Mental illness
11. Mental status examination
A mental status examination is used to assess the patient’s psychological func- tion and dysfunction that might have led the patient to ask for help. The mental status examination focuses on the patient’s cognitive functions such as judg- ment, reasoning, problem solving, thought pattern, and other factors that can provide insight into the patient’s mental function.
Here are questions to ask when conducting the mental status examination.
Figure 1-1 illustrates where the examination results are documented in an elec- tronic medical record (EMAR).
Appearance
• Is the patient appropriately groomed and dressed?
• Abnormal: Disheveled, inappropriately applied cosmetics
• Does the patient dress appropriately for their age?
• Abnormal: Dresses older or younger for their age
• Does the patient maintain proper hygiene?
• Abnormal: Odor, poorly maintained teeth, nails, and hair
• Does the patient hold an erect posture?
• Abnormal: Slouch, stiff posture, head lowered
• Is the patient’s weight appropriate to his height, and does the patient have good nutritional status?
• Abnormal: Overweight, underweight
• Does the patient have a normal gait?
• Abnormal: Slow, fast, unsteady gait
• Does the patient appear alert and have normal facial expressions?
• Abnormal: Sleepy, flat expression
• Does the patient make and maintain proper eye contact?
• Abnormal: Poor eye contact, blank stare, stares at you, breaks eye con- tact, looks at the floor or around the room
• Is the patient’s affect congruent with what the patient is saying?
• Abnormal: Sadness, overly happy
F i g U r e 1-1 • After examining the patient, results of the mental status examination are recorded by checking appropriate boxes in an electronic medical record.
Volume Behavior:
Attitude
Mood/Affect Behavior Thinking (Process) Thinking
Judgment - Insight Speech
Eye Contact
Fluency of Speech
Normal Cooperative
Calm Appropriate
Controlled
Aggressive/Combative Behavior
No Disturbance Noted No Disturbance Noted Ashamed Delusional Grandiose Guilty
Hallucination (Audio) Hallucination (Gustatory) Hallucination (Olfactory) Hallucination (Tactile) Hallucination (Visual) Homicidal Ideation Idea of Reference Magical Thinking Obsessions Paranoia Persecutory Delusion Phobias Poverty of Speech Suicide Ideation Other Concrete Thinking
Circumstantial Tangential Loose Association Flight of Ideas Perseveration Echolalia Clang Association Blocking Word Salad Derailment Logical Other
Intact Impaired Denies Problems
Understand Reason for Admission Recognizes Illness
Other Guarded
Preoccupied Impulsive Disorganized Refused Meal(s) Refused ADL(s) Refused Medication(s) Evasive
Hostile Sexual Hyperactive
Psychomotor Retardation Facial Movements (jaw/lip smacking) Distant
Aloof Verbally Abusive Suspicious Restless Fearful Intrusive Other Pleasant
Bright Constricted Evasive Guarded
Congruent with Mood Happy
Sad Angry Labile Elated Euphoric Neutral Worried Guilty
Mixed (anxious and depressed) Incongruent (sad and smiling) Inappropriate
Depressed Anxious Fearful Irritable Flat Withdrawn Other Med Compliant
Warm Friendly Brighter Hopeful Thankful Apathetic Hopeless Helpless Uncooperative Worried Other Normal
Slow Rapid Pressured Other
Good
No Disturbance Noted Mute
Hesitancy Late Other Fair Poor Loud Soft
36
• Abnormal: Hostile, uncooperative, indifferent, distant, tense, overly responsive, nonresponsive
• Are mannerisms appropriate?
• Abnormal: Restlessness, nail biting, appears to be listening to someone who is not there or seeing things that are not there
• Is the patient’s speech appropriate?
• Abnormal: Fast or slow pace, illogical responses, overproductive (uses too many words), underproductive (uses too few words), loud or soft, defects in speech, delays responding to questions, or flight of ideas
Affect and mood
• Does the patient experience a full range of emotions?
• Abnormal: Depressed, manic, no emotion, mood swings, or patient is unable to discuss their emotions
• Is the patient’s affect congruent with their mood?
• Abnormal: Neutral, flat, depressed, hypomanic, manic, labile (rapid change in range of emotions), or mood is inconsistent with body lan- guage
• Is the patient calm and in control?
• Abnormal: Overly excited, depressed, trembling, angry, provoking, sweating, or crying
Orientation
• What is your name? Where are you? What is today’s date?
• Abnormal: Unable to respond with the correct answers
memory
• Ask the patient to repeat the words apple, house, and umbrella immedi- ately to test immediate recall.
• Abnormal: Patient is unable to repeat all the words.
• Continue with the assessment. After 5 minutes, ask the patient to recall the three words to test delayed recall.
• Abnormal: Patient is unable to repeat all the words.
• Ask the patient about something that happened to them in the past day to test the patient’s recent memory.
• Abnormal: Patient is unable to recall the event
• Ask the patient about the neighborhood where they grew up to test the patient’s remote memory.
• Abnormal: Patient is unable to recall the neighborhood.
• Ask the patient to count backward from 100 by subtracting 7 to test the patient’s attention status. Stop after five or six iterations.
• Abnormal: Patient is unable to perform the subtraction.
• Ask the patient to read and explain a news story to test the patient’s com- prehension ability.
• Abnormal: Patient is unable to explain the news story.
• Ask the patient what is meant by the expression “no man is an island” to assess the patient’s ability to think abstractly.
• Abnormal: Patient is unable to explain the expression or explains the expression in concrete terms.
Judgment, Perception, and Insight
Explore the patient’s ability to make rational judgments and have an appropri- ate sense of reality. Also assess the patient’s insight into the patient’s clinical problem.
• Ask the patient what they would do if they were unable to keep an out- patient appointment.
• Abnormal: Any response that implies the patient would not reschedule the appointment
• Ask the patient to explain the role of the practitioner.
• Abnormal: Any response that implies the patient does not perceive that the practitioner is there to help the patient
• Ask the patient to indicate what might be causing their symptoms.
• Abnormal: The patient’s response shows no insight into their disorder.
Thought, Delusions, and sensory Perception
Thought processing explores how the patient thinks, what the patient says, and whether what the patient says is based on reality. The patient should be focused on answering the nurse’s questions and not be easily distracted or seem to be responding to internal stimuli.
Abnormal thought processing occurs when the patient experiences one of the following:
• Circumstantial Thinking: The conversation drifts off the point of discus- sion and then eventually returns and addresses the point.
• Flight of Ideas: The conversation changes quickly to a series of unrelated topics.
• Loose Associations: The conversation moves to a different but related topic.
• Tangential Thinking: The patient’s response is without reference to the question.
• Thought Blocking: The patient’s speech is interrupted before the patient completes the thought.
• Preservation: The patient uses few words to respond to questions
• Word Salad: The patient responds using real words when sentences are incoherent.
• Thought Broadcasting: The patient believes their thoughts are being trans- mitted into the environment.
• Thought Insertion: The patient believes someone is inserting thoughts into their mind.
• Magical Thinking: The patient has an irrational belief that a supernatural occurrence such as placing a spell on a person will cause the person to experience an adverse event.
• Ideas of Reference: The patient believes that an event has occurred, although the patient has no involvement in the event such as the patient feels they are the cause of an airplane crash.
• Depersonalization: The patient loses all sense of identity and expresses feeling that are different from the patient’s normal feelings. For example, the patient may feel as if they are outside their body.
• Delusion: The patient has false belief even when presented with evidence to the contrary.
• Phobias: The patient has an irrational fear of a situation such as fear that an elevator will fall when the patient rides an elevator.
• Obsession: The patient is unable to stop thinking about an idea such as becoming a billionaire.
• Sensory Perception: The patient experiences misperceptions referred to as an illusion or hallucination. An illusion is caused by the presence of an external stimulus such as reflection of the sun on the desert giving the illusion of water.
A hallucination occurs in the absence of an external stimulus such as hearing voices when no one is speaking (auditory); seeing things that are not there (visual); touching things that are not there (tactile); tasting things that are not present (gustatory); and smelling things that are not there (olfactory).
Cognitive Ability
Cognitive ability is the patient’s capacity to remember, understand, reason, and solve a problem. Be aware of factors that may influence the patient’s response.
For example, a patient who has been an inpatient for several days may not recall the month and date because the patient is disoriented related to disruption in their normal schedule. Likewise, the patient’s culture and primary language may provide misleading results. A patient whose primary language is other than English may have difficulty responding to questions. The patient may not have completed formal education.
Level of Consciousness
• Ask the patient their name, where they are, and the date and month.
• Abnormal: Confused, slow to respond, or sedated.
memory
• Immediate memory is assessed by telling the patient a series of numbers.
Wait 10 seconds and ask the patient to repeat those numbers forward and backward.
• Abnormal: The patient is unable to repeat the series of numbers for- ward and backward.
• Recent memory is assessed by asking the patient about an event that the patient was involved in yesterday. Be sure that you can verify the event.
• Abnormal: The patient is unable to recall any portion of the event.
or about schools they attended.
• Abnormal: The patient is unable to recall those events.
Concentration
• Ask the patient to start with 100 and continue to subtract 7 from the remainder for five iterations.
• Ask the patient to say the months of the year backward.
• Abnormal: The patient is unable to answer these questions within a reasonable time period.
Abstract Thinking
• Ask the patient to interpret the meaning of common proverbs such as:
• A stitch in time saves nine.
• A bird in the hand is worth two in the bush.
• Ask the patient to identify similarities between
• A bicycle and bus.
• An orange and apple.
• Abnormal: The patient is unable to interpret proverbs or compare similari- ties between pairs of objects.
Judgment
• Ask the patient questions whose answers give you insight into the ability to make rational judgment.
• Abnormal: The patient describes situations that demonstrated poor judgment by the patient such as blaming others for their poor behavior
Psychosocial Assessment
The psychosocial assessment collects objective data about the patient’s responsibilities, education, employment, family, spirituality, resources, and culture. Each element of the psychosocial assessment can introduce stressors into the patient’s life that could be an underlying cause of the patient’s men- tal status.
Summarize the data and ask the patient to verify that the information you recorded is accurate based on the patient’s knowledge. Remember that the information is based on the patient’s ability and willingness to share the infor- mation with you. The patient may not be a good historian. The information you collected may not be accurate. You must be aware of the patient’s cultural and cultural healthcare practices because the patient’s culture may influence the patient’s responses.
Validate the information provided by the patient with a secondary source after the patient gives you written consent. Secondary sources are family, friends, social services agencies, and healthcare providers who were treating the patient prior to admission.
Ask the patient the following:
• What is your primary language?
• How do you support yourself (e.g., employed, disability benefits, unem- ployment insurance, state subsidy)?
• Where do you live (e.g., house, apartment, homeless)?
• Who do you live with (e.g., significant other, alone)?
• Tell me about your family
• Do you have children? If so, then ask for detailed information about each child
• What is a typical day like for you?
• Do you practice or belong to any religion or spiritual group?
• What role does religion or spirituality play in your life?
• Describe your cultural background
• What do you do when you are upset?
• What relieves your stress?
Also assess the patient for the following:
• Does the patient have a positive attitude?
• Is the patient able to meet basic needs?
• Can the patient live independently?
• Is the patient able to make rational decisions?
• Does the patient have insight into their illness?
• Does the patient want to participate in treatment?
• Does the patient have a support system of family and friends?
medication and medical Assessment
The medication assessment collects objective data about the patient’s medica- tion. The assessment must explore the patient’s use of prescribed, over-the- counter, and herbal/supplement medications and street drugs. Keep in mind that the patient may not be a good historian, and therefore the psychiatric nurse should verify all reported medication with the patient’s prescriber and pharmacy, if possible. Always ask the patient or the patient’s family to bring the patient’s medication to the facility to enable you to properly identify medica- tion prescribed to the patient.
The medical assessment collects information about the patient’s general health. These include allergies, diet, acute or chronic medical conditions, preg- nancy, and recent laboratory and medical test results. Enter the results into the patient’s EMAR (Figure 1-2).
Here are questions to answer:
• What is the name of the medication?
• What is the dosage?
• How do you take the medication (route)?
• How frequently do you take the medication?
• What are the prescriber’s name and contact information?
• How long have you been taking the medication?
• Why was the medication prescribed?
• Has the patient experienced side effects?
• Has the patient experienced good results taking the medication?
• Is the patient compliant taking the medication? If not, why?
F i g U r e 1-2 • it is important that all medications taken by the patient are documented in the eMAr.
Home Meds Dose Route Frequency
SEROQUEL NEURONTIN BACLOFEN LISINOPRIL VENLAFAXINE NALTREXONE CARISOPRODOL
300 MG 300 MG 10 MG 10 MG 75 MG 50 MG 350 MG
BY MOUTH
3 × DAY 3 × DAY DAILY 3 × DAY DAILY 2 × DAY BY MOUTH
BY MOUTH BY MOUTH BY MOUTH BY MOUTH BY MOUTH
BED TIME
If the patient uses street drugs, then ask:
• What street drugs do you use?
• How much do you use?
• How frequently do you use?
• What is your behavior when you are under the influence of street drugs?
• When was the drug last used? Be alert that the patient may experience withdrawal symptoms if the patient uses street drugs regularly but has not used in the past several hours. Withdrawal symptoms can be severe and lead to seizures and delirium, depending on the drug.
• Have you ever experienced an overdose? If so, was it intentional or accidental?
• Have you ever attended a drug rehabilitation program? If so, ask for details.