Appendix A. Mental Status Assessment

Transcription

1 Appendix A Mental Status Assessment A mental status assessment (MSA) represents an examiner s observations and documentation of an individual s inner experiences expressed during an interview. A person s mental status vary across time, therefore findings from an MSA reflect a specific point in time. The information gathered in the MSA is gleaned through observation and direct questioning. Components of the MSA include general observations, mood and affect, speech, motor activity, interaction during the interview, emotional state, experiences, thinking and sensorium and cognition. There is some variation in the organization and documentation of the MSA across institutions, authors, and clinicians. For example, Alberta Health Services, uses the acronym, ABSCATT to assist staff documenting their mental status findings. ABSCATT stands for appearance, behavior, speech, cognition, affect/mood, thought processes and perceptions, and thought content. For the purpose of this lab, please use the MSA format provided on the NURS 309 eclass site. GENERAL DESCRIPTION APPEARANCE SPEECH This section provides a physical description of the person with enough detail to help readers visualize what the person looks like. General statement concerning the person s ethnicity, hair and eye color and relationship status, occupation, or educational status. Age apparent versus actual age (if known). Body build- small, medium or large frame and build; note physical abnormalities or disability. Eye contact sustained throughout the interview or fleeting/occasional. Attire describe what the person is wearing, including clothing type, color, condition and suitability for age and setting; also include details of accessories. Grooming/Hygiene includes details about make-up (if worn), shaving (men), hair appearance (i.e. short hair-cut, blonde, clean and styled), and nails Nutritional /General Health Status comment on apparent general health (e.g., wellnourished or cachexic) Pupils note constriction or dilation; it is not necessary to note if there is no abnormalities.

2 Rate rapid, slow or expected conversational rate; any delays in responding (e.g., response latency is common in persons who are depressed and have slowed thought processes). Rhythm is speech regular/fluent, spontaneous, and syntactically correct (i.e., ordering of words, phrases, and sentences was correct) Volume loud or soft Tone well modulated Quantity paucity, muteness (absence of speech); pressure of speech; How does the person respond to questions? Do they provide sufficient information and detail or does require prompting? Clarity is speech understandable, clear, and coherent? Are there problems with speech production or any accents? MOTOR ACTIVITY Gait characteristics of walk (unaided or with walker etc., short-stepped gait or shuffling) and how the person stands (wide stance) Posture Sitting, standing or lying tense looking or relaxed, arms folded, legs crossed or legs elevated on foot stool, hand gestures used to emphasize what is being said Rate of movement slowed or increased movements noted when walking or gesturing; lethargic; pacing Unusual movements note any unusual or repetitive movements (compulsions), tics, or tremors Coordination are movements fluid, intentional, coordinated, and symmetrical; any movement disorders such as dyskinesia or akinesia INTERACTION DURING INTERVIEW Attitude is the person hostile, uncooperative, irritable, hostile, aggressive, sarcastic, apathetic, defensive, suspicious, guarded or cooperative, friendly and eager to please; describe their general response to the interviewer or yourself Generally describe how the patient relates to the nurse during the interview EMOTIONAL STATE Mood- is the person s or patient s self-report of prevailing emotional state; ask in order to get the answer as it is self-report; for example, How are you feeling today? ; Rate your mod on a scale of 1 10, with 10 being the best mood you have ever felt.

3 *Somatic Functions appetite, body movements, bowel movements, and sex drive provide additional evidence of mood Affect Quality/Type the predominant emotion expressed such as happiness, fear, anxiety, sadness, interest Range/Variability refers to the range of emotions that are seen in the conversation; normally during any conversation there are several emotions that felt and expressed; restricted expresses few emotions, i.e., depression; wide or expanded range may be seen in cluster B personalities or substance abuse. Intensity/Degree is the energy that is expressed in the feeling; low intensity is called flat as in schizophrenia (no emotion shown), some emotion is called constricted, normal is responsive and high intensity exaggerated or dramatic Stability or Duration refers to the amount of time between emotions and the type of emotions labile is someone who switches quickly from one intense emotion to another; otherwise usually referred to as unstable Appropriateness or Congruence is the observed emotion congruent with the reported mood, the content of speech, and the situation EXPERIENCES Perceptions Two major types of perceptual problems Hallucinations false sensory impressions or experiences no external stimuli Types are auditory (most common), visual (2 nd most common), tactile, gustatory (least common and usually unpleasant taste, olfactory (uncommon and presence may indicate medical condition or may be psychiatric maybe present with somatic delusions (e.g., My intestines are rotting ). Command hallucinations tell the person to do something (e.g., hit that person!) Illusions false perceptions or false responses to sensory stimulus see a mirage in the desert mistake a curtain for a figure Note: If illusions or hallucination are present, describe what the person experiences or states they are experiencing. Often individuals do not admit to hallucinations embarrassment or shame or issue of trust so watch for behavioural indicators and describe these

4 THINKING Depersonalization change in the perception of the self feel as if they have become unreal Derealization change in the perception of the external world feel as if blend into the surroundings Both depersonalization and derealisation are unpleasant and the person is aware that the experience is unreal leaving one`s body, seeing oneself from the ceiling Thought Content (what the person`s conversation is the topics they discuss their concerns) Delusions Fixed false beliefs believed despite contradictions to social reality and not shared by others many different types and are as follows: religious (i.e. I am a prophet sent to save the World); somatic ( I have bladder cancer); paranoid (I am being poisoned); thought insertion thoughts placed into one s mind by outside influence; thought broadcasting thoughts being aired to the outside world; erotomania false belief someone is in love with the person; persecution ( I am an FBI agent and I am being followed); and grandiose (I am a MBA famous athlete. It is not appropriate to ask, Do you have delusions? [Consider the reasons for this]. A more effective question might be, Have you had recent occasions when other people have not agreed with things you believe? Ideas of Reference interpretation of innocent gestures or remarks made by other people as being an expression of disapproval directed towards themselves personally (may misinterpret radio or TV as referring to them) Magical thinking belief that thinking equates with doing; characterized by lack of realistic relationship between cause and effect (step on a crack.) Nihilistic ideas thoughts of nonexistence and hopelessness Obsession an idea, emotion, or impulse that repetitively and insistently forces itself into consciousness; is unwanted and cannot be controlled by the person; recognized as being a product of the person`s mind; themes cleanliness, order, doubt Phobia marked and persistent fears morbid viewed as excessive by the person; associated with a specific object or situation; associated with extreme anxiety; person may go to great lengths to avoid it Preoccupations being engrossed or lost in thought often to the exclusion of everything else; is willful thinking about a topic

5 Suicidal Thoughts note if suicidal thoughts are present if so, then must provide a suicide risk assessment (another lab) Rumination mulling over thoughts but never reaching a conclusion Hypochondriasis somatic over-concern (e.g. belief that one is physically ill despite lack of signs) Thought Process (looking for goal orientated thinking that is logical) How ideas are expressed; observed through speech patterns or forms of verbalization; assess the degree of connection between ideas and goal directedness; best assessed with open-ended questions Circumstantial thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is ultimately given Flight of ideas speech takes off from the original topic; over-productive and characterized by rapid shifting from one topic to another; remains logical; connection between ideas still recognizable; ideas are not expanded upon before moving to another topic Looseness of Association lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse and unfocused Neologisms new word or words created by the patient, often a blend of other words (e.g. a deathilating machine) Perseveration involuntary, excessive continuation or repetition of a single response, idea or activity; may apply to speech or movement Tangential the person does not answer the question or make a point, but speech is logical and proper grammar is used; similar to circumstantial Thought blocking sudden stopping in the train of thought or in the middle of sentence Word salad series of words that seem to totally unrelated *Example of no abnormalities - Thoughts are coherent, logical, and goal-directed SENSORIUM AND COGNITION Level of Consciousness Alert, confused, sedated, stuporous Orientation Person, place and time

6 Memory Ability to recall past experiences Remote memory recall of events, information and people from the distant past Recent memory recall of events, etc. from the past week or so Immediate memory recall of information or data to which a person was just exposed repeat a series of numbers either forward or backward within a 10 second interval (mini mental status examination name 3 objects and ask person to repeat this immediately and then a couple of minutes later) Level of Concentration and Calculation Attention is a person s ability to direct mental energy during the course of the interview. Concentration is the sustained focus of attention for a period of time. Calculation is the ability to do simple math (i.e., multiply 8x9). Many times this aspect is not formally tested, so this may also be described by noting the level of distractibility. To formally test attention ask the person to recall the number of numbers both forward and backward. Most people are able to recall between 5 to 7 numbers forward and 4 to 6 numbers backwards. For example: The interviewer says and then asks the person to repeat these forward. To test concentration ask the person to do serial 7 subtractions or serial 3 s from 20. For example: Serially subtract 7 from 100 (e.g., 100, 93, 86, 79, etc.) Information and Intelligence Intelligence involves the ability to recall and assimilate information, the person s fund of knowledge, vocabulary and level of education. Assess: Last grade level of school completed, general knowledge and use of vocabulary Level of literacy Ability to conceptualize and think abstractly, can be tested by having the person explain a series of common proverbs (e.g., A stitch in time saves nine; Still waters run deep; A bird in the hand is worth two in the bush). The ability to think abstractly is also demonstrated if a person is able to appreciate all meanings of an item and grasp the whole picture.

7 Judgment Insight Is a process that involves making decisions or taking actions that are constructive and adaptive requires ability to understand the facts, draw logical conclusions, and predict likely outcomes. In interview situations, judgment is often assessed in terms of what the person did or did not do with respect to his or her illness (e.g., person was admitted to acute care when they became symptomatic when they stopped taking antipsychotic medications). Explore the person s involvement in activities, relationships, and vocational choices to examine judgement. One may present hypothetical situations for evaluation, as outlined below, but what is more meaningful is the person s degree of judgment in relation to their illness and subsequent choices. What would you do if you found a stamped addressed envelope lying on the ground? What would you do if you entered your home and smelled gas? - Is the person s understanding of the nature of their problem or illness and awareness of how it impacts others. It also encompasses an awareness of the signs and symptoms they are experiencing and the need for treatment. It is a process and not a symptom. Maybe recorded as absent (no insight or impaired), partial or intact. Full insight is described as being able to recognize sign and symptoms that are part of an illness, ability to modify behavior, and cooperate with treatment. Partial insight is the ability to recognize that there are problems, but does not attribute them to an illness; may understand how others see them as ill; may have some ability to modify behavior and have some degree of cooperative behavior. Impaired insight is present when the person denies the illness, has no capacity to understand the concepts of others, and has poor compliance with treatment. Adapted from: Lasiuk, G. (2010). The assessment process. In Austin, W., & Boyd, M.A. Psychiatric and mental health nursing for Canadian practice (2nd edition), (pp ). Philadelphia: Lippincott Williams & Wilkins. Robinson, D. J. (2008). The mental status exam explained (2 nd edition). London, Canada: Rapid Psychler Press. Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed.). St. Louis: Elsevier Mosby.