Mental Status Examination Flashcards
What are the steps to the nursing assessment
- Establish therapeutic relationship
- Information on patients current problem
- Assess physical status and obtain baseline
- Assess for risk factors
- Assess psychosocial
- Goals of treatment
- Plan for care
What are some conditions that mimic that of a mental illness
- Brain tumour
- Heart Failure
- Sleep Apnea
- Hypothyroidism
-Hyperthyroidism
What is the first step in the MSE and what do you look for
Appearance (observed)
- Grooming and dressed
- level of hygiene
- pupil dilation or constriction
- facial expression
- height, weight, nutritional status
- Presence of tattoos or piercings, scars
- does the appearance and age make sense, go together
what is the second step in the MSE and what to look for
Behaviour (observed)
- what the person is actually doing during the interview
- mannerism
- body movements (excessive or minimal)
- abnormal movements (tremors, tardive dyskinesia)
- level of eye contact
- rapport (how open or closed off the patient was)
what is the third step in the MSE and what to look for
Speech (Observed)
- how fast or slow they are speaking
- what is the volume of their speech
- what is their tone
- how are they articulating
- what is the organization of their speech
- what is the quantity of their speech
what is the fourth step in the MSE and what to look for
Mood (Observed and Inquired)
affect
- appropriateness
- range of facial expressions
- stability
mood
- tone
- irritability
- stability
- degree
what is the fifth step in the MSE and what to look for
Thought (Observed and Inquired)
According to the persons thought content or thought process
- Thought content: delusions, preoccupations or obsessions, dark thoughts
- Thought Process: disorganized, coherent, flight of ideas, neologisms, thought blocking
what is the sixth step on the MSE and what to look for
Perception (observed and inquired)
- critical for determining severe mental health illness
Hallucinations (false perception involving all of the senses)
- sensory involvement (auditory, visual, tactile)
- Content of auditory hallucinations (command hallucination)
- how real is the hallucination
- level of associated distress
Illusion (misperception of reality) seeing insects on a patterned wall
Dissociations (feeling that the world around is not real)
- depersonalization
- derealization
what is the seventh step in the MSE and what to look for
Cognition (inquired)
- person’s current capacity to process information
- orientation to reality
- level of consciousness
- memory functioning
- knowledge or intelligence
- language
- abstraction
- attention and concentration
- visual or spatial processing
- insight (patients acknowledgement and understanding of problems, evaluated by exploring questions)
- judgement (patients general problem solving ability, evaluated by exploring recent decision making)
what is the last step in the MSE and what to look for
Ideas of harming self or others
- target of ideation
- frequency of ideation
- intent
- Ask patient if they have a plan (specificity, lethality of means, menas to carry out the plan, opportunity to carry out the plan)
What are the EPS
extrapyramidal symptoms
- they are the adverse effects of medication
- pseudoparkinsonism: stiffening of the muscles, impaired gait, reduced movements, tremors)
- dystonia: contraction of muscles, mostly in the head and neck)
- akathisia: being restless, pacing and fidgeting)
- tardive dyskinesia: involuntary tonic muscular contractions
what are the goals pertaining to mental health
- maintain safety
- restrain self mutilation
- improve thought process or perceptual disturbances
- control treatment related behaviour
- manage stress level
- reach mood equilibrium
what are the basic levels of interventions
- coordination of care
- health teaching and promotion
- milieu therapy (activities meeting patients needs)
- pharmacological, biological therapies (herbal remedies)
what are advanced level interventions
- psychotherapy
- consultation to other disciplines
what should always come after interventions
EVALUATION
- ongoing, specific
- seeing if goals were attained or if they need to be modified
- were the interventions successful?
