MENTAL STATUS ASSESSMENT

AREA OF ASSESSMENT A. General Appearance

TYPE OF ASSESSMENT Observations about dress, hygiene, posture, gait and appearance Appearance versus stated age

NORMAL PARAMETERS y y y y y y y y y y Clean Nails trimmed Tidy /neatly dressed hair is combed Dress/ clothing intact appropriate for age, weather and situation Teeth/dentures in good repair No unusual odors No obvious marks or scars Appears as stated age y

y y y y y y

y y y y y y y y y y

ALTERATIONS FROM NORMAL Disheveled (with messed-up hair or clothes) unkempt Untidy Dirty Foul smelling/ unusual odor (urine, alcohol) Inappropriate clothing (explain) Displays either unusual apathy or concern about appearance Malnourished appearance (emaciated) Flushed or pallid skin color Excessive sweating Injury or scarring Dilated or constricted pupils Dental carries or parotid swelling Erosion of nasal or oral mucosa Rope marks on neck Older appearance than stated age Drooling of saliva

IMPLICATIONS y Disinterest in appearance may reflect depression or low self-esteem Poor hygiene and a disheveled appearance may also reflect patients inability to care for himself or herself Worn clothing may indicate financial problems Bright colors or unusual dress are associated with mania Malnourished appearance may indicate eating disorder Flushed or pallid skin color are seen with anxiety Excessive sweating are seen with anxiety Injury or scarring from self injury or past suicide attempts or self mutilation Dilated or constricted pupils are seen with drug abuse Dental carries or parotid swelling are seen with eating disorders Erosion of nasal or oral mucosa maybe secondary

y y

y y y

y Posture Erect/upright Symmetrical extremities Comfortably positioned Slumped Stooped Defensive with hips and knees somewhat flexed and arms bent at the elbows Lordotic Scoliotic Kyphosis (+) spastic movements shuffling unsteady foot dragging limping with wide base of support and short stride length uses an assistive device (crutches)

y y y

y y y y

y y y y

Gait

y y

steady movement is smooth and coordinated

y y y y y y y y y y

to drug use Rope marks on neck seen in children with choking game or patients with history of hanging themselves Older appearance than stated age may be associated with depression Wearing of long sleeves even during warm weather may indicate drug abuse Drooling of saliva may indicate side effects of antipsychotic medication slumped position may indicate fatigue or depression stooped posture may be associated with depression Defensive is associated with paranoia

Gait problems may suggest a musculoskeletal or neurological problem Spastic movements or unsteady gaits maybe seen in patients with cerebral palsy or multiple sclerosis Wide base of support and short stride length may have a balance or cerebellar problem

Eye contact

Maintains eye contact

y y

Can not maintain/poor eye contact preoccupied

y Facial expression calm appropriate to words expressed happy Cooperative Calm Attentive Alert Awake Relaxed No unusual movement or behaviors Warm Friendly sad angry facial grimace uncooperative hostile aloof restless agitated irritable aggressive guarded lethargic tremors generalized weakness repeated movements unusual tics or tremors paranoid/suspicious automatism : repeated purposeless behaviors such as drumming of fingers, twisting locks of hair, or tapping the foot psychomotor retardation: overall slowed movements waxy flexibility: maintenance of posture or position over time even when it is awkward or uncomfortable repeated picking at clothes

inability to maintain eye contact may indicate low self esteem or depression pre-occupation may indicate signs of hallucination

B. Behavior /Activity

Observations about patients actions and reactions to health personnels

y y y y y y y y y y y y

y y y y y y y y y y y y y y y y y y

y y y y

y y y y y y

y y

uncooperative is associated with paranoia hostile/aloof are seen with psychosis guarded/aggressive are seen with psychosis unusual tics or tremors or abnormal muscle movement may indicate side effects of antipsychotic medications, drug or alcohol withdrawal agitation maybe seen with dementia or delirium automatism is indicative of anxiety restlessness, tension is associated with anxiety irritability is associated with anxiety suspiciousness are associated with paranoia generalized weakness and tremors are seen with anxiety repeated movements are

y y y y y y y

y y y

increased reflexes hyperactivity rigid catatonic jaw/lip smacking combative apathetic: not taking any interest on anything or not bothering to do anything distant hopeless Echopraxia: repetition or imitation of observed movements Pica :persistent ingestion of nonnutritive substances such as paint, hair, cloth, leaves, sand, clay or soil.

y y

y y

y y

associated with compulsive disorders psychomotor retardation/hypoactivity are associated with depression, catatonic states or drug induced stupor excessive body movements are associated with mania, anxiety or stimulant abuse repeated picking at clothes maybe associated with hallucinations, delirium or toxic conditions increased reflexes may be associated with anxiety hyperactivity is associated with anxiety, mania, or stimulant abuse rigidity may be a sign of NMS akathisia (restlessness) may be seen with extrapyramidal adverse effect from antipsychotic medications catatonia may be seen with schizophrenia unusual movements such as jaw/lip smacking may be associated with tardive dyskinesia, an adverse effect of antipsychotic medications

y y y

suspicious/combative are seen with paranoia apathetic are seen with depression warm/friendly/distant are seen with personality disorders hopeless are seen with depression

C. Speech

Observations of patients speech quantity and quality

y y y y y y

Humor Soft Appropriate Modulated voice/ tone audible Clear Fluent

y y y y y y y y y y y y

Frightened Hesitant Slurred Loud Superior Very soft/ not audible Garbled Mumbling Hesitant Mute Latency of response Poverty of speech

y y

y y

The patients vocabulary and sentence structure offer clues to her or his educational level Changes in voice quality may indicate neurological problem. Slurred speech may indicate drug and alcohol abuse Mumbling are seen with Huntingtons chorea Poor fluency ( mute/hesitation/latency of response)less likely to talk with depression Hesitation is seen with mistrust or paranoia Commonly seen in long term patients in the hospital suspiciousness is associated with paranoia choice of words reflect

Style and vocabulary covey

y y y

Formal Humor Appropriate

y y y

Arrogance Coyness: shy /reserved Fear

y y

No exaggeration

Stream of Talk

y y y

Spontaneous Normal pace Pleasant tone

y y y y y y y y y y

Organization of Talk

y y

Relevant Appropriate response

y y y

y y

Secrecy Superiority Suspiciousness exaggerated Deliberate: carefully thought out and done intentionally Pressured Slow Fast Stuttering Lisping: speech difficulty in which the sounds s and z are pronounced as th Thought blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea Irrelevant Disorganized Circumstantiality: patient gives much unnecessary detail that delays meeting a goal or point Clang Association: use of rhyming words Echolalia: parrot like repetition of another persons phrases or words Flight of Ideas: over productivity of talk characterized by verbal skipping from one idea to another composed of fragmented and unrelated

socio-economic status

y y

y y y

y y

Pressured speech, inappropriate responses, and illogical or incoherent speech may be indicative of psychiatric disorders Pressured, hurried speech may also be seen in patients with hyperthyroidism Pressured speech are seen in mania Slow speech and soft tone is associated with depression may be indicative of psychiatric disorders Disorganized speech are seen with schizophrenia Loose Association is associated with schizophrenia Flight of Ideas are associated with mania Perseveration is associated with brain damage and psychotic disorders

y y

ideas Incoherent: unable to express feelings clearly or logically Loose Association: disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts Neologism: invented words that have meaning only for the client Perseveration: tendency to stuck in one topic and unable to move to another idea Tangentiality: wandering off the topic and never providing information requested Word salad: flow of unconnected words that convey no meaning to the listener Derailment: off track Verbigeration: meaningless repetition of words of phrases Depressed Euphoric Labile : mood swings from depressed to crying (rapidly changing) Sad Anxious Worried y y y y Sad is associated with depression Anxious is seen with anxiety Worried /Angry are seen with personality disorders Mixed : anxious and depressed are seen with

D. Mood

Observation and y assessment to the y clients pervasive and enduring emotional y state

Happy Normal The nurse may ask the client to rate his or her mood on a scale of 1-10. If the client reports being depressed, the nurse might ask, On a scale of 1-10 with 1 being

y y y

y y y

least depressed and 10 being most depressed, where would you place yourself right now?

y y y y

E. Affect

Assessment of the outward expression of the clients emotional state or feelings

Appropriate to the situation and feelings verbalized

y y

y y

y y y y y F. Range of Affective Expression y y Consistent Appropriate to the situation and feelings verbalized y y

Angry Unpredictable Fearful Ambivalent : opposing impulses or feelings directed toward the same person or object at the same time Blunt: showing little or slow to respond facial expression Broad : displaying a full range of emotional expression Flat : showing no facial expression Inappropriate affect: displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances Restricted : displaying one type of expression, usually serious or somber Euphoric/Elated: happy and excited Angry Anxious Fearful Labile Labile Anhedonic; having no pleasure or joy in life; losing sense of pleasure from activities formerly enjoyed

depression

y y y

Labile affect may indicate mania Flat incongruent affect may reflect schizophrenia Inappropriate affect is associated with schizophrenia

G. Perception

a. Hallucination Auditory Gustatory Olfactory Tactile Visual b. Delusion Grandeur Persecutory Reference

y y y y y y y y y y

Assesses the way a person experiences reality. Observe the patients statements about his or her environment and the behaviors expressed in association with those statements. Assesses false sensory perceptions or perceptual experiences that do not really exist Hearing voices Tasting unusual tastes not related to food eaten Smelling things Able to feel something not really there Seeing things, people, etc that do not exist Fixed false belief not based in reality False belief of being great or almighty False belief of being persecuted Clients inaccurate interpretation that general events are personally directed to him or her, such as hearing speech on the news and believing the message has personal meaning A delusional belief that others can hear or know what the client is thinking A delusional belief that others are putting ideas or thought into the clients head- that is , the ideas are not those of the client A delusional belief that others are taking the clients thoughts away and the client is powerless to stop it Misperception of a real external stimulus Feeling of having something experienced before, although in fact it is the first time that it has been experienced Altered perception or experience that causes temporary loss of self or personal identity Client senses events are not real when in fact, they are Unconscious imitation of patterning ones mannerisms, behavior and feelings in accordance with those of the other person An irrational feeling, that what is being perceived has never

y y y y y

Associated with schizophrenia

Seen with organic problems, drug abuse, or delirium tremens (DTs) Often organic in nature Associated with psychosis

Thought Broadcasting Thought insertion Thought withdrawal c. Illusion Dj Vu Depersonalization Derealization Identification

y y y y y y y y

Common with dementia, Alzheimers, and schizophrenia

Seen with panic disorder

Jamais Vu

May be seen in some forms of epilepsy and some psychiatric

been seen before H. Thought Content Paranoia Phobias Assessment of what the patient is thinking Assessment of suspiciousness Illogical, intense, persistent fear of a specific object or social situation that causes extreme distress and interferes with normal functioning Thoughts of harming self or others y Are you thinking about killing yourself? y Do you have a plan to kill yourself? y How do you plan to kill yourself? y How would you carry out this plan? y Do you have acces to the means to carry out the plan? y Where would you kill yourself? y When do you plan to kill yourself? y What day or time of day do you plan to kill yourself? y Recurrent, persistent, intrusive, and unwanted thoughts and images or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational function y Primitive form of thinking that something will make it happen y Can not make sense of his or her surroundings or figure things out even if he is oriented y Assessment of patients awareness of date, time, place y What year is it? y What day is today? y What time is it now? y Where are you right now? y In what country do you live? y What is the capital of this province? y Who is sitting in front of you? y What is the name of the nurse? y Assesses immediate y Intact y y y

conditions, Seen in patients with schizophrenia Seen in patient with anxiety disorders

y y

Suicidal/homicidal

Associated with depression, anxiety or schizophrenia

Obsession

Seen in OCD

Magical thinking Confused I. Orientation

y y y Altered orientation may be seen with organic disorders or schizophrenia

Date Time Place

People (Examiner, etc.) J. Memory

Confabulation: giving

Seen with organic,

recall of recent and remote memory

Good

fictitious accounts of past events, believing they are true, in order to cover a gap in the memory

dissociative and conversion disorders Seen with dementia or Korsakoffs syndrome

Recent (24 hrs)

Past (1 week) Remote y Recall of events beyond 2 weeks before assessment

K. Neuro-vegetative Functioning

To test recent memory: y State clearly and slowly the name of three unrelated objects. After you say all three, ask the patient to repeat each. Continue until the patient is successful. Then, later in the assessment ask the patient to repeat the three words again. The patient should be able to identify the three words. y Ask the patient to recall events during the same day (e.g. what was eaten during the breakfast). Validate information with a family member. y Ask the patient about any news or events during the week y Ask patient to recall maiden name of mother, a birthday or a special day in history. It is best to ask open ended questions rather than simple yes or no questions y Normal Sleep

y y y y y y

Early morning awakening Middle night awakening Hyperinsomia Difficulty of falling asleep Interrupted sleep

May be seen in bipolar disorder

L. Elimination Bowel y Once a day y Twice a day

Three times a day y Others Bladder y Once a day y Twice a day y Three times a day Others M. Abstract Thinking Ability y

Enuresis

Enuresis may indicate anxiety

Assesses capacity to think abstractly

y y

Intact Good

y y

Intellectual functioning

The nurse must consider formal education of client

Ask patient to explain common sayings such as: y A stitch in time saves nine. y Dont count the chickens before they are hatched y You cant teach old dogs new tricks. y People who live in glass houses should not throw stones. y Intact y Good y y What is the similar about an apple and an orange? What do newspaper and the television have in common? Good Intact Appropriate

Lacking Concrete thinking :Impaired/unable to abstract: thinks in concrete terms

Seen with psychosis organic brain disorders

Impaired

May indicate level of education of client.

N. Judgment

Ability to interpret ones environment and situation correctly and to adapt ones behavior and decisions accordingly

y y y

y y y y

Poor Impaired Impulsive Risky behavior

y y

To test: y If you were walking down the street and saw a smoke coming

poor judgment is seen in psychosis poor impulse control is seen with OCD, psychosis, mania

O. Insight

Judgment requires a comparison and evaluation of facts and ideas to understand their relationships and to form appropriate conclusions. Attempts to measure patients logical ability to make logical decisions Awareness of the nature of illness/situation and accept some personal responsibility for that situation

out from a window of a home, what would you do? What would you do if somebody suddenly becomes ill at home?

y y

Good Intact

y y y

Partial Poor Impaired

poor insight is seen in psychosis

P. Ability to concentrate

y y y

Focused Attentive Receptive

To test: y Spell the word BIRD backwards y Begin with the number 100, subtract 7, and subtract 7 again, and so on. This is called the SERIAL SEVENS. y Repeat the days of the week backward. y Perform a three-part task, such as Take a piece of paper in your right

It is my wifes fault that I drink and gets into fight. The problem is my medication. As soon as the doctor gets the medication right, Ill be just fine. y impaired y Distracted y Preoccupied y Poor y Short attention span

Inability to maintain attention is associated with schizophrenia and depression Preoccupation is seen with patients experiencing hallucination

Q. Self concept

The way one views oneself in terms of personal worth and dignity

hand, fold it in half, put it on the floor. (The nurse should give the instructions one at a time.) Good

Poor

R. Roles and Relationships

To test y Ask the client to describe herself or himself and what characteristics he or she would like to change Assesses how a y Can manage roles and sustain person function in the relationships community (mother, wife, son, daughter, teacher, secretary) y Do you feel close to your family? y Do you have or want a relationship with a significant other? y Are your relationships meeting your needs for companionship or intimacy? y Can you meet your sexual needs satisfactorily? y Have you been involved in any abusive relationships?

Poor self concept is common to depressed patients

y y

Can not maintain satisfying relationship Has difficulty managing her roles and functions

Inability to sustain satisfying relationships can result from mental health problems or can contribute to the worsening of some problems.