Hello everyone and welcome back. Unfortunately, I had to stop recording the previous lecture. So we are on slide number 38. We had just finished uh speaking about the thought process and then I had to unfortunately stop recording. So now we are going on to the next set of domains in the MSSE which is insight and judgment. So, when we're talking about insight, we're really referring to the client's self-awareness and their understanding of their illness and situation. So, we're assessing their ability to understand their illness. And judgment is the client's ability to make sound and rational decisions about safety, about health, about money, about various aspects of their life. And often times insight and judgment they are closely linked because if you have a lack of insight it can result in a lack sorry in a in in poor judgment. So a lack of insight can often lead to poor judgment. So, when we're assessing the client's insight, we can ask ourselves, what is the client's understanding of the world around them? What is the client's understanding of their illness? So, do they have good insight into their illness? So, do they know and are they aware and do they acknowledge that they have a mental illness? So if we think back to the previous example I gave about auditory hallucinations, a client can have a diagnosis of a severe persistent mental illness such as schizophrenia and they can have good insight where they know that the voices that they're hearing are because of their illness. They know that the voices they're hearing are not really real, but it's because of their symptoms. Someone that has poor insight based on this similar example, they would not be able to differentiate from reality and the hallucinations. They wouldn't they there would be some sort of denial of their mental illness. So insight is about recognizing whether the client has a grasp and awareness and understanding of their illness. Judgment is their ability to make sound and rational decisions. So here we can ask, what have the client's recent decisions been like? Have they done anything to put themselves or others at risk or at harm's way? Are they behaving in a way that's motivated by perceptual uh disturbances or paranoia? Right? So, what is your confidence in this client's uh decision-making abilities? And of course, with this, you can assess based on the client's uh real current circumstances, but you can also ask hypothetical questions. So, if you smelled smoke in a theater, what would you do? Right? So, a reasonable person that has um good judgment, they would if they were in the theater, they would probably try to leave. They would probably call 911 and try to get help. So, you're also assessing this hypothetical situation based on what a rational person would do. So insight and judgment can give you some information about the client's overall mental status and they are um closely related because it can tell us about their reasoning. It can tell us about potential impulsivity. It can tell us about um you know the way they're self-monitoring. Um it can tell us a lot about the client. So the next domain is cognition. So when it comes to cognition, we're really assessing the higher level functions of the client. So some examples of uh assessing cognition include orientation. So is the client alert and oriented to the person to the place to the time to the situation. So you can even ask the client uh what is the date today right? So sometimes, you know, if we're not working, if we're not in school, if we're not following a structure, any any person might not even know what the date is, right? Like think about yourselves when it's, you know, Christmas break, um that that time period where you're not really in school, you're not really working, you're spending time with family, um you're not even looking at a calendar, you might not even know what the date is, right? But you still know that it's the month of December. You still know that it's the year say 2025. So we can still ask the client um you know what date is it or what month is it? Um if the date is too specific, we can ask more broader questions. You know do um where are we having this meeting today? Uh do you know what do you remember what my name is? um you know what is your date of birth um you know what is the year today so we're really trying to assess um their orientation through examples like that we can also assess their attention and their concentration so what is their ability to focus on tasks right are they able to follow with the conversation that you're having with them um we could even you know test their concentration based on small um tasks. If we feel that their concentration is potentially impaired, we can test their memory um short-term as well as long-term recall. We could even um give them an example of some sort of abstract um reasoning activity and see if they know uh what this means, right? Um, so an example of that is say you ask the client, um, what does it mean when they say people in glass houses shouldn't throw stones, right? That's abstract. Um, and they should be able to explain that to you. Of course, I understand that that example is very specific to North American, European um like idioms and metaphors. Um maybe if you're dealing with someone that is not born and raised in a North American setting, they may not know what that means, right? So, you have to use examples that the client has had some exposure to. um keeping the culture, the language barriers in mind, right? Because it's not fair to use an example of abstract thinking um that is very western cultural focused if you're dealing with a client who has a language barrier, who maybe hasn't spent too much time in Canada. Um because that's not fair. They they wouldn't know that, but that doesn't mean that they're cognitively impaired. So the reason that we want to assess the client's cognition is because we're really trying to identify conditions that can affect their cognitive functioning um from a you know neurological perspective. So is this impairment in their cognition because of their mental illness or is it some sort of uh neurological disorder such as Alzheimer's or dementia um or or you know all the other things. Um so we're really trying to differentiate between different conditions right between mood disorders between thought disorders and between um cognitive impairment. So now I have a case scenario where you have an an opportunity to really practice all of the domains that we just learned about. Um so take a moment to go through this case scenario and I have a few questions on the next slide that you can practice. Um, you can also even write the acronym aseptic down the paper and go through each one based on this scenario. So, what are you observing for the client's appearance? Of course, we don't, you know, have that full scope. Uh, their behavior, what could you assess for? Um, their speech, their emotion, so their affect and their mood. So, go through the list. Um and this the questions that I have are what objective findings can you make from this scenario? What subjective findings can you observe? Um assess the client using the component of the MSSE as mentioned and based on the MSE what nursing priorities would you focus on first? So this would be a really good way of putting everything that we've learned so far um into practice. And before we end off today's lecture on the MSE, I just wanted to summarize that the mental status exam is a snapshot, right? It's not the whole story because the mental status exam is giving you information about the client in that moment currently, right? As mentioned, the MSSE could change from the beginning of the day to the end of the night or the end of your shift, right? Components of it could change. Um, so you can use the MSSE repeatedly uh several times a week as well. And as I mentioned, it captures their presentation in that moment. So it could change with the setting. It could change with their treatment as well. And we have to understand that the embassy it's not just a checklist, right? We are working with a client that is struggling. So remembering that holistic approach, remembering why is this happening? Why is this client behaving this way? Right? We're trying to be curious. What is their treatment plan? What are their medications? How long have they been taking these medications? Is this a new medication that they're taking? And now have their symptoms worsened, have their symptoms stabilized, have they improved, um are they experiencing adverse effects from their medications which is now showing up in the MSSE. Right? So really trying to understand and put all the pieces of the puzzle together. And when we first start using components of the MSSE, it can be a little bit challenging. Um, it does take practice, right? The more you practice, the better your assessment is going to become, especially with terms like, you know, tangential and circumstantial and flight of ideas. Um, at first we might not catch on to some of these, but the more you practice, the better you do become. So, I encourage you even during your work or your placements um or even your interactions with one another, you know, think about the the embassy components. I'm not saying go and psychoanalyze everybody, but it's a way of putting it into practice because the more you practice, the better you get at it. And I'll just do a quick review so everyone gets um a snapshot of what we spoke about. So aseptic is the pneummonic that you can use to remember the domains. Appearance. So we're observing the client's grooming, their hygiene, their clothing, their posture, eye contact. Behavior. We're really assessing for their level of activity, right? Are they hypoactive? Are they hyperactive? Are they agitated? Um, are there any gestures or mannerisms? You know, what is their level of cooperation with this interaction? When we're talking about speech, we're assessing the rate. So, is it um a slow rate? Are they speaking very slowly? Are they speaking rapidly? Is there pressured speech where they're speaking so quickly that you can't even get a word in that you can't even interrupt them? What is their volume and their tone? Are they speaking very loudly? Are they whispering? Are they almost inaudible? Are they monotone? Is there varied um volume and tone based on the the conversation with their mood? Remember we are looking at uh this is subjective right? So this is what the client is reporting their emotional state is whereas the affect is objective. So this is what we are observing. This is the observable emotional expression. So for this we need to know the difference between blunted and flat. Flat a effect is emotionless. Whereas blunted there is mild emotions showing. Maybe they smile slightly, maybe they raise their eyebrows slightly. Flat once again expressionless in terms of stability of their affect. Is it stable throughout the conversation or is it labile where there are rapidly shifting unpredictable um moods that the client is is overtly showing? They're crying one minute then they're laughing hysterically the next. And for this we also have to between the mood and the affect we have to understand is there congruence? So, does the affect what we're observing match the stated mood with thought process? Um, and and then there's also um uh sorry, there's also there's thought content as well. So, with thought content, it's referring to what the client is thinking about. So, their actual thoughts and their beliefs, right? So they could have delusions which are a fixed false belief. They could have suicidal or homicidal ideiation. With thought process, it's referring to how the client is thinking. So is the structure of their thoughts organized and logical or is it circumstantial where um they provide excessive details um irrelevant details but eventually they return to the topic. Tangential is when they wander away from the topic and they never really get to the point. Flight of ideas. Do they uh jump around from one topic to another without completing the train of thought? When we're talking about uh perception here, we're trying to understand how the client is experiencing the world around them. So they could experience hallucinations which have a sensory involvement. For auditory hallucinations, we want to know are they experiencing command hallucinations? And if they are, we want to get more information on the content because they could be a risk to themselves or a risk to others. So, we have to perform a risk assessment. The client could experience illusions, uh, depersonalization or even derealization. With cognition, um, we're assessing for higher functions and for insight and judgment, we're assessing if the client has awareness of their illness and if they have the ability to make safe and appropriate decisions. So, when we are using the MSSE, of course, we have to use objective and descriptive language, right? And we want to avoid labels like crazy or weird or strange. Um and finally knowing that the MSE it guides the diagnosis, the treatment planning and even the risk assessment. And we always have to assess for safety first. Is the client a risk to themselves? Are they a risk to others? Thank you everyone for listening. This is the end of the lecture on the mental status exam. I have the YouTube link here where I got those clips in case um for some reason the lecture uh PDF is not opening up the videos. Um the link is here for you. Thank you everyone.