reluctant to discuss mental illness because of the associated stigma. Clinical reasoning in nursing practice depends on critical thinking skills such as problem solving and decision making, where nurses must analyze, interpret, and evaluate biopsychosocial data in the context of the nursing process.
A comprehensive nursing assessment enables the nurse to make sound clinical judgments and plan appropriate interventions. Assessment skills in psychiatric nursing are essential in-patient care. Although data collection and assessment vary among clinical agencies, the psychiatric examination consists of two parts: the psychiatric history and the mental status exam. Patients are often
THE MENTAL STATUS EXAMINATION
the same basic elements. These include an assessment of the patient’s appearance, behaviors, thoughts, and moods. These are called the ABC's of MSE: (1) A-appearance, (2) B- Behavior and (3) C- Cognition which includes mood, affect and speech. Speech is a reflection of cognition (https://psychscenehub.com/ psychinsights/ten-point-guide-to-mental-state-examination-mse- in-psychiatry; Boyd, 2018). Height and weight should be documented along with nutritional status. The nurse evaluates if the patient looks the stated age since chronological age may not be a reflection of the client’s physical/mental status. For example, a patient appears in their 50s, but the actual age is 35, suggesting poor self-care or illnesses (Boyd, 2018). and culturally aware during the mental status examination. For example, American culture considers eye contact to be a sign of respect and attention, but other cultures deem eye contact as offensive, challenging, or arrogant (Boyd, 2018). accompanied by a depressed affect. However, the affect may also be described as anxious or flat, meaning that there is no facial expression of feelings. A euphoric mood is an elevated emotional state that may be associated with an affect that is giddy, cheerful, or excessively bright. A labile affect is one that is rapidly changing and unpredictable – the patient may be cheerful, then suddenly become enraged with little provocation or may burst into tears unexpectedly. A labile affect can accompany various psychiatric disease states such as depression or psychosis. Substance use can also affect the patient’s mood in many ways, depending on the degree of intoxication, the substance used, and any withdrawal symptoms. Some medications can interfere with the physical expression of an emotion, resulting in a flat or blunted affect (Boyd, 2018). A patient’s thought processes may also show flight of ideas, as in the following example: “I came here in an ambulance. I wish I had more money! Did you see that TV show about Pekingese dogs the other night?” When a patient is experiencing a flight of ideas, speech is often accelerated and thoughts are random, abruptly changing with little association between thoughts (Boyd, 2018). When assessing a patient’s thought processes, the nurse might also note the phenomenon of word salad. In a word salad, the patient’s statements have no logical connections, and the thoughts are jumbled – for example: “I don’t. Here, he said. My house. Mouse. Spouse.” The previous statement also serves as an example of clang association, which is a pattern of using words because they have similar sounds and not because of the actual meanings of the words. A patient may use neologisms or words that don’t exist in the English language. Words such as “frugelzip” or “rappeliciosity” will have a meaning that is clear only to the patient.
The mental status examination is a structured means of evaluating the psychological, physical, and emotional state of a patient with a psychiatric disorder to facilitate appropriate healthcare treatments. The nurse may also identify significant problem areas to be addressed in the treatment plan. Mental status exams are an essential tool for evaluating the safety of the patient and caregivers. Although each healthcare facility may vary slightly in its approach, all mental status exams include Appearance Appearance includes primarily objective data based on observations of the patient's general appearance. The nurse assesses the patient’s overall hygiene and grooming, considering gender, apparent age, height/weight, dress, odors, and tattoos/ piercings. Behavior The patient’s behavior should be noted during the interview. Consider any mannerisms, notable movements such as agitation, physical slowing (retarded movements), tics, or other abnormal movements. It is important for the nurse to be developmentally Mood and affect Mood is subjective (whatever the patient states) so this must be asked directly (e.g., How is your mood?) and is typically documented in quotations (Mood is "happy"). Affect is objective data (the nurse’s observations) based on clinical descriptors that take into account the tone, range, and quality, together with facial expressions and body language that reveal the emotional state or feelings of the person. Mood and affect do not necessarily have to be consistent or similar. For example, a patient may state that their mood is “fine” but through their presentation they are expressing significant difficulty in their emotions with anger, sadness, or depression. Affect is the facial expression, body language, voice, or tone that reveals the emotional state or feelings of a person (Boyd, 2018). A dysphoric mood indicates that the patient is persistently depressed, lethargic, apathetic, or “down” and is usually Thought processes Thought processes refer to the way thoughts are organized and structured. One can think of thought process as HOW one is thinking and thought content as WHAT they are thinking. Speech assessment reveals both. Normally, thoughts are logical, sequential, and easily understood by others (in the absence of a known speech or communication disorder). Patients with disorganized thoughts may respond to questions with nonsensical speech because speech often reflects the thought process. There may be difficulty in performing simple activities such as bathing or eating without assistance, even in the absence of a physical impairment. Patients may mix up or confuse medications when a structured system (such as a weekly pill dispenser) is not available. Thoughts can be rapid, racing, or slowed. Poverty of speech can occur where questions are answered with one or two words and patients may be unable to expand on responses or use their imagination. Thoughts can be either abstract or concrete (Boyd, 2018). Thought content Thought content refers to what the patient is thinking about. Initially, it is helpful to assess preoccupations or obsessions about real-life events, such as finances, employment, or relationships
(Boyd, 2018). Sometimes a patient can experience intrusive or ruminating thoughts. An intrusive thought is an unwelcome idea that occurs without conscious effort, and ruminative thoughts
Book Code: ANCCUS3023
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