UNIVERSITY OF CAGAYAN VALLEY Tuguegarao City 3500 COLLEGE OF HEALTH PERFORMANCE CHECKLIST MENTAL STATUS EXAMINATION (MSE) NAME:

_____________________________ Year and Section: ________________ DIRECTION: Please put a check beside each criterion below the column that best described the students performance. Options: Satisfactory (2) - thestudent performs the procedure competently, with little or no guidance from clinical instructor. Unsatisfactory (1) lacks competency in the performance of the procedure, needing frequent guidance from clinical instructor. Not Performed (0) fails to perform the expected procedure, even under close supervision and guidance from the clinical instructor.
Core Competency
Score

NURSES RESPONSIBILITIES Secure the patient's permission including documentation except in an emergency situation. Build rapport to gain trust and cooperation during the test. Take note of any physical disabilities that the patient has that could interfere with the tests to be given. Elderly clients may have poor eyesight and coordination. Special considerations when interviewing patients: Provide an environment that is comfortable, private, and safe for both the client and the nurse (not isolated, fairly quiet with few distractions). Keep brief interviews because psychotic patients are easily stressed. Keep chairs to be used by the nurse and patient approximately equal in size so that neither person looks down on the other. Introduce yourself and be professional in attire. Avoid taking excessive notes during interview as this can cut down the nurses ability to listen. During communication, maintaining good eye contact is desirable but dont stare at the client. Always get the patients chief complaint during the initial interview. Use open-ended questions at start of assessment but if client cannot organize his thoughts, may use more direct questions. Questions need to be clear, simple and focused on one specific symptom or behaviour. Use a nonjudgmental tone and language when asking sensitive informations. MENTAL STATUS AND LEVEL OF CONSCIOUSNESS 1. Level of consciousness Assess level of consciousness like if client is alert, drowsy, confused, disoriented or stuporous. 2. Appearance Assess the overall appearance including clothing, grooming, hygiene, any physical deformity and distinguishing marks. Is the client appropriately dressed according to his age and weather? Does the client appear to be at his stated age? Are there scars or tattoos noted on the body?

Legal Responsibility

Safe and Quality Nursing Care

Safe and Quality Nursing Care Management of Resources and Environment

Quality Improvement

Management of Resources and Environment Personal and Professional Development Communication Ethico-Moral Responsibility Safe and Quality Nursing Care Communication

2 2 2 2

Communication Ethico-Moral Responsibility

2 2 2 26

Safe and Quality Nursing Care

Safe and Quality Nursing Care

3. Behaviour/Movements Assess the gait (manner of walking), posture, coordination, eye contact, facial expressions, and interpersonal and behavioural characteristics. Does he maintain or avoid eye contact throughout the interview? Is he alert, tense, nervous, hostile, or restless? 4. Communication: Speech and Language Observe and listen to tone, clarity, and pace of speech, fluency, articulation and comprehension. Ask the client to give names of nurses in the ward. Ask the client to read from printed material appropriate for his educational level. Ask the client to write a sentence. 5. Mood and Affect
Observe clients display of pervasive and enduring emotions (Mood) and outward expression of clients emotional state (Affect).

Safe and Quality Nursing Care

Safe and Quality Nursing Care Communication

Safe and Quality Nursing Care

6. Thought Content Assess what the patient is saying for indications of delusions, obsessions, magical ideation, symptoms ofdissociation, or thoughts ofsuicide etc. Have you made any plans to harm yourself? (Suicidal Ideation) Are there ever thoughts that you just cant get out of your head? (Obsession) 7. Thought Process Assess by observing the movement of clients thoughts, how one thought connects to the next for indications of echolalia, loose associations, neologisms, word salad, clang associations etc. I went to the market on Sunday. Sunday is the Sabbath day. (Loose Association) I want to say the play of the day, ray, stay, may I pay. (Clang Association) 8. Perception Assess by asking clients sensory experience and its immediate interpretation for indications of hallucinations, illusions, formication, depersonalization, Deja vu, etc. 9. Orientation Ask 4 Spheres of Orientation like: clients name/names of SOs (person), the hour, date, or season (time), and where the client lives or is now (place) and situation.

Communication Safe and quality Nursing Care

Safe and Quality Nursing Care

Communication Safe and Quality Nursing Care

Communication Safe and Quality Nursing Care

COGNITIVE FUNCTIONING 10. Judgment and Insight o Judgment Assess by observing clients ability to make wise decisions, especially in everyday activities and social matters. Ask questions like What will you do if you will win a lottery? and What do you do when you have pain?

Quality Improvement Communication

Insight Assess clients awareness that he has problems, what they are and their implications. Ask other specific questions as needed. 11. Level of Concentration and Calculations o Concentration Note clients ability to focus and stay attentive. Give the client directions such as Please pick up the pencil with your left hand, place it in your right hand, then hand it to me. o Calculation Ask clients to do simple calculations. 12.Memory o Immediate Memory( memory over seconds or minutes) Ask the client What did you have to eat today? or What is the weather like today? o Recent Memory(memory over minutes, hours, days, weeks) Ask the client Who is our visitor yesterday? o Remote Memory(memory over years) Name the last 5 Presidents of the Philippines. 13. Abstract Thinking and Intellectual Abilities Assess clients ability to go beyond concrete thought, use symbols, metaphors, and similes. Ask the client to compare objects. Compare and contrast sugar and salt. Ask the client to explain a proverb. All that glitters is not gold. If the cat is away, the mouse will play. Dont count your chicken before they hatch. May use the statement What do I mean if I say I am blue? 14. Document actual observations /data accurately, promptly and completely.

Communication Safe and Quality Nursing Care

Safe and Quality Nursing Care

Communication

2
Communication Safe and Quality Nursing Care

Safe and Quality Nursing Care

Communication

Records Management

2 34

Examples of questions to be asked. Examples of instructions to be made and manifestations of clients. Note: May use other than the examples made.

Total:

60

Students Score: ________

Evaluated by: _____________________________ (Signature over Printed Name)