

Mood and Affect

Speech

Cognition

Thought Patterns

Level of Consciousness 

MSE: general appearance

Appearance

• Grooming and dress

Hygiene

Posture

Height & Weight

Level of Eye Contact

Hair Color and Texture

Evidence of scars, tattoos, or other distinguishing marks

Evaluation of client’s appearance compared with age

MSE: psychomotor behavior

Tremors

• Lithium can cause hand tremors; not normal

Tics or other stereotypical movements

Mannerisms and gestures

Hyperactivity

Restlessness or Agitation

Aggressiveness

Gait Patterns

• Shuffling their feet (side affects of antipsychotics)

Echopraxia (Mimicking the actions of others) 

Psychomotor Retardation

• Slow movements - lethargy, depression

Freedom of Movement

MSE: mood

Depressed/Despairing

Irritable

Anxious

Elated

Euphoric (overly happy)

Fearful

Guilty

Labile (mood change very quickly and dramatically)

*How the patient feels today

MSE: affect

Congruent with mood?

• When mood and affect match

• Incongruent: when mood and affect don’t match

Constricted or blunted

Flat (just staring at you)

Appropriate/Inappropriate

What the patient shows

MSE: speech patterns

Slowness or rapidity of speech (super slow or rapid speech)

Pressure of speech

Intonation

Volume (quiet, loud/screaming)

Stuttering or other speech impairments

MSE: general attitude

Cooperative/Uncooperative

Friendly/Hostile/Defensive

Uninterested/Apathetic

Attentive/Interested

Guarded/Suspicious

MSE: form of thought (though process/thought flow)

Flight of Ideas (one idea to the next)

Associative Looseness

Circumstantiality (answer the question after a tangent)

Tangentiality (never going to answer the question after they go on a tangent)

Neologisms (made up words)

Concrete Thinking

Clang Associations (people will talk in rhyming words)

Word Salad (bunch of words together that don’t belong together)

Perseveration (saying the same thing over and over again)

Echolalia (patient repeats what you said)

Mutism (people that don’t talk)

Poverty of Speech (minimal responses)

Ability to Concentrate

MSE: content of thought

Delusions (belief of alternate reality that is held even though there is evidence that there is contrary to belief)

Suicidal/Homicidal Ideations

Obsessions

Paranoia/Suspiciousness

Magical Thinking (belief that ones ideas, actions, and beliefs can change what happens in real life)

Religiosity

Phobias

Poverty of Content

MSE: perceptual disturbances

Hallucinations (hearing or seeing or smelling what other people can’t hear/see/smell)

• Command hallucinations (when the voices are telling you that you have to do something - killing/hurting someone)

Illusions

Depersonalization (PTSD/traumatic events)

Derealization (being outside the body and looking in or feeling like what is happening to you isn’t actually happening)

Rule out medical conditions before you jump to a psych problem

MSE: judgement and insight

Ability to solve problems and make decisions

Knowledge about self

Adaptive/Maladaptive use of coping strategies

MSE: sensorium and cognitive ability

Level of Alertness/Consciousness

Orientation 

Memory

Capacity for Abstract Thought

MSE: suicide assessment

Plan

Means

Intent

Likelihood of being saved

Previous Attempts

Family History 

MSE: memory

• Immediate

  • 3 unrelated words: boy-plane-apple

• Recent

  • 24 hours /current event (breakfast?)

  • Repeat series of numbers

• Remote

  • 1st president

MSE: abstract thinking

Making distinctions between such abstractions 

• Name two objects: What is similar/different 

• Example: apple/orange

Mental status exam (extra)

• General Intellectual Level 

  • General grasp of information

  • Ability to calculate (serial 7’s)

• Focus and Concentration

  • Spell the word “WORLD” backwards

Assessment in Psychiatric Nursing Practice

What would you do if you were in a  movie theater and you smelled smoke?

What would you do if the garbage can was on fire?

Why do a MSE?

How do elements of the mental status exam correlate with the symptoms associated with mental illness??

• Major Depression

• Bipolar Mania

• Schizophrenia

Assessing for Major Depressive Symptoms: SIGECAPS

Sleep = Insomnia or hypersomnia

Interest Deficit = Anhedonia

Guilt = Worthlessness, hopelessness, regret

Energy deficit = Anergia

Concentration deficit

Appetite disorder = too much or too little

Psychomotor retardation or agitation

Suicidality

Assessing for Manic Symptoms: DIGFAST

Distractibility 

Indiscretion = Excessive involvement in pleasure activities 

Grandiosity = “I am the Queen of England”

Flight of ideas

Activity increase

Sleep deficit =  Decreased need for sleep

Talkativeness

Positive symptoms for Schizophrenia

Delusions

Hallucinations

Disorganized thinking

Bizarre behavior

*Adding to a person

Negative symptoms for Schizophrenia

Affective flattening - The person's range of emotional expression is clearly diminished; poor eye contract; reduced body language 

Alogia - A poverty of speech, such as brief, empty replies 

Avolition - Inability to initiate and persist in goal-directed activities (such as school or work) 

Anhedonia- Inability to feel pleasure

Attentional Impairment

*Taking away from a person

What else needs to be taken into account during a psychiatric evaluation?

Medical History

Social History

Family History

Nurses role in a MSE

Talk to the patient!

Complete the MSE 

Include assessing medical history, social history and family history

Medical history (done in ED or hospitalist)

Brief history; focus on any acute

Medications

Primary care physician

Allergies

Surgical history

Labs

Social history

• Current living situation

• Support systems (relationship status)

• Education

• Vocational 

• Sexual assault

• Physical assault

• Drug/alcohol use 

• Cigarette use

• Developmental history if relevant

• Legal issues/incarceration

Family history

• Blood relatives with mental health issues; hx of mental health medications

• May have to name diagnoses

• History of family suicide

• History of suicide attempts and/or completion in the family

Legal rights of mental health patients

• The right to humane treatment and care

• Informed consent 

• Right to Refuse Treatment (holds up for 3 days → starts at CPEP)

• Confidentiality, HIPPA

• Communication with people outside the mental health facility

• Interpretive services

• Provision of care with the least restrictive interventions necessary to meet the client’s needs without allowing client to threaten or harm himself or others

Seclusion and Restraints

1. Verbal

2. Escorting out of milieu

3. Offer of PO Meds

4. Chemical restraints

5. Seclusion/Restraints

Tarasoff Law

Duty to Warn, Duty to protect

Tarasoff vs. Regents of the University of California case

Ruling: a mental health professional has a duty not only to their client, but to also to those being threatened by their client. The law states that under certain circumstances, a therapist can notify an individual or the police and take whatever steps necessary to protect the individual

NY law: 2013 NY Safe Act Mental Health Professionals must report if their patients is “likely to engage in conduct that would result in serious harm to self or others.”

Voluntary commitment

9.13 - the client or client’s guardian chooses commitment to a mental health facility in order to obtain treatment.  The client has the right to write a request for release at any time.  Must be reviewed by MD within certain amount of time

Temporary emergency commitment

The client is in need of observation, a diagnosis and a treatment plan

In NYS – can hold for 72 hours

This is specific to state (CPEP)

Involuntary commitment

9.40 or 2PC - The client enters the mental health facility against her will for an indefinite amount of time.  In NYS – it is up to 60 days and then a court appearance is necessary

Criteria:

• Manifestations of mental illness

• Poses a danger to self or others

• Severe disability or inability to meet basic nescessities

• Requires treatment but unable to see it voluntarily due to impact of their mental illness

Long-term involuntary admission

Long-term involuntary admission (Hutching’s Psychiatric facility)

• Must be imposed by the courts

• Usually 60-180 days

Involuntary Outpatient Commitment

Assisted Outpatient Treatment (AOT): Court Ordered

Kendra’s Law (1999): A chronic schizophrenic in NYC stopped taking his medications and pushed a young woman into the path of an on-coming subway train

Elligibility criteria for AOT:

• History of decompensation requiring hospitalization

• Likelihood that without treatment the patient will require inpatient hospitalization

• Presence of severe and chronic mental illness.

• Risk of homelessness, incarceration, violence or suicide

• Existence of a treatment plan with a provider willing to provide treatment