Mental status exam Flashcards
What is the purpose of a mental status exam?
Evaluates functional state of mind
What is MSE based on?
CURRENT DATA - objective + subjective
+ Appearance
+ behavior
+ responsiveness to stimuli
+ speech
+ memory
+ judgment
Nursing considerations when performing MSE
+ Age-appropriate questions
+ age-appropriate vocabulary
+ minimal anxiety setting
Main assessment categories of MSE - 7
+ Appearance
+ behavior
+ speech
+ mood & affect
+ thought process
+ thought content
+ orientation
What to consider for appearance
+ Grooming
+ dressed appropriately for situation
+ cleanliness
+ posture
What to evaluate for assessing behavior and mood?
+ Body language
+ activity level - restless, agitated, lethargic, appropriate
+ behavior toward you – cooperative, uncooperative, friendly, hostile, suspicious
+ abnormal movements – bizarre gestures, ticks, repetitive behavior, EPS symptoms
+ gait and coordination
What to consider with speech
+ Quantity – normal, poverty of content, poverty of speech
+ quality – clear, pressured, slurred, monotone, dramatic
+ rate – slow, normal, rapid
Considerations for mood – subjective and objective
+ subjective (ask, scale 1-10 how they have been feeling): sad, happy, fearful, anxious, angry, depressed
+ objective: apathetic, elated, blunted, irritable, anxious, dysthymic
Considerations for affect
+ facial expressions, vocal fluctuations, gestures
+ broad
+ blunt
+ flat
+ restricted
+ is affect congruent or incongruent with mood or situation
Considerations for thought process
+ Logical or coherent
+ illogical or tangential
+ FOI, loose associations
+ word salad, neologism
+ Insight & judgment
+ attention & concentration
+ fund of knowledge
+ abstract reasoning
Considerations for thought content – with the patient thinks about
+ Central theme
+ hallucinations or delusions
+ obsessions or rituals
+ phobias
+ suicidal or homicidal ideation
Factors for determining suicidality (or homicidal)
+ Ideation
+ plan
+ method
+ access
+ where or when
+ timing
How to determine level of orientation?
+ Person
+ place
+ time
+ perception of current circumstances - reason for hospitalization
+ recent and remote memory
What is a DAR
+ Data
+ actions by nurse
+ response by patient
+ evaluation - progress towards goals
