MSE 3
\nName: _Richard Boateng___________________________\t\t\t\tDate:03\/12\/23______________<\/p>\n
Learning Objectives<\/p>\n
At the end of this activity students will be able to:<\/p>\n
1.\tApply observation and assessment skills essential to mental health nursing.
\n2.\tSuperior Essay Writers Describe physical, cognitive, and psychosocial changes related to mental illness.
\n3.\tIdentify risk factors related to mental illness, treatment and rehabilitation.
\n====
\nPhysical, Cognitive, and Psychosocial Changes Related to Mental Illness:
\nMental illnesses can cause a range of physical, cognitive, and psychosocial changes in individuals, which may vary depending on the type and severity of the illness. Some common changes associated with mental illness include:<\/p>\n
Physical Changes: Mental illness can lead to changes in physical functioning, such as altered sleep patterns, changes in appetite, fatigue, and increased susceptibility to physical illnesses. Certain mental illnesses may also be associated with specific physical symptoms, such as headaches or gastrointestinal problems.<\/p>\n
Cognitive Changes: Mental illness can also affect cognitive functioning, leading to changes in memory, attention, and decision-making abilities. Some individuals may experience difficulty concentrating, processing information, and making decisions due to their mental illness.<\/p>\n
Psychosocial Changes: Mental illness can impact an individual’s social and emotional functioning, leading to changes in behavior and interpersonal relationships. Individuals with mental illness may experience social withdrawal, irritability, mood swings, and difficulties with communication.<\/p>\n
Risk Factors Related to Mental Illness, Treatment, and Rehabilitation:
\nRisk factors associated with mental illness can be classified into various categories, including biological, environmental, and lifestyle factors. Some of the most common risk factors for mental illness include:<\/p>\n
Genetics: Certain genetic factors may increase an individual’s risk of developing certain mental illnesses.<\/p>\n
Environmental factors: Exposure to environmental stressors, such as trauma or abuse, can increase the risk of developing mental illness.<\/p>\n
Lifestyle factors: Poor nutrition, lack of exercise, substance abuse, and stress can all contribute to the development of mental illness.<\/p>\n
Lack of social support: Individuals who lack social support or who are isolated may be at increased risk of developing mental illness.<\/p>\n
Effective treatment and rehabilitation for mental illness can involve a combination of pharmacological and non-pharmacological approaches. However, certain risk factors may affect an individual’s ability to respond to treatment, such as:<\/p>\n
Substance abuse: Individuals who struggle with substance abuse may have difficulty adhering to treatment regimens for mental illness.<\/p>\n
Poor social support: A lack of social support or negative social relationships can make it more difficult for individuals to adhere to treatment and maintain good mental health.<\/p>\n
Limited access to healthcare: Individuals who lack access to healthcare may have difficulty receiving adequate treatment for mental illness.
\n4.\tPerform a mental status examination on patients with mental illness.<\/p>\n
Activity Instructions<\/p>\n
1.\tSelect a patient from assigned unit.
\n2.\tObtain approval from the primary RN and clinical instructor for appropriateness of patient.
\n3.\tComplete and submit the Mental Status Examination form as scheduled by your clinical instructor.
\n4.\tReview the Mental Status Examination (MSE) grading rubric.
\n5.\tUpload completed assignment to BrightSpace.<\/p>\n
Name: ____________________________\t\t\t\t\t\t\t\t\t Date: ______________<\/p>\n
Personal Information\/Demographics
\nPatient Name:
\nL.B
\nAdmission Date and Unit RM- 1614 Admitted to:03\/7\/23\tAge and Gender: Male
\n22years
\nMarital Status: Single\tReligious Preference: Christian\tRace: African – American
\nEthnic Background:\tEmployment: Unknown\tLiving Arrangements: Patient lives at 711 West Schiller #204 Chicago alone. Patient part of the Williams Quinn\/Colbert program and receive intensive management care.
\nPatient\u2019s Reason for Admission\/ Chief Complaint: Patient is a 22year male who presents in ED with Psychiatric behavior and was brought CFD with the social worker. The patient is delusional and states he needs treatment for foreign radiation\tCo-morbid Conditions: Acute Psychotic
\nSchizophrenia, Asthma
\nMental Status Examination<\/p>\n
What You See (list)\tDescriptive example (narrative)
\n1. Appearance (observed)
\n\u2022\tGrooming\/Clothing
\n\u2022\tLevel of hygiene
\n\u2022\tPupil dilation or constriction
\n\u2022\tFacial expression
\n\u2022\tHeight, weight, nutritional status
\n\u2022\tEvidence of scars\/ abrasions\/ bruises\/ tattoos\/ or other physical markings
\n\u2022\tRelationship between appearance and age<\/p>\n
The patient is wearing a hospital gown and socks. The patient\u2019s hair is uncombed, and the skin appeared disheveled.
\nPupil dilated\/constricting.
\nPatient facial expressions were relaxed and engaged with a morning greeting,
\nNo evidence of scars or tattoos was seen on the patient\u2019s skin.
\nThe patient\u2019s posture was erect in the chair and walked without additional support
\nThe patient was a 22-year-old African American who is short with disheveled hair that was not combed. His hygiene appeared good except for his hair. The patient had no foul smell and his cloth appeared to be clean. He looks age appropriate and there is no evidence of scars, bruises, tattoos, or any other marks on his skin
\nPatient\u2019s eye followed PEERLA.
\n2. Behavior (observed)
\n\u2022\tExcessive or reduced body movements
\n\u2022\tPeculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance and gait)
\n\u2022\tAbnormal movements: (e.g., tardive dyskinesia, tremor\/ tics\/ abnormal movements)
\n\u2022\tLevel of eye contact (keep cultural differences in mind)
\n\u2022\tPossible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia\tPatient was cooperative during the initial interview but experienced thought blocking.
\nPatient displayed no evidence of tremors\/abnormal movement. Patient was focused, not scanning the environment or repetitive gesture. Balance and gait are normal. Patient shows evidence of psychomotor retardation<\/p>\n
The patient maintained good eye contact with me and the nurse.<\/p>\n
Patient appeared to be hypoactive but was still able to participate in the group activities and communication
\nPatient could not answer a question without taking a break to put his thoughts together. No abnormal or peculiar body movement was observed.
\nPatient displays psychomotor retardation.
\n3. Attitude (observed)
\n\u2022\tAbility to follow commands
\n\u2022\tAbility to provide reliable information.
\nPossible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter\/good historian.
\nPatient was able to follow simple commands.
\nPatient provide reliable information and it was precise.
\nPatient was cooperative and calm during the interview.\tThroughout the interview, my patient was able to follow commands and answer questions in sequential order. Patient verbalized the reason for his admission stating hearing of voice as well as going to the sky for the invention of radiation.
\nThe patient was cooperative during the interview.
\n4. Speech
\n\u2022\tRate: slow, rapid, normal
\n\u2022\tVolume: loud, soft, normal
\n\u2022\tDisturbances (e.g., articulation problems, slurring, stuttering, mumbling)
\n\u2022\tCluttering (e.g., rapid, disorganized, tongue-tied speech)
\nPatient speech is slow and latent.
\nPatient shows flatted and the tone is soft.<\/p>\n
The patient was also willing to engage in conversation with the nurse and me. There was no evidence of slurred, stuttering speech.<\/p>\n
5. Mood and Affect (inquired\/observed)
\nAffect
\n\u2022\tHow the client outwardly is expressing emotion
\n\u2022\tAppropriateness to situation
\n\u2022\tCongruency with mood
\n\u2022\tCongruency with thought
\no\tOther descriptors include: broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate
\nMood
\n\u2022\tHow the patient describes what they are feeling
\no\tPossible descriptors include: labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable\tPatient has flat affect which is inconsistent and incongruent with his mood. He was inactive in group therapy discussions.
\nPatient displays average intensity in his communication.<\/p>\n
Patient displays a flat mood process.
\nPatient expresses the feeling of sadness and shows anxiety that someone wants to hurt him in the right arm.<\/p>\n
Upon observation of the patient, he did not say a word and did actively engage in group activities. Patient was calm and hostile to the group.
\nThe patient\u2019s chart described his mood and affect as flat and also appeared to be depressed. Patient is not cooperative, intelligence is average as well as poor insight and judgment<\/p>\n
According to the patient\u2019s chart on 03\/12\/23, he always sits with his peer mate but engages solemnly. The patient was found to be sadder, with more depression and lower energy. He was seen in the dining room sitting calmly and quite with his peers.
\n6. Thought (inquired\/observed)
\nProcess
\n\u2022\tSuperior Essay Writers Describes the rate of thoughts, how they flow and are connected
\no\tPossible descriptors: Linear, goal-directed, disorganized, circumstantial, tangential, loose associations, flight of ideas, coherent, incoherent, evasive, racing, thought blocking, perseveration, neologisms.
\nContent:
\n\u2022\tRefers to the themes that occupy the patient\u2019s thoughts and perceptual disturbances
\no\tPossible descriptors: preoccupations, ideas of reference, delusions, obsessions, suicidal\/homicidal ideation, rumination\tPatient thought process is circumstantial. Patient shows disorganized of thought process and is content with delusion, paranoid. The patient exhibited thought blocking and provided direct and appropriate answers to my questions and conversation.<\/p>\n
Patient denies any thought disturbance, hallucination, and current idea of reference.<\/p>\n
Patient denies no illusion or suicidal ideation.\tThroughout my observation on this patient, his thought process was circumstantial and disorganized. He responded to some of the answers were a loose of association. Patient was in delusional stage throughout our conservation. Patient was presented to the ED according to his chart with paranoid delusion that people are trying to hurt him.<\/p>\n
The patient displayed signs of disorganized, circumstantial, tangential, loose association, flight of ideas, coherent, incoherent, racing thought blocking, perseveration, and neologism.
\nPatient shows no signs of suicidal ideation despite the auditory hallucination during his admission.<\/p>\n
7. Perceptual disturbances
\n\u2022\tHallucinations (e.g., auditory, visual)
\n\u2022\tIllusions \tPatient shows no signs of auditory hallucination or delusion.
\nPatient displays thought disturbance, hallucination, and ideas of reference\tDuring the examination, the patient denies visual hallucinations and hearing voices.
\n8. Cognition
\n\u2022\tOrientation: time, place, person
\n\u2022\tLevel of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose)
\n\u2022\tMemory: remote, recent, immediate
\n\u2022\tAttention\/concentration: performance on serial sevens, spelling a word backwards
\n\u2022\tAbstract vs concrete thinking: proverbs, involving similarities
\nJudgment
\n\u2022\tGood, fair, or poor
\n\u2022\tImpulse control
\nInsight
\n\u2022\tGood, fair, partial, poor
\nAdaptive Coping Strategies vs Defense Mechanisms
\nPossible defense mechanisms:
\nDenial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression
\nPatient show impaired due to mood. This patient is X2 oriented place, and situation.
\nPatient displays confusion, clouded and stuporous.<\/p>\n
Patient was able to recall partial events that lead to his admission based on the chart.<\/p>\n
The patient directs poor insight and impaired judgment because he is not able to say any coping mechanism, he will use to experience a crisis.<\/p>\n
No coping mechanisms were found in this patient<\/p>\n
In my observation of this patient, he was not able to assess abstract and concrete cognition. His Alert and orientation was X2 to person, place, and situation<\/p>\n
Throughout my observation of this patient, he displays poor insight and impaired judgment because he definitely knows what is wrong with him.<\/p>\n
Patient displays no possible defense mechanism in solving problems of his mentally illness.
\n8. Safety of Self\/ Others
\nRisk of Self\/Suicidal\/Self-Injury
\n\u2022\tFully assessed-no indicators of risk
\n\u2022\tIf yes then
\no\tSuicidal ideation (current, past)
\no\tSuicide attempts (hx of)
\no\tPlans to attempt (current, past)
\no\tAccess to means
\no\tFamily history
\n\u2022\tNon-suicidal self-injury (cutting, scratching, or other self-mutilation) present?
\n\u2022\tUnintentional (when delusions, demented, intoxicated, in manic stages) present?
\nHarm to Others\/Aggression
\n\u2022\tFully assessed- no indication of risk identified
\n\u2022\tIf yes then
\no\tPlan (current, past) to assault
\nProperty Destruction
\n\u2022\tFully assessed- no indication of risk identified
\n\u2022\tIf yes then
\no\tCurrent admission
\no\tHx of
\nPatient verbalized that he has no intention of hurting himself.
\nPatient shows no sign of aggressive and impulsive behavior.<\/p>\n
Patient displays no self-harm to others in the facility<\/p>\n
No suicidal ideation.<\/p>\n
Patient denies harm to himself and to others.<\/p>\n
No plans to harm- himself.<\/p>\n
No indication of the risk of property destruction.
\nThe patient chart on records shows that he was admitted due to Acute psychotic and Asthma but denies no sign of suicidal ideation.
\nPatient has not destroyed any property in the facility.<\/p>\n
No report of the patient\u2019s willingness to harm- himself and others as well as destroying in the hospital facility,<\/p>\n
Feedback:<\/p>\n
Overall, your Mental Status Examination (MSE) report is well-done. You have effectively provided a thorough assessment of the patient’s mental state based on your observations and interactions with him. Your report covers all the required elements of the MSE, and you have included descriptive examples to support your findings.<\/p>\n
However, there are a few areas where you could improve:<\/p>\n
In the section on Appearance, you have repeated some of the information provided in the descriptive example. Try to avoid repetition in your report.<\/p>\n
In the section on Speech, you have described the patient’s speech as “slow and latent,” but you have not provided any additional information or examples to support this observation. It would be helpful to provide some additional details, such as the patient’s tone, fluency, and coherence.<\/p>\n
In the section on Mood and Affect, you have not provided a clear – description of the patient’s mood. Instead, you have focused primarily on his affect. Make sure to provide a separate – description of the patient’s mood, including any observations of his emotional state or subjective reports of his feelings.<\/p>\n
Overall, good job on this assignment! With a few minor revisions, your report will be even stronger.<\/p>\n","protected":false},"excerpt":{"rendered":"
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