mental status examination in nursing

1. Asma Ali
Nursing Lecturer-ATCON

2. By the end of the session learners will be able to
 Define Mental Status Examination (MSE)
 Discuss the component of history taking
 Discuss the important components of history
taking and MSE

3. “Mental status examination is an
organized, systematic approach to
assessment of an individual’s current
psychiatric conditions”
(Boyd, 2002)

4. Mental Status Examination represents a correlation of the
patient’s psychological life and the sum total of the nurse’s
observation and the impression at the moment.
It includes observing the patient’s behavior and describing it in
an objective, non judgmental manner.
(Stuart & Laraia, 2005)

5.  Demographic data
 Chief complaint
 Previous Psychiatric history
 Medical /surgical history
 Medication history
 Family history
 Social history (education, socialization, financial status,
employment, hobbies)

6.  Substance abuse history
 Quality of support system and strengths
 Present and past coping patterns/skills
 Self concepts, self esteem
 Spiritual and cultural needs
 health beliefs and practices
 Presence and history of suicidal ideations

7.  General Description
 Emotional State
 Experiences
 Thinking
 Sensorium and Cognition

8.  General Description
 Appearance
 Speech
 Motor activity
 behavior
 Emotional State
 Mood
 Affect
 Experiences
 Perception
 Thinking
 Thought content
 Thought process
 Sensorium and Cognition
 Level of consciousness
 Memory
 Level of concentration and
calculation,
 Information and intelligence
 Insight and Judgment

9. Appearance:
 Grooming: unkempt, neat and clean, appropriate dressing
 Posture: relaxed, slumped, erect
 Facial expressions: appropriate, flat, blunted, angry
 Eye contact: maintaining eye contact, minimal eye contact, staring
 General state of health and nutrition

10. Speech
 Rate: Rapid or slow
 Volume: loud or soft
 Amount: muteness, pressured speech, paucity
 Characteristics: stuttering, slurring.

11. Some of the speech abnormalities that can be observed during an MSE
include:
 Mutism: an inability to speak that is caused by a structural or motor
dysfunction of the vocal apparatus
 Dysarthria: the impaired articulation of words resulting from motor
dysfunction of the vocal apparatus
 Echolalia: the involuntary repetition of another person's speech
 Alogia: impaired thinking that manifests with reduced speech output (e.g.,
always replying to questions with one-word answers)
 Pressured speech: accelerated thoughts that are expressed as rapid,
loud, and voluminous speech often in the absence of social stimulation

12.  Neologisms: the creation and use of new words that are only
understood by the speaker (e.g., Pepsidiction = Pepsi +
addiction, Spritependency = Sprite + dependency)
 Word salad: incoherent thinking expressed as a sequence of
words without a logical connection Example: “They’re destroying
too many cattle and oil just to make soap. If we need soap when
you can jump into a pool of water, and then when you go to buy
your gasoline, my folks always thought they should get pop but the
best thing to get is motor oil and money.”

13. Motor activity
This is concerned with the patient physical movement
 Level of activity: Lethargic, tense, restlessness, agitation
 Type of Activity: Tics, Grimaces, or tremors
 Unusual gestures or mannerisms: Compulsion

14. Behavior (Interaction during Interview)
 Calm and cooperative
 Hostile
 Irritable
 Guarded
 Apathetic
 Defensive
 Suspicious

15. Mood
The patient’s self report of prevailing emotional state and reflects the
patient’s life situation.
Refers to the patient's subjective assessment of their emotions when
asked how they feel.
Is subjective feeling of:
 Sadness
 Fearfulness
 Anxiety
 Anger
 Euphoria
 Happiness
 Guilt

16. Affect
Objective emotional tone or objective expression of emotional feelings
Refers to the physician's objective assessment of a patient's emotions
conveyed both verbally and nonverbally during an interview
 Appropriate
 Flat
 Blunted
 Smiling
 Calm
 Anxious
 Irritable

17. Perceptions
Perception involves the organization,
identification and interpretation of sensory
information to understand the world around
us. Abnormalities of perception are a feature
of several mental health conditions.

18. Hallucinations:
False sensory impression in the absence of any external stimulus
 Visual (Sight)
 Auditory (Sound)
 Tactile (Touch)
 Olfactory (smell)
 Gustatory (Taste)

19. Illusions:
False perception or false responses to a sensory stimulus.
Misperception of a real external stimulus.
Depersonalization:
The patient feels that they are no longer their ‘true’ self and are
someone different or strange.
Derealization:
A sense that the world around them is not a true reality.

20. Thought Content
Thought content refers explicitly to what an individual is thinking
about (i.e., main themes and beliefs) and is usually evaluated based
on the presence of:
 Delusion
 Obsession compulsions
 Phobia
 Suicidal and homicidal ideation

21. Delusions
Delusions are fixed, false beliefs (unrelated to one's religious beliefs or
culture) that are maintained despite being contradicted by reality or
rational arguments.
Types of delusion
 Persecutory Delusion (others are deliberately trying to wrong, harm, or
conspire against another)
 Grandiose delusion (an exaggerated sense of one’s own importance,
power, or significance)

22.  Somatic Delusion (physical sensations or medical problems, belief that
one’s body or body parts are diseased or distressed)
 Religious delusion (false belief that the person has a special link with
God)
 Paranoid delusion (The patient has an exaggerated distrust of others
and is suspicious of their motives.)
 Delusion of reference The patient believes that normal events are of
special importance to them (e.g., an individual might feel that a
television reporter is talking about them).

23. Suicidal and homicidal ideation
 Suicidal ideation: any type of thoughts that an individual has
regarding ending their own life
 Homicidal ideation: thoughts regarding ending someone else's
life
Obsessions and compulsions
 Obsession: A repetitive, persistent, intrusive, and unpleasant
thought or urge that causes severe distress and anxiety.
 Compulsion: Ritualistic, repetitive behaviors (e.g., touching,
washing) or mental act (e.g., counting, repeating a word
silently) carried out in an effort to relieve urges and
decrease obsession-related distress.
Thought Content Contd…)

24. Phobias
A specific phobia is a persistent (≥ 6 months) and intense fear of one
or more specific situations or objects (phobic stimuli).
Some common examples of phobias includes:
 Agoraphobia (fear of unknown places and situations)
 Claustrophobia (fear of enclosed places)
 Arachnophobia (fear of spiders)
 Hematophobia (fear of blood)
Can be assessed by asking the patient whether they are scared of
anything and how long this fear has affected them
Thought Content Contd…)

25. Thought process
Is how of the patient self expression, is observed through speech.

26. Thought Process Description Example
Circumstantial thought process Nonlinear thought expressed as long-
winded explanations and with multiple
deviations from the central topic before a
central idea is finally expressed
When a patient is asked where they are
from, they describe their favorite
hometown diners before answering your
question.
Tangential thought process Nonlinear thought expressed as a gradual
deviation from a focused idea or question.
The patient provides multiple, unnecessary
details related to the question without
actually answering the question.
When asked about their medical history,
the patient describes the hospitals they
have stayed in without mentioning their
medical conditions.
Loose associations/derailments Incoherent thinking expressed as illogical,
sudden, and frequent changes of topic
When asked about their job, the patient
remembers some funny stories from their
childhood and then starts talking about the
weather.
Thought process
Is how of the patient self expression, is observed through
speech.

27. Thought Process Description Example
Flight of ideas The quick succession of thoughts
usually expressed as a continuous flow
of rapid speech and abrupt changes in
topic
When asked how they are feeling, the
patient delivers a 10-minute monologue
on different topics using rapid,
intangible speech.
Clang associations The use of words based on rhyme
patterns rather than meaning
When asked “Have you ever smoked?”
the patient responds with “Never have I
ever, never never ever.”
Perseveration The inappropriate repetition or
persistence of behavior, speech, or
sounds
When asked three different questions,
the patient gives the same answer each
time.
Thought blocking The abrupt ending of a thought
process expressed as a sudden
interruption in speech
The patient stops in the middle of
describing their condition.
Thought process

28. Sensorium: The evaluation of sensorium assesses a
patient's level of consciousness and their orientation to person,
place, and time.
Cognition: It is the mental process of gaining knowledge and
understanding via thinking, experiencing, and sensing, and
includes many aspects
 Level of Consciousness
 Awake
 Confusion
 Drowsiness
 Unconsciousness
 Orientation
 Person
 Place
 time

29.  Memory
 Immediate
 Recent
 Remote
 Level of concentration and calculation
 Concentration is the patient’s ability to pay attention during the
course of interview
 Calculation is the ability to do simple math

30.  Information and Intelligence
 Abstract thinking: Abstract thinking is assessed by asking similarities
or giving proverbs to interpret
 Judgment: Assess clients problem solving abilities via giving
scenarios.
 Insight: Assess clients understanding of his illness

32.  Antai-Otong, D . (2003). Psychiatric Nursing : Biological & behavioral
concepts. Texas : Thomson Learning
 Boyd, M. A. (2002). Psychiatric nursing: Contemporary practice (2nd ed.).
Philadelphia: Lippincott.
 Moher.W,K. (2006). Psychiatric- mental health nursing. (6th ed).
Philadelphia: Lippincott.
 Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric
nursing. (8th ed.). St. Louis: Mosby.
 Varcarolis, E.M., Carson, V. B., Shoemaker, N. C. (2006). Foundation of
psychiatric mental health nursing: a clinical approach. (5th ed). Saunders