Chapter 05 Mental Health Assessment Notes PDF

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Jarvis Chapter 5: Mental Status Assessment Loretto Heights School of Nursing Objectives Describe evaluation of mental status across the life span. Demonstrate appropriate gathering of subjective data of a mental status exam. Demonstrate general techniques of an objective assessment of mental status. Demonstrate documentation of subjective and objective data for a mental status assessment. MENTAL STATUS  A person’s emotional (feeling) and cognitive (knowing) function  Optimal functioning aims toward simultaneous life satisfaction in work, caring relationships, and within the self  Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally Mental Disorder: Significant behavioral or psychological pattern associated with: distress or disability and has a significant risk of pain, disability, or death, or a loss of freedom.  Organic brain disorders: brain disease of known specific organic cause o Ex. Dementia, intoxication, brain tumor or damage  Psychiatric mental illness: no organic etiology established  Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life Objective or Subjective?  Mental status not directly observed  Mental status is inferred through an individual’s behaviors o Behavior o Dress and hygiene  Behaviors include: o Consciousness: being aware of one’s own existence, feelings, thoughts and the surrounding environment. o Language: communication o Affect: Feelings at the moment, mainly expressed in facial expression  Ex. Flat-lacking expression and tone in voice  Sometimes this is not an accurate predictor of mood o Mood: Underlying feelings, more durable and prolonged o Orientation: awareness of the objective world in relation to self  Person  Do you know your name and who you are?  Place  Do you know where you are?  Time  Do you know what day or time it, time  Purpose

 Do you know why you’re here? o Attention: The ability to concentrate and focus without being distracted or going off on tangents o Memory: Ability to store experiences and recall them later.  Assess recent and remote o Abstract reasoning: Understanding logic and deeper meaning o Thought process: The way a person thinks. Ability to formulate logical thought  Is thought linear? o Thought content: What a person thinks- ideas, beliefs, use of words. o Perception: Awareness of objects and use of five senses Developmental Competence o Infants and children o Difficult to separate & trace development of just one aspect of mental status in childrenall aspects interdependent o Abstract reasoning develops between ages 12-15 o Aging adults o Knowledge and vocabulary are consistent, but response time is slower with age o Recent memory decreases with aging, but remote memory loss is NOT a normal part of aging. o Sensory perception declines affect mental status (hearing, vision especially) o Older adulthood contains more potential for losses of both function, health, and people o Grief and despair surrounding losses can affect mental status & can result in disability, disorientation, or depression o Chronic diseases-heart failure, cancer, diabetes, and osteoporosis- include fear of death Components of the Mental Status Examination  Full mental status examination is a systematic check of emotional and cognitive functioning  Usually, mental status can be assessed in the context of the health history interview  Keep in mind the four main headings of mental status assessment: A-B-C-T o Appearance: Hygiene, grooming, posture o Behavior: Is it consistent, normal, anxious, disinterested, angry o Cognition: Do they understand and are following instructions during the interview process o Thought processes: Is thought process linear or is it jumping around Mental Status Examination Integrating mental status examination into the health history interview is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction. When any abnormality in affect or behavior is discovered and in certain situations, then it is necessary to perform a full mental status examination. WHEN TO PERFORM A FULL MENTAL STATUS EXAMINATION . . .  Patients whose initial screening suggests an anxiety disorder or depression o May need to approach family members to complete the data collection

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Family member reporting concern for patient’s behavioral changes or health You also want a full Mental Status Examination when: o Behavior change (memory loss, inappropriate social interaction) o Brain lesions (trauma, tumor, brain attack) o Aphasia (secondary to brain damage): Language or communication disorder  Wernicke’s  Broca’s

Symptoms of psychiatric mental illness A,B,C,T abnormalities – Appearance – Behavior – Cognition – Thought processes Subjective contributions from Health History  Known illnesses or health problems (alcoholism or chronic renal disease)  Medications with side effects of confusion or depression  Chantix, anticonvulsives-depression, SSRIs, antihistamines-confusion, anticholinergicsconfusion, narcotics, benzodiazapines, sedatives, illicit drugs  Educational and behavioral level: note that factor as normal baseline, and do not expect performance on mental status exam to exceed it  Responses indicating stress in social interactions, sleep habits, drug and alcohol use  Anxiety disorders Question: The nurse understands that all of the following are components of the mental status assessment except? • YES: Known illness or health problem • YES: Current medications known to affect mood or cognition • Cultural background • YES: Personal history; current stress, social habits, sleep habits, and drug and alcohol use Objective Data Main components of a mental status examination Sequence of steps forms a hierarchy Most basic functions are assessed first First steps must be accurately assessed to ensure validity of steps that follow  Appearance o Posture o Body movements o Dress o Grooming and hygiene  Behavior o LOC: Level of consciousness  Awake and aware

 Lethargic  Obtunded (transient state between lethargy and stupor)  Stupor-respond only to vigorous arousal  Coma o Facial expression o Speech o Speed:  Rapid may indicate anxiety or mania.  Slow may indicated depression, hesitation o Mood and affect  Cognitive Functions o Orientation: Person, place, time, & purpose o Attention Span: ability to follow series of instructions o Recent memory: need to be able to corroborate  Use current event or something you know they did earlier in the day o Remote memory: anniversaries, historic events o New Learning – The Four Unrelated Words Test o Judgment- give scenario and ask what they would do o Word comprehension: point to articles in the room or articles from pockets and ask person to name them o Reading: ask person to read available print; be aware that reading is related to educational level o Writing: ask person to make up and write a sentence; note coherence, spelling, and parts of speech o Additional testing for persons with aphasia  Aphasia: loss of ability to speak or write coherently or to understand speech or writing due to a CVA  Broca’s- partial loss of ability to produce language while maintaining ability to comprehend  Wernicke’s  Higher intellectual function tests measure problem-solving and reasoning abilities o Have been used to discriminate between organic brain disease and psychiatric disorders; errors on tests indicate organic dysfunction o Although widely used, little evidence exists that these tests are valid in detecting organic brain disease – EBP??? o With little relevance for daily clinical care they are not discussed here  Thought Processes and Perceptions • Thought Processes • Thought Content • Perceptions • Screen for Suicidal Thoughts – Asking about suicidal thoughts does not increase risk of suicide! – Important to assess any risk of physical harm to self if expressing feelings of sadness, hopelessness, despair, or grief

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Begin with general questions and continue if needed

OBJECTIVE DATA Supplemental Mental Status Examination • The Mini-Mental State: Copyrighted (MMSE) – Valid tool for cognitive function to assess for organic disease. Repeatable. Supplemental Mental Status Examination • Mini-Mental State Exam – Concentrates only on cognitive functioning, not on mood or thought processes – Standard set of 11 questions, requires only 5 to 10 minutes to administer • Useful for both initial & serial measurement, so worsening or improvement of cognition over time & with treatment can be assessed • Good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness • Normal mental status average 27; scores between 24 and 30 indicate no cognitive impairment Developmental Competence • Infants and children – Covers behavioral, cognitive, and psychosocial development and examines how child is coping with his or her environment – Follow A-B-C-T guidelines as for adults, with consideration for developmental milestones – Abnormalities often problems of omission; child does not achieve expected milestone – Parent’s health history, especially sections on developmental history and personal history, yields most of mental status data Screening Tests • Infants and children – Denver II screening test gives a chance to interact directly with child to assess mental status • For child from birth to 6 years of age, Denver II helps identify those who may be slow to develop in behavioral, language, cognitive, and psychosocial areas • An additional language test is the Denver Articulation Screening Examination – “Behavioral Checklist” for school-age children, ages 7 to 11, is tool given to parent along with the history • Covers five major areas: mood, play, school, friends, and family relations • It is easy to administer and lasts about 5 minutes • Adolescents – Follow same A-B-C-T guidelines as for adults Denver II • Developmental Care of Aging Adults • Check sensory status, vision, and hearing before any aspect of mental status – Confusion common and is easily misdiagnosed • Make sure they have their glasses, hearing aids, able to hear you

– 1/3 to ½ of older adults admitted to acute-care medical and surgical services show varying degrees of confusion already present – In the community, ~ 5% of adults over 65 & almost 20% over 75 have some degree of clinically detectable impaired cognitive function Developmental Care of Aging Adults (Cont.) • Check sensory status before assessing any aspect of mental status – Vision & hearing changes due to aging may alter alertness and leave the person looking confused – When older people cannot hear questions, may test worse than they actually are – One group of older people with psychiatric mental illness tested significantly better when they wore hearing aids Testing Aging Adults • Follow same A-B-C-T guidelines for the younger adult with these additional considerations • Behavior: level of consciousness – In hospital or extended care setting, the Glasgow Coma Scale is useful in testing consciousness in aging persons in whom confusion is common – Gives numerical value to person’s response in eye-opening, best verbal response, and best motor response – Avoids ambiguity when numerous examiners care for same person Testing Aging Adults • Cognitive functions: orientation – Many aging persons experience social isolation, loss of structure without a job, change in residence, or some short-term memory loss – Oriented if they know generally where they are and the present period • oriented to time if year and month are correctly stated • orientation to place with correct identification of the type of setting (e.g., the hospital and name of town) Testing Aging Adults • Cognitive functions: new learning – In people of normal cognitive function, age-related decline occurs in performance in the Four Unrelated Words Test – Persons in the eighth decade average two of four words recalled over 5 minutes and will improve performance at 10 and 30 minutes after being reminded by verbal cues – The performance of those with Alzheimer disease does not improve on subsequent trials Aging Adults: Supplemental Testing • Supplemental Mental Status Exam – Mini-Cog: reliable, quick, & easily available instrument to screen for cognitive impairment in healthy adults – Three-item recall test and clock-drawing test – Tests person’s executive function (ability to plan, manage time, and organize activities, and working memory) – With no cognitive impairment or dementia -can recall the 3 words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested

Sample Charting Abnormal Findings: LEVELS OF CONSCIOUSNESS (Table 5-1) • Alert: A,A,Ox4 • Lethargic (somnolent): Drowsy, but responds to name, slow response, ↓spontaneous movements • Obtunded: Difficult to arouse, confused, needs constant stimulation • Stupor or semi-coma: Unconscious but able to arouse with pain, language impaired, +reflex activity • Coma: Unconscious, no response to pain • Acute confused state (delirium): clouded consciousness, incoherent, agitated, disoriented Abnormal Findings: SPEECH DISORDERS (Table 5-2) • Dysphonia – http://www.dysphonia.org/ • Dysarthria – http://www.csun.edu/~vcoao0el/de361/de361s52_folder/spasticDysmov.html • Aphasia – Global aphasia – Broca’s aphasia – Wernicke’s aphasia • http://www.youtube.com/watch?v=67HMx-TdAZI&feature=related Abnormal Findings: MOOD AND AFFECT (Table 5-3) • Flat affect • Depression • Depersonalization • Elation (over excited for the situation) • Euphoria (overly • Anxiety • Fear • Irritability • Rage • Ambivalence • Lability• Inappropriate affect Abnormal Findings: ANXIETY DISORDERS (Table 5-4) • Panic Attack • Specific Phobia • Generalized Anxiety Disorder (GAD) • Posttraumatic Stress Disorder (PTSD) • Agoraphobia

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Social Anxiety Disorder (Social Phobia) Obsessive-Compulsive Disorder (OCD)

Abnormal Findings: DELIRIUM, DEMENTIA, & DEPRESSION (Table 5-5) • Onset • Cause or contributing factors • Cognition • LOC • Activity level • Emotional state • Speech and language • Prognosis Websites of Interest Alzheimer’s Disease Education and Referral Center, http://www.nia.nih.gov/alzheimers American Federation for Aging Research, http://www.afar.org American Psychiatric Nurses Association, http://www.apna.org American Psychological Association, http://www.apa.org Association of Child and Adolescent Psychiatric Nurses, http://www.ispn-psych.org/html/acapn.html Centers for Disease Control and Prevention, http://www.cdc.gov National Institute of Mental Health, http://gopher.nimh.nih.gov/ National Mental Health Association, http://www.nmha.org American Psychiatric Association, http://www.psych.org Mini-Mental State Examination (MMSE), http://www.minimental.com Case Study- review again prior to exam A nursing student is learning about the importance of performing a mental status assessment on patients so as to provide an adequate indicator of cognitive status....