N325 C2: MSE (Mental Status Exam)

MSE Application Reminder! makes.... what would you do if you OPENed MAIL= ASSESSING WHAT OF MSE? What brought you here? Assessing what of MSE?

A formal MSE can be done in < 10 mins. Only about 5-6 direct formal questions to ask... (plus/follow-up ?'s as needed) Practice on the bus!! Mostly observation! COGNITION: JUDGEMENT COGNITION: INSIGHT

Behavior: "SAS 'EM" B-Behavior SENSORIUM B-Behavior Activity descriptions ACTIVITY= MANNERISMS FACIAL EXPRESSIONS= EYE CONTACT= Attitude= Reaction to Interview Relatedness B-Behavior SPEECH quality= quantity= rate/ rhythm= volume= very low, quiet, slow speech may indicate parkinson's disease pressured= other descriptors B-Behavior (Emotional State) RANGE= DURATION= INTENSITY= APROPRIATE= INTERNALLY PREOCCUPIED (IP) B-Behavior MOOD AND AFFECT Mood= subjective or objective? (3) Affect= subjective or objective? (2) WHICH ONE IS DESCRIBED IN PT'S OWN WORDS?

AOX4, LOC ACTIVITY= PMA/PMR (psychomotor agitation/ psychomotor retardation), hypoactive, hyperactive, restless, agitated, etc MANNERISMS= tremors, choreathetoid limb mobvements (serpentine like, repetitive movements charactristic of med side effects) FACIAL EXPRESSIONS= grimaces, etc. eye contect= direct, poor, vacant, piercing, vigilant , etc ATTITUDE= open, cooperative, guarded, irritable, etc reaction to interview= hostile, evasive, defensive, cooperative, motivated, initially helpful and open, becomes guarded as interview progresses especially around topic r/t (describe, give specific examples)... etc ability to establish rapport/connectedness SPEECH quality= clear, coherent, slurred, quantity= amount, whether the replies to questions are 1-word answers, monosyllabic, elaborate rate/rhythm= (staccato= interruptions, broken rhythm, slow, fast, even, etc.) volume= loudness pressured= is there an intensity behind the words? (indicative of narcotics/ alcohol abuse, stimulant abuse, coacaine, methamphetamines, bipolar mania) EMOTIONAL STATE range= availability of spectrum of moods (constricted= flat affect, expansive= lots of emotions) duration= stability vs rapid changeability (instability, lability) which may not be understandable; LABILITY= rapid change of emotions INTENSITY= INCREASED with insistence, diminished with shallow and limited conviction (sarcasm) appropriate= fits with what is being said ex:s restricted, euthymic, annoyed, sullen, enraged (do they look and seem sad)? Internally preoccupied (IP)= responding to internal stimuli including noises or voices MOOD= SUBJECTIVE, assessment "how is your mood?" how do you feel right now?" -MOOD AFFECT= OBJECTIVE -Your observations based on objective criteria -described in professional terminology (bright, dysphoric, full, euthymic , constricted, blunted, flat, tearful, manic, broad, expansive, etc.)

ABCs of MMSE Acronyms and Components (Basic)

Appearance -objective data collected using senses Behavior "SAS 'EM" -Sensorium (AOX4, LOC) -Activities, mannerisms, attitude, reaction to interview -Speech -Emotional State -Mood and Affect (subjective and objective data) Cognition "TV IR" -Thought content (delusions/ hallucinations) and thought process -Violence assessment (HA/VA/SI/HI/PI)- high priority -Insight and Judgement Insight= pt's awareness with why they're here/ getting treated "what brings you here?" judgement= whether pt is making appropriate decisions (assessed throughout) IJ-> assessed on a poor, fair, good

Pt reports and states that she is feeling depressed, but appears to look pleasant. What must the nurse document? Give the full words for the following abbreviations. AH, VH, SI, HI , PI What part of the MSE are they assessing? "I asked the pt how their mood was" Wrong or right documentation? When do you document the question you ask?

DOCUMENTATIONS Client states that she "feels depressed" Affect: Contented AH= auditory hallucinations VH= visual hallucinations SI= suicidal ideation HI=homocidal " PI= paranoid " thought CONTENT WRONG. Just document, "client reports he is fine" client states...= right documentation You document the question you asked when the client gives an absurd answer, for example, if you ask, how is your mood? and client replies purple stars it's a good idea to document the question

MSE is always done as part of the greater assessment known as a ___. components (3)?

psychosocial history -pt's developmental history -medication history -history of hospitalizations

MSE: C-Cognition (Violence Assessment) ALWAYS ASK DIRECTLY -Assess SI -Assess HI MSE: C-Cognition (ASSESS for Insight & Judgment and RELIABILITY/HISTORIAN) What is insight? What is judgement?

-ASSESS SI: PLAN (must be specific), what do they plan to do to harm/kill themselves?; the specificity of plan & details, heightens risk; INTENT, do they really want to or INTEND to carry out plan, MEANS, is the ability & ACCESS to carry out the plan. -Intent, Plan & Means And the Target of homicidal ideation (HI) Tarasoff Act- duty to warn potential victim of imminent danger of homicidal pts. law allows HC providers to break HIPPA/confidentiality to protect potential victim INSIGHT= pt's understanding of ILLNESS; assess if pt understands what the needs are that broguht them in for help, "what brought you here? why are you here? (FAIR/GOOD/POOR) JUDGEMENT= Estimate pt's judgement based on the history (whether they're making good plans/ decisions for themselves) (e.g. (ie. "If you have a problem with___, what would you do? Would you seek help?") or an imaginary (standardized) scenarios (e.g. "What would you do if you found an addressed stamped envelope in the street?") - can be done informally)

Appearance

-Age, race, ethnic background, gender (are these congruent with appearance, stated age, nutritional status, etc) -Gender unclear "TG" or "male to female pre-op" e.g. "Chronological age 45, appears much older than stated age" -Dress: casual, formal, clean, slovenly, etc. -Nutritional status: current body wt + appearance (obese/cachexic, malnourished?) -Grooming: hygiene, odo!r, neglected, etc. (sweetness or acetone ~ DKA, alcohol, leads to care plan) -Posture: rigid, relaxed, etc. (stooped posture= parkinson's)

What is reliability in regards to MSE? -Assessed when? -Where is it documented and reported? -Example of documentation:

-Perception that client has given correct & accurate information. -Assessed throughout & at end of interview. -Documented & Verbally reported at start "Client is a (poor/fair/good) historian; cannot recall details of.... Reliability of information is considered fair to poor based on inconsistencies of report regarding.... and with collateral info. aeb (ex's)...."

mini-mental status exam measures what? UNLIKE MSE, MMSE... MMSE SCORING highest and best functioning average loss per year w Dementia of Alzheimer's (DAT) Drops to ___ in early stages, noticeable signs Moderate DAT score Severe DAT score Functional Dementia Scale (2)

-baseline and cognitive changes over time like MSE -unlike MSE measures registration, short term memory STM, orientation, attention, concentration, (check boxes off, is less thorough) -30 -3 -18 -12-18 -<10-12 -Ability to perform self-care (ADL's) -memory loss, mood changes, safety risks

MSE what is it compared to the MMSE? objective data? subjective data? Formal direct questions vs unobtrusive, what is latter? advantage of latter? best for which pt?

-more inclusive, thorough, assesses MOOD AND THOUGHT CONTENT, in WRITTEN PARAGRAPH -here and now baseline assessment and follow-up measure that can change over time objective data: what you're seeing observationally subjective data: what the patient says -Unobtrusive= observe pt on bus, not letting them know you're assessing them, pt won't change behavior; best for paranoid patients

C- Cognition Thought Content (WHAT) -PI (paranoid ideation) = ___ -Delusions (false fixed belief) -persecutory, grandiose, religious, erotomanic, control) grandiose= "golden boy/ chosen one" religious= god chose me erotomanic= president/ celeb control= thought broadcasting, thoughts controlled VH,TH,OH v=visual, t=tactile, o= olfactory, very common in ____ causes? -Phobias= irrational fear that bothers pt Obsessions -Hallucinations: AH, VH, TH, OH; Command (C__0 -DTS SI/ DTO HI -Poverty of thought Thought Process (HOW) -Good: linear, organized, coherent -tangential, circumstantial, flight of ideas, LOA (loose associations) -word salad, racing, perseverative or focused (FOCUSED on one idea!) CAH? wHAT IS POVERTY OF THOGHT? What is preservative thinking?

-persecutory thinking -just an idea or thought doesn't mean that there's a whole complex system that is in place in the person's brain that is ingrained in all aspects of life -when it comes to this point it becomes a delusion = command auditory hallucinations, commanding pt to do something, has to do with things like using drugs, not eating, not taking their meds, can get into a dangerous area where voice is telling them to hurt themselves hurt you or someone else organic, - brain tumors, seizure disorders, migraine headaches, substance use disorders, substance use withdrawals -command auditory hallucinations, commanding pt to do something, has to do with things like using drugs, not eating, not taking their meds, can get into a dangerous area where voice is telling them to hurt themselves hurt you or someone else -assess for violence Poverty of thought= patient does not have a lot to think about, mind is sort of blank, maybe they're saying a lot but they're not really saying much content, IT'S VAGUE WHAT THEY'RE SAYING = focused on one thought, one idea, a complaint such as they are perseverating on the bad food, mistrust of doctors, mistreatment in the hospital, etc.

MSE What are two direct questions? (2) objective or subjective data?

1 How is your mood? 2 Thought content: AH, VH, SI, HI, PI = both objective and subjective; mostly subjective

Psychiatric terminology: THOUGHT PROCESS 1 lack of logical relationship between ideas & thoughts. 2 overly detailed, circuitous 3 rapid change of ideas but able to see how client connects the changes. 4 initially addresses point but goes in different direction, never reaching the point. 5 stops speaking, "mind goes blank" some voice was telling them/ commanding them to stop talking or telling you something. 6 speech starts w/ totally different idea. 7 shifting of topics to incoherence, words w/ no connections Psychiatric Terminology: Thought Content 1 unwanted repetitive, insistent ideas or thoughts 2 actions, rituals that must be performed 3 false fixed beliefs, e.g. Religious, paranoid, Thought broadcasting, Grandiose 4 false perceptions to real sensory stimulus e.g. curtain blowing in window: person/ ghost misinterpretation 5 false sensory experience without external stimulus 4 AND 5 ARE ALSO KNOWN AS?

Psychiatric terminology: THOUGHT PROCESS 1 loose associations 2 circumstantial 3 flight of ideas 4 tangential 5 blocking 6 derailment 7 word salad Psychiatric terminology: THOUGHT CONTENT 1 obsessions 2 compulsions 3 delusions 4 illusions 5 hallucinations PERCEPTIONS