Mental status exam Flashcards
Mental Status exam Overview
A -Appearance
S - Speech.
E - Emotion (Mood and Affect)
P - Perception (Auditory/Visual Hallucinations)
T - Thought Content (Suicidal/Homicidal Ideation) and Process.
I - interaction, Insight
C - Cognition
J - judgement
A - abstraction
M - motor behavior
Appearance
dress, hair, hygeine, height/weight, eye contact, general posture, general health
Speech
rate, volume, amount, amount, stuttering, slurring, accent
Emotion
Affect
what does the nurse see? (outward emotional expression)
what is the patient’s apparent emotional tone?
range, duration, intensity, appropriateness
possibly: flat, blunt, restricted, labile, incongruent
Mood State
1-10 scale of patient mood
describe how you are feeling today
asking more about the mood they are experiencing/how long they have felt it, and when the last remember feeling differently
Perception
Presence of hallucinations: event that stimulates the senses
Do you ever hear or see things other people do not
illusions: misinterpretation of stimuli (ex. seeing a clock as a monster)
delusions: false, fixed belief (ex I am Jesus Christ)
do not reaffirm their belief
Thoughts
Thought content
what is the underlying meaning of what the patient says
what is the general background story/underlying issue
do they have an recurrant/persistant thoughts – like fears, phobias or “special powers”
worries?
thought insertion or broadcasting?
thought insertion – experiencing ones’ own thoughts as someone elses
thought broadcasting – think other people can hear your thoughts
Thought Process
“how” the pt is thinking
logical, with clear order → responding to the questions you are asking
disorganized/illogical
flight of ideas
loose associations/ tangential
Insight and interaction
Insight - does the patient understand/accept their condition/ hospitalization/need for intervention
Interaction - comfortable, suspecious, confused, irritable, cautious “vibes”
Cognition
LOC
AOx4 (time, place, situation, self)
Memory
remote: ex tell me about an important event as a teenager
recent: last few days/week – what was your favorite thing you did this week
immediate: give them 3 objects, ask them to repeat and then recall 5 mins later
concentration
calulation ability (serial 7s from 100, or 3s from 20)
information/ intelligence (literacy, vocabulary)
judgement
ability to understand facts and use them to make decisions
“what would you do if you were at home and smelled gas?”
Abstraction
concrete vs abstract (picture vs map)
can a patient interpet a proverb
can also be due to a lack of cultural/ethnic exposure
ex show a pic of a glass house and ask what it means
Motor activity
restlessness, agitation, tics, facial activity, ability to sit, compulsive behaviors
note: you are not trying to stop any of these behaviors, just noting them
