Transcript Mental Status Assessment

Chapter 5 - Jarvis
MENTAL STATUS ASSESSMENT
Mental Status
 Mental status is a person’s emotional and
cognitive functioning
 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
Copyright © 2016 by Elsevier, Inc. All rights reserved.
2 Inc.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier
Question
The nurse understands that all of the following
are components of the mental status
assessment except?
1. Known illness or health problem
2. Current medications known to affect mood
or cognition
3. Cultural background
4. Personal history; current stress, social habits,
sleep habits, and drug and alcohol use
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
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Mental Status
 Emotional and cognitive function
 Mental disorder: person’s response is much
greater than the expected reaction to a
traumatic life event
 Organic disorder: brain disease with a known
specific cause
 Psychiatric mental illness: no organic etiology has
been established
Defining Mental Status
 Mental status cannot be scrutinized directly
like the characteristics of skin or heart sounds
 Its functioning is inferred through assessment
of an individual’s behaviors:
 Consciousness
 Language
 Mood and affect
 Orientation
 Attention
 Memory
 Abstract reasoning
 Thought process
 Thought content
 Perceptions
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
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Components of Mental Status
Exam
 Usually mental status can be assessed
throughout the health history
 Four components of mental status
assessment:
 A = Appearance
 B = Behavior
 C = Cognition
 T = Thought Process
Question
Which of the following basic functions should
the nurse test first in an assessment of mental
status?
1. Behavior
2. Consciousness
3. Judgment
4. Language
Copyright © 2016 by Elsevier, Inc. All rights reserved.
Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc.
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Question
 When would a full mental status exam be
warranted?
 What data from the health history would
have to be considered when interpreting
mental status findings?
OBJECTIVE DATA
Appearance
 Posture
 Body movements
 Dress
 Grooming and hygiene
Behavior
 Level of consciousness
 Orientation to Person, Place, Time
 Facial expression
 Speech
 Mood and affect
Cognitive Function
 Orientation
 Attention span
 Recent memory
 Remote memory
 New learning
 The Four Unrelated Words Test
 Person with Aphasia
 Word comprehension, reading, and writing
 Higher Intellectual Function
 Judgment
Thought Processes and
Perceptions
 Thought processes
 Thought content
 Perceptions
 Screen for anxiety disorders
 Screen for depression
 Screen for suicidal thoughts
Mini-Mental Status Exam
 Simplified scored form of the cognitive functions
of the mental status examination
 11 questions
 Quick and easy to administer
 Initial and serial measurement
 Maximum score is 30
 People with normal mental status average 27
 Scores between 24-30 indicate no cognitive
impairment
DEVELOPMENTAL CONSIDERATIONS
Infants and Children
 Emotional and cognitive function mature
progressively
 Consciousness and language develop by 18-24
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months
Abstract thinking develops by 12-15 years
Consideration should be taken for
developmental milestones
Denver II Screening
Behavioral Checklist
Aging Adult
 General knowledge remains intact
 Response time is slower
 Recent memory will decrease with age
 Vision loss may occur; hearing loss of highfrequency sounds
 Check sensory before mental status
 People in their 80’s will have an age related
decline in mental function
 Mini-Cog – 3 item recall and clock drawing
ABNORMAL FINDINGS
Levels of Consciousness
 Alert
 Lethargic (or somnolent) – not fully alert;
drowsy; awakes when stimulated
 Obtunded – sleeps most of time; difficult to
arouse
 Stupor or Semi-Coma – spontaneously
unconscious
 Coma – completely unconscious
 Acute Confusional State (Delirium)
Speech Disorders
 Dysphonia – voice problem
 Dysarthria – articulation problem
 Aphasia – language comprehension problem
 Expressive (producing) Aphasia or Receptive
(understanding) Aphasia
 Global Aphasia – most severe; speech and
comprehension impaired
 Broca’s Aphasia – understand language but cannot
express self
 Wernicke’s Aphasia – can speak (sometimes
incomprehensible) but cannot understand
Mood and Affect
 Flat Affect (blunted affect) – lack of emotion
 Depression – sad, gloomy, depression
 Depersonalization (lack of ego boundaries) – loss of
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identity
Elation – joy and optimism
Euphoria – excessive well-being
Anxiety – worry, uneasy, apprehensive; source unknown
Fear – worry, uneasy, apprehensive; danger known
Irritability – annoyed, impatient
Rage – furious, loss of control
Ambivalence – existence of opposing emotions
Lability – rapid shift of emotions
Inappropriate Affect – affect discordant with speech
Thought Process
 Blocking – sudden interruption in train of thought
 Confabulation – fabricates events to fill memory gaps
 Neologism – coining a new word
 Circumlocution – round-about expression
 Circumstantiality – talks with excessive and
unnecessary detail
 Loosening associations – shifting to unrelated topics
 Flight of ideas – abrupt change; topics usually have
associations
 Word salad – incoherent mix of words
Thought Process
 Perseveration – persistent repeating of verbal or
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motor response
Echolalia – imitation; repeating
Clanging – word choice based on sound, not meaning
Phobia – strong, persistent, irrational fear
Hypochondriasis – morbid worrying about health
Obsession – unwanted, persistent thoughts or
impulses
Compulsion – unwanted, repetitive, purposeful acts
Delusions – firm, fixed, false beliefs; unrational
Perception
 Hallucination – sensory perceptions for which
there are no external stimuli, may be any
sense
 Illusion – misperception of an actual existing
stimulus, by any sense
Schizophrenia
 Two or more of the following symptoms present
for a significant part of a 1-month period
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Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
 One or more major areas of functioning are
decreased
 Signs persist for at least 6 months (including
initial month)
Delirium, Dementia, and
Amnestic Disorder
 Delirium
 Disturbance of consciousness
 Change in cognition
 Develops over a short period of time
 Dementia
 Memory impairment
 Aphasia, Apraxia, Agnosia, &/or disturbance in
executive functioning
 Amnestic Disorder
 Memory Impairment
 Impairment in social or occupational functioning
Mood Disorders
 Table 5-11
 Major Depressive Episodes
 Manic Episodes
 Major Depressive Disorder – 1 or more major
depressive episode
 Dysthymic Disorder – 2 years of depressed
mood for more days than not
 Bipolar Disorder – one or more manic episode
accompanied by major depressive episodes
Anxiety Disorders – Table 5-12
 Panic Attack – intense fear or discomfort
 Agoraphobia – places & situations
 Panic Disorder – recurrent panic attacks with
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worry
Specific Phobia – marked & persistent fear
Social Phobia – fear in social situations
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Generalized Anxiety Disorder – excessive anxiety
and worry for 6 months