Download Appendix A Mental Status Assessment A mental

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
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.
SPEECH
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.”
*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 (2nd 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
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
THINKING
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
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
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 “4-7-8-2-4-3-1-0-6-7-8-9-0” 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.
Judgment
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?
Insight
-
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. 173-190). Philadelphia:
Lippincott Williams & Wilkins.
Robinson, D. J. (2008). The mental status exam explained (2nd edition). London, Canada: Rapid
Psychler Press.
Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed.). St. Louis:
Elsevier Mosby.