Mental Status Exam

What information should we obtain during the initial nursing assessment?

• Education level

• Legal status

• marital history

• Social History

• Support systems

• Insight into diagnosis and medication

• Value system (including spiritual)

• Special needs (including cultural)

• Discharge goals

What is the mental status exam?

• State-related exam

• Information is based on the client’s current functioning and the mental status can and does change frequently

• Represents a cross-section of the client’s psychological life at a given moment in time

Mental status exam: Appearance

• Apparent age

• Manner of dress

• Cleanliness

• Posture

• Gait

• Facial expressions

• Eye contact (may vary depending on culture)

• Changes in pupillary reaction

• General state of health and nutrition

Mental status exam: Speech

• Rate: rapid or slow

• Volume: loud or soft

• Amount: paucity, muteness, pressured speech

• Characteristics: stuttering, slurring of words, unusual accents

Mental status exam: Motor Activity

• Level of activity: lethargic, tense, restless, agitated

• Type of activity: tics, grimaces, tremors

• Unusual gestures or mannerisms

• Compulsions

Mental status exam: Interaction during the interview

Is the client:

• Friendly/hostile

• Cooperative/uncooperative

• Irritable

• Guarded/suspicious/defensive

• Apathetic

• Seductive

Mental status exam: Mood

Mood is the client’s self-report of their:

• Prevailing emotional state and reflection on current life situation

• Ask the patient, “How are you feeling today,”

  • Examples: sad, fearful, hopeless, euphoric, anxious

• Ask the patient to rate his/her mood on a scale of 1-10

• Address suicidal/homicidal thoughts and plans

Mental status exam: Affect

Affect is the client’s apparent emotional tone, as observed by the nurse.

• Range: does the client show a broad range of affect or does she/he have a blunted or flat affect

• Duration: lability

• Intensity: blunted or flat

• Appropriateness: congruent, incongruent

Mental status exam: Delusions

False beliefs that are held despite a lack of evidence to support them

• Most common involve persecutory, paranoid, grandiose, or religious ideas

• Example: someone who has poor self-esteem may think that he is God, possibly driven by a need to feel important or powerful

Mental status exam: Perceptual disturbances

• Illusions

• Depersonalization (altered perception of self)

• Derealization (altered perception of the environment)

Illusions

• Errors in the perception of sensory stimuli

• A confused person may mistake folds in the blanket for white rates or the cord of a window blind for a snake

• A stimulus is a real object in the environment, but the person misinterprets it

• Unlike delusions or hallucinations, you can explain and clarify illusions for the individual

Hallucinations

• False sensory stimulation (can be auditory, visual, tactile (touch), olfactory (smell), or gustatory (taste))

• Patient can see bugs crawling on or under the ir bodies

• May be aware that something is wrong

Persecutory delusion

• Believing that one is being singled out for harm or preventing from making progress by others

Referential delusion

A belief that events or circumstances that have no connection to you are somehow related to you

Grandiose delusions

Believing that one is a powerful or important person

Erotomanic delusions

Believing that another person desires you romantically

Nihilistic delusions

The conviction that a major catastrophe will occur

Somatic delusions

Believing that the body is changing in unusual ways

Control delusions

Believing that another person, group, or external force controls your thoughts, feelings, impulses, or behavior

Mental status exam: Thought content

Assess the patient’s thought content (delusions, obsessions) and these other things:

• Thought broadcasting

• Thought insertion

• Depersonalization

• Hypochondriasis

• Ideas of reference

• Magical thinking

• Obsession

• Phobia

Mental status exam: Thought processes (form of thought)

• Circumstantial

• Flight of ideas

• Loose associations

• Neologisms

• Preservation

• Tangential

• Thought blocking

• Word salad

• Concrete thinking (taking things literally)

• Clang associationns

• Echolalia

• Mutism

• Poverty of speech

• Ability to concentrate

• Attention span

Mental status exam: Level of consciousness (LOC)

• Confusion

• Sedated

• Stuporous

• Orientation to time, place, and person

Mental status exam: Memory

• Remote memory: recall of events, people, and information from the distant past

• Recent memory: recall of events and information, and people from the past week or so

• Immediate memory: recall of information to which a person was just exposed

Mental status exam: Impulse control

• Aggression

• Hostility

• Fear

• Guild

• Affection

• Sexual feelings

Mental status exam: Judgement and insight

• Ability to problem solve

• Ability to make decisions

• Knowledge of self (limitations, consequences of actions, awareness of illness)

• Adaptive/maladaptive use of coping mechanisms and ego defense mechanisms

• Are they engaged in dangerous or illegal activities?

• Destructive relationships?

• “What would you do if you found a stamped addressed envelope lying on the ground?”

What is the nursing process in psychiatric mental health nursing?

1. Assessment

2. Nursing diagnosis

3. Outcomes identification

4. Planning

5. Implementation

6. Evaluation

What are the three parts of a nursing diagnosis?

1. Nursing problem

2. Etiology factors (related to)

3. Defining characteristics, specific to patient (AEB)

How do we determine the outcomes identification?

• Identify attainable and culturally expected outcomes

• Document expected outcomes as measurable goals

• Include time estimate

• Usually the opposite, positive aspect of the nursing diagnosis

A 19-year-old college freshman visits the college nurse and reports that he has recently had two “anxiety attacks.” He says that he cannot predict when these attacks are coming.

1. What questions should the nurse ask to assess the extent of his current problem?

2. The young man reveals that he is afraid of losing his mind. What observations should the nurse make and document?

1. “What are you doing before these attacks happen?”

2. “Tell me more. What does losing your mind mean to you?”