NURS310 Lecture Notes - Lecture 9: Hypersexuality, Cluster B Personality Disorders, Bladder Cancer
22 Jun 2018
School
Department
Course
Professor
Mental Status Lab 2
Learning objectives
The student will:
◦Identify elements of a mental status assessment
◦Practice mental status assessment
◦Practice interviewing skills and techniques
Mental Status Assessment (MSA)
Purpose
◦Provides current assessment only
◦Assists to identify nursing needs
◦Assists to identify symptoms experienced
◦Snapshot of mental functioning
◦The first MSE maybe used as a baseline (usually on admission)
Mental Status Assessment (MSA)
Represents
◦observations and documentation of an individual’s inner experiences expressed
during an interview
How?
Observation
Questioning (direct)
Predicated on building trust and rapport
Use of therapeutic skills – open ended question – Initial question could be… How are
you?
Use reflection to direct conversation to patient’s areas of concern
Leave sensitive questions to the end of the conversation or interview
How?
Observation – more than 60% of the MSE is based on observation
The following areas require only observation:
◦Appearance,
◦Motor Activity
◦Speech
◦Affect
◦Interaction with the Interviewer
◦Judgment
◦Thought Processes
How
Direct Questioning
◦Mood – self report and always requires asking the person to report how they are
feeling
◦Most areas of cognition
◦Thought content
◦Perceptions
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◦Components
Appearance
Speech
Motor Activity
Interaction during Interview
Mood
Affect
Perceptions
Thought Content
Thought Processes
Sensorium and Cognition
ABSCATT
ABSCATT - acronym used by AHS to assist staff chart all components of the mental
status assessment
Charted in order of letters
Notice - it is not a comprehensive list as ABSCATT section Behaviour combines the areas
of Motor Activity and Interaction During Interview (thought process and perception are
a similar example)
There are many correct ways to record MSA.
MSE
formal
Informal
Frequency
Every interaction with the patient the nurse observes MSA
At least once a shift the MSA needs to be recorded or charted
Appearance
This section provides a physical description of the person in enough detail that you
could easily visualize what the person looks like.
Identifying Data – name, ethnicity, eye color, hair color, relationship status or
occupation
Age –apparent versus actual age (if known).
Body Build- small, medium or large frame and build; any physical abnormalities or
disability.
Eye Contact – sustained throughout the interview or fleeting/occasional.
Attire – very specific details of what the person is wearing, such as clothing type, color,
condition and suitability for age and setting; also include details of accessories/jewelry.
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 – statement as to general health (e.g., well-nourished
or cachexic)
Pupils – note if there is constriction or dilation (substance use) –not necessary to note if
there is no abnormalities.
Motor Activity
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find more resources at oneclass.com
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 - any unusual or repetitive movements (compulsions), tics, or
tremors noted?
Coordination – are movements fluid, intentional, coordinated, and symmetrical; any
movement disorders such as dyskinesia or akinesia
speech
Rate – rapid, slow or expected conversational rate; any delays in responding (response
latency as seen with depression and 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/quiet
Tone – well modulated
Quantity – paucity, muteness (absence of speech), pressure of speech (driven to keep
talking with increased amount) or does the person respond readily to questions and
provide sufficient information and detail or does the person require prompting
Clarity – is speech understandable, clear, and coherent? are there problems with speech
production or any accents? is speech fluent?
Interaction
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
Mood- is the person’s or patient’s self-report of their prevailing emotional state
Ask in order to get the answer as it is subjective and described in their own words.
For example, ask “how are you feeling today?”; “Rate your mod on a scale of 1 – 10 with
10 being the best mood you have ever felt.”
Emotional State
Affect- is the expression of the person’s or patient’s mood as it APPEARS to the health
profession.
Quality/Type – the predominant emotion that is expressed such as happiness, fear,
anxiety, sadness, interest, euthymic, irritable, angry, or dysphoric.
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.
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
The student will: identify elements of a mental status assessment, practice mental status assessment, practice interviewing skills and techniques. Purpose: provides current assessment only, assists to identify nursing needs, assists to identify symptoms experienced, snapshot of mental functioning, the first mse maybe used as a baseline (usually on admission) Represents: observations and documentation of an individual"s inner experiences expressed during an interview. Use of therapeutic skills open ended question initial question could be how are. Leave sensitive questions to the end of the conversation or interview. Use reflection to direct conversation to patient"s areas of concern. Observation more than 60% of the mse is based on observation. The following areas require only observation: appearance, motor activity, speech, affect, interaction with the interviewer, judgment, thought processes. Direct questioning: mood self report and always requires asking the person to report how they are feeling, most areas of cognition, thought content, perceptions, components.
