PURPOSE

Mental status examination is a commonly performed nursing procedure. In this chapter you will be introduced to the terminology used, the components of the mental status examination including assessing a person’s mental health, the rationale and methods of examination of mental status and how to record the assessment accurately.

KEY CONCEPTS

• Definitions of mental status

• Mental status health history

• Components of the mental status examination

– Appearance

– Behaviour

– Cognitive functions

– Thought processes and perceptions

• Abnormalities related to:

– Mood and affect

– Thought processes

– Thought content

– Perceptions

• Overview of substance use disorders

• Screening for suicide risk

• Supplemental mini mental status examination

• Complete mental status assessment

While you are completing your reading assignment, ensure you understand each of the key concepts listed above.

READING ASSIGNMENT

Jarvis, Forbes & Watt (JF&W): Jarvis’s Physical Examination and Health Assessment, Chapter 21, pp. 555–574.

GLOSSARY

After reading the corresponding chapter in the text, learn the following terms. You should be able to cover the definition on the right and state the associated definition in your own words.

Abstract reasoning pondering a deeper meaning beyond the concrete and literal

Affect temporary expression of feelings and state of mind

Aphasia true language disturbance, defect in word choice and grammar or defect in comprehension; defect is in higher integrative language processing; is the loss of the ability to speak or write coherently, or to understand speech or writing

Attention concentration, ability to focus on one specific thing without being distracted

Consciousness being aware of one’s own existence, feelings and thoughts and being aware of the environment

Dysarthria distorted speech sounds; speech may sound unintelligible; basic language (word choice, grammar, comprehension) are intact

Dysphonia difficulty or discomfort in talking, with abnormal pitch or volume, due to laryngeal disease. Voice sounds hoarse or whispered, but articulation and language are intact

Language using the voice to communicate one’s thoughts and feelings

Memory ability to lay down and store experiences and perceptions for later recall

Mental disorder a significant behavioural or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability or death or a loss of freedom (American Psychiatric Association, 2000)

Mental status a person’s emotional and cognitive functioning

Mood prolonged display of a person’s feelings affecting their whole emotional life

Orientation awareness of the objective world in relation to the self

Perceptions awareness of objects through any of the five senses

Thought content what the person thinks—specific ideas, beliefs, the use of words

Thought process the way a person thinks—the logical train of thought

PREPARATION FOR YOUR LABORATORY SESSION

1. Prior to attending the laboratory, prepare questions that you may ask—during a regional health history—of a patient who presents with another presenting illness, to elicit information about the patient’s mental health status and coping strategies. Write these additional questions in the space provided before the regional write-up worksheet so you can use the questions as a prompt.

2. To enhance your learning concerning examining for mental health issues, choose one of the following mental health disorders, read about the presentation, signs and symptoms of the condition and prepare yourself to become a ‘patient’ with this underlying condition. You may choose another condition if it is of more interest to you.

a. depression

b. suicidal ideation

c. hallucinations

d. anxiety disorder

STUDY GUIDE

After completing the reading assignment, you should be able to answer the following questions in the spaces provided.

1. Define the term ‘mental disorder’ including the subcategories, and provide examples of each.

_____________________________________________________________

2. Mental status function is inferred through the assessment of a patient’s behaviour. List the 10 behavioural areas that are assessed, providing a brief description of each.

_____________________________________________________________

3. Circle True or False to answer the following statements concerning infant and childhood developmental considerations. If the answer is false, state the correct answer.

4. List the 4 main headings/components of a mental state assessment.

i. _____________________________________________________________

ii. _____________________________________________________________

iii. _____________________________________________________________

iv. _____________________________________________________________

5. Explain why mental status can be assessed if integrated into the health history interview.

_____________________________________________________________

6. State 4 situations in which it would be necessary to perform a complete mental status examination.

i. ______________

ii. ______________

iii. _____________________________________________________________

iv. _____________________________________________________________

7. Explain 4 factors that could affect a patient’s response to the mental status examination but have nothing to do with mental disorders.

i. ______________

ii. ______________

iii. ______________

iv. ______________

8. The sequence of steps in the objective mental state examination forms a hierarchy in which the most basic functions are assessed first. Explain why it is vital to accurately assess this first step.

_____________________________________________________________

9. Describe the presentation of patients with each of the following disorders:

anxiety ______________

_____________________________________________________________

depression ______________

_____________________________________________________________

Alzheimer’s or dementia ______________

_____________________________________________________________

10. Distinguish dysphonia from dysarthria.

_____________________________________________________________

11. Define ‘unilateral neglect’ and state the condition with which it is associated.

_____________________________________________________________

12. List the order in which ‘orientation’ is lost.

_____________________________________________________________

13. Describe how you would assess attention span during a health history interview.

_____________________________________________________________

14. State methods of assessing a person’s recent and remote memory within the context of the initial health history and provide examples of when memory may be altered.

_____________________________________________________________

15. What is the Four Unrelated Words Test intended to test? Include the procedure to be followed during the test and which conditions may cause incorrect responses.

_____________________________________________________________

16. State how and why you would assess for the following while you are performing a health history interview:

word comprehension

_____________________________________________________________

ability to read

_____________________________________________________________

purpose of tests for higher level functioning

_____________________________________________________________

judgment

_____________________________________________________________

thought processes

_____________________________________________________________

thought content

_____________________________________________________________

perceptions

_____________________________________________________________

17. Identify at least 3 questions you could ask a patient that would screen for suicidal ideation.

i. _____________________________________________________________

ii. _____________________________________________________________

iii. _____________________________________________________________

18. List 10 cues and warning signs that would indicate a risk of suicide.

i. _____________________________________________________________

ii. _____________________________________________________________

iii. _____________________________________________________________

iv. _____________________________________________________________

v. _____________________________________________________________

vi. _____________________________________________________________

vii. _____________________________________________________________

viii. _____________________________________________________________

ix. _____________________________________________________________

x. _____________________________________________________________

19. Discuss purpose and reasons for using the MiniMental State Examination, the scoring method and what scores may indicate.

_____________________________________________________________

20. Differentiate between delirium and dementia.

_____________________________________________________________

21. State the symptoms and physical signs that are characteristic of alcohol withdrawal.

_____________________________________________________________

22. Very briefly define each of the following conditions:

depersonalisation (lack of ego boundaries)

_____________________________________________________________

euphoria

_____________________________________________________________

anxiety

_____________________________________________________________

fear

_____________________________________________________________

lability

_____________________________________________________________

inappropriate affect

_____________________________________________________________

confabulation

_____________________________________________________________

circumlocution

_____________________________________________________________

flight of ideas

_____________________________________________________________

word salad

_____________________________________________________________

perseveration

_____________________________________________________________

echolalia

_____________________________________________________________

phobia

_____________________________________________________________

delusions

_____________________________________________________________

hallucination

_____________________________________________________________

REVIEW QUESTIONS

This test is for you to check your own mastery of the content. Answers are provided in Appendix A.

1. Although a full mental status examination may not be required, the nurse must be aware of the four main headings of the assessment while performing the interview and physical examination. These headings are:

a. mood, affect, consciousness and orientation

b. memory, attention, thought content and perceptions

c. language, orientation, attention and abstract reasoning

d. appearance, behaviour, cognition and thought processes

2. Select the finding that most accurately describes the general appearance of a patient.

a. tense posture and restless activity. Clothing clean but not appropriate for season; patient wearing T-shirt and shorts in cold weather

b. orientated × 3. Affect appropriate for circumstances

c. alert and responds to verbal stimuli. Tearful when diagnosis discussed

d. laughing inappropriately, orientated × 3

3. The ability to lay down new memories is part of the assessment of cognitive functions. One way to identify the ability to form new memories is by:

a. noting whether the patient completes a thought without wandering

b. testing general knowledge

c. asking for a description of past medical history

d. the use of the Four Unrelated Words Test

4. In order to accurately plan for discharge teaching, additional assessments may be required for the patient with aphasia. This may be accomplished by asking the patient to:

a. calculate serial 7s

b. name their grandchildren and their birthdays

c. demonstrate word comprehension by naming articles in the room or on the body as you point to them

d. interpret a proverb

5. During an interview with a patient newly diagnosed with a seizure disorder, the patient states, ‘I plan to be an airline pilot’. If the patient continues to have this as a career goal after teaching regarding seizure disorders has been provided, the nurse might question the patient’s:

a. thought processes

b. judgment

c. attention span

d. recent memory

6. Auditory and visual hallucinations occur with all of the following conditions except:

a. psychiatric disorders

b. organic brain disease

c. psychedelic drugs

d. antidepressant drugs.

7. On a patient’s second day in an acute care hospital, the patient complains about the ‘bugs’ on the bed. The bed is clean. This would be an example of altered:

a. thought process

b. orientation

c. perception

d. higher intellectual function

8. One way to assess cognitive function and to detect dementia is with:

a. the Proverb Interpretation Test

b. the MiniMental State Examination

c. the Four Unrelated Words Test

d. the Older Adult Behavioural Checklist

9. The Behavioural Checklist, completed by a parent, is used to assess the mental status of:

a. infants

b. children 1 to 5 years of age

c. children 7 to 11 years of age

d. adolescents

10. Circle True or False to answer the following statements about the over 65-year-old. If the answer is false, state the correct answer.

11. A major characteristic of dementia is:

a. impairment of short and long-term memory

b. hallucinations

c. sudden onset of symptoms

d. substance-induced

12. Match Column B with the definition in Column A.

13. Nicotine withdrawal is characterised by all of the following signs or symptoms except:

a. vasodilation, headaches

b. anger, irritability, frustration, anxiety, nervousness

c. awakening at night, difficulty concentrating

d. loss of appetite

14. A thin, scruffy person walks into the ward waiting room and tells the patients that he is a famous international rugby union player. This is an example of:

a. persecution

b. delusion

c. obsession

d. compulsion

e. Write a narrative account of a mental status assessment with normal findings.

PRACTICAL SKILLS IN THE LABORATORY/CLINICAL SETTING

Integrating the mental status examination into the health history interview is adequate for most patients you will deal with, as you can collect enough data to be able to assess mental health strengths, coping skills and the need to screen for dysfunction.

You should already be aware that alterations in mental status can significantly affect the patient’s ability to manage their health, roles and relationships, sexuality, self-concept, coping ability and activities of daily living.

You need to be cognisant that the consequence of illness and its treatment can also impact on mental health and that there will be many times that you will need to perform a complete mental status examination or a minimental status examination in a variety of clinical settings.

Now that you have been introduced to the steps in the mental status examination and reviewed a number of abnormalities you are ready for the clinical component of the mental status examination.

The purpose of the clinical component is to take an integrated subjective health history (to assess the need for further mental health assessment), achieve beginning competency with the administration of the mental status examination (MSE) and/or with the supplemental MiniMental State Examination (MMSE).

CLINICAL OBJECTIVES

At the completion of the clinical laboratory session, with further practice and self-directed learning you should be able to:

1. collect a health history demonstrating the integration of questions related to mental health signs and symptoms

2. demonstrate satisfactory performance of both the MSE and MMSE

3. record assessment findings accurately.

INSTRUCTIONS

1. Form pairs. (Do not reveal the condition you will be role-playing to your peer.)

2. Prepare the environment to promote security and confidentiality. Gather equipment: a piece of blank paper (place patient addressograph, or write patient name and unit number. Keep with hard copy data forms), wrist watch, pencil, standardised form with ‘Close your eyes’, standardised form with intersecting pentagons.

3. Wash your hands.

4. Gain consent to perform the examination from either your peer or the patient.

5. Obtain a health history integrating the questions you have developed to identify the presence of any mental health issues.

6. Practise the steps of the full mental status examination on a peer or a patient in the clinical setting, providing appropriate instructions as you proceed.

7. Record your findings using the regional write-up worksheet.

8. Next, practise the steps of the MiniMental State Examination (a simplified scored form of the cognitive functions found on the full mental status examination. It is used frequently in clinical and research settings).

9. Record your findings using the MiniMental State Examination form.

10. Swap roles and repeat steps 2–9.

11. Discuss your assessment and questioning techniques, findings and performance with your peer to develop a complete understanding of the process of performing a MSE and/or MMSE.

12. Document your findings using the SOAP format.

ADDITIONAL QUESTIONS TO INCLUDE IN HEALTH HISTORY/EXAMINATION

REGIONAL WRITE-UP WORKSHEET–MENTAL STATUS EXAMINATION

Date______________

Interview conducted by ______________

Designation ______________

Patient ____________________________Age_______________ Gender______________

Occupation ________________________________Medical Record Number______________

A. Complete mental status examination

(Prior to commencing the examination, tell the person the four words you want them to remember and to recall in a few mnutes. These are for the Four Unrelated Words Test.)

1. Appearance

Posture ______________

Body movements ______________

Dress ______________

Grooming and hygiene ______________

2. Behaviour

Level of consciousness ______________

Facial expression ______________

Speech:

Quality ______________

Pace ______________

Articulation ______________

Word choice ______________

Mood and affect ______________

3. Cognitive functions

Orientation:

Time ______________

Place ______________

Person ______________

Attention span ______________

Recent memory ______________

Remote memory ______________

New learning—Four Unrelated Words Test ______________

Additional testing for aphasia:

Word comprehension ______________

Reading ______________

Writing ______________

Judgment ______________

4. Thought processes and perceptions

Thought processes ______________

Thought content ______________

Perceptions ______________

Suicidal thoughts? (When indicated) ______________

B. Perform the MiniMental State Examination

The MiniMental State Examination (MMSE) is an assessment of overall cognitive function.

TABLE 21.1 Mini-Mental State Examination (MMSE)

MMSE Sample Items
Orientation to Time
“What is the date?”
Registration
“Listen carefully. I am going to say three words. You say them back after I stop.
Ready? Here they are …
APPLE (pause), PENNY (pause), TABLE (pause). Now repeat those words back to me.”
[Repeat up to 5 times, but score only the first trial.]
Naming
“What is this?” [Point to a pencil or pen.]
Reading
“Please read this and do what it says.” [Show examinee the words on the stimulus form.]
CLOSE YOUR EYES

Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549, from the Mini Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. by calling +1 (813) 968-3003.

NOTES

REGIONAL DOCUMENTATION (SOAP)–MENTAL HEALTH STATUS

Summarise your findings using the SOAP format.

Subjective (Reason for seeking care, health history)

Objective (Physical exam findings as needed)

Assessment (Assessment of health state or problem, diagnosis)

Plan (Diagnostic evaluation, follow-up care, patient teaching)