Chapter 5Mental StatusTerminology in Mental Status AssessmentFunctional Areas of BrainDevelopmental ConsiderationsDevelopmental CareDevelopmental cont’d.When to Perform a Full Mental Status ExaminationRemember: In Assessing Mental StatusWhat can affect a MS exam?Objective DataLevel of ConsciousnessLOC TerminologyGlascow Coma ScaleRange of Scores for the GCS: 3 - 15Language: Abnormalities (Suffixes: a- and dys-)AphasiaBehavior: Mood and AffectTerminology: Mood and AffectAbnormalities: Mood DisordersDepressionSuicidal IdeationSuicide Ideation: Is Your Patient at Risk?Suicide ContinuumProfiling Suicide RisksDon’t be Afraid to AskMost Critical Risk FactorsWhat to Assess in Cognitive FunctioningSet Test: FACTMini-Mental Status Exam (MMSE)MMSEMini-CogAbnormalities: Delirium, Dementia, Amnestic DisorderMental Status: Assessing Thought Processes and PerceptionsAssessing Thought Processes and ContentAssessing Judgment and InsightSpatial Perception and Abstract ReasoningTerminology: Abnormal Thought ProcessesTerminology: Abnormal Thought ContentAbnormalities in PerceptionAbnormalities: SchizophreniaTerminology: Anxiety DisordersAbnormalities: Substance Use DisordersNursing DiagnosesSample ChartingChapter 5Mental Status AssessmentMental Status•Definition–The emotional and cognitive functioning–Includes LOC and behavior•What to assess–Physical appearance–Level of consciousness–Behavior–Communication–Cognitive abilities –MentationTerminology in Mental Status Assessment•Consciousness•Language•Mood and affect•Orientation•Attention•Memory•Abstract reasoning•Thought process•Thought content•PerceptionsFunctional Areas of BrainDevelopmental Considerations•Infants and Children–Development of consciousness (18-24 months)–Language development–Ability to concentrate (school-age)–Ability to reason and understand (usually by 7)–Abstract reasoning (12 – 15 years)Developmental Care•Infants and Children–Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are interdependent•Aging Adults–Older adulthood contains more potential for losses–Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or depression –Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of lifeSlide 5-6Developmental cont’d.•Aging Adult:•Aging Adults–Older adulthood contains more potential for losses–Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or depression –Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of life –Tests: MMSE, Mini-Cog, Set Test, othersWhen to Perform a Full Mental Status Examination•Family’s concern about behavioral changes•Brain lesions•Aphasia•Symptoms of psychiatric mental illnessRemember:In Assessing Mental Status•A: Appearance•B: Behavior•C: Cognition•T: Thought processWhat can affect a MS exam?•Illness or health problem–Ex: alcoholism or chronic renal disease•Current medications–May cause confusion or depression•Education level•Age-defined behavior•Other–Stress, drug and alcohol use, sleep problems, social interaction disordersObjective Data•Appearance•Posture•Body Movements•Dress•Grooming and HygieneLevel of Consciousness•Degree in which patient is alert and aware of surroundingsLOC Terminology•Alert•Lethargic•Obtunded•Stupor or semi-coma•ComaGlascow Coma ScaleRange of Scores for the GCS: 3 - 15•15: Highest (fully alert, oriented individual)•14: Confusion•13-14: Lethargy•12-13: Stupor•8-10: Responds to pain, no cognitive response, reflexes abnormal• ≤ 6: Coma, varied response to pain, reflexes abnormal or absent•3: Lowest (brain death)Language: Abnormalities(Suffixes: a- and dys-)•Aphasia•Dysarthria•Dysphonia•Aphonia•Apraxia•Agraphia•AlexiaAphasia•Aphasia: language difficulty–Loss of ability to speak or write coherently–Loss of ability to understand speech or writing•Different classifications–Receptive (Wernicke’s) vs. expressive (Broca’s)–Global: spontaneous speech is absent or reduced•Most severe•Prognosis poor•Large brain lesion is causeBehavior: Mood and Affect•Facial Expression•Speech–Quality –Pace–Articulation–Word choice•Mood and Affect–See Table 6-5 (pg. 110) in Jarvis for description of typesTerminology: Mood and Affect•Flat affect•Depression•Depersonalization•Elation•Euphoria•Anxiety•Fear •Irritability•Rage•Ambivalence•Lability•Inappropriate affectAbnormalities: Mood Disorders•Major Depressive Episode•Manic Episode•Categories:–Major depressive disorder–Dysthymic disorder–Bipolar disorderDepression•Symptoms: “IN SAD CAGES”–IN Interest (loss of pleasure)–S Sleep disturbance–A Appetite change–D Depressed mood–C Concentration difficulties–A Activity level (retardation or agitation)–G Guilt feelings (low self-esteem)–E Energy loss–S Suicide ideationSuicidal Ideation•If patient has expressed feelings of sadness, hopelessness, despair, worthlessness, or grief, explore feelings further•Ask:–Have you ever felt so bad that you wanted to hurt yourself?–Do you feel like hurting yourself now?Suicide Ideation: Is Your Patient at Risk?•Rare: patients attempt suicide while admitted because of accelerated treatment and d/c–Sentinel event: death or permanent loss of function not consistent with disease process•Most nurses don’t routinely screen for suicide risk –Shorter stays hinder relationship development –nurses are uncomfortable discussingSuicide Continuum•Ideation•Suicidal gestures•Suicide attempts•SuicideProfiling Suicide Risks•By age, gender and race–White men over 85 have one of the highest rates of suicide–Females attempt suicide 3X more than males, but males complete suicide at a rate 4X that of females–Whites have 2X the suicide rate of any other group except American Indians–Black teenage boys: 3rd leading cause of death.•By marital status:–Highest among divorced, separated and widowed persons•By method:–Firearms account for >55%–Drug overdose is the method chosen by 70- 80% who attempt suicideDon’t be Afraid to Ask•First assess for depression–“Are you feeling