Mental Status Exam and Suicide Risk Assessment

Question 1

MSE

Answer 1

a systematic assessment of an individual’s appearance, affect, behaviour, and cognitive processes. It provides a “snapshot” of a person’s subjective report and experiences and the examiner’s observations and impressions at the time of the interview. It is performed by health practitioners across several disciplines and clinical settings to evaluate developmental, neurological and psychiatric nursing

Question 2

Components of the MSE

Answer 2

1. Observations (appearance, psychomotor behaviour, attitude towards interviewer)
2. Mood
3. Affect
4. Speech characteristics
5. Perception
6. Thought (content, process/form)
8. Sensorium (LOC, orientation, memory, attention & concentration, comprehension & abstract reasoning)
9. Insight
10. Judgement

Question 3

Risk Factors

Answer 3

Characteristics, conditions, situations and events that increase the individual’s vulnerability to threats to safety or well-being. (family history, substance use, negative environment, unemployment, loneliness)

Question 4

Protective Factors

Answer 4

Attributes or conditions of an individual, family, and/or community that when present reduces, mitigates, or eliminates risk. (positive attitude, positive self-esteem, strong social support, conflict resolution skills, good physical, spiritual, and emotional health

Question 5

Assessment

Answer 5

a purposeful, systematic, and dynamic process in nurses’ relationships with individuals in their care. It involves the collection, validation, analysis, synthesis, organization, and documentation of patient health-illness information

Question 6

How is and MSE and Risk Assessment done?
The MSE is comprised of:

Answer 6

• Observation (much of the MSE can be conducted through direct observation of the patient. The MSE begins as soon as you see the patient)
• Examination (includes a health history, physical examination and diagnostic testing)
• Interview (interaction with the individual in which the nurse builds the therapeutic relationship & acquires information about the patients current level os functioning)

Question 7

Factors that Facilitate

Answer 7

• negotiate the terms of the interview
• choose a private, comfortable space
• realistic time management
• attend to your non-verbal communication
• avoid jargon
• begin with less sensitive topics and more towards sensitive issues
• leave time for closure and future planning

Question 8

Barriers to Effective Interviewing

Answer 8

• lack of clarity about the purpose & parameters of the interview
• asking too many closed-ended questions
• avoiding silence
• asking complex questions
• making assumptions
• avoiding or ignoring expressions of emotion

Question 9

MSE: ABC STAMP LICKER

Answer 9

Appearance
Behaviour
Cooperation
Speech
Thought
Affect
Mood
Perception
Level of consciousness
Insight & judgement
Cognitive function & Sensorium (attention, memory, concentration)
Knowledge base
Endings (suicidal/homicidal ideation)
Reliability of information provided

Question 10

Assessing For Suicide Risk: Is Path Warm

Answer 10

Ideation - thinking about suicide
Substance abuse: problems with drugs or alcohol
Purposelessness
Anxiety
Trapped
Hopelessness or helplessness
Withdrawal: avoiding family, friends
Anger, feeling unreasonable anger
Recklessness: engaging in risk or harmful behaviour
Mood change: a significant change in mood

Question 11

4 key things to ask about

Answer 11

1. Do you have a plan?
2. Do you have the means to carry out your plan?
3. Are the means accessible?
4. How lethal is your plan?