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MENTAL STATUS ASSESSMENT

By Thelma Lawson,2014-08-12 14:18
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MENTAL STATUS ASSESSMENT ...

    NORFOLK STATE UNIVERSITY

    MENTAL STATUS ASSESSMENT

    Purpose

    The Mental Status Assessment is used to detect changes or abnormalities in a person’s

    intellectual function, thought content, judgment, mood and affect.

     For your practicum, do a Mini-Mental State Examination (MMSE) of your client using the topics listed below with a * behind them. You may ask questions from any of the other assessments areas as well if you feel it will help you. Rate the client in one of the three categories: 1) normal, 2) mild to moderately impaired (not needing hospitalization, but needing out-patient counseling and possibly medication) or 3) severely impaired (needing hospitalization).

    Write your observations during the interview. Develop (2) nursing diagnoses. Using your MMSE sheet with notes, explain your rating and your nursing diagnoses to your instructor by addressing at least 5 of the topics from your interview.

Considerations assess for:

    ; Possible hearing/ vision limitations

    ; Understanding of English language, cultural aspects that may influence response

    ; Level of education

    ; “handedness” (right or left dominant)

    ; Current medications or recent substance abuse that may impair cognition ; Understanding of situation and purpose of evaluation

Preparation

    ; Minimize background noise/ distraction

    ; Speak clearly eye contact

GENERAL DESCRIPTION: *

    Appearance

    age, dress, cleanliness, posture, gait, facial expressions, eye contact, pupil dilation/

    restriction, general state of health and nutrition

    Speech

     rate, volume, amount, characteristics

    Motor activity

     Level, type, unusual observations

    Interaction/Attitude

     Level of cooperation/ ability to relate

Observations

EMOTIONAL STATE:

Mood

    Affect *

     Range, duration, intensity, appropriateness

Observations

EXPERIENCES:

Perceptions *

     Hallucinations, illusions

    ; Chief complaint Why is the patient seeking treatment?* ; Characteristics of problem frequency/ duration/triggers/ patterns/ understanding/

    expectations

Observations

THINKING *

Thought content

     “what”, delusions

    Thought process

     “how”

Observations

SENSORIUM & COGNITION

    Level of consciousness Memory

Level of concentration and calculation

    Information & intelligence

    Judgement

    Insight

; Orientation person/ place/ time/ situation/ familiar objects/ other people*

    ; Language comprehension response to a series of commands “Take this paper, fold it

    in half and place it on the floor in front of you”; OR instruct patient to read and follow

    CLOSE YOUR EYES written on a card

    Fluency identify as many words starting w/ A,S, F,P in 30 sec.

    Expressive repeat statement “no ifs ands or buts”

    ; Attention/ concentration alphabet recitation, spelling word backwards

    ; Coordination/ perceptual motor integration copy geometrical object

    ; Memory recognition (find/ identify), reproduction (repeat/ copy), recall (remember w/out

    cue)

    Immediate (10-30sec) vs. delayed recall (few minutes, recent, or after intervening*

    activity)

    Short term few minutes to 1-2hours*

    Recent hours to 1-4 days*

    Recent past - last few weeks & months*

    Remote 6mths to lifetime*

    ; Fund of information - events/ things/ people

    ; Opposites hard, fast, large, out, high

    ; Similarities & differences between objects ; Calculation serial 7s

    ; Abstract reasoning proverbs “Don’t cry over spilled milk”

    I. “Rome wasn’t built in a day” *

; Practical reasoning/ social judgment general, hazard recognition*

    ; Decision making*

    ; Self image*

; Insight into illness acceptance/ accurate understanding of cause*

Observations

    *Mini-Mental State Examination (MMSE) Circle one.

    normal, mild to moderate impairment, severe impairment

    MENTAL STATUS ASSESSMENT

    I. GENERAL ATTITUDE AND BEHAVIOR

    Behavior: Cooperative; Passive; Domineering ; Withdrawn ; Restless ; Dramatic ; Hostile ; Intimidating ; Suspicious ; Uncooperative ; Other ________________________

Appearance: Unkempt ; Disheveled ; Clean ; Neat ; Unusual ;

    Attire: Appropriate ; Seductive ; Loud ; Meticulous ; Untidy ; Atypical ;

    Facial Expression: Unremarkable ; Sad ; Angry ; Perplexed ; Fearful ; Elated ; Immobile ; Grimacing ; Atypical ;

Gait: Normal ; Parkinsonian ; Ataxic ; Shuffling ; Unusual ; Other __________________

    Motor Activity: Unremarkable ; Agitated ; Hypoactive ; Tremor ; Tic ; Hyperactive ; Pacing ; Hand wringing ; Mannerisms ;

    II. STREAM OF MENTAL ACTIVITY

    Productivity: Spontaneous ; Verbose ; Pressured ; Slow ; Soft ; Mute ; Atypical ;

    Progression: Logical ; Association ; Loose Association ; Circumstantiality’s ; Perseveration ; Halting ; Incoherent ; Fragmented ; Tangential ; Flight of Ideas ; Ruminations ; Confabulation ; Neologism ;

Language: Normal ; Childlike ; Peculiar ; Stilted ;

    III. Emotional State/Reaction

    Affect: Unremarkable ; Indifferent ; Fearful ; Angry ; Euphoric ; Anxious ; Sad ;

Range: Normal ; Labile ; Constricted ;

Depth: Normal ; Shallow ; Increased ;

    Vegetative Sx of Depression: Depressed mood ; Loss of interest or pleasure ; Appetites Disturbance ; Sleep Disturbance ; Psychomotor Agitation or Retardation ; Fatigue or Loss of energy ; Decreased concentration ; Feelings of worthlessness or guilt ; Diurnal mood variation ;

Suicidal/Homicidal: Denies ; Ideation ; Plan ; Attempt ;

    IV. MENTAL TREND AND THOUGHT CONTENT

    Perception: Unremarkable ; Depersonalization ; Derealization ; Dissociation ;

Hallucinations: Auditory ; Visual ; Tactile ; Olfactory ; Gustatory ;

    Cognitive Style: Obsessive ; Self Deprecatory ; Intellectualized ; Autistic ; Global (Histrionic) ; Other: _____________________________

    Cognitive Content: Obsessions ; Phobias ; Compulsive Rituals ; Religiosity ; Ideas of Reference ; Bizarre Ideas ; Self Depreciations ; Delusions ; Nihilistic ;

Somatic ; Grandiose ; Paranoid ; Guilt ;

    V. SENSORIUM, MENTAL GRASP AND CAPACITY

    Consciousness: Alert ; Clouded ; Fluctuating ; Stuporous ;

Orientation: Normal ; Mild ; Moderate ; Severe ;

Disorientation to: Time ; Place ; Person ; Situation ;

    Memory: Intact ; Mild ; Moderate ; Severe ; Memory Deficits ;

     Immediate ; Recent ; Remote ;

    Digit span: Forward: Good ; Poor ; Backward: Good ; Poor ;

    Disorders of: Counting ; Calculation ; Reading ; Writing ; Attention ; Concentration ; Comprehension ;

    General Knowledge: Good ; Poor ; Consistent with education ;

     Inconsistent with education ; Personalized ; Superficial ; Pseudoabstraction ;

Intelligence: Normal ; Below ; Above Normal ;

Insight: Good ; Fair ; Poor ; None ;

Judgment: Good ; Fair ; Poor ; None ;

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