In documenting a mental status exam (MSE) for Janet, a 54-year-old female
In documenting a mental status exam (MSE) for Janet, a 54-year-old female, you note that she is flat and bradykinesic. In addition to these findings, she has poverty of speech, is depressed, and appears “spacey.” Her affect is blunted and her speech is slow, deliberate, and pressured. The PMHNP documents this as a “flat affect” in the “Assessment” section of the MSE
By documenting observation, assessment, and analysis (O-A-A) in the mental status exam, you can provide information to help the PMHNP prioritize nursing diagnoses and plan patient care. Janet’s PMHNP notes on her MSE that she is bradykinetic, has poverty of speech, is depressed, and appears flat.
Nursing Assessment & Diagnosis: Janet is a 54-year-old Hispanic female with a history of type II diabetes mellitus and prior myocardial infarction who presents to the emergency department with crushing chest pain and shortness of breath that suddenly occurred while she was eating dinner. Her pulse is 72 beats per minute with a blood pressure of 138/70 (BP) while lying on a cardiac monitor. Her skin is pale, warm, and dry and she complains of right-sided chest pain. On examination, she is diaphoretic, appears pale, and exhibits lethargy, restlessness and a feeling of being uneasy. The PMHNP performs an MSE on Janet which reveals bradykinesia, poverty of speech and depression utilizing all key information described in the above section.
In documenting a mental status examination (MSE) of Janet, the nurse practitioner includes all the following elements of a physical examination except:
Examination of Janet, a 54-year-old female with a diagnosis of schizophrenia, revealed the following. She was alert and oriented to name, date, and place. Her mental status examination showed that she was bradykinesic, but she still responded appropriately to questions. She spoke slowly and softly but had no problems with comprehension of questions. She stated that she had trouble sleeping at night, evidenced by her sleeplessness during the day. Her affect was appropriate for her age and overall presentation; her mood was depressed although she did not cry while speaking with the clinician.
Which of the following elements is not part of a physical mental status exam in terms of recording a patient’s appearance?
Ackerman’s psychosocial health assessment is a technique used to assess the physical status of an individual. It concludes that there is a positive correlation between physical state and mental state. The objective of this assessment method is to determine whether the patient is physically fit or not and receive an appropriate plan for treatment.
The physical examination shows vital signs within normal limits. The hair is brown with gray roots. The skin is clear and the mucous membranes are pink without lesions or exudates. There is no edema present peripherally or in the sacral area. The nurse performs a complete neurovascular assessment that reveals intact capillary refill of less than 4 seconds, full range of motion in all extremities and findings consistent with an acute stroke.”
The physical examination includes a complete looking at the head, eyes, ears, nose, mouth and throat; and a complete overall looking-over of the body.
In documenting a mental status exam (MSE) for Janet, a 54-year-old female, the PMHNP notes that she is bradykinesic, has poverty of speech, is depressed, and appears flat. This includes all the following elements of physical examination except: