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o motor and speech activity

NCM 117: PSYCHIATRIC NURSING o mood and affect
MENTAL STATUS EXAM o thought and perception
o attitude an insight and their action invoke in the examiner
o higher cognitive abilities
WHAT IS PSYCHIATRIC NURSING?
- Focuses on care of individuals and families requiring clinical treatment and REMEMBER:
uses all components of the nursing process with increasing degrees of skill “The specific cognitive functions of alertness language memory construction ability
- this course prepares the students to apply the nursing process to the care of and abstract reasoning are the most clinically relevant”
clients with psychiatric problems
R MSE of patient can change from day to day or hour to hour
- specialty within the field of nursing that provides holistic care to individuals
R Do not rely on what was recorded on the chart= part of history
with mental disorders or behavioral problems so as to promote their R Have your own MSE and do not copy from the chart
physical and psychosocial well-being
- emphasizes the use of interpersonal relationships as a therapeutic agent
and considers the environmental factors that influence mental health
OBJECTIVES:

WHAT IS MENTAL STATUS EXAMINATION?  communicate effectively with culturally diverse clients with mental health
issues
- part of clinical assessment that describes the sum total of examiner’s
 provides important information for diagnosis and for assessment of the
observations and impressions of the pt at the time of interview
disorder’s course and response to treatment
- involves observing the patient’s behavior and describing it in an objective
 utilize the teaching/learning process in providing safe and effective nursing
and nonjudgmental manner
care for the psychiatric client across the life cycle
- MSE: Psychiatric nursing while Physical Examination: General medical
nursing
- Psychiatric tool to objectively and descriptively and thoroughly describe the COMPONENTS OF MENTAL STATUS EXAM
mental state at the time of interview
I. Presentation/ Appearance
- Interpreted in conjunction with patient’s history pe and lab studies
II. Stream Of Talk/ Behavior And Speech
- Consideration is given to all aspects of mental fx-ing
III. Emotional State And Reaction
- Describes the mental states and behavior of person
IV. Disturbances In Thinking
- Has a standard format but not rigid planned for interviewing the patient
V. Disturbances In Perception
- Guide to interviewer
VI. Neurovegative Dysfunction
- structured assessment of the patients behavioral and cognitive function
VII. General Sensorium And Intellectual Stats
- it includes descriptions of the patient’s:
VIII. Insight/ Judgement
o appearance and general behavior
o level consciousness and attentiveness

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Facial expression
PRESENTATION
GENERAL APPEARANCE - may use the ff:
o anxious
- Describes the patient’s appearance and overall physical impression as o pleasure
reflected by apparent: o confidence
o Age o blunted
o facial expressions o pleasant
o posture o have/ can maintain eye to eye contact or not
o poise o can build rapport easily or not
o clothing o drowsy or unconscious
o grooming o behavior is over friendly (nge fc.)
o hair and nails o disinhibited
- what do you see during your first interaction/ interview? o preoccupied
- describe the body build of the client, posture, manner of dressing (if o aggressive
appropriate), grooming (dirty/clean), and prominent physical abnormalities, o normal behavior
level of alertness (somnolence or alert)
- emotional facial expression dressing and grooming
- attitude to examiner (cooperative or not)
- may use the ff:
- give the examiner an overall impression of the patient
o well dressed (appropriate with situation or season)
- may use the ff terms:
o neat and tidy/ dirty
o healthy
o sickly ACTIVITY AND BEHAVIOR
o ill at ease
o poised - level of activity
o old or young looking compared to the age of client - examiners description of the amount and type of motoric behavior:
o disheveled o mannerism
o child-like o tics and gestures
o demonstrate bizarre behavior o twitches and stereotyped behavior
o have signs of anxiety or not o psychomotor agitation and retardation
o moist hands o echopraxia and catatonia
o perspiring o automatisms and ataxia
o tensed posture - not whether drinking alcohol so be aware of the pt smell
o wide eyes - Stereotype activity
o common to pt with mental retardation
o repetitive fixed pattern of physical activity such as:

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 hand waving o unaware with surroundings
 bed rocking o pt is comfortable with position and unaware
 head banging (taylor swift ka gohrl) - Catatonic rigidity
- Dyskinesia o voluntary assumption of a rigid posture
o involuntary irregular movements of muscles of head, limb, and o held against all efforts to be moved
trunk - Catatonic posturing
o exacerbated by stress and relieve during sleep o voluntary assumption of inappropriate or bizarre posture
- Echopraxia
o imitation or repetition of body movement of another person ATTITUDE TOWARDS EXAMINER
o in schizophrenic patients
- How patient relates to examiner:
- Catatonia
o Irritable
o psychologically induced immobility with muscular rigidity
o Aggressive
o interrupted by agitation
o Seductive (usually females)
o immobility with extreme muscular rigidity or less commonly as
o Guarded
excessive impulsive activity of pt
o Defensive
- Automatism
o Indifferent
o repetitive undirected behavior that is consciously controlled
o Apathetic
- Ataxia
o Cooperative
o impaired ability to coordinate movement
o Sarcastic
o caused by lesion in spinal cord
o Attentive
o staggering gait and postural imbalance if with ataxia
o Angry
OTHER PRESENTATIONS - There are clients who are suspicious (those with paranoid schizophrenia)

- Waxy flexibility REMEMBER:

o fixed posturing in pt schizophrenia R Remind the client of your contract that he/she is your patient, and
o maintaining the desired position for long periods of time without you are the nurse
discomfort
o ex: pt cross her legs and she is very comfortable with it
- Catatonic excitement STREAM OF TALK
o having agitation
- Is the examiner’s description of the patient’s ability to articulate thoughts
o purposeless motor activity
(physical characteristics):
o uninfluenced by external stimuli
o Rate
- Catatonic stupor
 Increased or pressured
o slowed motor activity
 Decreased or monosyllabic; there is latency
o point of immobility

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o Rhythm o Depressed
 Is there dysarthria or monotone o Fearful
 Slurring of speech o Suicidal
o Volume o Grandiose thoughts (? Lol mao ako pag dungog)
 Loud - Ask “How are you feeling today?”
 Soft
 Mute AFFECT
o Content
- Emotional state we observe in our patient in the course of interview
 Fluently
- Blunt
 Paucity
o Severe reduction of emotional state
 Impoverish
- Flat
o Amount
o Absence or near absence
o Articulation/ characteristic
- Lability
 Stuttering
o Shifting of expression
 Slurring
- Inappropriate
o Disharmony between stimuli and emotional reaction
EMOTIONAL STATE AND REACTION
SUICIDAL AND HOMICIDAL IDEATION
MOOD
- Depersonalization and derealization
- Pervasive and sustained emotion that colors the person’s perception of the
o Strangeness towards self and environment
world
o Depersonalization
- Prevalent emotional state the patient tells you how they feel as of the
 strangeness or unreality concerning to oneself or
moment
environment
- In quotes because it is what the patient tells you
 result to anxiety
- Ex: if in recording; being fantastic, elated, depressed, anxious, sad, angry,
o Derealization
irritated, in good mood
 feeling that outer environment is unreal
- Common terms:
 detach from environment
o Gloomy
- If the patient has potential for suicide
o Tense
- Inquire about thoughts of self-destruction
o Hopeless
o Ask “Do you have thoughts that life is not worth living?”
o Ecstatic
o “Do you want to harm yourself?”
o Sad
- Assess the pt’s plans and ability to carry out plans
o Exultance
- Assess attitude about death
o Elated
o Euphoric

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o Incoherent gibberish
DISTURBANCES IN THINKING
o Ex: why do people comb their hair?
THOUGHT PROCESS  Because it makes a twirl in life
 My box is broken
- The way in which a person puts together ideas and associations,
 Help me blue elephants
- the form in which and person thinks
- Perseveration
- involve
o Repetition out of context of words, phrases or ideas of a single
o logical and coherent
response
o illogical and incomprehensible
o Similar to echolalia
- ask what the pt thinks
o Different question but same answer
- ask to interpret proverbs and look for concrete answers
o May be applied through movement but mostly verbal
- Circumstantiality
- Thought blocking
o overinclusion of details usually irrelevant and eventually get back
o Sudden disruption of thought or a break in the flow of ideas
to the original point
o Ex: am I early? No yore just about on
o ex; patient will have a lot of introduction and then he/ she can give
o Joke and the speaker forgot the line
concrete answer
o The speaker cannot recall the topic
- Tangentiality
- Neologism
o similar to circumstantiality but person never answers the original
o Pathological creation of new words often blend to another words
question
o Term newly coined with a new meaning in psychiatry
o A lot of unnecessary verbalization but cannot give you the
o Word meaningful only to the patient
concrete answer
o Only the patient can understand what he/she means
- Clang association
o Association of words similar in sound but not in meaning REMEMBER:
o Words have no logical connection R what the patient thought can also be noted on how the patient
o Rhyming verbalized what he/ she thinks
- Flight of ideas R the manner of talking or speech is also interpreted because it is
o Shifting of topic from one subject to another in somewhat related what the patient is thinking about, what is going on or what the
way patient is having as part of his though process
o Ex: the sun is shining; where is the sun; love lucy; lets play ball
- Looseness of association THOUGHT CONTENT
o Shifting of a topic from one subject to another in a completely
- What a person is actually thinking about:
unrelated way
o Ideas
- Word salad
o Beliefs
o Incoherent mixture of words and phrases
o Preoccupations
o No relationship of words; illogical
o Obsessions

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- Delusions
NEUROVEGETATIVE DYSFUNCTION
o False fixed beliefs which is inconsistent to knowledge and culture
o Types: - Assess for the following:
 Persecutory or paranoia-excessive or irrational suspicion o Sleep
and distrust to others  Insomnia
 Grandiose- an individual is convinced that they have o Appetite
special power, talent or ability  Describe if loss or increase in appetite
 Jealous o Diurnal variation
 Somatic  A change in the mood that is related to time of the day
 Religious  Change in activity pattern and responses
 Ideas of reference  Night or day person
o Persistent belief or perception held inviolable by the person o Weight
despite evidence that refuse it  Note for rapid changes
o False fixed belief of individual o Libido
o Ex: a person thinks that he is a priest and conducts rituals related  Psychic energy or instinctual desire
to religious activities  Energy level
- Obsessions and compulsions
- Phobia GENERAL SENSORIUM & INTELLECTUAL STATUS
- Thought broadcasting - Seek to assess brain function, intelligence, capacity of abstract thought,
level of insight and judgment
DISTURBANCES IN PERCEPTION - Ability to perform certain mental tasks
- False sensory perception with or without external stimuli
- Level of Consciousness
- Illusion
o Awareness to the environment
o False sensory perception with external stimuli but there is
 Alert – being mentally quick, active
misinterpretation or word distortion with the actual stimulus
 Drowsy – excessive sleepiness & difficulty in remaining
- Hallucination
alert
o Not associated with real external stimuli
 Lethargy – state of dullness, prolonged sleepiness and
o Distortion in senses
serious drowsiness
 Auditory – hearing voices telling him to kill someone
 Stupor – state of unresponsiveness, unaware of the
 Visual – seeing forms or images
surroundings
 Tactile – feel a chronic sensation
 Coma – state of profound unconsciousness, absence of
 Gustatory – unpleasant taste
spontaneous eye opening and unable to response to
 Olfactory – false perception of smell
stimuli and vocalization

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o Orientation  Similarities between objects in the same class – “what are
-appears in order the similarities between bikes and bus?”
 Time – “what is today’s date?”  Ability to discuss emotions & see content of thought
 Place – “What Place is this?” o Judgement and Reasoning
 Person – “do you know who am I?”  Social Judgement – does patient understand the likely
-when the patient recovers, he/she will remember first the “person” outcome of personal behaviour; does his behaviour affect
followed by “place” and lastly the “time” or acceptable to others
o Memory  Test Judgement – prediction in imaginary situations;
 Ability to recall past experiences “what will you do if you will win the lotto?”
 Remote – past historical events or data that can be
verified i.e, address, SSS, DOB INSIGHT
 Recent – recall of past few days, yesterday’s events,
o Patient’s degree and awareness & understanding about being ill
meals eaten today
o Any denial or some awareness that they are ill but place the blame
 Intermediate – recall 3 words at 5 min, recall names of
on others
people in immediate environment
 Déjà vu – feeling of having been to a place that has not = Good or Poor
yet been visited by the person
 Jamais vu – feeling of not having been to a place which  “do you think you have problem?”
one has already visited  “what are your plans in the future?”
- Concentration/Attention & Calculation  Describe if patient has complete denial of the illness
o ability to pay attention during the course o interview & ability to  Slight awareness of being sick
do simple mathematics
 Subtracting serial 7s from 100
 Spell WORLD backwards
 Functional calculation by practical questions
- General Information
o Estimate of overall fund of knowledge
o Patients educational level & socioeconomic status must be taken
into account
- Abstract Thinking
o Ability to deal with concepts how they conceptualize & handle
ideas
 Meaning of simple proverbs – explain “raining cats and
dogs”

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MINI MENTAL STATUS EXAMINATION

- Mini-Mental State Examination (MMSE) or Folstein test is a 30 point
questionnaire that is used extensively in clinical and research settings to
measure cognitive impairment
- 5 areas to assess:
o Orientation
o Registration
o Attention and calculation
o Recall
o Language
- Indication
o Commonly used in medicine and allied health to screen for
dementia

- Interpretation
o 24 ≥ = normal cognition
o 19 – 23 = cognitive impairment
o 10 – 18 = moderate
o ≤9 = severe

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