Mental status examination

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mental status exam

mental status exam

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  • 1. By Eric F. Pazziuagan, RN, MAN
  • 2. Mental Status Examination Focuses on the patient’s current state in terms of thoughts, feelings and behaviors. An overall description of the client’s mental status, including general appearance, mood and affect, quality of speech, thought content and processes, level of consciousness and cognition, impulsivity, ability to abstract, judgment and insight, and reliability.
  • 3. Major goals: Gather baseline data about the client’s level of functioning Identify actual and potential problems Facilitate making accurate psychiatric and medical diagnoses
  • 4. Major Components:
  • 5. General Appearance LOC Dress Facial expressions Posture Level of understanding Gait Grooming Psychomotor behavior or activity level Eye contact
  • 6.  Attitude toward the nurse With whom and how the client arrived
  • 7. Mood and affect Mood  Pervasive and sustained emotional state that depicts the client’s perception of the world  Depressed  Sad  Labile  Elated  Expansive anxious
  • 8.  Affect  Present state of emotional responsiveness and is observable with body language.  Blunted  Flat  Restricted  Depressed  Expansive  Angry Major point: whether thought is congruent, appropriate, or both, with the mood and affect.
  • 9. Quality of Speech Speech  Process of expressing ideas, thoughts, and feelings through language  The use of words or language Involves physical descriptions of the client’s speech
  • 10.  Note:  Quality and articulation  Quantity and rate  Other descriptions:  Spontaneous  Talkative  Rapid  Whispered  Loud  Stuttered  Accent
  • 11. Perceptual- Sensory Disturbances Hallucinations:  False sensory perceptions of internal stimuli  Can be visual, olfactory, auditory, or tactile Illusions  Misinterpretation of external stimulus such as shadow of the person Inquire about the content and the circumstances in which they occur Consider cultural factors
  • 12. Thought content and processes Thought content: what the client is thinking about  Preoccupations: recurrent thoughts that center on a particular idea or thought with an intense emotional component.  Obsessions: Maladaptive patterns of thoughts, images, or feelings that generate anxiety.  Compulsions: maladaptive urges to act on an impulse and involve ritualistic behaviors such as excessive hand washing.  Delusions: fixed false beliefs and includes persecutory, somatic, or jealous types  Assess whether the client has homicidal or suicidal ideations
  • 13.  Thought processes:  Loose associations: flow of thoughts or ideas unrelated to each other and shift from one subject to another.  Flights of ideas: rapid thinking ideas that have a common theme.
  • 14. Higher brain function Level of consciousness Orientation: refer to one’s sense of time, person, and place. Memory: complex form of brain function that involves storing and retrieving information that is later recalled to consciousness.  Remote (long term)  Recent  Recent past (current events)  Immediate memory (short term)  Immediate recall
  • 15.  Concentration and attention: various conditions produce disturbances, including delirium or other medical anxiety or depressions. Cognition: ability to think and know Visuouspatial: refers to time and space Ability to read and write; consider:  Cultural factors  Educational preparations  Previous level of functioning
  • 16.  Ability to abstract: testing for concrete thinking Impulsivity: ability to control or manage various urges appropriately. Judgment: ask “what if” questions Insight: involves the client’s understanding about being ill and the need for treatment when warranted. Reliability: whether the client’s perception of the present problem and its history are credible.