mental assessment status

8/6/2019 Mental Assessment Status

1/14

MENTAL STATUS ASSESSMENT

AREA OFASSESSMENT

TYPE OFASSESSMENT

NORMAL PARAMETERS ALTERATIONS FROMNORMAL

IMPLICA

A. General Appearance y Observations aboutdress, hygiene,posture, gait andappearance

y Appearance versusstated age

y Clean

y Nails trimmed

y Tidy /neatly dressed

y hair is combed

y Dress/ clothing intact

y

appropriate for age, weather andsituation

y Teeth/dentures in good repair

y No unusual odors

y No obvious marks or scars

y Appears as stated age

y Disheveled (withmessed-up hair orclothes)

y unkempt

y Untidy

y Dirty

y Foul smelling/ unusualodor (urine, alcohol)

y Inappropriate clothing(explain)

y Displays either unusualapathy or concern aboutappearance

y Malnourished

appearance (emaciated)y Flushed or pallid skin

color

y Excessive sweating

y Injury or scarring

y Dilated or constrictedpupils

y Dental carries or parotid

swellingy Erosion of nasal or oral

mucosa

y Rope marks on neck

y Older appearance thanstated age

y Drooling of saliva

y Disinterest in may reflect delow self-estee

y Poor hygiene disheveled apmay also refleinability to caror herself

y Worn clothingfinancial prob

y Bright colors odress are assmania

y Malnourished

may indicate edisorder

y Flushed or paare seen with

y Excessive swseen with anx

y Injury or scarrinjury or past

attempts or sey Dilated or con

pupils are seeabuse

y Dental carriesswelling are seating disorde

y Erosion of nasmucosa mayb


2/14

to drug use

y Rope marks o

in children witgame or patiehistory of hanthemselves

y Older appearastated age maassociated wi

y Wearing of loneven during wmay indicate d

y Drooling of saindicate side eantipsychotic

Posture y Erect/upright

y Symmetrical extremities

y Comfortably positioned

y Slumped

y Stooped

y Defensive

y with hips and knees

somewhat flexed and armsbent at the elbows

y Lordotic

y Scoliotic

y Kyphosis (+)

y slumped positindicate fatigudepression

y stooped postu

associated wiy Defensive is a

with paranoia

y

Gait y steady

y movement is smooth andcoordinated

y spastic movements

y shuffling

y unsteady

y foot draggingy limping

y with wide base of supportand short stride length

y uses an assistive device(crutches)

y Gait problemsa musculoskeneurological p

y Spastic moveunsteady gaitsin patients witpalsy or multip

y Wide base of short stride lehave a balanccerebellar pro


3/14

Eye contact y Maintains eye contact y Can not maintain/poor eyecontact

y preoccupied

y inability to macontact may in

self esteem y pre-occupatio

indicate signshallucination

Facial expression y calm

y appropriate to words expressed

y happy

y sad

y angry

y facial grimace

B. Behavior /Activity Observations about

patients actions andreactions to healthpersonnels

y Cooperative

y

Calmy Attentive

y Alert

y Awake

y Relaxed

y No unusual movement orbehaviors

y Warm

y

Friendly

y uncooperative

y

hostiley aloof

y restless

y agitated

y irritable

y aggressive

y guarded

y lethargic

y

tremorsy generalized weakness

y repeated movements

y unusual tics or tremors

y paranoid/suspicious

y automatism : repeatedpurposeless behaviors suchas drumming of fingers,twisting locks of hair, ortapping the foot

y psychomotor retardation:overall slowed movements

y waxy flexibility: maintenanceof posture or position overtime even when it isawkward or uncomfortable

y repeated picking at clothes

y uncooperative

associated wiy hostile/aloof a

psychosis

y guarded/aggreseen with psy

y unusual tics oabnormal musmovement maside effects ofantipsychotic drug or alcoho

y agitation maydementia or d

y automatism isanxiety

y restlessness, associated wi

y irritability is asanxiety

y suspiciousnesassociated wi

y generalized wtremors are seanxiety

y repeated mov


4/14

y increased reflexes

y hyperactivity

y rigidy catatonic

y jaw/lip smacking

y combative

y apathetic: not taking anyinterest on anything or notbothering to do anything

y distant

y

hopelessy Echopraxia: repetition or

imitation of observedmovements

y Pica :persistent ingestion ofnonnutritive substances suchas paint, hair, cloth, leaves,sand, clay or soil.

associated widisorders

y

psychomotorretardation/hyassociated widepression, cstates or drugstupor

y excessive bodmovements awith mania, an

stimulant abuy repeated pick

maybe associhallucinationstoxic condition

y increased reflassociated wi

y hyperactivity i

with anxiety, mstimulant abu

y rigidity may beNMS

y akathisia (resmay be seen extrapyramidaeffect from an

medicationsy catatonia ma

with schizoph

y unusual moveas jaw/lip smaassociated widyskinesia, aneffect of antipmedications


5/14

y suspicious/coseen with par

y apathetic are depression

y warm/friendlyseen with perdisorders

y hopeless are depression

C. Speech Observations ofpatients speechquantity and quality

y Humor

y Soft

y Appropriate

y Modulated voice/ tone audible

y Clear

y Fluent

y Frightened

y Hesitant

y Slurred

y Loud

y Superior

y Very soft/ not audible

y Garbled

y Mumbling

y Hesitant

y Mute

y Latency of response

y Poverty of speech

y The patients and sentenceoffer clues to educational le

y Changes in vomay indicate nproblem.

y Slurred speec

indicate drug abuse

y Mumbling areHuntingtons c

y Poor fluency (mute/hesitatioresponse)lesswith depressio

y Hesitation is smistrust or pa

y Commonly seterm patients hospital

Style and vocabularycovey

y Formal

y Humor

y

Appropriate

y Arrogance

y Coyness: shy /reserved

y

Fear

y suspiciousnesassociated wi

y

choice of word


6/14

y No exaggeration y Secrecy

y Superiority

y Suspiciousnessy exaggerated

socio-econom

Stream of Talk y Spontaneous

y Normal pace

y Pleasant tone

y Deliberate: carefully thoughtout and done intentionally

y Pressured

y Slow

y Fast

y Stuttering

y

Lisping: speech difficulty inwhich the sounds s and zare pronounced as th

y Thought blocking: stoppingabruptly in the middle of asentence or train of thought;sometimes unable tocontinue the idea

y Pressured speinappropriate and illogical ospeech may bof psychiatric

y Pressured, hu

may also be spatients withhyperthyroidis

y Pressured speseen in mania

y Slow speech is associated depression

Organization of Talk y Relevant

y Appropriate response

y Irrelevant

y Disorganized

y Circumstantiality: patientgives much unnecessarydetail that delays meeting agoal or point

y Clang Association: use ofrhyming words

y Echolalia: parrot like

repetition of another personsphrases or words

y Flight of Ideas: overproductivity of talkcharacterized by verbalskipping from one idea toanother composed offragmented and unrelated

y may be indicapsychiatric dis

y Disorganized seen with sch

y Loose Associassociated wischizophrenia

y Flight of Ideasassociated wi

y Perseverationassociated widamage and pdisorders


7/14

ideas

y Incoherent: unable to

express feelings clearly orlogically

y Loose Association:disorganized thinking that

jumps from one idea toanother with little or noevident relation between thethoughts

y Neologism: invented words

that have meaning only forthe client

y Perseveration: tendency tostuck in one topic and unableto move to another idea

y Tangentiality: wandering offthe topic and never providinginformation requested

y Word salad: flow ofunconnected words thatconvey no meaning to thelistener

y Derailment: off track

y Verbigeration: meaninglessrepetition of words ofphrases

D. Mood Observation andassessment to theclients pervasive andenduring emotionalstate

y Happy

y Normal

y The nurse may ask the client torate his or her mood on a scale of1-10. If the client reports beingdepressed, the nurse might ask,On a scale of 1-10 with 1 being

y Depressed

y Euphoric

y Labile : mood swings fromdepressed to crying (rapidlychanging)

y Sad

y Anxious

y Worried

y Sad is associadepression

y Anxious is seeanxiety

y Worried /Angrwith personali

y Mixed : anxioudepressed are


8/14

least depressed and 10 being mostdepressed, where would you place

yourself right now?

y Angry

y Unpredictable

y Fearfuly Ambivalent : opposing

impulses or feelings directedtoward the same person orobject at the same time

depression

E. Affect Assessment of theoutward expressionof the clientsemotional state orfeelings

y Appropriate to the situation andfeelings verbalized

y Blunt: showing little or slowto respond facial expression

y Broad : displaying a fullrange of emotionalexpression

y Flat : showing no facialexpression

y Inappropriate affect:displaying a facialexpression that isincongruent with mood orsituation; often silly or giddy

regardless of circumstancesy Restricted : displaying one

type of expression, usuallyserious or somber

y Euphoric/Elated: happy andexcited

y Angry

y Anxious

y Fearfuly Labile

y Labile affect mmania

y Flat incongruereflect schizop

y Inappropriate associated wischizophrenia

F. Range of AffectiveExpression

y Consistent

y Appropriate to the situation andfeelings verbalized

y Labile

y Anhedonic; having nopleasure or joy in life; losingsense of pleasure fromactivities formerly enjoyed

y


9/14

G. Perception y Assesses the way a person experiences reality. Observe thepatients statements about his or her environment and the

behaviors expressed in association with those statements.

a. Hallucination y Assesses false sensory perceptions or perceptual experiences

that do not really existAuditory y Hearing voices y Associated with schizophreniaGustatory y Tasting unusual tastes not related to food eaten yOlfactory y Smelling thingsTactile y Able to feel something not really there y Seen with organic problems, drug abuse, or delir

(DTs)

Visualy

Seeing things, people, etc that do not existy

Often organic in nature

b. Delusion y Fixed false belief not based in reality y Associated with psychosisGrandeur y False belief of being great or almightyPersecutory y False belief of being persecutedReference y Clients inaccurate interpretation that general events are

personally directed to him or her, such as hearing speech onthe news and believing the message has personal meaning

ThoughtBroadcastingy

A delusional belief that others can hear or know what the clientis thinkingThought insertion y A delusional belief that others are putting ideas or thought into

the clients head- that is , the ideas are not those of the clientThought withdrawal y A delusional belief that others are taking the clients thoughts

away and the client is powerless to stop itc. Illusion y Misperception of a real external stimulus y Common with dementia, Alzheimers, and schizo

Dj Vu y Feeling of having something experienced before, although in

fact it is the first time that it has been experiencedDepersonalization y Altered perception or experience that causes temporary loss ofself or personal identity

y Seen with panic disorder

Derealization y Client senses events are not real when in fact, they areIdentification y Unconscious imitation of patterning ones mannerisms,

behavior and feelings in accordance with those of the otherperson

Jamais Vu y An irrational feeling, that what is being perceived has never y May be seen in some forms of epilepsy and some


10/14

been seen before conditions,

H. Thought Content y Assessment of what the patient is thinking

Paranoia y Assessment of suspiciousness y Seen in patients with schizophrenia

Phobias y Illogical, intense, persistent fear of a specific object or socialsituation that causes extreme distress and interferes withnormal functioning

y Seen in patient with anxiety disorders

Suicidal/homicidal 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 Associated with depression, anxiety or schizophr

Obsession y Recurrent, persistent, intrusive, and unwanted thoughts andimages or impulses that cause marked anxiety and interferewith interpersonal, social, or occupational function

y Seen in OCD

Magical thinking y Primitive form of thinking that something will make it happen yConfused y Can not make sense of his or her surroundings or figure things

out even if he is orientedy

I. Orientation y Assessment ofpatients awarenessof date, time, place

y Altered orientseen with orgor schizophre

Date y What year is it?

y What day is today?

Time y What time is it now?Place y Where are you right now?

y In what country do you live?

y What is the capital of thisprovince?

People (Examiner,etc.)

y Who is sitting in front of you?

y What is the name of the nurse?J. Memory y Assesses immediate y Intact y Confabulation: giving y Seen with org


11/14

recall of recent andremote memory

y Good fictitious accounts of pastevents, believing they are

true, in order to cover a gapin the memory

dissociative aconversion dis

y

Seen with demKorsakoffs sy

Recent (24 hrs) y To test recent memory:

y State clearly and slowly the nameof three unrelated objects. Afteryou say all three, ask the patient torepeat each. Continue until thepatient is successful. Then, later inthe assessment ask the patient to

repeat the three words again. Thepatient should be able to identifythe three words.

y Ask the patient to recall eventsduring the same day (e.g. whatwas eaten during the breakfast).Validate information with a familymember.

Past (1 week) y Ask the patient about any news orevents during the week

Remote y Recall of eventsbeyond 2 weeksbefore assessment

y Ask patient to recall maiden nameof mother, a birthday or a specialday in history. It is best to askopen ended questions rather thansimple yes or no questions

K. Neuro-vegetativeFunctioning

y Normal Sleep y Early morning awakening

y

Middle night awakeningy Hyperinsomia

y Difficulty of falling asleep

y Interrupted sleep

y May be seen

disorder

L. Elimination

Bowel

y Once a day

y Twice a day

y y


12/14

y Three times aday

y

OthersBladder

y Once a day

y Twice a day

y Three times aday

Others

y Enuresis y Enuresis mayanxiety

M. Abstract ThinkingAbility

y Assesses capacity tothink abstractly

y Intact

y Good

Ask patient to explain commonsayings such as:

y A stitch in time saves nine.

y Dont count the chickens beforethey are hatched

y You cant teach old dogs newtricks.

y People who live in glass housesshould not throw stones.

y Lacking

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

y Seen with psyorganic brain

Intellectualfunctioning

y The nurse mustconsider formaleducation of client

y Intact

y Good

y What is the similar about an appleand an orange?

y What do newspaper and the

television have in common?

y Impaired y May indicate leducation of c

N. Judgment y Ability to interpretones environmentand situationcorrectly and toadapt ones behaviorand decisionsaccordingly

y Good

y Intact

y Appropriate

To test:

y If you were walking down thestreet and saw a smoke coming

y Poor

y Impaired

y Impulsive

y Risky behavior

y poor judgmenpsychosis

y poor impulse seen with OCmania


13/14

y Judgment requires acomparison and

evaluation of factsand ideas tounderstand theirrelationships and toform appropriateconclusions.

y Attempts to measurepatients logicalability to make logical

decisions

out from a window of a home, whatwould you do?

y

What would you do if somebodysuddenly becomes ill at home?

O. Insight y Awareness of thenature ofillness/situation andaccept somepersonalresponsibility for thatsituation

y Good

y Intact

y Partial

y Poor

y Impaired

It is my wifes fault that I drinkand gets into fight.The problem is my medication.

As soon as the doctor gets themedication right, Ill be just f ine.

y impaired

y poor insight ispsychosis

P. Ability toconcentrate

y Focused

y Attentive

y Receptive

To test:

y

Spell the word BIRD backwardsy Begin with the number 100,

subtract 7, and subtract 7 again,and so on. This is called theSERIAL SEVENS.

y Repeat the days of the weekbackward.

y Perform a three-part task, such asTake a piece of paper in your right

y Distracted

y Preoccupied

y Poor

y Short attention span

y Inability to maattention is asschizophreniadepression

y Preoccupation

patients expehallucination


14/14

hand, fold it in half, put it on thefloor. (The nurse should give theinstructions one at a time.)

Q. Selfconcept y The way one viewsoneself in terms ofpersonal worth anddignity

y Good

To test

y Ask the client to describe herself orhimself and what characteristics heor she would like to change

y Poor y Poor self conccommon to depatients

R. RolesandRelationships

y Assesses how aperson function in the

community (mother,wife, son, daughter,teacher, secretary)

y Can manage roles and sustainrelationships

y Do you feel close to your family?

y Do you have or want a relationshipwith a significant other?

y Are your relationships meetingyour needs for companionship orintimacy?

y Can you meet your sexual needssatisfactorily?

y Have you been involved in anyabusive relationships?

y Can not maintain satisfyingrelationship

y Has difficulty managing herroles and functions

y Inability to sussatisfying rela

result from meproblems or cto the worsenproblems.

mental assessment status

Documents