NSG 5130 - Week 3 - Mental Status Exam Notes

Mental Status Exam

Nursing Assessment

  • First step in the nursing process: assessment, diagnosis, planning, intervention, evaluation (ADPIE).
  • On-going, purposeful, systematic process.
  • Nurse is required to:
    • Collaborate with the client and health care team.
    • Assess, document, and analyze data (hx, mse, etc.).
    • Formulate and document a plan of care.
    • Compare baseline assessment data with new data and client goals.
    • Continually assessing social determinants of health to identify client risks and needs.
    • Determine the most appropriate therapeutic modality and assist the client to access resources.

Factors Influencing Assessment

  • Client participation/feedback.
  • Client’s health status.
  • Client’s previous experiences/misconceptions about health care.
  • Client’s ability to understand.
  • Ethnicity, culture, social value, socio-economic factors, age etc.
  • Nurse’s attitude, approach.
  • Therapeutic relationship development.

Components of a Therapeutic Relationship

  • Trust (box 5.1).
  • Respect:
    • Genuine Interest
    • Acceptance
    • Positive regard
  • Empathy.
  • Professional intimacy.
  • Self-awareness.
  • Boundaries.
  • Power.
  • Therapeutic use of self.

Influence of Culture on Assessment

Culture affects attitudes, beliefs, behaviors, rituals, customs, art/drama/music, food, language, faith/religion.

Types of Assessment

Comprehensive Assessment:

  • May include: health hx, physical exam, holistic assessment.
  • Purpose: to develop a holistic understanding and baseline of a person’s problems and needs to establish a dx, identify goals, and plan of care.
  • Time intensive.
  • Conducted at the start of care i.e. admission, not in an emergency.
  • Sources: client, family, other HCP; social, justice, education works, employers, health records.
  • Requires collaboration with client and multidisciplinary team.

Focused Assessment:

  • Specific assessment or screening of a client’s risk, need, problem, situation.
  • Brief, narrow focus.
  • Oriented on the client’s immediate needs.
  • May include: Glasgow Coma Scale, Mini-Mental Status Exam, Depression Scale, Mental Status Exam.

Assessment Techniques

  • Observation
  • Examination
  • Interview
  • Collaboration: Negotiate the terms of the interview with the client; purpose, time frame, the use of note taking, input from family and friends; inclusion of other HCP
  • Environment: Comfortable, private, safe, quiet with few distractions
  • Empathetic listening & approach
  • Be non-judgemental, respectful, open body posture, avoid jargon
  • Be sensitive to the client’s responses and attempt to understand their experiences

Barriers to Effective Interviewing (Box 10.2)

  • Lack of clarity about the purpose and parameters of the interview
  • Asking too many closed-ended questions
  • Avoiding silence
  • Asking complex questions
  • Making assumptions
  • Avoiding or ignoring expressions of emotion

Bio/Psycho/Social/Spiritual NSG Assessment Model

  • Biologic
    • Health status
    • Physical examination
    • Physical function
    • Pharmacologic
  • Psychological
    • Responses to mental health problems
    • Mental status
    • Behaviour
    • Self-concept
    • Stress and coping
    • Risk assessment
  • Social
    • Functional status
    • Social systems
    • Cultural
    • Family
    • Community
    • Spiritual
    • Occupation
    • Legal
    • Quality of life
  • Spiritual
    • What gives life meaning?
    • Believes in sacred power?
    • Participates in religious activities?

Biological Domain of Assessment

  • Biological assessment focuses on the person’s physical functioning:
    • Health History: previous illness, family hx, psychological trauma, current health status, current medications, sleep, relaxation, nutrition, exercise, substance use (Table 10-1)
    • Physical Examination: Head to toe, vital signs laboratory studies specific to hepatic, renal, urinary function, electrolytes, and WBC as significant indicators of metabolism and excretion of psychiatric medication (Table 10.2)

Psychological Domain

  • Assess Response to mental health problems: what is their experience with illness?, what are their specific fears rt illness?, what have been their strategies for managing the mental illness and how effective have these been?
  • Assess MENTAL STATUS (covered in the next set of slides)

Psychological Domain: Mental Status Exam

  • Mental Status Exam:
    • “A structured assessment of a client’s behavioural and cognitive functioning… assists with evaluation of mental health conditions… Can be used across clinical settings. Should only take a few minutes to administer”
  • Purpose:
    • To assesses a client’s current state including: General appearance, mood and affect, speech, thought process and content, perceptual disturbances, impulse control, cognition, knowledge, judgment and insight
  • Basis for developing plan of care
  • Clinical baseline to evaluate effectiveness of treatment or measure client’s progress

Components of Mental Status Exam

  • General observations:
    • Appearance
    • Psychomotor behaviour
    • Attitude toward interviewer
  • Mood & Affect
  • Speech
  • Perception
  • Thought Content & Process
  • Sensorium
    • LOC
    • Orientation (person, place, time)
    • Memory
    • Attention & concentration
    • Comprehension & abstract reasoning
  • Insight
  • Judgement

General Observations

  • Appearance:
    • Dress/clothing; appropriate fit/rt weather
    • Hygiene
    • Identifying characteristics
    • Physical signs of general level of health
  • Psychomotor behaviour:
    • Posture, gait, motor coordination
    • Mannerisms, level of activity
    • Muscle tension, repetitive purposeless movement (automatisms)
  • Attitude toward interviewer:
    • Ex. Accommodating and cooperative, bored, guarded, suspicious, hostile

General Observations Example

  • Example documentation of general client observations
    • Mr. D. is a tall, thin, Caucasian man, who looks older than his stated age of 47 years. He is unshaven, his hair is uncombed, and he has a strong body odour. His clothing is stained and disheveled but appropriate to the season. He reports feeling “jumpy,” and he declined to sit during the interview, opting instead to pace around the interview room. His posture is erect and his movements are quick, purposeful, and well coordinated; he displays no unusual mannerisms. Mr. D. was cooperative with the interview process, although his verbal responses were brief and he did not maintain eye contact.

Mood and Affect

  • MOOD
    • “Pervasive and sustained inner emotions – prevailing emotional state and disposition that is stable over time”
    • Ex. Generally positive/content vs negative/depressed
    • Subjective data = client reported
    • Assessment questions: “How have you being feeling over the last while?” “Is this feeling typical or a change?”
    • Description: Euthymic (normal), Euphoric (elated), Dysphoric (depressed, restless)
  • AFFECT
    • “Outward expression of an emotional state”
    • Objective data: Nurse and other’s observations
    • Assess:
      • Range: Full vs constricted
      • Intensity: Heightened, blunted, flat
      • Appropriateness: According to norms and personal meaning
      • Stability: Mobile (normal) or labile

Speech and Language

  • Quantity: Poverty of speech (minimal), talkative (excessive), absence
  • Rate: “pressured” or slowed
  • Volume & tone: Monotone, tremulous, loud, quiet
  • Fluency: Articulate, clear, slurred, pressured
  • Quality: Monotone, slurred, Rhyming, neologisms, relevance to question, response latency

Perception

  • Perception: taking in sensory information from the environment and processing it into mental representations
  • Perceptual Alterations
    • Hallucinations: a sensory perception without any external stimulation of the relevant sense that the patient believes IS real (e.g. hears voices but no sound present)
    • Illusions: Misperception or misrepresentation of real sensory stimuli (e.g. thinking an IV tube is a snake)
    • Ask questions like: “Do you ever see, hear, smell, feel, or taste things that are not really there?” “Did you think this was real at the time?” “Do you still believe it was real?”

Thoughts: Content

  • Thought content:
    • The subject matter occupying a person’s thoughts
  • Alterations in Thought content:
    • Delusions:
      • Fixed, false belief, not based in reality, not shared by others
      • Person cannot be corrected or convinced otherwise
      • Delusions of control; thought insertion, thought broadcasting, ideas of reference
      • Paranoid: irrational distrust or belief that others intend them harm
      • Bizarre: implausible beliefs
      • Somatic: involving the body
      • Delusions of grandeur: exaggerated belief of one’s importance
    • Obsession: repetitive thought, emotion, impulse
    • Phobia: persistent and exaggerated fear

Thoughts: Process

  • Thought Process:
    • Manner in which thoughts are formed and expressed
  • Alterations in thought process:
    • Loosening of association
    • Circumstantiality
    • Tangential
    • Neologisms
    • Thought blocking
    • Flight of ideas
    • Word salad
    • Perseveration
    • Clang association
    • Echolalia
    • Verbigeration
    • Pressured speech

Sensorium

  • Sensorium: assessment of brain functioning and cognitive abilities
  • Level of consciousness:
    • Assessment of arousal or wakefulness
    • Glascow Coma Scale
    • Descriptions: alert, awake, lethargic, stuporous, comatose
  • Orientation:
    • Awareness of person, place, time
    • Assess in order of time, place, person
    • Documentation: “Oriented to person and place”
  • Memory: Assessment of immediate, recent, short and long term memory. Verifiable questioning
  • Attention & Concentration:
    • Assess through task performance: counting or spelling backward

Insight and Judgement

  • Insight
    • Is the patient able to understand/recognise they have a mental illness/disorder?
    • What does the patient think about the problem/cause?
  • Judgement
    • Problem solving abilities
    • Capacity to learn from experience
    • Adaptation of behaviour
    • Decision-making ability

Psychological Domain: Stress & Coping

  • Asses Stress and Coping Patterns:
    • Identify current stressors, current coping strategies and effectiveness
  • Assess for Protective/Promotive Factors:
    • reduce, mitigate, eliminate risk of mental illness or enhance well-being
  • Assess Risk Factors:
    • increase vulnerability to safety risk, mental illness, exacerbating existing mental illness
    • Ex. Social determinants undermining health (Table 10.3)
    • Assess for risk of self-harm, suicide, violence (next slide)

Suicide Risk Assessment

  • Ideation: “Have you ever or are you thinking about killing yourself?”
  • Plan: “Do you have a plan?” “When” “How?”
  • Access: “Do you have access to the means to kill yourself?”
  • Preparations: “Have you made preparations for your death?”
  • Thoughts of the future: “What does the future hold?” -hopelessness, helplessness, anhedonia

Risk of Harm Towards Others

If someone is making threats or experiencing delusions / hallucinations involving harming others

  • “Do you intend to harm someone?”
  • “What is your plan? What are the details?”
  • “Do you have the means to carry out this plan?”
  • Directly question, inquire, LISTEN, document, duty to report

Social Domain of Mental Health Assessment

  • Assessment of the person’s social relationships:
    • Living situation
    • Roles and relationships; interactions
    • Disability identity
    • Gender identity
    • Cultural assessment
    • Education, work, social, leisure activities
    • Functional status (how an individual functions in their day-to-day)
      • Mobility, self-care, cognition, life activity, participation

Spiritual Domain of Mental Health Assessment

  • What gives your life meaning?
  • What brings joy to your life?
  • Do you believe in God or a higher power?
  • Do you participate in religious activities?
  • Do you feel connected with the world?

Self-Awareness

  • Gather all information needed
  • Judgments not part of assessment process
  • Be open, clear, direct when asking about personal or uncomfortable topics
  • Prioritize client care and safety needs
  • Examine own beliefs, gain self-awareness (growth- producing experience)
  • Do not allow personal beliefs to interfere with nurse–client relationship and assessment process
  • Practice and consultation with colleagues

Summary

  • Review key terms in chapter – consider creating a glossary
  • Box 11.5 & 11.6
  • Comprehensive assessment includes holistic assessment using the four domains of the bio/psycho/social/spiritual model
  • Focused assessments focus on specific need/problem- brief, narrow, present oriented
  • Mental status exam- snap shot of individual’s appearance, affect, cognitive function
  • Protective/promotive factors prevent or reduce risk and promote mental well-being
  • Risk factors increase vulnerability to threats to safety/well-being
  • Social determinants of health
  • Risk for self-harm, suicide, violence