Components of MSE (mental status exam)
Appearance, Behavior, Cognition, Thought Processes and Perceptions
Appearance (MSE)
Appearance: grooming; Attitude: cooperative, guarded, tense; Activity: physical
movements inappropriate/incongruent with the context.
Level of Consciousness (MSE)
Facial expression
Speech
Mood and Affect - how you present your mood
Cognitive Functions (MSE)
Orientation (person, place, time can include season and time of day)
Attention span
Recent memory
Remote memory
Judgement
Mini Mental State Exam (MMSE) is used when cognitive function is declining
Thought Process (MSE)
Thought Process: logical, coherent, and relevant, do they help problem solve
Thought Content: what client is thinking about
Perception: Should reflect reality
Further screening may be indicated if person expresses hopelessness, despair,
extreme sadness - suicidal ideation
Screen for Suicidal Thoughts
,When a person expressed feelings of sadness, hopelessness, despair, or grief, it
is important to assess any possible risk of physical harm.
Begin with general questions; if affirmative then continue with more specific
questions.
Have you ever felt so blue you thought of hurting yourself? Do you feel like
hurting yourself now? Do you have a plan to hurt yourself? How would you do
it? What would happen if you were dead? How would other people react if you
were dead?
Mini-Mental State Examination (MMSE)
Brief 30-point questionnaire test that is used to screen for cognitive impairment;
commonly used to screen for dementia and delirium.
MMSE Evaluates
orientation, registration, attention and calculation, recall, language.
Disadvantages of MMSE
Fails to identify mild, global deficits
Fails to identify well-educated pts with significant deficits
Education dependent (scores likely to be lower in patients with less than an 8th
grade education
Relevance of MMSE
It depends on the nurse learning how to use the tool correctly to ensure
credibility and reliability of the results. Nurses need to learn these before using
the tool: administering the MMSE, Scoring the MMSE, Interpreting the score
Documentation
Subjective: whatever the client states, use quotes
Objective: uses factual language, what is actually observed, avoid assumptions,
judgements, inferences about behaviors/actions
What is aging?
,A natural process of our lives. As we age, we experience gradual changes to our
brains and bodies. Some of these changes affect our physical and mental
abilities, and may increase our risk of disease.
Factors that Affect Aging
Genetics, Lifestyle, Environment
Mild Cognitive Impairment (MCI)
represents a transitional state between the cognitive changes of normal aging
and very early disease
Dementia
a slowly progressive decline in mental abilities, including memory, thinking,
and judgment, that is often accompanied by personality changes
Signs of Memory Loss as part of Normal Aging
You're able to remember details of conversation or event that took place a year
ago.
You're unable to remember the name of acquaintance
You forget things and events occasionally
Occasionally have difficulty with words
Signs of Dementia
-worsening ability to remember NEW information
-progressive deterioration in cognitive functioning and ability to solve problems
and learn new skills
-inability to perform ADLs
-anxiety
-mood lability
-depression
-hallucinations
-delusions
What is mental health?
includes our emotional, psychological, and social well-being. It affects how we
think, feel, and act. It also helps determine how we handle stress, relate to
, others, and make choices. Mental health is important at every stage of life, from
childhood and adolescence through adulthood
Anxiety in older adults
May have anxiety due to financial problems related to housing and medical
expenses. Feeling vulnerable, fear of the unknown may also contribute
May manifest as confusion, behaviour changes, or withdrawal
Assessment should include questions about loss of significant others, relocation,
fears about future self-care abilities, alcohol or drug use, and perceptions on
effectiveness of coping methods
Anxiety can be:
constructive (ex: mild - causes you to study for a test). But when it becomes
moderate or severe more issues arise (increase BP & HR, narrowed perception
of information, disorganized & distorted thinking, physical & emotional
fatigue)
generalized anxiety disorder
chronic worrying on daily basis for 6+ months. Worrying is out of proportion
with reality. Other signs & symptoms of anxiety are included
Phobic Disorder (Phobia)
person manifests exaggerated fear (commonly insects, animals, life experiences
such as roller coasters, etc)
obsessive-compulsive disorder (OCD)
manifested by the performance of an anxiety-relieving ritual (compulsion) to
terminate a disturbing, persistent, and recurring thought (obsession) (ex:
cleaning, checking, counting, touching, repeating)
post-traumatic stress disorder (PTSD)
a delayed anxiety response 3+ months after an emotionally traumatic experience
Nursing Interventions for Anxiety
Build trust: be available & attentive to needs. Don't leave them alone
(abandonment can escalate anxiety)
Restore comfort: ask client to suggest what may be comforting (nonverbal
Appearance, Behavior, Cognition, Thought Processes and Perceptions
Appearance (MSE)
Appearance: grooming; Attitude: cooperative, guarded, tense; Activity: physical
movements inappropriate/incongruent with the context.
Level of Consciousness (MSE)
Facial expression
Speech
Mood and Affect - how you present your mood
Cognitive Functions (MSE)
Orientation (person, place, time can include season and time of day)
Attention span
Recent memory
Remote memory
Judgement
Mini Mental State Exam (MMSE) is used when cognitive function is declining
Thought Process (MSE)
Thought Process: logical, coherent, and relevant, do they help problem solve
Thought Content: what client is thinking about
Perception: Should reflect reality
Further screening may be indicated if person expresses hopelessness, despair,
extreme sadness - suicidal ideation
Screen for Suicidal Thoughts
,When a person expressed feelings of sadness, hopelessness, despair, or grief, it
is important to assess any possible risk of physical harm.
Begin with general questions; if affirmative then continue with more specific
questions.
Have you ever felt so blue you thought of hurting yourself? Do you feel like
hurting yourself now? Do you have a plan to hurt yourself? How would you do
it? What would happen if you were dead? How would other people react if you
were dead?
Mini-Mental State Examination (MMSE)
Brief 30-point questionnaire test that is used to screen for cognitive impairment;
commonly used to screen for dementia and delirium.
MMSE Evaluates
orientation, registration, attention and calculation, recall, language.
Disadvantages of MMSE
Fails to identify mild, global deficits
Fails to identify well-educated pts with significant deficits
Education dependent (scores likely to be lower in patients with less than an 8th
grade education
Relevance of MMSE
It depends on the nurse learning how to use the tool correctly to ensure
credibility and reliability of the results. Nurses need to learn these before using
the tool: administering the MMSE, Scoring the MMSE, Interpreting the score
Documentation
Subjective: whatever the client states, use quotes
Objective: uses factual language, what is actually observed, avoid assumptions,
judgements, inferences about behaviors/actions
What is aging?
,A natural process of our lives. As we age, we experience gradual changes to our
brains and bodies. Some of these changes affect our physical and mental
abilities, and may increase our risk of disease.
Factors that Affect Aging
Genetics, Lifestyle, Environment
Mild Cognitive Impairment (MCI)
represents a transitional state between the cognitive changes of normal aging
and very early disease
Dementia
a slowly progressive decline in mental abilities, including memory, thinking,
and judgment, that is often accompanied by personality changes
Signs of Memory Loss as part of Normal Aging
You're able to remember details of conversation or event that took place a year
ago.
You're unable to remember the name of acquaintance
You forget things and events occasionally
Occasionally have difficulty with words
Signs of Dementia
-worsening ability to remember NEW information
-progressive deterioration in cognitive functioning and ability to solve problems
and learn new skills
-inability to perform ADLs
-anxiety
-mood lability
-depression
-hallucinations
-delusions
What is mental health?
includes our emotional, psychological, and social well-being. It affects how we
think, feel, and act. It also helps determine how we handle stress, relate to
, others, and make choices. Mental health is important at every stage of life, from
childhood and adolescence through adulthood
Anxiety in older adults
May have anxiety due to financial problems related to housing and medical
expenses. Feeling vulnerable, fear of the unknown may also contribute
May manifest as confusion, behaviour changes, or withdrawal
Assessment should include questions about loss of significant others, relocation,
fears about future self-care abilities, alcohol or drug use, and perceptions on
effectiveness of coping methods
Anxiety can be:
constructive (ex: mild - causes you to study for a test). But when it becomes
moderate or severe more issues arise (increase BP & HR, narrowed perception
of information, disorganized & distorted thinking, physical & emotional
fatigue)
generalized anxiety disorder
chronic worrying on daily basis for 6+ months. Worrying is out of proportion
with reality. Other signs & symptoms of anxiety are included
Phobic Disorder (Phobia)
person manifests exaggerated fear (commonly insects, animals, life experiences
such as roller coasters, etc)
obsessive-compulsive disorder (OCD)
manifested by the performance of an anxiety-relieving ritual (compulsion) to
terminate a disturbing, persistent, and recurring thought (obsession) (ex:
cleaning, checking, counting, touching, repeating)
post-traumatic stress disorder (PTSD)
a delayed anxiety response 3+ months after an emotionally traumatic experience
Nursing Interventions for Anxiety
Build trust: be available & attentive to needs. Don't leave them alone
(abandonment can escalate anxiety)
Restore comfort: ask client to suggest what may be comforting (nonverbal
