Performing Mental Status Examination

Definition

Mental status examination (AMSE) is an assessment of general motor behavior, thought and emotional functioning, along with evaluation of insight and judgment of the patient’s current status.

Purposes

1. Mental status examination serves as a basis for comparison, to track the progress of patient.
2. It is used to detect changes or abnormalities in a person’s psychological functioning

General instructions

1. Collect identification data before doing mental status examination.
2. Perform a physical assessment from head to toe including vital signs.
3. Provide a comfortable environment for mental status examination.
4. Prepare some questions under each aspect of mental status examination.

Format for mental status examination

General appearance and behavior

• Appearance: Looking one’s age/Older/Younger.
• Level of grooming: Well-kept/Shabbily dressed/Over dressed.
• Level of cleanliness: Adequate/Inadequate/Overly clean.
• Level of consciousness: Fully conscious and alert/Drowsy/Stuporous/ Comatosed.
• Acceptance of need for help: Reached willingly/Persuaded/Brought using physical force.
• Cooperativeness: Normal/More than normal/Less than normal.
• Eye to eye contact: Maintained/Not maintained/Difficult.
• Psychomotor activity: Normal/Increased/Decreased.
• Rapport: Spontaneous/Difficult/Not established.
• Gesturing: Normal/Exaggerated/Odd.
• Posturing: Normal posture/Catatonic posture.
• Other movements: Stereotypic/Tremors/EPS/Abnormal involuntary movements.
• Other catatonic behaviors: Automatic obedience/ Negativism/Excessive cooperation/Waxy flexibility/Echolalia/Echopraxia.
• Conversion and dissociation signs.
• Compulsive acts or rituals.
• Hallucinatory behavior: Smiling and talking to self/odd gesturing.

Speech

• Initiation: Spontaneous/Speaks when spoken to/Minimal/Mute.
• Reaction time: Normal/Delayed/Shortened/Difficult to assess.
• Rate: Normal/Slow/Rapid.
• Productivity: Monosyllabic/Elaborate replies/Pressured.
• Volume: Normal/Increased/Decreased.
• Tone: Normal variation/Monotonous.
• Relevance: Fully relevant/Sometimes off target/Irrelevant.
• Stream: Normal/Circumstantial/Tangential.
• Coherence: Fully coherent/Loss of association.
• Others: Rhyming/Punning/Neologism.
• Sample of speech (in response to open-ended questions).

Mood

• Subjective.
• Objective.
• Sad/Depressed/Despairing/Irritable/Anxious.
• Elated/Euphoric/Fearful/Guilty/Labile.
• Predominant mood state: Appropriate/Inappropriate/ Irritable/ Labile/Blunted/Flattened.

Thought

a.Stream

• Normal/Pressure of thoughts/Poverty of thought.
• Thought block/Muddled or unclear thinking/Flight of ideas

b.Form

• Normal/Formal thought disorder (Specify with a sample of speech).

c.Content

• Ideas or Delusions Worthlessness/ Hopelessness/ Helplessness/ Guilt/ Hypochondriacal/ Poverty/Nihilistic/Death wishes/Suicidal thoughts/ Grandiose/ Reference/ Persecution/ Bizarre.
• Compulsive acts/Rituals (Obsessional-compulsive phenomenon) Thoughts/ Images/Ruminations/Impulsive rituals/Doubts.
• Thought alienation phenomena
  Thought insertion/Thought withdrawal/Thought broadcasting.

Perception

• Illusion.
• Hallucination: Auditory/Visual/Olfactory/Gustatory/Tactile.
• Somatic passivity.

Cognitive functioning (Neuropsychiatric assessment)

• Conscious/Cloudy/Comatosed.
• Orientation:
• Time-Appropriate time/Day/Date/Month/Year.
• Place Name of place/Area/City.
• Person-Self/Close associates/Hospital staff.
• Attention: Normally aroused/Aroused with difficulty.
• Concentration: Normally sustained/Sustained with difficulty/Distractible.
• Ability to name month: Name of months backwards.
• Ability to name days of week: Name of weekdays backwards.
• Ability to count: Counting numbers backwards.
• Memory:
• Recent memory: Immediate events:
• Short-term memory: Recent happenings-Last meal/Last visitor.
• Long-term memory: Remote events-Childhood/Early life memories Events
•  Intelligence
• General fund of information:
• Arithmetic ability: Mental arithmetic/written sums.
• Abstraction
• Similarity between paired objects.
• Differences between paired objects.
• Interpretation of proverbs.

Insights

• Awareness of abnormal behavior/Experience.
• Attribution to physical causes.
• Recognition of personal responsibility.
• Willingness to take treatment

Judgment

• Personal: Intact/Impaired.
• Social: Intact/Impaired.

General information

• Relevance to educational background.
• Relevance to social background.

Nursing Considerations while Performing Mental Status Examination

When performing a Mental Status Examination (MSE), nurses must consider several factors to ensure accurate assessment and patient comfort. Here are the key nursing considerations:

1. Establishing a Comfortable Environment

• Conduct the examination in a quiet, private setting to minimize distractions.
• Ensure the patient feels safe and respected throughout the process.

2. Building Rapport

• Use a calm and empathetic approach to establish trust.
• Explain the purpose of the MSE to the patient to reduce anxiety or resistance.

3. Cultural and Individual Sensitivity

• Be aware of the patient’s cultural background and how it may influence their responses or behavior.
• Consider the patient’s age, education level, and language proficiency when framing questions.

4. Observation Skills

• Pay close attention to nonverbal cues, such as body language, facial expressions, and tone of voice.
• Note any inconsistencies between verbal and nonverbal communication.

5. Avoiding Bias

• Approach the assessment with an open mind, avoiding assumptions or judgments about the patient’s condition.
• Document findings objectively, focusing on observed behaviors and responses.

6. Comprehensive Assessment

• Cover all components of the MSE, including appearance, behavior, mood, thought processes, cognition, and insight.
• Use open-ended questions to encourage detailed responses.

7. Safety Considerations

• Be alert to signs of agitation or distress and adjust the approach accordingly.
• Ensure the environment is free from objects that could pose a risk if the patient becomes aggressive.

8. Documentation

• Record findings systematically and accurately for future reference.
• Highlight any significant changes or abnormalities in the patient’s mental state.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. R.Sreevani, A Guide to Mental Health & Psychiatric Nursing, 6th Edition, 2024, Jaypee Publishers, ISBN 978-9366161686
8. Sheila L. Videbeck, Psychiatric Nursing, Seventh Edition , 2017, Wolters Kluwer Publications, ISBN: 978- 1496355911
9. Voss RM, Das JM. Mental Status Examination. [Updated 2024 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546682/

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