Maladaptive Pattern of Behavior B. 2.

Hygiene
Mental Health Status a. Note evidence of body or breath odor.
b. Note condition of skin, fingernails.
Learning Objectives:
At the end of the topic, the student will be able to: B. 3. Posture
1. Remember the components of Mental Status a. Note if standing upright, rigid, slumped over.
Examination. B. 4. Height and weight
2. Understand each component when conducting MSE. a. Perform accurate measurements.
3. Apply the principles in gathering the right information B.5. Level of eye contact
about the client’s mental status. a. Intermittent?
4. Analyze information gathered from the client during b. Occasional and fleeting?
interview. c. Sustained and intense?
5. Create and develop appropriate plan of care for the d. No eye contact?
client with mental illness. B. 6. Hair color and texture
a. Is hair clean and healthy-looking?
The mental status examination is a description of all the b. Greasy, matted, tangled?
areas of the client’s mental functioning. The following are the B. 7. Evidence of scars, tattoos, or other distinguishing skin
components that are considered critical in the assessment of a marks
client’s mental status. Examples of interview questions and
criteria for assessment are included.
a. Note any evidence of swelling or bruises.
b. Birth marks?
A. Identifying Data c. Rashes?
1. Name 8. Evaluation of client’s appearance compared with
2. Gender chronological age
3. Age
a. How old are you? C. Motor Activity
b. When were you born? C. 1. Tremors
4. Race/culture a. Do hands or legs tremble?
a. What country did you (your ancestors) come from? • Continuously?
5. Occupational/financial status • At specific times?
a. How do you make your living? C. 2. Tics or other stereotypical movements
b. How do you obtain money for your needs? a. Any evidence of facial tics?
6. Educational level b. Jerking or spastic movements?
a. What was the highest grade level you completed in C.3. Mannerisms and gestures
school? a. Specific facial or body movements during
7. Significant other conversation?
a. Are you married? b. Nail biting?
b. Do you have a significant relationship with another c. Covering face with hands?
person? d. Grimacing?
8. Living arrangements C.4. Hyperactivity
a. Do you live alone? a. Gets up and down out of chair.
b. With whom do you share your home? b. Paces.
9. Religious preference c. Unable to sit still
a. Do you have a religious preference? C.5. Restlessness or agitation
10. Allergies a. Lots of fidgeting.
a. Are you allergic to anything? b. Clenching hands
b. Foods? Medications? C.6. Aggressiveness
11. Special diet considerations a. Overtly angry and hostile.
a. Do you have any special diet requirements? b. Threatening.
b. Diabetic? Low sodium? c. Uses sarcasm
12. Chief complaint C.7. Rigidity
a. For what reason did you come for help today? a. Sits or stands in a rigid position.
b. What seems to be the problem? b. Arms and legs appear stiff and unyielding.
13. Medical diagnosis C.8. Gait patterns
a. Any evidence of limping?
B. General Description b. Limitation of range of motion?
B.1 Appearance c. Ataxia?
B.1.1 Grooming and dress d. Shuffling?
a. Note unusual modes of dress. C.9. Echopraxia
b. Evidence of soiled clothing? a. Evidence of mimicking the actions of
c. Use of makeup? others?
d. Neat; unkempt? C.10. Psychomotor retardation
a. Movements are very slow.
 b. Thinking and speech are very slow. F5. Euphoric
c. Posture is slumped a. Demonstrates a heightened sense of
C11. Freedom of movement (range of motion) elation.
a. Note any limitation in ability to move. b. Expresses feelings of grandeur
(“Everything is wonderful!”).
D. Speech Patterns F6. Fearful
D1. Slowness or rapidity of speech a. Demonstrates or verbalizes feeling of
Note whether speech seems very rapid or slower than apprehension associated with real or perceived
normal. danger.
D2. Pressure of speech F7. Guilty
a. Note whether speech seems frenzied. a. Expresses a feeling of discomfort
b. Unable to be interrupted? associated with real or perceived wrongdoing.
D3. Intonation b. May be associated with feelings of
a. Are words spoken with appropriate sadness and despair.
emphasis? F8. Labile
b. Are words spoken in monotone, without a. Exhibits mood swings that range from
emphasis? euphoria to depression or anxiety
D4. Volume
a. Is speech very loud? Soft? G. Affect
b. Is speech low-pitched? High-pitched? G1. Congruence with mood
D5. Stuttering or other speech impairments a. Outward emotional expression is
a. Hoarseness? consistent with mood (e.g. if depressed, emotional
b. Slurred speech? expression is sadness, eyes downcast, may be crying).
D6. Aphasia G2. Constricted or blunted
a. Difficulty forming words a. Minimal outward emotional expression is
b. Use of incorrect words observed.
c. Difficulty thinking of specific words G3. Flat
d. Making up words (neologisms) a. There is an absence of outward emotional
expression.
E. General Attitude G4. Appropriate
E1. Cooperative/uncooperative a. The outward emotional expression is what
a. Answers questions willingly. would be expected in a certain situation (e.g.
b. Refuses to answer questions crying upon hearing of a death).
E2. Friendly/hostile/defensive G5. Inappropriate
a. Is sociable and responsive. a. The outward emotional expression is
b. Is sarcastic and irritable. incompatible with the situation (e.g.,
E3. Uninterested/apathetic laughing upon hearing of a death).
a. Refuses to participate in interview
process. H. Thought Processes
E4. Attentive/interested Form of Thought
a. Actively participates in interview process. 1. Flight of ideas
E5. Guarded/suspicious a. Verbalizations are continuous and rapid,
a. Continuously scans the environment. and flow from one to another.
b. Questions motives of interviewer. 2. Associative looseness
c. Refuses to answer questions. a. Verbalizations shift from one unrelated
topic to another.
F. Emotions 3. Circumstantiality
F1. Mood a. Verbalizations are lengthy and tedious,
F1.1 Depressed; despairing and because of numerous details, are delayed
a. An overwhelming feeling of reaching the intended point.
sadness 4. Tangentiality
b. Loss of interest in regular a. Verbalizations that are lengthy and
activities tedious, and never reach an intended point
F2. Irritable 5. Neologisms
a. Easily annoyed and provoked to anger. The individual is making up nonsensical
F3. Anxious sounding words, which only have meaning
a. Demonstrates or verbalizes feeling of to him or her
apprehension. 6. Concrete thinking
F4. Elated a. Thinking is literal; elemental.
a. Expresses feelings of joy and intense b. Absence of ability to think abstractly.
pleasure. c. Unable to translate simple proverbs
b. Is intensely optimistic. 7. Clang associations
 a. Speaking in puns or rhymes; using words (e.g.,“If you step on a crack, you break your mother’s
that sound alike but have different meanings. back!”)
8. Word salad 6. Religiosity
a. Using a mixture of words that have no a. Is the individual demonstrating obsession
meaning together; sounding incoherent with religious ideas and behavior?
9. Perseveration 7. Phobias
a. Persistently repeating the last word of a a. Is there evidence of irrational fears (of a specific
sentence spoken to the client. (e.g., Ns: “George, it’s object, or a social situation)?
time to go to lunch.” George: “lunch, lunch, lunch, 8. Poverty of content
lunch”). a. Is little information conveyed by the client because
10. Echolalia of vagueness or stereotypical statements or clichés?
a. Persistently repeating what another person
says. Perceptual Disturbances
11. Mutism 1. Hallucinations (Is the person experiencing
a. Does not speak (either cannot or will not). unrealistic sensory perceptions?)
12. Poverty of speech a. Auditory (Is the individual hearing voices
a. Speaks very little; may respond in or other sounds that do not exist?)
monosyllables. b. Visual (Is the individual seeing images
13. Ability to concentrate and disturbance of attention that do not exist?)
a. Does the person hold attention to the topic c. Tactile (Does the individual feel
at hand? unrealistic sensations on the skin?)
b. Is the person easily distractible? d. Olfactory (Does the individual smell
odors that do not exist?)
Content of Thought e. Gustatory (Does the individual have a
1. Delusions (Does the person have unrealistic ideas false perception of an unpleasant taste?)
or beliefs?) 2. Illusions
a. Persecutory: A belief that someone is out a. Does the individual misperceive or
to get him or her is some way (e.g., “The FBI will be misinterpret real stimuli within the environment?
here at any time to take me away.”). (Sees something and thinks it is something else?)
b. Grandiose: An idea that he or she is all- 3. Depersonalization (altered perception of the self)
powerful or of great importance (e.g., “I am the a. The individual verbalizes feeling “outside
king...and this is my kingdom! I can do anything!”). the body;” visualizing him- or herself from
c. Reference: An idea that whatever is afar
happening in the environment is about him or her 4. Derealization (altered perception of the
(e.g., “Just watch the movie on TV tonight. It is about environment)
my life.”) a. The individual verbalizes that the
d. Control or influence: A belief that his or environment feels “strange or unreal.” A
her behavior and thoughts are being controlled by feeling that the surroundings have changed
external forces (e.g., “I get my orders from Channel
27. I do only what the forces dictate.”). Sensorium and Cognitive Ability
e. Somatic: A belief that he or she has a 1. Level of alertness/consciousness
dysfunctional body part (e.g., “My heart is at a a. Is the individual clear-minded and attentive to the
standstill. It is no longer beating.”). environment?
f. Nihilistic: A belief that he or she, or a part b. Or is there disturbance in perception and
of the body, or even the world does not exist or has awareness of the surroundings?
been destroyed (e.g., “I am no longer alive.”). 2. Orientation. Is the person oriented to the following?
2. Suicidal or homicidal ideas a. Time
a. Is the individual expressing ideas of b. Place
harming self or others? c. Person
3. Obsessions d. Circumstances
a. Is the person verbalizing about a 3. Memory
persistent thought or feeling that he or she is a. Recent (Is the individual able to remember
unable to eliminate from their occurrences of the past few days?)
consciousness? b. Remote (Is the individual able to remember
4. Paranoia/suspiciousness occurrences of the distant past?)
a. Continuously scans the environment. c. Confabulation (Does the individual fill in memory
b. Questions motives of interviewer. gaps with experiences that have no basis in fact?)
c. Refuses to answer questions 4. Capacity for abstract thought
5. Magical thinking a. Can the individual interpret proverbs correctly? m
a. Is the person speaking in a way that “What does ‘no use crying over spilled milk’ mean?”
indicates his or her words or actions have power? Impulse Control
 1. Ability to control impulses. (Does psychosocial
history reveal problems with any of the following?)
a. Aggression
b. Hostility
c. Fear
d. Guilt
e. Affection
f. Sexual feelings
Judgment and Insight
1. Ability to solve problems and make decisions
a. What are your plans for the future?
b. What do you plan to do to reach your
goals?
2. Knowledge about self
a. Awareness of limitations
b. Awareness of consequences of actions
c. Awareness of illness
• “Do you think you have a problem?”
• “Do you think you need treatment?”
3. Adaptive/maladaptive use of coping strategies and
ego defense mechanisms (e.g., rationalizing
maladaptive behaviors, projection of blame,
displacement of anger)

References:
Townsend, M.C. (2015). Psychiatric Mental Health Nursing:
Concepts of Care in Evidence- Based Practice 8th ed.
Halter, Margaret Jordan. (2018). Varcarolis’ Foundations of
Psychiatric-Mental Health Nursing: A Clinical Approach, 8th
ed. Elsevier Inc

Thank you
Prof. L. C. Balao, RN, MAN, MA-PSYCHOLOGY