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Posted: September 4th, 2023

MSE 3

MSE 3
Name: _Richard Boateng___________________________ Date:03/12/23______________

Learning Objectives

At the end of this activity students will be able to:

1. Apply observation and assessment skills essential to mental health nursing.
2. Describe physical, cognitive, and psychosocial changes related to mental illness.
3. Identify risk factors related to mental illness, treatment and rehabilitation.
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Physical, Cognitive, and Psychosocial Changes Related to Mental Illness:
Mental 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:

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.

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.

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.

Risk Factors Related to Mental Illness, Treatment, and Rehabilitation:
Risk 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:

Genetics: Certain genetic factors may increase an individual’s risk of developing certain mental illnesses.

Environmental factors: Exposure to environmental stressors, such as trauma or abuse, can increase the risk of developing mental illness.

Lifestyle factors: Poor nutrition, lack of exercise, substance abuse, and stress can all contribute to the development of mental illness.

Lack of social support: Individuals who lack social support or who are isolated may be at increased risk of developing mental illness.

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:

Substance abuse: Individuals who struggle with substance abuse may have difficulty adhering to treatment regimens for mental illness.

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.

Limited access to healthcare: Individuals who lack access to healthcare may have difficulty receiving adequate treatment for mental illness.
4. Perform a mental status examination on patients with mental illness.

Activity Instructions

1. Select a patient from assigned unit.
2. Obtain approval from the primary RN and clinical instructor for appropriateness of patient.
3. Complete and submit the Mental Status Examination form as scheduled by your clinical instructor.
4. Review the Mental Status Examination (MSE) grading rubric.
5. Upload completed assignment to BrightSpace.

Name: ____________________________ Date: ______________

Personal Information/Demographics
Patient Name:
L.B
Admission Date and Unit RM- 1614 Admitted to:03/7/23 Age and Gender: Male
22years
Marital Status: Single Religious Preference: Christian Race: African – American
Ethnic Background: Employment: Unknown Living Arrangements: Patient lives at 711 West Schiller #204 Chicago alone. Patient part of the Williams Quinn/Colbert program and receive intensive management care.
Patient’s 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 Co-morbid Conditions: Acute Psychotic
Schizophrenia, Asthma
Mental Status Examination

What You See (list) Descriptive example (narrative)
1. Appearance (observed)
• Grooming/Clothing
• Level of hygiene
• Pupil dilation or constriction
• Facial expression
• Height, weight, nutritional status
• Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings
• Relationship between appearance and age

The patient is wearing a hospital gown and socks. The patient’s hair is uncombed, and the skin appeared disheveled.
Pupil dilated/constricting.
Patient facial expressions were relaxed and engaged with a morning greeting,
No evidence of scars or tattoos was seen on the patient’s skin.
The patient’s posture was erect in the chair and walked without additional support
The 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
Patient’s eye followed PEERLA.
2. Behavior (observed)
• Excessive or reduced body movements
• Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance and gait)
• Abnormal movements: (e.g., tardive dyskinesia, tremor/ tics/ abnormal movements)
• Level of eye contact (keep cultural differences in mind)
• Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia Patient was cooperative during the initial interview but experienced thought blocking.
Patient 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

The patient maintained good eye contact with me and the nurse.

Patient appeared to be hypoactive but was still able to participate in the group activities and communication
Patient could not answer a question without taking a break to put his thoughts together. No abnormal or peculiar body movement was observed.
Patient displays psychomotor retardation.
3. Attitude (observed)
• Ability to follow commands
• Ability to provide reliable information.
Possible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian.
Patient was able to follow simple commands.
Patient provide reliable information and it was precise.
Patient was cooperative and calm during the interview. Throughout 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.
The patient was cooperative during the interview.
4. Speech
• Rate: slow, rapid, normal
• Volume: loud, soft, normal
• Disturbances (e.g., articulation problems, slurring, stuttering, mumbling)
• Cluttering (e.g., rapid, disorganized, tongue-tied speech)
Patient speech is slow and latent.
Patient shows flatted and the tone is soft.

The patient was also willing to engage in conversation with the nurse and me. There was no evidence of slurred, stuttering speech.

5. Mood and Affect (inquired/observed)
Affect
• How the client outwardly is expressing emotion
• Appropriateness to situation
• Congruency with mood
• Congruency with thought
o Other descriptors include: broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate
Mood
• How the patient describes what they are feeling
o Possible descriptors include: labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable Patient has flat affect which is inconsistent and incongruent with his mood. He was inactive in group therapy discussions.
Patient displays average intensity in his communication.

Patient displays a flat mood process.
Patient expresses the feeling of sadness and shows anxiety that someone wants to hurt him in the right arm.

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.
The patient’s 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

According to the patient’s 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.
6. Thought (inquired/observed)
Process
• Describes the rate of thoughts, how they flow and are connected
o Possible descriptors: Linear, goal-directed, disorganized, circumstantial, tangential, loose associations, flight of ideas, coherent, incoherent, evasive, racing, thought blocking, perseveration, neologisms.
Content:
• Refers to the themes that occupy the patient’s thoughts and perceptual disturbances
o Possible descriptors: preoccupations, ideas of reference, delusions, obsessions, suicidal/homicidal ideation, rumination Patient 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.

Patient denies any thought disturbance, hallucination, and current idea of reference.

Patient denies no illusion or suicidal ideation. Throughout 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.

The patient displayed signs of disorganized, circumstantial, tangential, loose association, flight of ideas, coherent, incoherent, racing thought blocking, perseveration, and neologism.
Patient shows no signs of suicidal ideation despite the auditory hallucination during his admission.

7. Perceptual disturbances
• Hallucinations (e.g., auditory, visual)
• Illusions Patient shows no signs of auditory hallucination or delusion.
Patient displays thought disturbance, hallucination, and ideas of reference During the examination, the patient denies visual hallucinations and hearing voices.
8. Cognition
• Orientation: time, place, person
• Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose)
• Memory: remote, recent, immediate
• Attention/concentration: performance on serial sevens, spelling a word backwards
• Abstract vs concrete thinking: proverbs, involving similarities
Judgment
• Good, fair, or poor
• Impulse control
Insight
• Good, fair, partial, poor
Adaptive Coping Strategies vs Defense Mechanisms
Possible defense mechanisms:
Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression
Patient show impaired due to mood. This patient is X2 oriented place, and situation.
Patient displays confusion, clouded and stuporous.

Patient was able to recall partial events that lead to his admission based on the chart.

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.

No coping mechanisms were found in this patient

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

Throughout my observation of this patient, he displays poor insight and impaired judgment because he definitely knows what is wrong with him.

Patient displays no possible defense mechanism in solving problems of his mentally illness.
8. Safety of Self/ Others
Risk of Self/Suicidal/Self-Injury
• Fully assessed-no indicators of risk
• If yes then
o Suicidal ideation (current, past)
o Suicide attempts (hx of)
o Plans to attempt (current, past)
o Access to means
o Family history
• Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present?
• Unintentional (when delusions, demented, intoxicated, in manic stages) present?
Harm to Others/Aggression
• Fully assessed- no indication of risk identified
• If yes then
o Plan (current, past) to assault
Property Destruction
• Fully assessed- no indication of risk identified
• If yes then
o Current admission
o Hx of
Patient verbalized that he has no intention of hurting himself.
Patient shows no sign of aggressive and impulsive behavior.

Patient displays no self-harm to others in the facility

No suicidal ideation.

Patient denies harm to himself and to others.

No plans to harm- himself.

No indication of the risk of property destruction.
The patient chart on records shows that he was admitted due to Acute psychotic and Asthma but denies no sign of suicidal ideation.
Patient has not destroyed any property in the facility.

No report of the patient’s willingness to harm- himself and others as well as destroying in the hospital facility,

Feedback:

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.

However, there are a few areas where you could improve:

In the section on Appearance, you have repeated some of the information provided in the descriptive example. Try to avoid repetition in your report.

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.

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.

Overall, good job on this assignment! With a few minor revisions, your report will be even stronger.

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