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Mental Status Examination Focuses on the patient’s current state in terms of thoughts, feelings and behaviors. An overall description of the client’s mental status, including general appearance, mood and affect, quality of speech, thought content and processes, level of consciousness and cognition, impulsivity, ability to abstract, judgment and insight, and reliability.
Major goals: Gather baseline data about the client’s level of functioning Identify actual and potential problems Facilitate making accurate psychiatric and medical diagnoses
General Appearance LOC Dress Facial expressions Posture Level of understanding Gait Grooming Psychomotor behavior or activity level Eye contact
Attitude toward the nurse With whom and how the client arrived
Mood and affect Mood Pervasive and sustained emotional state that depicts the client’s perception of the world Depressed Sad Labile Elated Expansive anxious
Affect Present state of emotional responsiveness and is observable with body language. Blunted Flat Restricted Depressed Expansive Angry Major point: whether thought is congruent, appropriate, or both, with the mood and affect.
Quality of Speech Speech Process of expressing ideas, thoughts, and feelings through language The use of words or language Involves physical descriptions of the client’s speech
Note: Quality and articulation Quantity and rate Other descriptions: Spontaneous Talkative Rapid Whispered Loud Stuttered Accent
Perceptual- Sensory Disturbances Hallucinations: False sensory perceptions of internal stimuli Can be visual, olfactory, auditory, or tactile Illusions Misinterpretation of external stimulus such as shadow of the person Inquire about the content and the circumstances in which they occur Consider cultural factors
Thought content and processes Thought content: what the client is thinking about Preoccupations: recurrent thoughts that center on a particular idea or thought with an intense emotional component. Obsessions: Maladaptive patterns of thoughts, images, or feelings that generate anxiety. Compulsions: maladaptive urges to act on an impulse and involve ritualistic behaviors such as excessive hand washing. Delusions: fixed false beliefs and includes persecutory, somatic, or jealous types Assess whether the client has homicidal or suicidal ideations
Thought processes: Loose associations: flow of thoughts or ideas unrelated to each other and shift from one subject to another. Flights of ideas: rapid thinking ideas that have a common theme.
Higher brain function Level of consciousness Orientation: refer to one’s sense of time, person, and place. Memory: complex form of brain function that involves storing and retrieving information that is later recalled to consciousness. Remote (long term) Recent Recent past (current events) Immediate memory (short term) Immediate recall
Concentration and attention: various conditions produce disturbances, including delirium or other medical anxiety or depressions. Cognition: ability to think and know Visuouspatial: refers to time and space Ability to read and write; consider: Cultural factors Educational preparations Previous level of functioning
Ability to abstract: testing for concrete thinking Impulsivity: ability to control or manage various urges appropriately. Judgment: ask “what if” questions Insight: involves the client’s understanding about being ill and the need for treatment when warranted. Reliability: whether the client’s perception of the present problem and its history are credible.