Question

I need an example of a mental status exam for a client who is on haldol, hears voices, paces the halls, agitated unless on medication, and has a nursing diagnosis of altered mental status.

Thank you for your help!

Answer 1

Your data is not sufficient to write a specific MSE, but here I am trying to explain generally

MSE(mental status examination) is a psychological status examination of a patient, it includes both subjective data by patient and observation by clinicians.

Components of MSE with the example

1. Appearance- body builds, posture, dress, grooming of patient and see any physical abnormality. because of a patient in a mental disorder having self-care deficit and they also have primary senses deficit like hunger, thirst.

we also have to examine the level of alertness, behavior towards examiners like co-operative or not and facial expression of the patient.

2.The behavior of patient- like example stereotype behavior.

eye contact of the patient towards examiner, Psychomotor activity example agitation. abnormal physical activity like thumb sucking.

3. Speech pattern- Rate of speech like increase or pressured, decrease or monosyllabic.

Rhythm- slurred, articulation, dysarthria, monotone.

The volume of voice like loud, smooth, mute.

4.Mood- (It is subjective data)

the mood of a patient, example - depressed, sad, angry, good, anxious, irritable

5. Affect- it is objective data

like type euthymic, dysphoric, euphoric

see mood congruent vs mood-incongruent

see stable vs labile

6. Thought process- Examine the thought process by asking some question, whether it is normal(logical, liner and goal-directed) or it is abnormal(association are not clear and disorganized)

example- circumstantial, tangentially, the flight of ideas, word salad

7.Thought content- Delusion, Hallucination, Derealisation, ideas of reference.

8. Cognition- we have to see the level of consciousness, the concentration and attention of the patient like the ability to focus. the memory of the patient(long, short, immediate)

9. Insight and judgment- the patient is aware of his own illness or about his own situation or not.

the patient is able to take the right decision regarding her health and safety.