Psychological Context of Psychiatric Nursing Care
1. Describe the nature, purpose, and process of the mental status examination.
2. Examine the observations and clinical implications of each category of the mental status examination.
3. Identify commonly used psychological tests.
4. Analyze the value of using behavioral rating scales in psychiatric nursing practice.
The mental status examination is a cornerstone in the evaluation of any patient with a medical, neurological, or psychiatric disorder that affects thought, emotion, or behavior (American Psychiatric Association, 2006). It is used to detect changes in a person’s intellectual functioning, thought content, judgment, mood, and affect. The mental status examination is to psychiatric nursing what the physical examination is to general medical nursing.
Mental Status Examination
The mental status examination represents a cross section of the patient’s psychological life and the nurse’s observations and impressions at one point in time. It involves observing the patient’s behavior and describing it in an objective, nonjudgmental manner. The elements of the examination depend on the patient’s clinical presentation, as well as on the patient’s educational and sociocultural background. It also serves as a basis for future comparison in tracking the patient’s progress over time.
The examination itself is usually divided into several parts. They can be arranged in different ways, as long as the nurse covers all the areas. Much of the information needed for the mental status examination can be gathered during the course of the routine nursing assessment. It should be integrated into the nurse’s assessment in a smooth manner.
Some parts of the mental status examination are completed through simple observation of the patient, such as noting the patient’s clothing or facial expressions. Other aspects require asking specific questions, such as those related to memory or attention span. Most of all, the nurse should remember that the mental status examination does not reflect how the patient was in the past or will be in the future. The mental status examination is an evaluation of the patient’s current state.
Information obtained during the mental status examination is used along with other objective and subjective data. These include findings from the physical examination; laboratory test results; patient history; description of the presenting problem; and information obtained from family, caregivers, and other health professionals. With these data the nurse is able to formulate nursing diagnoses and design the plan of care with the patient.
Obtaining Clinical Information
The mental status examination requires a clinical rather than social approach to the patient. The nurse listens closely to what is said and reflects on what is not said. The nurse structures the process to allow for the broad exploration of many areas, the uncovering of potential problems, and the identification of symptoms or maladaptive coping responses. The patient is observed carefully, and recorded information is specific and objective, not global or judgmental.
The skilled nurse attends to both the content and the process of the patient’s communication. Content is the overtly communicated information. Process is how the communication occurs and includes feelings, intuition, and behaviors that accompany speech and thought. The content and process may not always be congruent. For example, a patient may deny feeling depressed and yet appear sad and cry. In this case the stated message does not match the process, and the nurse should record this incongruity.
It also is important for nurses to monitor their own feelings and reactions while implementing the mental status examination. A nurse’s gut reactions may reflect subtle emotions being expressed by the patient. For example, a depressed patient may make the nurse feel sad, and a hostile patient may make the nurse feel threatened and angry. The nurse’s feelings are useful information to consider in formulating the mental status assessment of a patient. The nurse needs to be aware of these feelings and respond in a therapeutic manner toward the patient, regardless of the nature of such feelings.
The nurse should remain calm throughout the interview and simply reflect observations back to the patient. These observations should be related in an objective and nonthreatening manner, as in “You are obviously quite upset about this,” or “It seems like you don’t feel safe here.” By conveying a sense of calm, the nurse also demonstrates being in control, even if the patient is not.
The nurse should try to blend specific questions into the general flow of the interview. For example, questions about orientation, arithmetic problems, or proverbs may be introduced by talking with the patient about potential problems with concentration, memory, or understanding of written material. The nurse might then suggest that the patient try answering a few questions to determine whether such problems exist. As with any skill, nurses need to practice performing the mental status examination to gain proficiency and be comfortable with the process. The nurse might start by observing a colleague conduct the examination. Videos and simulations of patient interviews are particularly effective teaching-learning tools.
Content of the Examination
The mental status examination includes information in a number of categories (Box 6-1). It is one part of a complete psychiatric nursing assessment tool. In completing this examination, it is critically important to be aware that sociocultural factors can greatly influence the outcome of the examination (Box 6-2). The content, observations, and some of the clinical implications associated with each category are described in the following sections (Robinson, 2002).
Speech
Speech is usually described in terms of rate, volume, amount, and distinct characteristics. Rate is the speed of the patient’s speech, and volume is how loud a patient talks.
Clinical Implications
• Speech disturbances are often caused by specific brain disturbances. For example, mumbling may occur in patients with Huntington chorea, and slurring of speech may occur in intoxicated patients.
• Manic patients often show pressured speech.
• People with depression often are reluctant to speak at all.
Motor Activity
Motor activity describes the patient’s physical movement.
Clinical Implications
• Excessive body movement may be associated with anxiety, mania, or stimulant abuse.
• Little body activity may suggest depression, organic mental disorders, catatonic schizophrenia, or drug-induced stupor.
• Tics and grimaces may suggest medication side effects.
• Repeated motor movements or compulsive behavior may indicate obsessive-compulsive disorder.
• Repeated picking of lint or dirt off of clothing is sometimes associated with delirium or toxic conditions.
Interaction During the Interview
Interaction describes how the patient relates to the nurse during the interview. Because this part of the examination relies heavily on nurses’ emotional subjectivity, nurses must carefully examine their responses based on their own personal and sociocultural biases. They must guard against overinterpreting or misinterpreting patients’ behavior because of social or cultural differences between patients and nurses (Chapter 7).
Mood
Mood is the patient’s self-report of one’s emotional state and reflects the patient’s life situation.
Observations.
Mood can be evaluated by asking a simple, nonleading question, such as “How are you feeling today?” Does the patient report feeling sad, fearful, hopeless, euphoric, or anxious? Asking the patient to rate his mood on a scale of 0 to 10 can help provide the nurse with an immediate reading. It also can be valuable for comparing changes that occur during treatment.
If the potential for suicide is suspected, the nurse should ask the patient directly about thoughts of self-harm (Chapter 19). Has the patient felt the desire to harm himself or someone else? Have any previous attempts been made to cause harm, and if so, what events surrounded the attempts? To judge a patient’s suicidal or homicidal risk, the nurse should assess the patient’s plans, the patient’s ability to carry out those plans (e.g., the availability of guns), the patient’s attitude about death, and support systems available to the patient.
Affect
Affect is the patient’s apparent emotional tone. The patient’s statements of emotions and the nurse’s empathic responses provide clues to the appropriateness of the affect.
Observations.
Affect can be described in terms of the following:
Flat affect is the absence of emotional expression, as seen by a patient who reports significant life events without showing any emotional response. Other patients may demonstrate great lability in expression by undergoing frequent changes from one affective response (such as sadness) to another (happiness) quickly in the same conversation. The nurse also should assess whether the patient’s emotional response is congruent or in agreement with the speech content. For example, it would be incongruent if a patient reports being persecuted by the police and then laughs.
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