Mental Status Exam 101. A Concurrent Disorders Lunch & Learn
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1 Mental Status Exam 101 A Concurrent Disorders Lunch & Learn
2 2 HELLO! Bradley Labuguen RN BScN MHM CPMHN(c) Nurse Educator St. Joseph s Healthcare Hamilton
3 3 Objectives Time: 50 minutes Identify what is a Mental Status Exam (MSE) Identify the purpose of a MSE Identify and explore the components of a MSE *Resources to be sent out*
4 4 The MSE is a clinical assessment that: What is the Mental Status Exam (MSE)? Is structured in order to describe and observe the client s current state across multiple domains. Uses the client s subjective selfreport Uses our own observations and interpretations of the client s presentation
5 5 Appearance Judgment Speech Insight Perception Mental Status Exam Mood Affect Thought Content Thought Process Sensorium Components of a MSE
6 6 Multiple benefits to using a MSE: Why Use a MSE? Same lens & structure Establish a baseline Track changes over time & evaluate care Same language and descriptors Allows us to be more concise Guides diagnostic formulation & treatment planning
7 Concurrent Disorder (CD): individual living with both mental health and substance use problems. Concurrent Disorders & the MSE Mental illness & substance use can impact the presentation of the individual before us. With CDs, consider the interplay between mental health symptoms and substance use. Insight Perception Judgment Thought Content Appearance Mental Status Exam Thought Process Speech Mood Affect Sensorium
8 8 Therapeutic Relationship A purposeful, goal-directed relationship that is directed at advancing the best interest and outcome of the client (RNAO, 2006). Built on trust, empathy, and acceptance Impacts the level of engagement and the breadth of information we obtain. Self-reflection allows us to identify our own emotions, values, and beliefs that can impact our ability to form a therapeutic relationship.
9 the therapeutic relationship is especially crucial to the success of interventions with clients requiring [care] because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success. -Videbeck, 2009, p. 78
10 10 Appearance Judgment Speech Insight Perception Mental Status Exam Mood Affect Thought Content Thought Process Sensorium Components of a MSE
11 11 Appearance & Behaviour
12 12 Appearance: Encompasses a client`s general presentation Appearance & Behaviour Physique Grooming Age Attire Eye contact Distinguishing features Attentiveness Alertness Attitude towards interviewer & interaction
13 13 Psychomotor Behavior: observing physical movement, conduct, & coordination. Appearance & Behaviour Normal Psychomotor retardation Psychomotor agitation Gait Akathisia Posturing Stereotyped movements Negativism Echopraxia Waxy flexibility Tremors, tics, and abnormal movements
14 14 Speech
15 15 Speech: our observations of the client s speech characteristics. Speech Rate: slowed, hesitant, fast, pressured Volume: loud, soft, whispered Quality: monotone, slurred, mumbled, stuccato (monosyllabic) Quantity: talkative/verbose, subdued, taciturn/silent
16 16 Mood & Affect
17 17 Mood is: a pervasive, prevailing, and sustained emotion that describes the person s perception of the world. Mood Described by the client Influenced by internal and external changes, but is generally stable over time. Explore with client (changes, patterns, triggers). How have you been feeling over the past while? How would you describe your mood over the past week? Does your mood fluctuate throughout the day?
18 18 Affect: the client s observed emotional responsiveness during the MSE Affect Inferred by the clinician Over-arching: Euthymic (normal), euphoric (elated), dysphoric (saddened) Range: full, heightened, constricted, blunted, flat Appropriateness: relative to the client s situation consider cultural and social norms Stability: consistent, labile Congruence: alignment between reported mood and affect I ve been feeling great never better!
19 19 Sensorium
20 20 Sensorium: examines cognitive abilities and brain functioning. Sensorium Level of Consciousness: alert, awake, lethargic, stuporous, comatose Orientation: to person, place, time Memory: immediate, recent, short-term, longterm Attention & Concentration: sufficient, easily distractible, short attention, preoccupied various tasks
21 21 Thought Process & Thought Content
22 22 Thought Process & Thought Content Thought Process: Assessing the manner in which the client delivers their message Thought Content: Assessing the message/ what is actually being said by the client.
23 23 Thought Process: Assessing the manner in which the client delivers their message Thought Process Logical Circumstantial Tangential Loose Associations Flight of ideas Neologisms Thought blocking Word Salad Perseveration Clang Association Echolalia Verbigeration How s your mood today? II?
24 24 Thought Content (1/3) Thought Content: Assessing the message/ what is actually being said by the client Delusions: fixed false beliefs based on incorrect inferences about reality: Delusions of control Thought insertion Thought broadcasting Ideas of reference Paranoid delusions Bizarre delusions Somatic delusions Delusions of grandeur Religious delusions Depersonalization Magical thinking Erotomania Nihilism What is the impact on the client?
25 25 Thought Content (2/3) Homocidal Ideation (HI): thoughts about inflicting harm to others. Facets to assess: History, plan, intent, immediacy, access, feasibility, lethality, thought frequency Static Dynamic Risk Factors Historical aggression Criminal conduct Cognitive deficits Personality disorders History of weapon use Insight Mental health symptoms Substance use Medication non-adherence Lack of participation in programs
26 26 Suicidal Ideation (SI): thoughts about deliberate self-inflicted death or self-harm. Thought Content (3/3) Static Dynamic Be direct and clear when inquiring about suicide Facets to assess: History, plan, intent, lethality, preparation, access, feasibility, thought frequency Risk Factors Age Male Aboriginal & LGBTQ community Family history of suicide Single (eg. widowed) Hopelessness Mental illness (eg. depression, schizophrenia) Current substance use Psychosocial stress (eg. job loss) Protective Factors Intact social supports Marriage & presence of children Engagement in a religious affiliation Relationship with caregivers Management of mental and substance use Postive self-regard/esteem Life satisfaction
27 27 Perception
28 28 Perception (1/2) Perception: Involves taking in information from the environment through our five senses and processing such information into mental representations. Illusions: misperception of real external sensory stimuli Hallucinations: false sensory perceptions not associated with external stimuli/not shared by others What is the impact on the client? Has there been an instance where you ve heard another person s voice even thought you were alone? Auditory Hallucinations Trends & Triggers Impact (eg. Daily function) Coping mechanisms Presence of commands intent to follow Have you been hearing voices that perhaps others may not hear?
29 29 Insight & Judgment
30 30 Insight & Judgment Insight: understanding and self-awareness of the client s circumstances. Judgment: the ability to make logical decisions upon examining and analyzing a situation.
31 31 Applications Tigger (0:19-0:53): ook Eeyore (0:00-1:22): GY Silver Linings Playbook clip: Z6I Assess your colleagues, friends, and family
32 32 Take Home Messages A MSE is structured in order to describe and observe the client s current state across multiple domains. Uses both a client s self-report & the clinician s observations Influenced by the therapeutic relationship Multiple domains influenced by mental illness & substance use Practice, practice, practice
33 33 Appearance Judgment Speech Insight Perception Mental Status Exam Mood Affect Thought Content Thought Process Sensorium Questions?
34 34 Thanks! Bradley Labuguen RN BScN MHM CPMHN(c) Nurse Educator St. Joseph s Healthcare Hamilton *Resources to be sent out*
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