Mental Status Exam

Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Mental Status & Substance Mental Status & Substance Abuse AssessmentAbuse Assessment

Chapter 6Chapter 6


Chapter 6: Mental Status AssessmentChapter 6: Mental Status Assessment

Anatomy and PhysiologyAnatomy and Physiology

The cerebrum is primarily responsible for a person’s mental The cerebrum is primarily responsible for a person’s mental status.status.

The brain is divided into two sides: right and left hemispheres.The brain is divided into two sides: right and left hemispheres. These are further divided into lobes: frontal (speech formation, These are further divided into lobes: frontal (speech formation,

emotional states, concentration, and short term memory); emotional states, concentration, and short term memory); parietal (sensory data); temporal (perception and interpretation parietal (sensory data); temporal (perception and interpretation of sounds, long term memory, integration of behaviors and of sounds, long term memory, integration of behaviors and personality); occipital (sight); limbic system (reactions to personality); occipital (sight); limbic system (reactions to emotions, affect) and cerebellum (coordination).emotions, affect) and cerebellum (coordination).

The gray outer layer houses the higher mental functions, as The gray outer layer houses the higher mental functions, as perception and behavior.perception and behavior.

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The BrainThe Brain

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NeurotransmittersNeurotransmitters

The normal brain has neurotransmitters working properly to The normal brain has neurotransmitters working properly to transmit information from synapse to synapsetransmit information from synapse to synapse

There are normal levels of serotonin, norepinephrine, and There are normal levels of serotonin, norepinephrine, and dopamine. When there is dysfunction or disease either there is dopamine. When there is dysfunction or disease either there is an excess or a deficit of these transmitters, as dopamine or an excess or a deficit of these transmitters, as dopamine or GABA -gamma-aminobutyric acid- inhibits or suppresses GABA -gamma-aminobutyric acid- inhibits or suppresses transmitter activity.transmitter activity.

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Defining Mental StatusDefining Mental Status

Mental status—emotional and cognitive Mental status—emotional and cognitive functioning; an essential part of one’s total functioning; an essential part of one’s total health, not just the absence of mental illness.health, not just the absence of mental illness.

Factors affecting mental health:Factors affecting mental health: Economic and socialEconomic and social

Unhealthy lifestyle choicesUnhealthy lifestyle choices

Exposure to violenceExposure to violence

PersonalityPersonality

Spiritual and CulturalSpiritual and Cultural



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Other factors affecting mental healthOther factors affecting mental health Impairments in function of neurological systemImpairments in function of neurological system

Psychosocial developmental level and issuesPsychosocial developmental level and issues

Mental disorderMental disorder Organic disorder or biological dysfunctionOrganic disorder or biological dysfunction

Psychiatric mental illnessPsychiatric mental illness




Mental status is a person’s emotional and Mental status is a person’s emotional and cognitive functioningcognitive functioning Optimal functioning aims toward simultaneous life Optimal functioning aims toward simultaneous life

satisfaction in work, caring relationships, and satisfaction in work, caring relationships, and within the selfwithin the self

Usually, mental status strikes a balance between Usually, mental status strikes a balance between good and bad days, allowing person to function good and bad days, allowing person to function socially and occupationallysocially and occupationally

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Defining Mental Disorder and Defining Mental Disorder and Organic DisordersOrganic Disorders

Mental disorder:Mental disorder: Significant behavioral or psychological pattern Significant behavioral or psychological pattern

associated with: associated with:

• Distress, a painful symptomDistress, a painful symptom

• Disability, impaired functioningDisability, impaired functioning

• Significant risk of pain, disability, or death, or a loss of Significant risk of pain, disability, or death, or a loss of freedomfreedom

Organic disordersOrganic disorders Due to brain disease of known specific organic Due to brain disease of known specific organic

cause, e.g., delirium, dementia, alcohol and drug cause, e.g., delirium, dementia, alcohol and drug intoxication and withdrawalintoxication and withdrawal

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Defining Psychiatric Mental Defining Psychiatric Mental IllnessesIllnesses

Organic etiology has not yet been established, Organic etiology has not yet been established, e.g., anxiety disorder or schizophreniae.g., anxiety disorder or schizophrenia

Mental status assessment documents a Mental status assessment documents a dysfunction and determines how that dysfunction dysfunction and determines how that dysfunction affects self-care in everyday lifeaffects self-care in everyday life

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History PreparationHistory Preparation

Explain the purpose of the examinationExplain the purpose of the examination

Give the patient permission not to respond to Give the patient permission not to respond to any of the questionsany of the questions

Ensure confidentiality and respectEnsure confidentiality and respect

Be prepared for a variety of emotional Be prepared for a variety of emotional responses and a discussion of sensitive responses and a discussion of sensitive issues, as sexuality or dying.issues, as sexuality or dying.

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Mental StatusMental Status

Mental status is inferred and observed through Mental status is inferred and observed through individual’s behaviorsindividual’s behaviors

ConsciousnessConsciousness

LanguageLanguage

Mood and affectMood and affect

Orientation Orientation

AttentionAttention

MemoryMemory

Abstract reasoningAbstract reasoning

Thought processThought process

Thought contentThought content

PerceptionsPerceptions



Mental Status Areas DefinedMental Status Areas Defined

Defined:Defined:

Consciousness: Consciousness: alertness, safety, ability alertness, safety, ability to navigate in the world to navigate in the world around usaround us

Language: Language: communication issuescommunication issues

Mood and affect: Mood and affect: emotional expression emotional expression and manifestationsand manifestations

Defined:Defined:

Orientation: perception of Orientation: perception of time, place and person time, place and person

Attention: ability to Attention: ability to concentrate, stay on concentrate, stay on task, safetytask, safety

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Mental Status Areas DefinedMental Status Areas Defined

Defined:Defined:

Memory: short and Memory: short and long termlong term

Abstract reasoning: Abstract reasoning: comprehension of comprehension of ideas such as caringideas such as caring

Thought processes: Thought processes: ability to make sense ability to make sense of issues and of issues and rationalizerationalize

Defined:Defined:

Thought content: Thought content: obsessions, topics, obsessions, topics, issuesissues

Perceptions: Perceptions: awareness of reality, awareness of reality, including including hallucinations, hallucinations, delusions, illusions, delusions, illusions, and paranoiaand paranoia

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Developmental CareDevelopmental Care

Infants and ChildrenInfants and Children

Difficult to separate and trace development of just one Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are aspect of mental status in children, because all aspects are interdependentinterdependent

Aging AdultsAging Adults

Older adulthood contains more potential for lossesOlder adulthood contains more potential for losses

Grief and despair surrounding theses losses can affect Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or mental status and can result in disability, disorientation, or depression depression

Chronic diseases such as heart failure, cancer, diabetes, Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of lifeand osteoporosis include fear of loss of life

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Complete Mental Status ExamComplete Mental Status Exam Full mental status examination is a systematic Full mental status examination is a systematic

check of emotional and cognitive functioningcheck of emotional and cognitive functioning Usually, mental status can be assessed in the Usually, mental status can be assessed in the

context of the health history interviewcontext of the health history interview Keep in mind the four main headings of Keep in mind the four main headings of

mental status assessment: A-B-C-Tmental status assessment: A-B-C-T AppearanceAppearance

BehaviorBehavior

CognitionCognition

Thought processesThought processes

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Important Screening ToolsImportant Screening Tools CAGE:CAGE: a quick questionnaire used to a quick questionnaire used to

determine if a further, thorough alcohol determine if a further, thorough alcohol assessment is needed.assessment is needed.

SAD Persons Suicide Risk Assessment: SAD Persons Suicide Risk Assessment: considers risk factorsconsiders risk factors

Alzheimer’s disease and dementia risk factors: Alzheimer’s disease and dementia risk factors: - Age - smoking- Age - smoking

- Genetic predisposition - hormone therapy- Genetic predisposition - hormone therapy

- Latino or African descent - dysrhythmias- Latino or African descent - dysrhythmias

- Vascular disease - non-healthy behaviors- Vascular disease - non-healthy behaviors

- Head trauma- Head trauma

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Complete Mental Status ExamComplete Mental Status Exam Integrating mental status examination into the Integrating mental status examination into the

health history interview is sufficient for most health history interview is sufficient for most people people

You will collect ample data to be able to You will collect ample data to be able to assess mental health strengths and coping assess mental health strengths and coping skills and to screen for any dysfunctionskills and to screen for any dysfunction

It is necessary to perform a full mental status It is necessary to perform a full mental status examination when any abnormality in affect examination when any abnormality in affect or behavior is discovered and in certain or behavior is discovered and in certain situationssituations

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When to Perform a When to Perform a Complete Mental Status ExaminationComplete Mental Status Examination

Behavior changesBehavior changes

Brain lesions (trauma, tumor, brain attack)Brain lesions (trauma, tumor, brain attack)

Aphasia (caused by brain damage)Aphasia (caused by brain damage)

Symptoms of psychiatric mental illnessSymptoms of psychiatric mental illness

The shorter exam (MMSE) is commonly used The shorter exam (MMSE) is commonly used for health visits when no known neurological for health visits when no known neurological problem is apparent. Information and problem is apparent. Information and observations are generally made during the observations are generally made during the history.history.



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Contributions from Health HistoryContributions from Health History

Note these factors from the health history that Note these factors from the health history that could affect interpretation of findings:could affect interpretation of findings: Known illnesses or health problems, such as Known illnesses or health problems, such as

alcoholism or chronic renal diseasealcoholism or chronic renal disease

Medications with side effects of confusion or Medications with side effects of confusion or depressiondepression

Educational and behavioral level: note that factor Educational and behavioral level: note that factor as normal baseline, and do not expect as normal baseline, and do not expect performance on mental status exam to exceed itperformance on mental status exam to exceed it

Responses indicating stress in social interactions, Responses indicating stress in social interactions, sleep habits, drug and alcohol usesleep habits, drug and alcohol use



Preparing the Client for the ExamPreparing the Client for the Exam

Tell client the some of the questions may be Tell client the some of the questions may be embarrassing or silly to themembarrassing or silly to them

Gather your equipment, as pencil & paper, Gather your equipment, as pencil & paper, Glasgow coma scale, depression Glasgow coma scale, depression questionnaire, SAD persons suicide risk questionnaire, SAD persons suicide risk assessment tool, SLUMS assessment, CAGE assessment tool, SLUMS assessment, CAGE questionnaire, or AUDIT toolquestionnaire, or AUDIT tool

If older person, check vision and hearing first.If older person, check vision and hearing first.

Avoid premature judgements.Avoid premature judgements.

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Objective DataObjective Data

Main components of a mental status Main components of a mental status examinationexamination

A—AppearanceA—Appearance

B—Behavior and AffectB—Behavior and Affect

C—CognitionC—Cognition

T—Thought processesT—Thought processes

Sequence of steps forms a hierarchy in which the Sequence of steps forms a hierarchy in which the most basic functions are assessed first most basic functions are assessed first

First steps must be accurately assessed to ensure First steps must be accurately assessed to ensure validity of steps that followvalidity of steps that follow



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Objective Data Objective Data (cont.)(cont.)

AppearanceAppearance Posture and GaitPosture and Gait

• Erect and position relaxedErect and position relaxed

Body movementsBody movements

• Body movements voluntary, deliberate, coordinated, and Body movements voluntary, deliberate, coordinated, and smooth and evensmooth and even

Dress and GroomingDress and Grooming

• Appropriate for setting, season, age, gender, and social Appropriate for setting, season, age, gender, and social groupgroup



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AppearanceAppearance Grooming and hygieneGrooming and hygiene

• Person is clean and well groomed; hair is neat and clean Person is clean and well groomed; hair is neat and clean

• Use care in interpreting clothing that is disheveled, Use care in interpreting clothing that is disheveled, bizarre, or in poor repair, as well as piercings and bizarre, or in poor repair, as well as piercings and tattoos, because these may reflect person’s economic tattoos, because these may reflect person’s economic status or deliberate fashion trend, especially among status or deliberate fashion trend, especially among adolescentsadolescents

• Disheveled appearance in previously well-groomed Disheveled appearance in previously well-groomed person is significantperson is significant

• Base assessment on developmental, cultural, or Base assessment on developmental, cultural, or socioeconomic status.socioeconomic status.



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BehaviorBehavior Level of consciousnessLevel of consciousness

• Person is awake, alert, aware of stimuli from Person is awake, alert, aware of stimuli from environment and within self, and responds appropriately environment and within self, and responds appropriately and reasonably soon to stimuliand reasonably soon to stimuli

• Use Glasgow coma scale for those at high risk for Use Glasgow coma scale for those at high risk for deterioration.deterioration.

Facial expressionFacial expression

• Appropriate to situation and changes appropriately with Appropriate to situation and changes appropriately with topic; comfortable eye contact unless precluded by topic; comfortable eye contact unless precluded by cultural normcultural norm



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BehaviorBehavior SpeechSpeech

• Judge the quality of speech noting that person makes Judge the quality of speech noting that person makes sounds effortlessly and shares conversation sounds effortlessly and shares conversation appropriatelyappropriately

• Pace of conversation is moderate, and stream is fluentPace of conversation is moderate, and stream is fluent

• Articulation, the ability to form words, is clear and Articulation, the ability to form words, is clear and understandableunderstandable

• Word choice is effortless and appropriate to educational Word choice is effortless and appropriate to educational level; person completes sentences, occasionally pausing level; person completes sentences, occasionally pausing to thinkto think



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BehaviorBehavior Mood and affectMood and affect

• Judge by body language and facial expression and by Judge by body language and facial expression and by asking directly, “How do you feel today,” or “How do you asking directly, “How do you feel today,” or “How do you usually feel?”usually feel?”

• Mood should be appropriate to person’s place and Mood should be appropriate to person’s place and condition and should change appropriately with topics; condition and should change appropriately with topics; person is willing to cooperateperson is willing to cooperate

• Use Quick Inventory of Depressive Symptoms or Use Quick Inventory of Depressive Symptoms or Geriatric Depression Scale f needed.Geriatric Depression Scale f needed.



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Objective Data: Objective Data: Cognitive FunctionsCognitive Functions

Thought processes and perceptionsThought processes and perceptions Thought processes- clarityThought processes- clarity



Screen for suicidal thoughts: Screen for suicidal thoughts: “Have you ever had “Have you ever had thoughts of hurting yourself?”thoughts of hurting yourself?”

Use Suicide Risk Assessment GuideUse Suicide Risk Assessment Guide



Cognitive FunctionsCognitive Functions

JudgmentJudgment

• Ability to compare and evaluate alternatives and reach Ability to compare and evaluate alternatives and reach an appropriate course of actionan appropriate course of action

• Test judgment about daily or long-term goals, likelihood Test judgment about daily or long-term goals, likelihood of acting in response to hallucinations or delusions, and of acting in response to hallucinations or delusions, and capacity for violent or suicidal behaviorcapacity for violent or suicidal behavior

• Note what person says about job plans, social or family Note what person says about job plans, social or family obligations, and plans for the future; job and future plans obligations, and plans for the future; job and future plans should be realistic, considering person’s health situationshould be realistic, considering person’s health situation

• Ask for rationale for his or her health care, and how he or Ask for rationale for his or her health care, and how he or she decided about compliance with prescribed health she decided about compliance with prescribed health regimens; actions and decisions should be realisticregimens; actions and decisions should be realistic

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Objective Data Objective Data Cognitive functions Cognitive functions

Orientation – time usually lost first and person last.Orientation – time usually lost first and person last.

Concentration or Attention spanConcentration or Attention span

Recent memory—”What did you eat today?”Recent memory—”What did you eat today?”

Remote memory- “When did you get your first Remote memory- “When did you get your first job?”job?”

New learning—the four unrelated words testNew learning—the four unrelated words test

Then repeat words: at 5, 10, & 30 minutes.Then repeat words: at 5, 10, & 30 minutes.

JudgmentJudgment



OrientationOrientation

• Discern orientation through course of interview, or ask Discern orientation through course of interview, or ask for it directly, using tact: “Some people have trouble for it directly, using tact: “Some people have trouble keeping up with dates while in the hospital; what is keeping up with dates while in the hospital; what is today’s date?”today’s date?”

• Time: day of week, date, year, seasonTime: day of week, date, year, season

• Place: where person lives, address, phone number, Place: where person lives, address, phone number, present location, type of building, name of city and statepresent location, type of building, name of city and state

• Person: own name, age, who examiner is, type of workerPerson: own name, age, who examiner is, type of worker

• Many hospitalized people normally have trouble with Many hospitalized people normally have trouble with exact date, but are fully oriented on remaining itemsexact date, but are fully oriented on remaining items

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Attention spanAttention span

• Check person’s ability to concentrate by noting whether Check person’s ability to concentrate by noting whether they complete a thought without wanderingthey complete a thought without wandering

• Attention span commonly is impaired in people who are Attention span commonly is impaired in people who are anxious, fatigued, or intoxicatedanxious, fatigued, or intoxicated

Recent memoryRecent memory

• Assess in context of interview by 24-hour diet recall or by Assess in context of interview by 24-hour diet recall or by asking time person arrived at agencyasking time person arrived at agency

• Ask questions you can corroborate to screen for Ask questions you can corroborate to screen for occasional person who confabulates or makes up occasional person who confabulates or makes up answers to fill in gaps of memory lossanswers to fill in gaps of memory loss

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Remote memoryRemote memory

• In the context of the interview, ask the person verifiable In the context of the interview, ask the person verifiable past events; for example, ask to describe past health, the past events; for example, ask to describe past health, the first job, birthday and anniversary dates, and historical first job, birthday and anniversary dates, and historical events that are relevant for that personevents that are relevant for that person

• Remote memory is lost when cortical storage area for Remote memory is lost when cortical storage area for that memory is damaged, such as in Alzheimer disease, that memory is damaged, such as in Alzheimer disease, dementia, or any disease that damages cerebral cortexdementia, or any disease that damages cerebral cortex

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New learning: the Four Unrelated Words TestNew learning: the Four Unrelated Words Test

• Highly sensitive and valid memory testHighly sensitive and valid memory test

• Requires more effort than recall of personal or historic Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recallevents, and avoids danger of unverifiable recall

• Pick four words with semantic and phonetic diversity; ask Pick four words with semantic and phonetic diversity; ask person to remember the four wordsperson to remember the four words

• To be sure person understood, have them repeat wordsTo be sure person understood, have them repeat words

• Ask for the recall of four words at 5, 10, and 30 minutesAsk for the recall of four words at 5, 10, and 30 minutes

• Normal response for persons under 60 is an accurate Normal response for persons under 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes3- or 4-word recall after 5, 10, and 30 minutes

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Use SLUMS Dementia Exam if needed.Use SLUMS Dementia Exam if needed.

Use CAM if patient is suspected of deliriumUse CAM if patient is suspected of delirium

Additional testing for persons with aphasiaAdditional testing for persons with aphasia

• Aphasia is loss of ability to speak or write coherently or Aphasia is loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular to understand speech or writing due to a cerebrovascular accidentaccident

• Word comprehension: point to articles in the room or Word comprehension: point to articles in the room or articles from pockets and ask person to name themarticles from pockets and ask person to name them

• Reading: ask person to read available print; be aware Reading: ask person to read available print; be aware that reading is related to educational levelthat reading is related to educational level

• Writing: ask person to make up and write a sentence; Writing: ask person to make up and write a sentence; note coherence, spelling, and parts of speechnote coherence, spelling, and parts of speech

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Higher intellectual functionHigher intellectual function

• Tests measure problem-solving and reasoning abilitiesTests measure problem-solving and reasoning abilities

• Have been used to discriminate between organic brain Have been used to discriminate between organic brain disease and psychiatric disorders; errors on tests disease and psychiatric disorders; errors on tests indicate organic dysfunctionindicate organic dysfunction

• Although widely used, little evidence exists that these Although widely used, little evidence exists that these tests are valid in detecting organic brain disease tests are valid in detecting organic brain disease

• With little relevance for daily clinical care they are not With little relevance for daily clinical care they are not discussed herediscussed here

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Thought Processes and Thought Processes and PerceptionsPerceptions

Thought processesThought processes

• Way person thinks should be logical, goal directed, Way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughtscoherent, and relevant; should complete thoughts


• What person says should be consistent and logicalWhat person says should be consistent and logical


• Person should be consistently aware of reality; Person should be consistently aware of reality; perceptions should be congruent with yoursperceptions should be congruent with yours

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Screen for Suicidal ThoughtsScreen for Suicidal Thoughts

• When the person expresses feelings of sadness, When the person expresses feelings of sadness, hopelessness, despair or grief, it is important to assess hopelessness, despair or grief, it is important to assess any possible risk of physical harm to themselvesany possible risk of physical harm to themselves

• Begin with more general questions; if you hear Begin with more general questions; if you hear affirmative answers, continue with more specific probing affirmative answers, continue with more specific probing questionsquestions

Have you ever felt so blue you thought of hurting yourself Have you ever felt so blue you thought of hurting yourself or do you feel like hurting yourself now?or do you feel like hurting yourself now?

Do you have a plan to hurt yourself? How would you do it?Do you have a plan to hurt yourself? How would you do it?

What would happen if you were dead?What would happen if you were dead?

How would other people react if you were dead?How would other people react if you were dead?

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Screen for Suicidal ThoughtsScreen for Suicidal Thoughts

It is very difficult to question people about possible It is very difficult to question people about possible suicidal wishes for fear of invading privacysuicidal wishes for fear of invading privacy

Risk is far greater skipping these questions if you Risk is far greater skipping these questions if you have the slightest clue that they are appropriate; have the slightest clue that they are appropriate; you may be only health professional to pick up you may be only health professional to pick up clues of suicide riskclues of suicide risk

For people who are ambivalent, you can buy time For people who are ambivalent, you can buy time so person can be helped to find alternate remedyso person can be helped to find alternate remedy

Share any concerns you have about a person’s Share any concerns you have about a person’s suicide ideation with a mental health professionalsuicide ideation with a mental health professional

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Supplemental Mental Status Supplemental Mental Status ExaminationExamination

MiniMental StateMiniMental State OrientationOrientation

RegistrationRegistration

Attention and calculationAttention and calculation

RecallRecall

LanguageLanguage



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Supplemental Mental Status Supplemental Mental Status ExaminationExamination

Concentrates only on cognitive functioning, not on Concentrates only on cognitive functioning, not on mood or thought processesmood or thought processes

Standard set of 11 questions, requires only 5 to 10 Standard set of 11 questions, requires only 5 to 10 minutes to administerminutes to administer

• Useful for both initial and serial measurement, so Useful for both initial and serial measurement, so worsening or improvement of cognition over time and worsening or improvement of cognition over time and with treatment can be assessedwith treatment can be assessed

• Good screening tool to detect dementia and delirium and Good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illnessto differentiate these from psychiatric mental illness

• Normal mental status average 27; scores between 24 Normal mental status average 27; scores between 24 and 30 indicate no cognitive impairmentand 30 indicate no cognitive impairment



Sample ExamSample Exam

MiniMental StateMiniMental State Orientation: Orientation: What is the date?What is the date? Registration: Registration: Listen carefully, I am going to say three words. You Listen carefully, I am going to say three words. You

say them back after I stop. House, Car, Lake Now, repeat the say them back after I stop. House, Car, Lake Now, repeat the words back to me. Score only the first trial.words back to me. Score only the first trial.

Attention and calculation: Attention and calculation: Subtract 7 from 100 and continue to do Subtract 7 from 100 and continue to do this until I tell you to stop.this until I tell you to stop.

Recall: Recall: What were the three words I told you to remember?What were the three words I told you to remember? Language: Language: Please read this and do what it says. “Close your eyes.”Please read this and do what it says. “Close your eyes.”

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Clinical PearlClinical Pearl

When a patient is visually impaired, test When a patient is visually impaired, test recent memory by using unrelated words recent memory by using unrelated words rather than test objects.rather than test objects.

Pick four unrelated words with distinct sound Pick four unrelated words with distinct sound differences, as green, daffodil, hero, and differences, as green, daffodil, hero, and sofa.sofa.

Or bird, carpet, treasure, and orangeOr bird, carpet, treasure, and orange

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Clinical PearlClinical Pearl

Two simple questions to use when screening Two simple questions to use when screening for depression may be as effective as long for depression may be as effective as long screening tools as Beck Depression screening tools as Beck Depression Inventory.Inventory.

1.1. Over the past two weeks, have you felt down, Over the past two weeks, have you felt down, depressed or hopeless?depressed or hopeless?

2.2. Over the past two weeks, have you felt little Over the past two weeks, have you felt little interest or pleasure in doing things?interest or pleasure in doing things?

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Suicide Risk AssessmentSuicide Risk Assessment

Nurses have a serious responsibility to be alert to the Nurses have a serious responsibility to be alert to the warning warning signs of suicidesigns of suicide: : decreased performance, withdrawal, decreased performance, withdrawal, loneliness; loss of initiative, sadness, decreased appetite; and loneliness; loss of initiative, sadness, decreased appetite; and altered sleep patterns, and increased talk of death.altered sleep patterns, and increased talk of death.

Suicide is the third leading cause of adolescent death between Suicide is the third leading cause of adolescent death between the ages of 15 and 24.the ages of 15 and 24.

Contributing factors areContributing factors are: a history of depression, a history of : a history of depression, a history of past suicidal attempts, the loss of someone known or close, past suicidal attempts, the loss of someone known or close, addiction to drugs or alcohol, self-hate, unsupported psychiatric addiction to drugs or alcohol, self-hate, unsupported psychiatric or gender identity concernsor gender identity concerns

Social factors: unprotected firearms, a lack of social support, Social factors: unprotected firearms, a lack of social support, isolation, and a lack of opportunities.isolation, and a lack of opportunities.

Family factors: abusive parents or divorced parentsFamily factors: abusive parents or divorced parents

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Grief and Loss AssessmentGrief and Loss Assessment

Stages of grief reaction: Stages of grief reaction: denial, anger, bargaining, denial, anger, bargaining, and acceptanceand acceptance

Grief response: Varies among persons, assess what Grief response: Varies among persons, assess what behaviors reflect the grief reaction, assess what loss behaviors reflect the grief reaction, assess what loss means to the patient?means to the patient?

Assess stage of grief, client’s expectations of grief as Assess stage of grief, client’s expectations of grief as “I want to be pain free.”, the quality and extent of the “I want to be pain free.”, the quality and extent of the client’s family support, assess end of life decisions or client’s family support, assess end of life decisions or check on advanced directives, be aware of own check on advanced directives, be aware of own response to death, “I see illness and sometimes I am response to death, “I see illness and sometimes I am overwhelmed.”overwhelmed.”

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Self Concept AssessmentSelf Concept Assessment

Self-concept is the perception that an individual holds Self-concept is the perception that an individual holds of himself or herself and includes the person’s body of himself or herself and includes the person’s body image, identity, and role performance.image, identity, and role performance.

Each person is unique.Each person is unique. Observe nonverbal behavior.Observe nonverbal behavior. Watch for symptoms of stress.Watch for symptoms of stress. Listen to conversation contentListen to conversation content.. Questions to consider if person has change in body Questions to consider if person has change in body

image are: image are: What does this mean to you? What are What does this mean to you? What are your strengths, weaknesses? What would you your strengths, weaknesses? What would you like to like to change about yourself? change about yourself?

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Stress and Coping AssessmentStress and Coping Assessment

Stress affects multiple body systems and mental Stress affects multiple body systems and mental processes.processes.

General Adaptation Syndrome (GAS) with three General Adaptation Syndrome (GAS) with three stages: alarm, resistance, exhaustion affects stages: alarm, resistance, exhaustion affects physiologic functioning.physiologic functioning.

http://www.holisticonline.com/stress/stress_GAS.htmhttp://www.holisticonline.com/stress/stress_GAS.htm Stress suppresses the immune system.Stress suppresses the immune system. The nurse should assess: the person’s physiologic The nurse should assess: the person’s physiologic

response, the support systems as family or friends, response, the support systems as family or friends, and the person’s usual coping methods as relaxation and the person’s usual coping methods as relaxation exercisesexercises..

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Validating and DocumentingValidating and Documenting

To ensure reliability and accuracyTo ensure reliability and accuracy

Describe the patient’s response, do not label Describe the patient’s response, do not label or make judgments.or make judgments.

Cluster data to reveal patterns or Cluster data to reveal patterns or abnormalitiesabnormalities

Select Nursing diagnoses: Health Promotion, Select Nursing diagnoses: Health Promotion, Risk, Actual, or Selected Collaborative Risk, Actual, or Selected Collaborative problems.problems.

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Sample ChartingSample Charting



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Sample Charting Sample Charting (cont.)(cont.)




Infants and childrenInfants and children Covers behavioral, cognitive, and psychosocial Covers behavioral, cognitive, and psychosocial

development, and examines how child is coping development, and examines how child is coping with his or her environmentwith his or her environment

Follow A-B-C-T guidelines as for adults, with Follow A-B-C-T guidelines as for adults, with consideration for developmental milestonesconsideration for developmental milestones

Abnormalities often problems of omission; child Abnormalities often problems of omission; child does not achieve expected milestonedoes not achieve expected milestone

Parent’s health history, especially sections on Parent’s health history, especially sections on developmental history and personal history, yields developmental history and personal history, yields most of mental status datamost of mental status data

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Infants and childrenInfants and children Denver II screening test gives a chance to interact Denver II screening test gives a chance to interact

directly with child to assess mental statusdirectly with child to assess mental status

• For child from birth to 6 years of age, Denver II helps For child from birth to 6 years of age, Denver II helps identify those who may be slow in development in identify those who may be slow in development in behavioral, language, cognitive, and psychosocial areas behavioral, language, cognitive, and psychosocial areas

• An additional language test is the Denver Articulation An additional language test is the Denver Articulation Screening ExaminationScreening Examination

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Infants and childrenInfants and children ““Behavioral Checklist” for school-age children, Behavioral Checklist” for school-age children,

ages 7 to 11, is tool given to parent along with the ages 7 to 11, is tool given to parent along with the historyhistory

Covers five major areas: mood, play, school, Covers five major areas: mood, play, school, friends, and family relationsfriends, and family relations

It is easy to administer and lasts about 5 minutesIt is easy to administer and lasts about 5 minutes

AdolescentsAdolescents Follow same A-B-C-T guidelines as for adultsFollow same A-B-C-T guidelines as for adults

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Aging adultsAging adults Check sensory status, vision, and hearing before Check sensory status, vision, and hearing before

any aspect of mental statusany aspect of mental status

• Confusion is common and is easily misdiagnosedConfusion is common and is easily misdiagnosed

• One third to one half of older adults admitted to acute-One third to one half of older adults admitted to acute-care medical and surgical services show varying care medical and surgical services show varying degrees of confusion already presentdegrees of confusion already present

• In the community, about 5% of adults over 65 and almost In the community, about 5% of adults over 65 and almost 20% of those over 75 have some degree of clinically-20% of those over 75 have some degree of clinically-detectable impaired cognitive functiondetectable impaired cognitive function

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Aging adultsAging adults• Vision and hearing changes due to aging may alter Vision and hearing changes due to aging may alter

alertness and leave the person looking confusedalertness and leave the person looking confused

• When older people cannot hear your questions, they When older people cannot hear your questions, they may test worse than they actually aremay test worse than they actually are

• One group of older people with psychiatric mental illness One group of older people with psychiatric mental illness tested significantly better when they wore hearing aidstested significantly better when they wore hearing aids

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Aging adultsAging adults Follow same A-B-C-T guidelines for the younger Follow same A-B-C-T guidelines for the younger

adult with these additional considerations:adult with these additional considerations:

Behavior: level of consciousnessBehavior: level of consciousness

• In hospital or extended care setting, the Glasgow Coma In hospital or extended care setting, the Glasgow Coma Scale is useful in testing consciousness in aging persons Scale is useful in testing consciousness in aging persons in whom confusion is commonin whom confusion is common

• Gives numerical value to person’s response in eye-Gives numerical value to person’s response in eye-opening, best verbal response, and best motor response opening, best verbal response, and best motor response

• Avoids ambiguity when numerous examiners care for Avoids ambiguity when numerous examiners care for same personsame person

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Aging adultsAging adults• Many aging persons experience social isolation, loss of Many aging persons experience social isolation, loss of

structure without a job, change in residence, or some structure without a job, change in residence, or some short-term memory lossshort-term memory loss

• Aging persons may be considered oriented if they know Aging persons may be considered oriented if they know generally where they are and the present periodgenerally where they are and the present period

• Consider them oriented to time if year and month are Consider them oriented to time if year and month are correctly statedcorrectly stated

• Orientation to place is accepted with correct identification Orientation to place is accepted with correct identification of the type of setting, e.g., the hospital and name of townof the type of setting, e.g., the hospital and name of town

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Aging adultsAging adults Cognitive functions: new learningCognitive functions: new learning

• In people of normal cognitive function, age-related In people of normal cognitive function, age-related decline occurs in performance in the Four Unrelated decline occurs in performance in the Four Unrelated Words Test Words Test

• Persons in the eighth decade average two of four words Persons in the eighth decade average two of four words recalled over 5 minutes and will improve performance at recalled over 5 minutes and will improve performance at 10 and 30 minutes after being reminded by verbal cues10 and 30 minutes after being reminded by verbal cues

• Those with Alzheimer disease do not improve their Those with Alzheimer disease do not improve their performance on subsequent trialsperformance on subsequent trials

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Aging Adults: Supplemental Mental Status ExamAging Adults: Supplemental Mental Status Exam• Mini-Cog is reliable, quick, and easily available instrument to Mini-Cog is reliable, quick, and easily available instrument to

screen for cognitive impairment in healthy adultsscreen for cognitive impairment in healthy adults

• Consists of 3-item recall test and clock-drawing testConsists of 3-item recall test and clock-drawing test

• Tests person’s executive function, including ability to plan, Tests person’s executive function, including ability to plan, manage time, and organize activities, and working memorymanage time, and organize activities, and working memory

• Those with no cognitive impairment or dementia can recall the Those with no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence, and with all face numbers in correct position and sequence, and hour and minute hands indicating time you requested hour and minute hands indicating time you requested

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Abnormal FindingsAbnormal FindingsLevels of ConsciousnessLevels of Consciousness

AlertAlert

Lethargic (somnolent)Lethargic (somnolent)

ObtundedObtunded

Stupor or semicomaStupor or semicoma

ComaComa

Acute confusional state (delirium)Acute confusional state (delirium)



LOC DefinedLOC Defined

Alert-oriented, fully aware of stimuli, interacts in a Alert-oriented, fully aware of stimuli, interacts in a meaningful waymeaningful way

Lethargic (somnolent)-drowsy, falls asleep quickly, Lethargic (somnolent)-drowsy, falls asleep quickly, loses train of thoughtloses train of thought

Obtunded-sleep most of time, difficult to arouse then Obtunded-sleep most of time, difficult to arouse then confusedconfused

Stupor or semi-coma- arousable for short periods to Stupor or semi-coma- arousable for short periods to visual, verbal or painful stimuli, slow responsesvisual, verbal or painful stimuli, slow responses

Coma- neither awake nor aware, decerebrate Coma- neither awake nor aware, decerebrate posturing to painful stimuliposturing to painful stimuli

Acute confusional state (delirium)-marked anxiety Acute confusional state (delirium)-marked anxiety with motor or sensory excitement, inappropriate with motor or sensory excitement, inappropriate reactions to stimuli, disordered perceptionsreactions to stimuli, disordered perceptions

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Abnormal FindingsAbnormal FindingsAbnormalities of Mood and AffectAbnormalities of Mood and Affect

Flat affect (blunted affect)Flat affect (blunted affect)

DepressionDepression

Depersonalization (lack of ego boundaries)Depersonalization (lack of ego boundaries)

ElationElation

EuphoriaEuphoria

AnxietyAnxiety



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Abnormal FindingsAbnormal FindingsAbnormalities of Mood and Affect Abnormalities of Mood and Affect

FearFear

IrritationIrritation

RageRage

AmbivalenceAmbivalence

LabilityLability

Inappropriate affectInappropriate affect



Causes of Dementia Causes of Dementia

D=drugs and medsD=drugs and meds E= emotional illness and depressionE= emotional illness and depression M= metabolic and endocrine disordersM= metabolic and endocrine disorders E= eye and ear involvementE= eye and ear involvement N= nutritional and neurologic problemsN= nutritional and neurologic problems T= tumor or traumaT= tumor or trauma I= infectionI= infection A= alcoholism, anemia, or atherosclerosisA= alcoholism, anemia, or atherosclerosis

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Abnormal Thought ProcessesAbnormal Thought Processes

derailment- speech vacillates from one subject to anotherderailment- speech vacillates from one subject to another

flight of ideas- content jumps abruptly from one topic to another flight of ideas- content jumps abruptly from one topic to another in a continuous flow of speechin a continuous flow of speech

neologisms- words are distorted or inventedneologisms- words are distorted or invented

confabulation- patient fabricates facts or events to fill in the gaps confabulation- patient fabricates facts or events to fill in the gaps where memory loss has occurred.where memory loss has occurred.

clanging- patient chooses a word based on sound rather than clanging- patient chooses a word based on sound rather than meaningmeaning

echolalia- patient repeats words or phrases others sayecholalia- patient repeats words or phrases others say

incoherence- speech is incomprehensibleincoherence- speech is incomprehensible

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Abnormal Thought ContentAbnormal Thought Content

obsessions- recurrent, uncontrollable thoughts, images, or obsessions- recurrent, uncontrollable thoughts, images, or impulses that the patient considers unacceptableimpulses that the patient considers unacceptable

compulsions- repetitive behaviors that results from an attempt to compulsions- repetitive behaviors that results from an attempt to alleviate an obsessionalleviate an obsession

phobia- irrational fear of objects or situationsphobia- irrational fear of objects or situations

depersonalization- feeling that one has become detached from depersonalization- feeling that one has become detached from one’s mind or body or has lost one’s identityone’s mind or body or has lost one’s identity

delusions- false, fixed ideas not based in realitydelusions- false, fixed ideas not based in reality

hallucinations- hearing, seeing, feeling, tasting, or smelling hallucinations- hearing, seeing, feeling, tasting, or smelling objects or sensations that are not based in reality or where no objects or sensations that are not based in reality or where no external stimuli existexternal stimuli exist

illusions- misperceiving or misinterpretation of reality, as an IV illusions- misperceiving or misinterpretation of reality, as an IV pole as a snake.pole as a snake.

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Absolutes of Mental IllnessAbsolutes of Mental Illness

Mental illnesses are disorders of the brain that disrupt a Mental illnesses are disorders of the brain that disrupt a person's thinking, feeling, moods, and ability to relate to others. person's thinking, feeling, moods, and ability to relate to others. Just as diabetes is a disorder of the pancreas, mental illnesses Just as diabetes is a disorder of the pancreas, mental illnesses are disorders of the brain that often result in a diminished are disorders of the brain that often result in a diminished capacity for coping with the ordinary demands of life. capacity for coping with the ordinary demands of life.

Mental illnesses do not discriminate; they affect people of every Mental illnesses do not discriminate; they affect people of every age, gender, race, religion, or socioeconomic status. age, gender, race, religion, or socioeconomic status.

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Absolutes of Mental IllnessAbsolutes of Mental Illness

Mental illnesses are not the result of personal weakness, lack of Mental illnesses are not the result of personal weakness, lack of character, or poor upbringing. In the United States, character, or poor upbringing. In the United States, over seven million over seven million adults and over five million children and adolescents suffer from a adults and over five million children and adolescents suffer from a serious, chronic brain disorder.serious, chronic brain disorder. These illnesses have a great impact on These illnesses have a great impact on society. society. Four of the top ten leading causes of disability are mental Four of the top ten leading causes of disability are mental illnessesillnesses including major depression, bipolar disorder, schizophrenia including major depression, bipolar disorder, schizophrenia and obsessive compulsive disorder, and and obsessive compulsive disorder, and the estimated cost of mental the estimated cost of mental health care is over $150 billion per yearhealth care is over $150 billion per year. But far more important is the . But far more important is the effect untreated mental illness has on the lives of individuals and their effect untreated mental illness has on the lives of individuals and their loved ones. loved ones.

These brain disorders are treatable. As a person with diabetes, takes These brain disorders are treatable. As a person with diabetes, takes

insulin, most people with serious mental illness need medication to help insulin, most people with serious mental illness need medication to help control symptoms. Supportive counseling, self-help groups, housing, control symptoms. Supportive counseling, self-help groups, housing, vocational rehabilitation, income assistance and other community vocational rehabilitation, income assistance and other community services can also provide support and stability, contributing to recoveryservices can also provide support and stability, contributing to recovery. .

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Pregnant Woman AssessmentPregnant Woman Assessment

Baby blues within 4 weeks of pregnancyBaby blues within 4 weeks of pregnancy

Feelings of guilt and inadequacy as a motherFeelings of guilt and inadequacy as a mother

Signs of depression and psychosis, Signs of depression and psychosis, delusions, and thoughts of harming the childdelusions, and thoughts of harming the child

Use screening tool: Postpartum checkist Use screening tool: Postpartum checkist (Beck 1995). (Beck 1995).

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CrisisCrisis

An acute event triggering stressAn acute event triggering stress A crisis for one person might not be a crisis for another.A crisis for one person might not be a crisis for another.

Assess the patient’s perception of the event, his or her support Assess the patient’s perception of the event, his or her support systems, and past ability and methods of coping.systems, and past ability and methods of coping.

Crises can be maturational as with the beginning of Crises can be maturational as with the beginning of adolescence, or situational as with a plane crash or a adolescence, or situational as with a plane crash or a hurricane .hurricane .

The best outcome is the restoration of equilibrium.The best outcome is the restoration of equilibrium.

Treatment is to explore support systems and referrals, explore Treatment is to explore support systems and referrals, explore the stressor, and develop stress management options.the stressor, and develop stress management options.

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Crisis Assessment-BatheCrisis Assessment-Bathe

B=background-what is going on? What B=background-what is going on? What brought you here?brought you here?

A=affect-How does this make you feel?A=affect-How does this make you feel?

T=trouble-What troubles you most in this T=trouble-What troubles you most in this situation?situation?

H=handling-How are you going to handle this H=handling-How are you going to handle this problem?problem?

E=empathy-Show understanding of patient’s E=empathy-Show understanding of patient’s view of situation.view of situation.

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Which of the following is the most basic Which of the following is the most basic function and therefore should be tested first function and therefore should be tested first

in an assessment of mental status?in an assessment of mental status?

A.A. BehaviorBehavior

B.B. ConsciousnessConsciousness

C.C. JudgmentJudgment

D.D. LanguageLanguage



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Which of the following is not a significant Which of the following is not a significant contributor to the assessment of contributor to the assessment of

mental status? mental status?

A.A. Known illness or health problemKnown illness or health problem

B.B. Current medications known to affect mood Current medications known to affect mood or cognitionor cognition

C.C. Racial backgroundRacial background

D.D. Personal history; current stress, social Personal history; current stress, social habits, sleep habits, drug and alcohol usehabits, sleep habits, drug and alcohol use



AnswersAnswers

1.1. Correct Answer: B. According to your Correct Answer: B. According to your textbook, consciousness is the most textbook, consciousness is the most fundamental of these particular fundamental of these particular characteristics; therefore, it would be tested characteristics; therefore, it would be tested first.first.

2. Correct answer: C. The other choices are all 2. Correct answer: C. The other choices are all elements of the interview that contribute to elements of the interview that contribute to interpretation of the findings of the interpretation of the findings of the examination.examination.

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Mental Status Exam