mental exam

NUR 4445 Mental Health Nursing Mental Status Examination Form Guidelines

Name: Date: Objectives

1. Enhance student’s observation and assessment skills. 2. Increase student’s awareness of physical, cognitive, psychosocial changes related to

mental illness. 3. Facilitate student’s knowledge of risk factors related to mental illness, treatment and

rehabilitation. 4. Perform mental status examination on patients with mental illness.

Instructions:

1. Select a patient from assigned unit. 2. Obtain approval from the primary RN and clinical instructor for appropriateness of

patient. 3. Complete and submit the Mental Status Examination form as scheduled by your clinical

instructor. 4. Review the Mental Status Examination (MSE) grading rubric. 5. Upload completed assignment to BrightSpace.

NUR 4445 Mental Health Nursing Mental Status Examination Form

Name: Kelli Spurlock Date: 3/23/20 Patient Name:

F.R.

Admission Date:

3/4/2020

Patient Age and Unit Admitted to:

57 years old / 16th floor B.H.

Patient’s Reason for Admission/ Chief Complaint: Patient presented in ED for psych eval due to showing aggressive behavior and voicing suicidal ideations while pacing in hallway at nursing home. Chart states that patient was A/O x 4 with irritable mood and affect, labile. Patient had steady gait and motor behaviors.

Co-morbid Conditions: Paranoid schizophrenia, hypertension, diabetes

Mental Status Examination

What You See (list) Descriptive example (narrative)

1. Appearance (observed)

• Grooming/Clothing • Hygiene • Posture • Gait • Obese/average or normal/

underweight

• Patient wearing jeans, black t- shirt, and hospital socks.

• Patient’s skin appeared clean and hair was uncombed. Patient had no foul odor present.

• Patient’s posture was erect in the chair and walked without

The patient was a 57-year-old Hispanic male with short, dark hair that was uncombed. His hygiene appeared good, with the exception of his hair, he had no foul odors and his clothes appeared to be clean. He was wearing dark denim jeans, a black t- shirt, and hospital issued socks. He looked his age, with a few wrinkles around his eyes and mouth. There was no evidence of tattoos, scars, bruises, or any other marks on the skin that was visible.

• Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

any additional support. Gait was steady and smooth.

• Patient appeared to be overweight.

• No scars/abrasions/bruises/ tattoos

While in group therapy, the patient was sitting in a chair without any assistance. He appeared to be relaxed and calm and he participated in the group music therapy. When he left therapy his gait was smooth and steady with no evidence of shuffling or needing assistance in ambulation.

2. Behavior (observed)

• Mannerisms • Gestures • Eye contact • Psychomotor activity (ex.

retardation or agitation) • Movements: tremor/ tics/

abnormal movements • Possible descriptors: agitated,

restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia

• Patient cooperative while participating in group.

• No evidence of tremors/tics/abnormal movements

• Patient maintained good eye contact with group therapist

• There was no psychomotor retardation observed

• Patient able to follow command

• Pt appears to be a good historian as evidenced by relevant and reliable

Initial interaction with patient was during group music therapy. Patient was goal directed in his communication with therapist. He stated that coping mechanism he uses to calm down is walking and breathing. Patient maintained appropriate eye contact with therapist while talking. Patient was cooperative with listening to other patients and waiting his turn to request a song. Patient did not exhibit any psychomotor retardation or agitation.

3. Attitude (observed)

• Ability to follow commands • Ability to provide reliable

information. • Possible descriptors:

cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian

information provided during his admission.

The patient was able to listen and obey the therapist in waiting his turn to request a song in group music therapy. He was able to verbalize how he copes with stressors. He stated that he walks and breaths if he is getting upset.

4. Cognition (observed/inquired)

• Level of Consciousness • Orientation • Attention • Memory (immediate, recent,

remote) • Abstract vs. concrete

cognition

• Patient was alert and oriented x 4.

• Patient attention was focused during group therapy

• Unable to assess memory and abstract v. concrete cognition

The patient was aware of his surroundings and participated in group therapy. He was compliant with participation within the group and provided goal-oriented communication. The patient’s chart supports the A/Ox4, specifically when assessment was noted upon admission to ED.

I was unable to assess the patient’s memory (although it can be inferred that he had recent memory as he was requesting his favorite song). I was also unable to assess the patient’s abstract vs. concrete cognition due to limited patient interaction.

5. Speech and Language (observed)

• Content of speech • Rate • Volume • Tone and Rhythm

• Patient’s content of speech was free from hallucinations, suicidal ideations, homicidal ideations, and delusions.

• Patient was talkative and participated in group in an even rate.

• Patient spoke at medium volume.

• Patient spoke with even tone and rhythm

The conversation I observed with the patient was free from any content of hallucinations, suicidal or homicidal ideations, and delusions. The patient was on task and on subject with what the therapist was asking. The patient was talkative and cooperative in group as evidenced by stating how he copes in situations and by requesting his favorite songs. He was speaking at a medium tone, I was able to hear him from across the room but he was not yelling. He spoke evenly in tone and rhythm.

6. Mood and Affect (inquired/observed)

Mood

• How the patient describes what they are feeling

• Possible descriptors include: o Labile, sad, angry,

hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable

Affect

• How the client outwardly is expressing emotion

MOOD:

• Observed patient in positive mood. He was compliant in participation and had a pleasant demeanor.

AFFECT:

• Patient affect was appropriate to the situation his thoughts and affect was consistent and congruent with his mood and affect.

While observing group therapy, the patient stated that they were doing “good” and was in a positive mood. The patient had a pleasant demeanor while participating in group. The patient did not present with any angry, hostile, or anxious affect.

The patient’s chart described the patient’s mood and affect as irritable and labile upon admission, but my observation of the patient was that he had positive mood and affect during group therapy. During group therapy, the patient’s affect was congruent with mood and thought and was appropriate to the situation. He stated that he was doing “good” while he presented with a pleasant affect and when he stated which song he wanted to hear he also appeared to be in a calm mood.

• Appropriateness to situation • Congruency with mood • Congruency with thought • Other descriptors include:

o Broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate

• Patient displayed a normal intensity within his communication and had appropriate affect.

7. Thought Disturbance (inquired/observed)

Process

• Describes the rate of thoughts, how they flow and are connected

o Possible descriptors: Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking, perseveration, neologisms.

Content and/or perceptual disturbances:

• Patient’s thoughts were goal- oriented and linear and there was no presence of neologisms or loose associations.

• Patient did not exhibit thought blocking and provided direct and appropriate answers to questions and conversation.

• Patient presented to the ED with voiced suicidal ideations and thought disturbances. He also presented with delusions and command auditory hallucinations. However, pt did not display any signs of responding to internal stimuli.

While watching the patient during group therapy, his conversations with others and conversation with the therapist were goal-directed. He directly answered questions that were asked by the therapist such was “ What do you do to cope with stress” and the patient answered that he “walks and takes deep breaths”. I did not observe the patient use any neologisms or loose associations. The patient was free of delusion and preoccupations throughout his conversations. However, when the patient presented to the ED, according to his chart he was pacing in the hallway and reported hearing voices to “kill myself”, reported having suicidal ideations, and delusions that he was being followed by the “government”.

• Refers to the themes that occupy the patient’s thoughts and perceptual disturbances

o Possible descriptors: preoccupations, illusions, ideas of reference, hallucinations, derealization, depersonalization, delusions, obsessions, suicidal/homicidal ideation, rumination

8. Judgment and Insight (Inquired/Observed):

Judgment

• Good, fair, or poor • Impulse control

Insight

• Good, fair, partial, poor

Adaptive Coping Strategies vs Defense Mechanisms

Possible defense mechanisms:

• Not able to assess judgment or insight.

• Patient uses walking and deep breathing as coping strategies, I was not able to observe any defense mechanisms

I was not able to assess the patient’s judgment or insight during the group therapy session however I was able to learn about his coping strategies. He stated that he uses walking and deep breathing to cope with situations that may make him angry or stressed out. I was unable to observe the patient using defense mechanisms.

In the patient’s chart, the ED stated that he had poor insight and poor judgment and stated that he said he did not want to live in the nursing home and was able to live with his sister “whenever he wanted” which displays the lack of insight to his living situation.

Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression

9. Safety of Self/ Others

Risk of Self/Suicidal/Self- Injury

• Fully assessed-no indicators of risk

• If yes then o Suicidal ideation

(current, past) o Suicide attempts

(hx of) o Plans to attempt

(current, past) o Access to means o Family history

• Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present?

• Unintentional (when delusions, demented,

• Patient was on SP but has not displayed any self-harm behavior.

• Pt has not displayed any

aggressive behavior towards staff or peers for current hospitalization.

• There were incidents of

property destruction for the current inpatient hospitalization.

Per the patient’s chart, he was admitted for suicidal ideation and paranoid delusions. He is currently denying suicidal and homicidal ideation and denied any thoughts of self-injury. The patient is on SP but has not been ordered to be on 1:1 observation. The patient has not destroyed any property and has been cooperative and appropriate with staff and peers.

intoxicated, in manic stages) present?

Harm to Others/Aggression

• Fully assessed- no indication of risk identified

• If yes then o Plan (current,

past) to assault

Property Destruction

• Fully assessed- no indication of risk identified

• If yes then o Current admission o Hx of