University:
West Coast University
Course:
NURS 222 | Mental Health/Psychiatric Nursing: Promoting Wellness in the Mentally Ill C
Academic year:

2022
Views:

389

Pages:

2
Author:

Mia Hobbs

MENTAL STATUS EXAM GENERAL OBSERVATION Appearance, initial impressions/patient presentation Ie. withdrawn, engaging, disheveled MOOD- pt reports Prominent, sustained emotion (the patient describes their mood in their own words) AFFECT- what we pick up. Capacity to vary emotional expression Responsive to fluctuations in thought content Ie. range, lability SPEECH Quality and quantity Pressured, rapid, fragmented THOUGHT PROCESSES Often disturbed/disrupted with mental disorders Ie. fluidity, speed, connected, words make sense COGNITIVE/INTELLECTUAL FUNCTIONINGAbility to think and know Attention and concentration – use of MMSE Abstract reasoning – proverb – “people in glass houses…..” Memory recall – immediate Short – 5” –15” to yesterday Recent – within past few months Remote - years ago JUDGEMENT Logical decision-making, course of action chosen INSIGHT Awareness of own thoughts and feelings Aware of others view of them BEHAVIOR Assessed throughout, connect behavior to assessment SELF-CONCEPT Develops over lifetime. Dynamic, variable Body image – beliefs/ attitudes about own body/appearance Self-esteem – attitude about overall self Personality identity – know who you are RISK ASSESSMENT Suicide and Violence MENTAL STATUS EXAM – GUIDE- this is how we would document APPEARANCE General –average/under or overwt Older-younger looking Neat/clean Appropriately dressed/groomed Unkempt/disheveled Poor hygiene BEHAVIOR/MOTOR ACTIVITY Normal Eye contact – poor Restless/overactive Agitate/tense circumstance Slowed/lethargic Worthless, hopeless Tremors/tics Peculiar mannerisms SPEECH Normal for age/intellect ` Childlike Rate: rapid, pressured, slowed Long pauses between answering Rhythm: monotonous, stuttering Volume: loud, soft, whispered Amount: monosyllabic, mute, hypertalkative Articulation: slurred, mumbled, dysarthric MOOD Euthymic Pessimistic Depressed Anxious Angry Irritable Euphoric AFFECT Appropriate for thought content Mood congruent Incongruent with thought content Labile, constricted, flat, blunted Dysphoric, calm, cheerful, irritable Fearful, tearful, hostile, suspicious THOUGHT PROCESS Coherent, logical, incoherent, illogical, goal-directed, circumstantial, tangential, rambling, loose association, disorganized, flight of ideas, blocking, perseveration, clang association THOUGHT CONTENT appropriate to mood depressive, cognitions guilt, obsession, rumination phobias delusions, ideas of reference, Magical thinking overvalued ideas, paranoid, suicidal, homicidal PERCEPTIONS hallucinations: command. auditory/visual/tactile/olf/gus illusions, depersonalization/ derealization ORIENTATION person, place, time INSIGHT good, fair, poor JUDGEMENT normal, impulsive, fair, poor MEMORY short term-intact/impaired long-term- intact/impaired