NUR 448

Mental Status Examination

Appearance

Yes, appearance is just as straightforward as it seems. For example how does your patient look, smell, behave, or speak .

What can you say about this patient?

Age Grooming

Sex Dress

Build Activity

Appearance

How the patient relates to the interviewer is also important.

Is the patient withdrawn, cooperative, distant, shy, relaxed cautious, hostile or FRIGHTENED?

Speech

Speech patterns can be assessed for speed. Some illness conditions have concomitant speech patterns. One of those patterns is a characteristic rate.

Rate and amount Normal (culturally derived) Pressured –rapid speech Slow-difficulty finding words Impoverished or paucity of speech

Speech

Sometimes called prosody-rhythm also alludes to the quality of the voice

Rhythm Stuttering Monotone Slurred Mumbled Poor articulation Clear Coherent

Speech

The softness of loudness of voice can indicate sensory problems, e.g., deafness, mood problems, e.g., depression or mania; or cognitive problems, e.g., dementia

Volume Soft-spoken Loud Poor articulation

Speech

Spontaneity Animated- excited Little detail No speech

Eye contact

Usually included in the Appearance section, be cautioned to respect the cultural component of eye contact.

No eye contact is considered rude in some cultures and direct eye contact is considered rude in other cultures

Mood and Affect

Mood- the subjective state of a person or how the person “feels”

.

Mood Euthymic (normal) Euphoric (elated) Dysphoric (sad)

Mood

Some other recognized subjective feelings (mood) are:

AnxiousCalm IrritatedAngry

Affect

Affect is the outward display of mood and can be judged on four parameters:

Range

Intensity

Lability

Appropriateness

Range The degree of variation in emotion Expansive Normal Restricted – Dull- Blunted Flat

Intensity

Emotional power being emitted from the patient

Intensity High Low

Lability

Moodiness or the “swing” of moods

Outside of highly emotional events such as weddings, labile affect can be noted in some disease conditions, e.g. chronic alcoholism, or bipolar disorder 1.

Labile affect Extreme change in a short period

of time Laughing and crying at the same

time

Appropriateness

Affect- the outward display of mood – should be congruent with mood and circumstances.

The patient below says, “I am so happy today.” His affect is inappropriate to his mood and circumstance.

Orientation

Areas of orientation are Person

Place

Time

and

Circumstance

Failure of orientation usually occurs in the following sequence:

Time Place Person

Never document person is oriented times three. Proper documentation is person is oriented to person, place, and time.

Circumstance

Not understanding that this presentation is a lesson on the mental status exam and thinking it is a group of cartoons is a misunderstanding of the circumstance or CONFUSION

Confused is the attribute given to persons who become unaware of the circumstances surrounding them.

CONFUSION

Sometimes called disorientation to circumstance

Confusion is quite common in high anxiety states or in delirium, dementia, or mood disordered states

So, a person can be oriented to person, place, and time and still be confused.

Intellectual and Cognitive Functioning

Two closely related attributes

Intelligence is considered to be

Average

Above Average

Below Average

Intellectual Capacity is based on: Vocabulary Ability to understand complex

concepts General fund of information

Cognition

Cognitive ability is usually examined by testing

Level of Abstraction

Executive Function

Memory

Level of AbstractionDon’t cry over spilled milk.

Does the patient interpret literally?

How are an orange and a banana alike?

Both are fruit or both are in the

world?

Executive function

The ability to make a sequence or plan

Executive function- How to study for an exam in NUR 448

1. Order a latte grande 2. Add extra sugar 3. Sit by the library 4. Study for the exam 5. Get a good night’s sleep

Memory

The first memory to be lost is recent.

Memory Recent -within the relative past

short time e.g. breakfast Remote – not in the relative past

short time e.g. name of first boyfriend

Recall-ability to say one’s SS # Retain- ability to learn and then

recall new information, e.g., nurse’s name.

A special case

Confabulation is sometimes used by persons with brain damage or dementia.

Confabulation is the construction of unreal events which seem real, even to the person who construct them, yet the e vents are unreal.

Confabulation

“I went out on a date with Brad Pitt last night.”

Thought Processes

The only way to examine is by analyzing speech:

Tangentiality

Circumstantiality

Flight of Ideas

Blocking

Loose Associations

Perseveration

Tangentiality– digressing, often multiple times, during the relating of an episode or story. Noted in states of high anxiety

Thought Processes

Circumstantiality is note d with persons who are highly anxious, suffer from Bipolar disorders, or from Dementia

Circumstantiality- an unnecessary telling of details when relating an episode or story.

Thought processes

Blockng is noted in high anxiety states, depressive states, and in thought disordered conditions

Blocking---train of thought stops in mid sentence.

Flight of Ideas

Moving quickly from one idea to another in a very short period of time. Often noted in persons with Bipolar disorder

Flight of Ideas

Thought Processes

Loose associations are most often noted in persons suffering from Schizophrenia

Loose Associations- words spoken at random and not in sentences

Thought Processes

Perseveration- the inability to move on to another topic or the continual return to the same topic

PerseverationNow is the time for every good

man to come to the aid of the country. Now is the time for every good man to come to the aid of the country. Now is the time for every good man to come to the aid of the country. Now is the time for every good man to come to the aid of the country. Now is the time for every good man to come to the aid of the country. Now is the time for every good man to come to the aide of the country

Thought Content

Delusions- false beliefs

Life themes-recurrent beliefs

Control-degree of control over one’s thoughts

Delusions—false beliefs--Ideas of reference

(People are talking about me)--Paranoid

(People are after me)--Grandeur

(I am the President of UM)--Nihilistic

(My muscles are disappearing)

Life themes-Recurrent beliefs

--Loss--Anger--Victimization

Thought Control

These disorders of thought are often found in persons who suffer from schizophrenia

Thought Control Thought broadcasting (thinking

one’s thoughts are being heard by others)

Thought insertion (thinking one’s thoughts are being inserted by someone or something else)

Thought withdrawal (thinking one’s thoughts are being stolen)

Perceptual Problems

All senses can be involved in sensory perceptual problems

Hallucinations

Illusions

Hallucinations- the experiencing of a perception in the absence of a stimulus

Auditory (hearing voices)Visual (seeing people of

objects)Tactile (feeling things)Gustatory (tasting things)Olfactory (smelling aromas)

Illusions- common in fatigue and delirium

Illusions --the experiencing of a mis-perception

Auditory (hearing a sound and thinking it is a knock on the door)

Visual (seeing a towel and thinking it is a cat)

Tactile (feeling a touch and thinking it is a burn)

Gustatory (tasting onions and thinking they are chocolate)

Olfactory (smelling fish and thinking it is apple pie)

Final components of the MSE

Judgment

Insight

Impulse control

Judgment- stable quality of persons decision making

Insight- the ability for one to understand his or her condition.

Impulse control

Impulse control-the ability to talk out rather than act out.