Mental Status Examination Flashcards
refers to a client’s level of cognitive functioning (thinking, knowledge, and problem solving) and emotional functioning (feelings, mood, behaviors, and stability).
Mental status
is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity -WHO
Health
The WHO further defines ??? as “a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community.”
mental health
any condition characterized by cognitive and emotional disturbances, abnormal behaviors, impaired functioning, or any combination of these
mental disorder
APA
American Psychological Association
APA notes that mental disorder is also called (4)
mental illness, psychiatric disorder, psychiatric illness, or psychological disorder
Mental disorders are characterized by problems that people experience with their ??? and their ???
mind (thoughts) and their mood (feelings)
NAMI
The National Alliance on Mental Illness
Culture plays a role in perception of illness, especially of illnesses associated with mood and mental status, called ???
culture-bound syndromes
can be defined as “disorders that affect mood, behavior, and thinking, such as depression, schizophrenia, anxiety disorders, and addictive disorders.
Mental illness
Mental disorders often cause ??? or ??? or both.
significant distress or impaired functioning
Mental disorders may affect ??? when prompt assessment and intervention are delayed.
other body systems
The WHO describes ??? as the “harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.”
substance abuse
Assessment of mental status is accomplished by ??? the client and ???.
interviewing;
observing their behaviors
Essential assessment areas for mental status include (4)
appearance,
general behavior,
cognitive function and memory,
and thought processes.
What is your name, address, and telephone number?
RATIONALE
These answers will provide baseline data about the client’s level of consciousness, memory, speech patterns, articulation, or speech defects. Inability to answer these questions may indicate a cognitive/neurologic defect.
Why do we need to note if the client is male or female?
Women tend to have a higher incidence of depression and anxiety, whereas
men tend to have a higher incidence of substance abuse and psychosocial disorders.
What is your marital status?
RATIONALE
Either healthy or dysfunctional relationships will affect one’s mental health status.
What is your educational level and where are you employed?
RATIONALE
Clients from higher socioeconomic levels tend to participate in more healthy lifestyles. They are less likely to smoke and more likely to exercise and eat healthfully. Healthy lifestyles may influence one’s ability to more effectively cope with mental disorders.
headaches that may be seen in clients experiencing stressful situations.
Tension headaches
Do you ever have trouble breathing or have heart palpitations?
RATIONALE
Clients with anxiety disorders may hyperventilate or have palpitations.
The sleep–wake cycle may be reversed in
delirium
Decreased sleep and a tendency to awaken early are seen with ????
depression
Rapid mood swings, anxiety, and fearfulness are seen in ???
delirium
Agitation or a flat affect is seen in ???
dementia
sadness, apathy, irritability, and anxiety are seen in ???.
depression
Do you suffer from fatigue?
RATIONALE
Fatigue is often seen in depression.
hallucinations that are often seen with alcohol withdrawal, Parkinson disease, or adverse medications effects.
visual
hallucinations that may be experienced in some psychotic disorders.
Olfactory or tactile
hallucinations that can be associated with use of methamphetamines or hallucinogens.
Tactile
Have you ever served on active duty in the armed forces? Explain.
RATIONALE
Posttraumatic syndrome may be seen in veterans who experienced traumatic conditions in military combat.
Poor appetite may be seen with
(3)
depression, eating disorders, and substance abuse.
A decrease in weight may be seen with (3)
eating disorders, early dementia, and anxiety.
Irritable bowel syndrome or peptic ulcer disease may be associated with
psychological disorders
(sleep pattern) is often seen in depression, anxiety disorders, bipolar disorder, and substance abuse.
Insomnia
(sleep pattern) may also be a symptom of depression.
Hypersomnolence
is a psychostimulant with the potential to increase stress (Ferré, 2016)
Caffeine
in some older adults may cause symptoms of forgetfulness or confusion, which could be mistaken for signs of Alzheimer disease.
Drinking
SBIRT
(Screening, Brief Intervention, and Referral to Treatment)
tools that can be used to assess alcohol-related disorders
CAGE self-assessment
AUDIT questionnaires
Use ??? if depression is suspected in the older client
Geriatric Depression Scale
AUDIT
Alcohol Use Disorders Identification
Test
AUDIT: Total scores of ??? are recommended as indicators of hazardous and harmful
alcohol use, as well as possible alcohol dependence.
8 or more
SAD PERSONS Suicide Risk Assessment (risk factors)
Sex
Age
Depression
Previous attempt
Ethanol abuse
Rational thinking loss
Social supports lacking
Organized plan
No spouse
Sickness
It is best to validate client responses by asking ???, ??? data with another health care professional, or comparing ??? with ??? findings before completing the entire assessment
additional questions;
verifying;
objective with subjective
When assessing the mental status of an older client, be sure to first check ??? and ??? before assuming that the client has a mental problem.
vision and hearing
When assessing level of consciousness, always begin with the least noxious stimulus:
verbal, tactile, to painful
Slumped posture may reflect feelings of powerlessness or hopelessness characteristic of ??? or ???
depression or organic brain disease
In the older adult, purposeless movements, wandering, aggressiveness, or withdrawal may indicate ???
neurologic deficits
is the expression of emotions or the individual’s emotional state (mood).
Affect
Normal, steady, tranquil mental state
Euthymic
A mildly diminished range or intensity of emotional expression
Constricted
Markedly diminished emotional expression
Blunted
AFFECT
is often associated with autism, schizophrenia, depression, posttraumatic stress disorder, brain injury (tumor, head trauma, dementia, brain damage, or side effects from medications)
Reduced affect (constricted, blunted)
A severely reduced emotional expressiveness
Flat
Irregular and severe mood swings
Labile
Emotional responses that are not in keeping with the situation or are incompatible with expressed thoughts or wishes, such as smiling when told about the death of a friend (APA, 2018a)
Inappropriate
Levels of Consciousness:
Client opens eyes, answers questions, and falls back asleep.
Lethargy
Levels of Consciousness:
Client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment.
Obtunded
Levels of Consciousness:
Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep.
Stupor
Levels of Consciousness:
Client remains unresponsive to all stimuli; eyes stay closed.
Coma
is voice volume disorder caused by laryngeal disorders or impairment of cranial nerve X (vagus nerve).
Dysphonia
is irregular, uncoordinated speech caused by multiple sclerosis.
Cerebellar dysarthria
is a defect in muscular control of speech (e.g., slurring) related to lesions of the nervous system, Parkinson disease, or cerebellar disease.
Dysarthria
is difficulty producing or understanding language, caused by motor lesions in the dominant cerebral hemisphere.
Aphasia
is rapid speech that lacks meaning, caused by a lesion in the posterior superior temporal lobe.
Wernicke aphasia
is slowed speech with difficult articulation, but fairly clear meaning, caused by a lesion in the posterior inferior frontal lobe.
Broca aphasia
It is defined as a systematic and
continuous collection of data on the health status with the patient
ASSESSMENT
TECHNIQUES AND ELEMENTS (assessment of mental health status)
Psychiatric nursing history.
Mental status examination.
Psychological test.
It is a standardised format in which the clinician records the psychiatric signs and symptoms present at the time of interview
MENTAL STATUS EXAMINATION
purpose of MENTAL STATUS EXAMINATION
to evaluate, quantitatively and qualitatively, a range of mental functions and behaviors at a specific point in time.
Components of MSE (7)
General appearance
Psychomotor activity
Mood & affect
Speech
Thought
Perception
Cognitive function
GAAB
general appearance and behavior
GAAB: things to observe are anxiety, pleasure, confidence, blunted, pleasant
facial expression
GAAB: things to observe are stooped, stiff, guarded, normal
posture
GAAB: things to observe are stereotype, negativism, tics, normal
mannerisms
GAAB: things to observe are is it maintained or not
eye to eye contact
GAAB: things to observe are build easily or not built or built with difficulty
rapport
GAAB: things to observe are conscious or drowsy, or unconscious
consciousness
GAAB: things to observe includes social behavior (overfriendly, disinhibited, preoccupied, aggressive, normal)
behavior
GAAB: things to observe are if the client is well dressed/appropriate to season and situation/neat and tidy/dirty
dressing and grooming
GAAB: things to observe are if the client looks older/younger than actual age/ underweight/ overweight/ physical deformity
physical features
motor activity: apparent restlessness, lip smacking, tongue protrusion
drug side effects
motor activity: difficulty in initiation of movement/slow, stiff movement
parkinsonism
motor activity: patient’s movement having the feeling of a plastic resistance (e.g. in catatonic schizophrenia)
wavy flexibility
motor activity: patient resist attempts to move him and does opposite to what is asked
negativism
negativism is a sign of?
catatonia
speech findings:
normal
very slow
rapid
pressure of speech
rate
speech findings:
spontaneous
hesitant
slurring
stuttering
speaks only on question
muttering mute
flow
speech findings:
audible,
excessive loud
abnormally soft
volume
speech findings:
normal
abundant
scanty
amount
speech findings:
normal fluctuations
monotonous
tone
speech findings:
coherent
incoherent
coherence
speech findings:
relevant
irrelevant
relevance
fails to produce any vol. of sound, e.g. in laryngeal or vocal cord disorder. If despite this he/she is able to cough normally, probably hysterical
Aphonia
may be a feature of psychomotor retardation
Slow speech
normal anxiety but may indicate Mania or Schizophrenia
Fast speech
rapid speech that is increased in amount and difficult to interrupt. Seen in Mania
Pressure of speech
restriction in amount of speech, replies may be monosyllabic
Poverty of speech
speech is adequate in amount but covers little information due to vagueness, emptiness
Poverty of content of speech
repetition of sentence just uttered by the examiner.
Echolalia
repetition of only last uttered word or phrase said by the examiner.
Palilalia
(thought) creative day dreaming
fantasy
content of thought (5)
delusion
obsession
phobia
preoccupation
fantasy
describes the rate of thoughts, how they flow and are connected
thought process
there are rapid shifts in the frame of reference and their associations are incoherent (e.g. mania)
flight of ideas
continuity of thoughts abnormalities:
When thinking proceeds slowly with many unnecessary detail but eventually get to the point. Goal is never completely lost. It can occur in context of learning disability and in individual with obsessional personality traits, schizophrenia, dementia, and anxiety disorders.
circumstantial
continuity of thoughts abnormalities:
Move from thought to thought that relate in some way but never get to the point. e.g. In Psychosis and Dementia
tangential
continuity of thoughts abnormalities:
Sudden arrest of the train of thought, leaving a blank, then entirely a new thought may begin. May be seen in exhausted or very anxious state. When clearly present, it highly suggests Schizophrenia.
thought blocking
continuity of thoughts abnormalities:
Inappropriate repetition of words or phrases. It is common in generalized & local disorders of brain, when present provide strong support for such a diagnosis. Also seen in OCD & Psychosis.
preserveration
thought possession/alienation (abnormalities)
Hearing one’s own thought being spoken aloud
Thought Echo
thought possession/alienation (abnormalities)
Other person or forces are implanting thoughts in a person’s mind
Thought Insertion
thought possession/alienation (abnormalities)
Other person or forces are removing thoughts from a person’s mind
Thought Withdrawal
thought possession/alienation (abnormalities)
One’s own thoughts experienced as being transmitted to another person or agency
Thought Broadcasting
all thought possession/alienation (abnormalities) are features of?
schizophrenia
formal thought disorder abnormalities seen:
Illogical shifting between unrelated topics. It is a hallmark feature of Schizophrenia.
Loosening of association
formal thought disorder abnormalities seen:
Gradual or sudden deviation in train of thought without blocking.
Derailment
formal thought disorder abnormalities seen:
Extreme version of LOA in which changes in topics are so extreme and the associations so loose that the resulting speech is completely incoherent.
Word Salad
formal thought disorder abnormalities seen:
Constant repetition of a phrase(or behavior) in many different settings, irrespective of context.
Stereotypes
formal thought disorder abnormalities seen:
Disappearance of understandable speech replaced by strings of incoherent utterance
Verbigeration
formal thought disorder abnormalities seen:
are word approximation e.g. paper skate for pen
Metonyms
formal thought disorder abnormalities seen:
words are chosen or repeated based on similar sounds, instead of semantic meaning.
Seen in mania
Clang association
formal thought disorder abnormalities seen:
It refers to the new word formation by the patient or ordinary word that are used in new way.
Seen in Schizophrenia.
Neologism
refers to the themes that occupy the patient’s thoughts and perceptual disturbances
thought content
thought content abnormalities:
This is a thought, which because of associated feeling tone, take precedence over all other ideas and maintains this precedence permanently or for a long period of time. It tend to be less fixed than delusions and tend to have some degree of basis in reality. (McKenna, 1984).
overvalued ideas
thought content abnormalities:
False, firm (fixed), unshakable belief that is out of keeping with the patient’s social, cultural, and educational background
delusions
delusions: outside forces are controlling actions
control
delusions: a person, usually of a higher status, is in love with the patient
erotomanic
delusions: inflated sense of self-worth, power or wealth
grandiose
delusions: patient has a physical defect
somatic
delusions: unrelated events apply to them
reference
delusions: others are trying to cause harm
persecutory
thought content abnormalities:
e.g. obsessions, phobias, hypochondriacal symptoms, specific antisocial urges or impulse
preoccupation
repetitive preoccupation with a thought, acknowledged by the patient to be irrational or compulsions
Obsessions
persistent and irrational fear of delineated aspects of nonhuman object or environment
Phobias
The incorrect idea that words and actions of others refer to oneself or the projection of causes of one’s own imaginary difficulties upon someone else.
ideas of reference
Process of transferring physical stimulation into psychological information i.e. mental process by which sensory stimuli are brought to awareness.
perceptions
perceptual disturbances:
A false perception which is not a sensory distortion or a misinterpretation, but which occurs at the same time as real perception
hallucination
perceptual disturbances:
Misinterpretation of stimuli arising from an external object
illusion
illusion types:
delirium
visual
illusion types:
due to inattention (e.g. misreading in newspaper or missing misprints)
complete
illusion types:
arise in context of particular mood state
affect
illusion types:
vivid illusion without any effort by the patient
pareidolia
perceptual disturbances:
Feelings the outer environment feels unreal and detached from environment
derealization
perceptual disturbances:
Sensation of unreality concerning oneself or parts of oneself (detached from self
Depersonalization
subjective or objective?
mood
subjective
subjective or objective?
affect
objective
is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment
The Mini–Mental State
Examination (MMSE) or Folstein test
MMSE indication: It is commonly used in medicine and allied health to screen for ???
dementia
MMSE score 24-30
normal cognition
MMSE score 19-23
mild cognitive impairment
MMSE score 10-18
moderate cognitive impairment
MMSE score 9 and below
severe cognitive impairment
level of consciousness: arouses with great difficulty and co-operates minimally when stimulates
stuporous
level of consciousness: pt. has lost ability to respond to verbal stimuli; some response to painful stimuli; little motor function
semi-comatose
level of consciousness: when pt is stimulated, no response to verbal/painful stimuli;
no motor activity
comatose
widely used to measure the patient’s level of consciousness
Glasgow coma scale
inability to recognize common objects through senses
agnosia
patient cannot carry out skilled act in the absence of paralysis
apraxia
inability to communicate
aphasia
provides information about the brainstem & related pathways
cranial nerve examination
