Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
159 Cards in this Set
- Front
- Back
|
Significance of Mental Health Assessment For Canadians |
nothing to put here |
|
|
What does the World Health Organization (2008) estimate to be the leading causes of disability globally? |
Mental disorderssuch as depression. alcohol use disorders, and psychoses (e.g., bipolar disorder and schizophrenia) |
|
|
What percentage of all Canadians experience a diagnosed illness during their lifetime? |
20% of all Canadians |
|
|
How many of all Canadians are expected to experience a mental health problem at some point in their life? |
One per three of all Canadians |
|
|
What factors influence a person's mental health? |
A variety of factors; Some are internal, such as emotional problems Some come from within the person's social network and include the development of values, self-knowledge, self-control, and common sense (which helps us to learn from experience and plan for the future) Others are related to the person's broader community This "broader community" extends to the health care and mental health care systems and also to other sectors such as employment, education, and housing |
|
|
Does a single circumstance influence mental health? |
No, a single circumstance does not influence mental health; rather, people are affected by a complex series of interacting factors Strategies to improve the mental health of Canadians therefore require active involvement from all community sectors |
|
|
What other things influence mental health other than internal, familial, and community influences? |
Larger social issues, such as poverty, racism, and other forms of discrimination influence mental health |
|
|
What do the members of immigrant groups and Aboriginal groups often face? |
Members of these groups often face unique challenges in maintaining cultural, social, and economic integrity Without adequate social resources or access to needed services, the stressors experienced by some ethnocultural and social groups in Canada can lead to increases in mental illnesses and suicide |
|
|
Defining Mental Health and Mental Illness |
Mental healthis a crucial dimension of overall health and an essential resource for everyday living |
|
|
What is mental health broadly defined? |
The capacity to feel, think, express emotions, and behave in ways that enhance personal capacity to manage challenges, adapt successfully to a range of demands, and enjoy life |
|
|
How does the World Health Organization (2007) describe mental health? |
A relative and ongoing state of well-being in which individuals realize their abilities, cope with the normal stresses of life, work productively, and contribute meaningfully to the community |
|
|
What are the characteristics indicative of mental health? |
They include finding balance in all aspects of life - social, physical, spiritual, economic, and mental - and developing resilience, flexibility, and self-actualization |
|
|
What does optimal mental health entail? |
Satisfaction within work, caring relationships, and the self; it draws on a learning process in which individuals can greatly benefit from developing positive coping, assertiveness, interpersonal, and time management skills |
|
|
What is mental disorder? |
Mental disorder is the medical term for mental illness and is defined and diagnosed in Canada according to criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-V) by the American Psychiatric Association |
|
|
What are mental disorders depicted as? |
They are depicted as constellations of co-occurring symptoms that may involve alterations in thought, experience, and emotion that are serious enough to cause distress and impair functioning, cause difficulties in sustaining interpersonal relationships and performing jobs, and sometimes lead to self-destructive behaviour and suicide |
|
|
How many factors may contribute to the development of a mental disorder? |
Multiple factors - including the physical environment, genetics, biology, personality, culture, socioeconomic status, and life events - may contribute to the development of a mental disorder |
|
|
Can mental illness affect everyone? |
Yes, it can affect everyone |
|
|
What do mental illnesses account for every year? |
They account for a large percentage of hospital stays every year |
|
|
Is mental disorder positioned on the same continuum as mental health? |
No; rather, mental disorder is represented as a level of impairment and distress ranging from absence of to maximal illness |
|
|
What is a major detriment for persons with a mental illness? |
Stigma and its associated cycle of alienation and discrimination, which affect the abilities to seek and obtain help and support in the community |
|
|
What is a responsibility shared by health professionals, communities, and people with mental illness? |
Reducing stigma |
|
|
What do you need to do as a nurse working within this population? |
You need to self-monitor for stigmatizing behaviours and beliefs |
|
|
Mental Health Nursing Assessment |
nothing to put here |
|
|
To the end of the nurse-patient relationship being directed toward advancing the best interest and best health outcome of the patient, what is the purpose of the mental health assessment? |
To understand the patient's health and illness experiences, problems and deficits in daily living, and strengths and resources in relation to mental health |
|
|
Methods and Components |
nothing to put here |
|
|
What do you do to provide a comprehensive mental health nursing assessment? |
You will integrate close observations and routine social interactions into the collection of information about the patient's circumstances |
|
|
What will you combine? |
You will combine (a) observation (b) interview (c) examination (d) physical assessment (e) collaboration with others |
|
|
What information does observing the patient at different times of the day and in differing situations provide? |
It provides information about hygiene, grooming, attire, facial expressions, gestures, and interactions with others |
|
|
What should you identify? |
You should identify disturbances in perception and thought Any inconsistencies between what the patient states and what you notice |
|
|
What should you analyze? |
You should analyze findings from physical, mental, cognitive, and diagnostic examinations to reveal symptoms and potential problems in self-care |
|
|
Who do you collaborate with and why? |
You collaborate with the patient's family and with other members of the health care team to develop and evaluate treatment plans and risk of harm |
|
|
What may the mental health nursing assessment include? |
It may include the methods and components described in Table 6-1 (page 84) |
|
|
Sources of Information |
nothing to put here |
|
|
What kinds of information can patient information be? |
Subjective (symptoms reported that are not directly observable or measurable) Objective (signs directly observed and measured, such as diagnostic test) |
|
|
Although the patient is ideally the primary provider of information, when is collaboration with secondary sources (including family, health care providers, and patient records) needed? |
It is needed for children and when the patient is at risk of harm to self or others |
|
|
Indication for Comprehensive Mental Health Nursing Assessment |
The full comprehensive mental health examination and accompanying things rarely need to be entirely performed; you can usually assess mental health through the context of the health history interview |
|
|
What is a distinguishing component of the mental health assessment? |
The mental status examination (Box 6-1, page 85) |
|
|
What is mental status |
An aspect of mental health that involves emotional and cognitive functioning |
|
|
What is the mental status assessment? |
A structured way of observing and describing a person's current state of mind, under the domains of appearance, behaviour, cognition, and thought processes |
|
|
When is it beneficial to assess mental status? |
When you sense that something is "not quite right" (speech is slow and unclear, eyes do not focus, etc.) |
|
|
When is it necessary to perform the mental health assessment? |
It is necessary to perform it when you discover any abnormality in mood or behaviour and in the following situation: - Family members are concerned about a person's behaviour changes, such as memory loos or inappropriate social interaction - Brain lesions (trauma, tumour, stroke): A mental health assessment documents any emotional, cognitive, or behavioural change associated with the lesion. Not recognizing these changes hinders care planning and creates problems with social adjustment - Aphasia (the impairment of language ability secondary to brain damage): A mental health assessment documents language function, as well a any associated emotional problems such as depression or agitation - Symptoms (e.g., extreme worry and avoidance) of psychiatric mental illness, especially with acute onset, are evident |
|
|
What factors that could affect your interpretation should you note in every mental health assessment? |
- Any known illnesses or health problems, such as alcoholism or chronic renal disease - Current medications, the adverse effects of which may cause confusion or depression - The usual educational and behavioural level; note that factor as the normal baseline, and do not expect performance on the mental health assessment to exceed it - Responses to personal history questions, including current stress, social interaction patterns, sleep habits, drug and alcohol use |
|
|
Developmental Considerations |
nothing to put here |
|
|
Children and Adolescents |
All aspects of mental health are interdependent Progression through developmental stages toward independence and the full range of health determinants affects the experience of adolescents At this time, multiple cellular, molecular, and anatomical modifications contribute to pronounced changes in cognition, behaviour, and temperament; risk taking and novelty seeking are perhaps the greatest changes Few adolescents never achieve abstract thinking Leading cause of mortality among youth in Canada is unintentional injuries at a rate of 21.3 per 100,000 population For adolescent aged 15 to 19 years, suicide (intentional self-harm) is the second leading cause of death Another increasing trend is homicide (rate of mortality from firearms among Canadians younger than 15 years is one of the highest in the world) Most common mental health disorders among adolescents include depression, anxiety disorders, attention-deficit/hyperactivity disorder, and substance use disorder Half of diagnosable mental health disorders over the lifetime begin by age 14 Eating disorders represent the third most common chronic illness among Canadian female adolescents Adolescent girls tend to have poorer self-confidence (a measure of mental health), and higher rates of depression and experience more sexual harassment than do adolescent boys Youth who are Aboriginal, immigrant, homeless, and within a sexual minority (those who identify as lesbian, gay, bisexual, transgender, or questioning) in Canada were more likely to experience discrimination, stigmatization, harassment, bullying, less sense of belonging to their school community, and a lack of appropriate education, services, and protective measures and policies - all of which increase their risk for mental health problems |
|
|
Young Adults |
A task of young adulthood is adopting health behaviours while facing different types of health challenges, which may include experience social isolation and adjusting to disabilities and academic stressors during postsecondary education programs Young adults report the highest incidence of depression By age 34, 75% of mental disorders diagnosable over the lifetime have begun Many young adults also begin their working lives in debt from their years in postsecondary education |
|
|
Middle-Aged Adults |
People in their 40s, 50s, and early 60s commonly process information more slowly and are more vulnerable to distraction than in their youth They use experience to compensate for age-related deficiencies in memory and reaction time There is evidence that the brain can remain strong and even improve its performance well through the middle years, a period of maximum performance for some of the more complex, higher order mental abilities Middle age may also bring more confidence, more skill at quick assessment, and adaptability Men reach their peak performance in these abilities in their 50s and women in their early 60s Challenges during middle ages requires skills in organizing, problem solving, and multitasking The effect of being caught in the middle, even though it is not a typical experience for adults, may be severe High demands and low social support within the workforce can cause the development of depressive symptoms among middle-aged workers Job losses cause by firings or layoffs reduce health, self-esteem, and the sense of control Concurrently, daily stressors directly affect emotional and physical functioning, and the accumulation of persistent irritations and overloads may result in more serious stress reactions such as anxiety and depression Middle-aged adults with high mastery (e.g., successful problem-solving skills) reported less emotional reactivity to stressors Biological changes related to menopause or late onset male hypogonadism may influence cognition and well-being Middle-aged people tend to reassess their achievements in therms of ideals and may subsequently make significant changes in day-to-day life or situations |
|
|
Older Adults |
The aging process leaves the parameters of mental health intact No decrease in general knowledge and little to no loss in vocabulary Takes a bit longer for the brain to process information and react to it, performance on timed intelligence test may be poorer Slower response time affects learning Recent memory, which requires some processing, decreases somewhat with aging Intelligence and remote memory are not affected Age-related change in sensory perception can effect mental functioning (vision loss, hearing changes) The era of older adulthood contains much potential for loss of loved ones, job status, and prestige income, energy, and resilience of the body The grief and despair surrounding these losses can affect mental health and result in disorientation, disability, or depression |
|
|
Screening |
There is fair evidence to support routine screening for depression in primary care settings as a way of improving detection rates Screening linked to an integrated system of treatment and follow-up improved patient outcomes More extensive patient education about depression, and targeting of specific at-risk groups, including older individuals, is recommended |
|
|
Mental Health Assessment: Adults |
Patient can perceive the mental health assessment as threatening Some nurses may assess mental health before working with the patient so that the findings can serve as a template against which to measure the accuracy of the rest of the health history Must develop a style in which much of the assessment is performed through relatively unstructured observations made during history taking and physical examination The way in which patients relate the history of the current situation and interact in the clinical setting reveals much about their mental health |
|
|
Identification/Biographical Information |
Note the primary language spoken by the patient The name the patient prefers to be called Legal name Address Telephone numbers Birthdate and birthplace Gender Relationship status Ethnicity Education Employment Usually questions about this information are nonthreatening and thus a safe way to begin |
|
|
Reason for Seeking Care |
Record the patient's explanation verbatim to describe the reason for the visit Be knowledgable of the psychiatric diagnoses (DSM-V) provided by the attending physician psychiatrist Ask what the patient understands about the need to visit your agency |
|
|
Past Health |
Nothing to put here |
|
|
Past Illness, Injury, Hospitalization |
Note childhood diseases Surgeries Trauma (especially if any resulted in concussion of loss of consciousness) Ask about parental use of alcohol and drugs Birth Trauma Any pattern of injury suggestive of childhood abuse or neglect Any obstetrical history Ask specifically "Have you ever experienced or witnessed anything that threatened your life or safety or the life and safety of a loved one?" If the answer is "yes", ask for details, keeping in mind that psychological trauma is associated with many mental disorders (e.g., anxiety, depression) |
|
|
Chronic Illnesses |
The stress of chronic illnesses, even when well managed, may affect mental health |
|
|
Family Health History |
Ask the age and current health of close relatives (e.g., partner, children, parents, siblings, grandparents, aunts and uncles) If the patient reports a family member's death, ask for the date, the cause, and the effect on the patient Ask about any illnesses that "run in the family" because many mental disorders are genetically linked and family health history provides information about the patient's risk factors Ask about any history of postpartum depression because this can induce maternal physical, marital, social, and vocational difficulties; impair maternal infant interactions; and affect an infant's cognitive and emotional development Assessing family health identifies sources of social support, family stress, coping ability, and resources |
|
|
Developmental Considerations |
Ask about the achievement of educational and developmentally appropriate tasks and milestones that may indicate attention, interpersonal, or behavioural problems. Ask specifically about parental death or separation at an early age because these are often associated with issues of attachment and later relationships Residential schools perpetuated social and psychological trauma among First Nations people |
|
|
Current Health |
Using a systematic approach to ensure comprehensiveness, sort and cluster information about conditions that affect patient mental health, overall functioning, and quality of life In addition to asking the patient to describe the critical characteristics of specific concerns, note the following: 1. Known allergies, type of reaction, and usual treatment and relief measures 2. Status of immunizations, human immunodeficiency virus (HIV), infection, and hepatitis infection. Persons experiencing mental illness may often dwell in poverty, lack knowledge and supports for health promotion, and have lifestyles that put them at risk for communicable diseases 3. Current medications. Specify the name of the medication, purpose, usual dose, frequency, effectiveness, side effects, name of prescriber, duration of taking the medication, and any over-the-counter and herbal preparations. This information helps identify health maintenance behaviours, drug interactions, and potential knowledge deficits |
|
|
Detailed Mental Health Examination |
Strive to ask questions that can be corroborated, to enhance reliability |
|
|
Preparation |
Record the exact time and date of the mental status examination because the mental status can change quickly, as in delirium |
|
|
Equipment Needed |
Pencil Paper Reading material (occasionally) |
|
|
Appearance |
nothing to put here |
|
|
Posture |
Posture is erect Position is relaxed |
|
|
Body Movements |
Body movements are voluntary, deliberate, coordinated, smooth, and even |
|
|
Dress |
Dress is appropriate for setting, season, age, gender, and social group Clothing fits and is put on appropriately |
|
|
Grooming and Hygiene |
The patient is clean and well-groomed Hair is neat and clean Women have moderate of no makeup Men are shaved, or beard or moustache is well-groomed Nails are clean (though some jobs leave nails chronically dirty) Take care in this section |
|
|
Behaviour |
nothing to put here |
|
|
Level of Consciousness |
The patient is awake, alert, and aware of stimuli from the environment and within the self and responds appropriately to stimuli |
|
|
Facial Expression |
The expression is appropriate to the situation and changes appropriately with the topic There is comfortable eye contact unless precluded by cultural norm, e.g., for members of some Aboriginal cultures |
|
|
Speech |
Judge the quality of speech by noting that the patient makes laryngeal sounds effortlessly and makes conversation appropriately Note whether the voice is raised or muffled Whether the replies to questions are one-word or elaborative How fast or slow the patient speaks Normally, the pace of the conversation is moderate, and stream of talking is fluent Articulation (ability to form words) is clear and understandable Word choice is effortless and appropriate to educational level The patient completes sentences, occasionally pausing to think |
|
|
Mood and Affect |
Judge this by body language and facial expression and by the answer to the direct question "How do you feel today?" or "How do you feel most days?" Ask about the length of a particular mood Whether the mood has been reactive or not Whether the mood has been stable or unstable The affect (expression) should be appropriate to the mood and change appropriately with topics |
|
|
Cognitive Functions |
nothing to put here |
|
|
Orientation |
You can discern orientation through the course of the interview, or you may ask for it directly but tactfully "Some people have trouble keeping up with the dates while in the hospital. Do you know today's date?" Assess the patient's orientation Time: day of week, date, year, season Place: where person lives, present location, type of building, names of city and province Person: who examiner is, type of worker Self: person's own name, age Many hospitalized patients normally have trouble with the exact date but are fully oriented on the remaining items |
|
|
Attention Span |
Check ability to concentrate by noting whether the patient completes a thought without wandering Note any distractibility or difficulty attending to you An alternative approach is to give a series of directions to follow in a correct sequence of behaviours, such as "Please put this label on your keys, place the keys into the brown envelope, and give the envelope to the clerk for safe keeping during your admission" |
|
|
Immediate Memory |
Immediate memory enables making sense of what is going on For example, it is used during reading to recall what happens sentence by sentence Assess by asking the patient to recall a statement you just made |
|
|
Recent Memory |
Assess recent memory in the context of the interview by the 24-hour diet recall or by asking what time the patient arrived at the agency Ask verifiable questions to screen for the occasional person who confabulates (makes up) answers to fill in the gaps of memory loss |
|
|
Remote Memory |
In the context of the interview, ask the patient about verifiable past events For example, ask to describe historical events that are relevant for the patient |
|
|
New Learning: The Four Unrelated Words Test |
This tests the patient's ability to acquire new memories It is a highly sensitive and valid memory test that avoids the danger of unverifiable material Say to the patient, "I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them." To be sure that the patient has understood, repeat the words Pick four words with semantic and phonetic diversity (brown, honesty, tulip, eyedropper) (fun, carrot, ankle, loyalty) After 5 minutes, ask the patient to recall the four words To test the duration of memory, ask for a recall at 10 minutes and at 30 minutes The normal response for persons younger than 60 years is an accurate three- or four- word recall after a 5-, 10- and 30-minute delay |
|
|
Additional Testing for Patients with Aphasia |
nothing to put here |
|
|
Word Comprehension |
Point to articles in the room, and ask the patient to name them |
|
|
Reading |
An awareness of a patient's reading and writing impairment is important in planning health teaching and rehabilitation To assess reading, ask the patient to read available print, being careful not to test just literacy |
|
|
Writing |
Ask the patient to compose and write a sentence Note coherence Spelling Parts of speech (the sentence should have a subject and verb) |
|
|
Higher Intellectual Function |
Measure problem-solving and reasoning abilities Must be assessed in view of educational and cultural backgrounds Have been widely used to distinguish between organic brain disease and psychiatric disorders; however there is little evidence that most of these tests validly detect organic dysfunction and have relevance for daily clinical care |
|
|
Insight and Judgement |
Insight is the ability to recognize one's own illness, need for treatment, and consequences of one's behaviour as stemming from an illness Patients exercise judgement when they compare and evaluate the alternatives in a situation and reach an appropriate course of action To assess judgement in the context of an interview, note what the patient says about job plans and social or family obligations Plans for the future Capacity for violent or suicidal behaviour Jobs and future plans should be realistic, in view of the patient's health situation To assess insight into illness, ask whether patients believe they need help or whether they believe their feelings or conditions are normal Further assess insight by asking patients to describe their rationale for personal health care and how they decided about whether to comply with prescribed health regimens The patient's actions and decisions should be realistic |
|
|
Thought Processes, Thought Content, and Perceptions |
Nothing to put here |
|
|
Thought Processes |
Ask yourself "Does this person make sense? Can I follow what the person is saying?" Note whether the patient responds directly to the questions or deviates from the subject at hand and has to be guided back to the topic more than once The way a patient thinks should be logical, goal directed, coherent, and relevant The patient should complete a thought |
|
|
Thought Content |
What the patient says should be consistent and logical To identify any obsessions or compulsions, ask such questions as these: "How often do you wash your hands or count things over and over?" "Do you perform specific actions to reduce certain thoughts?" Explore ritualistic behaviours further to determine the severity of the obsession or compulsion To identify any fears that cause the patient to avoid certain situations, ask if he or she has any fears, such as fear of animals, needles, heights, snakes, public speaking, or crowds To determine whether a person is having delusions, ask "Do you have any thoughts that other people think are strange?" or "Do you have any special powers or abilities?" |
|
|
Perceptions |
The patient should be consistently aware of reality, and his or her perceptions should be congruent with yours Ask the following: "How do people treat you?" "Do you feel as if you are being watched followed, or controlled?" "Is your imagination very active?" "Have you heard your name when you're alone?" If the responses to these questions suggest that a person is experiencing hallucinations, ask some of the following questions: "Do you ever hear voices when no one else is around?" "Can you sometimes see things that no one else can see?" "Do you have other unexplained sensations such as smells, sounds, or feelings?" If command-type hallucinations are experienced, always ask what the person will do in response For example, "When the voices tell you to do something, do you obey their instructions or ignore them?" |
|
|
Supplemental Mental Status Examination |
nothing to put here |
|
|
What is the Montreal Cognitive Assessment (MoCA)? |
An assessment that is quick, includes standard sets of questions, has standardized administration methods, requires only 10 to 15 minutes to administer, and is free for nonprofit use (Figure 6-1, pg. 93) |
|
|
The MoCA demonstrated adequate psychometric properties as a screening instrument for what things? |
The detection of mild cognitive impairment or dementia in Parkinson's disease, in transient ischemic attack and stroke, and in psychiatric rehabilitation |
|
|
What is the maximum score on the MoCA and what scores above what number indicate no cognitive impairment? |
Maximum score is 30 and scores above 26 indicate no cognitive impairment |
|
|
Functional Assessment (Including Activities of Daily Living) |
Record the dates of the most recent medical examination, eye examination, and dental examination Ask the patient to describe a typical day and what the patient does on a daily, weekly, and annual basis to promote and maintain health Assess self-care abilities, including activities of daily living such as bathing, hygiene, dressing, toileting, eating, walking, housekeeping, shopping, cooking, communicating with others, social relationships, finances, and coping In particular, note the following: |
|
|
Nutritional Patterns |
Record the dietary intake recalled by the patient over the past 24 hours Ask whether recent dietary changes have occurred Note any dissatisfaction with body size Weight Shape Practices directed at weight loss, particularly if the patient is female, an elite athlete, or engaged in an occupation that emphasizes physical appearance, inasmuch as these factors contribute to eating disorders |
|
|
Sleep/Rest Changes |
Ask about sleep onset (how much time it takes to fall alseep) Sleep maintenance (frequency wakening and returning to sleep) Early awakening (before the patient needs to be awake) Sleep hygiene (measures to promote sleep, such as avoiding caffeine) Sleep satisfaction (feeling rested and refreshed) Alterations in sleep are common in many mental disorders (e.g., mania, depression, schizophrenia) |
|
|
Activity/Mobility |
Withdrawal from usual activities may signal illness Avolition (lack of motivational drive and energy) is a symptom of depression, schizophrenia, and chronic marijuana use. Excessive pursuit of physical activity may be associated with mania and eating disorders |
|
|
Elimination |
Psychotropic medications may lead to constipation and urinary retention People may misuse laxatives and diuretics in an attempt to lose weight |
|
|
Interpersonal Relationships and Resources |
Assess the patient's role in family and social networks to identify sources of stress and support Any withdrawal from usual relationships could indicate declining mental health |
|
|
Self-Esteem/Self-Concept |
Ask the patient to rate self on a scale from 0 to 10, on which 10 represents the best possible way to feel about self Ask about values, beliefs, practices, and accomplishments that are most important to the patient |
|
|
Spirituality |
Ask questions to understand the meaning of faith, spirituality, and religion: "What is it that gives your life meaning? What gives you joy?" "What, if any, religious activities do you participate in?" "Do you feel connected with the world?" "Do you believe in God or a higher power?" |
|
|
Coping and Stress Manangement |
Ask about major stressors to understand and evaluate current coping behaviours |
|
|
Smoking, Alcohol/Drug Use, and Problem Gambling |
Inquire about usual patterns of alcohol use, drug use, and gambling Recent changes to those patterns Ask whether persons close to the patient would believe that alcohol, drug use, or gambling is a problem in the patient's life |
|
|
Home and Environmental Hazards |
Ask about safety issues associated with meal preparation Bathing Walking in the home and community Lighting Home heating Transportation to health care clinics Social and commercial services Social events |
|
|
Risk Assessment |
nothing to put here |
|
|
Screen for Suicidal Thoughts |
It is difficult to ask patients about possible suicidal wishes, especially for novice examiners but the risk is far greater if you skip these questions When the patient expresses sadness, hopelessness, despair, or grief, assess any possible risk that the patient will cause physical harm to himself or herself Begin with more general questions; if you hear affirmative answers, continue with more specific questions: "Have you ever felt so blue you thought of hurting yourself?" "Do you feel like hurting yourself now?" "Do you have a plan to hurt yourself?" "What would happen if you were dead?" "How would other people react if you were dead?" Inquire directly about specific plans, suicide notes, family history (anniversary reaction) and impulse control Use a matter-of-fact tone of voice and open posture, and attend with interest (e.g., lean toward the person) If you are unsure whether the patient is at high risk for suicide, get help from an experienced health care team leader |
|
|
What are important clues and warning signs for suicide? |
- A precise suicide plan to take place in the next 24 to 48 hours with the use of a lethal method (constitutes high risk) - Prior suicide attempts - Depression, hopelessness - Social withdrawal, running away - Self-mutilation - Hypersomnia or insomnia - Slowed psychomotor activity - Anorexia - Verbal suicide messages (defeat, failure, worthlessness, loss, giving up, desire to kill self) - Death themes in art, jokes, writing, behaviours - Saying goodbye (giving away prized possessions) |
|
|
Screen for Assaultive or Homicidal Intention |
In addition to assessing suicide threat, inquire about past acts of self-harm or violence "Do you have any thoughts of wanted to hurt anyone?" "Do you have any feelings of thoughts that you wish someone were dead?" If the reply to either question is positive, ask about any specific plans to injure someone and how the patient plans to control these feelings if they occur again |
|
|
Screen for Elopement Risk |
Increases risk of injury for patients and others in community and increases potential litigation against the facility To reduce risk, check the following: - Are the doors locked? Are they unlocked manually (not electronically) so that the patient does not slip out with visitors? - Is the patient restricted to the unit, or does the patient have off-unit privileges? - Does the patient have an adequate understanding of the need for hospitalization? - Does the family have adequate knowledge of the risk of elopement? - Should the patient be placed in hospital clothing, with street clothing and shoes removed, to discourage elopement? - Has the patient been placed on increased observation status? |
|
|
Global Assessment of Functioning |
Performed by the psychiatrist or qualified clinician Used to estimate overall psychological, social, and occupational functioning within any limitations imposed by patient physical and environmental factors Findings are scored from low functioning (0 to 10) to high functioning (91 to 100) Scores change over time, and scoring is calculated at the start of treatment |
|
|
Assessing Patient Attitude Toward The Examiner/Assessment |
Record whether the patient appears hostile, defensive, guarded, or uncomfortable Often, the patient is willing to cooperate and appears interested, friendly, relaxed, or perhaps bored with the interview |
|
|
Developmental Considerations |
nothing to put here |
|
|
Children and Adolescents |
Essentially follow the same guidelines, with an emphasis on developmental milestones Can use the Nipissing District Developmental Screen or the Pediatric Symptom Checklist-17 For adolescents, continue to follow the same guidelines as described for adults Specifically evaluate weight in the appearance assessment Regulation (self-soothing capacity and anger management skills) in the behaviour assessment Sleep patterns, eating patterns, interpersonal behaviours (with parents, teachers, and examiner), risk (to self and others), high risk behaviours (e.g., bullying/fire setting/running away/high risk sexual activity/cruelty/ breaking curfew/lying/stealing/truancy), academic performance (grade, least and most favourite subjects), and substance use with the cognition and thought processes assessments |
|
|
Adults and Older Adults |
Always conduct even a brief examination of all older people Check sensory status before assessing their mental health Recommended that you take time, reduce distractions, and minimize sensory impairments to help older people maintain their dignity and perform at the actual level of ability Ageis the greatest risk factor for Alzheimer's disease Follow the guidelines as described for adults with the additional considerations listed (next few cue cards) |
|
|
Behaviour |
nothing to put here |
|
|
Level of Consciousness |
Scales such as the Glasgow Coma Scale avoid ambiguity when numerous examiners care for the same person |
|
|
Cognitive Functions |
nothing to put here |
|
|
Orientation |
May not provide the precise date or complete name of the clinic or setting May consider older adults oriented to time if the year and month are correctly stated Orientation to place is considered acceptable if the patient correctly identifies the type of setting (e.g., the hospital) and the name of the town |
|
|
New Learning |
An age-related decline occurs in performance in the Hour Unrelated Words Test |
|
|
Supplemental Mental Status Examination |
nothing to put here |
|
|
Set Test |
It's a quantifiable test, designed to screen for dementia Ask the patient to name 10 items in each of four categories or sets: fruits, animals, colours, and towns (FACT) Do not coach, prompt, or hurry the person Each correct answer is scored 1 point Maximum total score is 40 No one with a score over 25 has been found to have dementia |
|
|
Clock Test |
Patient is asked to draw a clock face to depict a specific time There are advantages to this test including the short time it takes to administer it (approximately 2 minutes) Not recommended for use as the sole-screening tools for dementia because the results are influenced by the severity of the cognitive impairment, limited education, and advanced age |
|
|
Abnormal Findings |
nothing to put here |
|
|
To increase clarity, what should you record in addition to the other terms? |
1. The level of stimulus used, ranging progressively from - Name called in normal tone of voice - Name called in loud voice - Light touch on person's arm - Vigorous shake of shoulder - Pain applied 2. The patient's response - Amount and quality of movement - Presence and coherence of speech - Opening of eyes and making eye contact 3. What the patient does on cessation of your stimulus |
|
|
Alert |
Awake or readily aroused, oriented, fully aware of external and internal stimuli and responds appropriately, conducts meaningful interpersonal interactions |
|
|
Lethargic (or Somnolent) |
Not fully alert, drifts off to sleep when not stimulated, can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions or commands but thinking seems slow and fuzzy, inattentive, loses train of thought, spontaneous movements are decreased |
|
|
Obtunded |
(Transitional state between lethargy and stupor) Sleeps most of the time, difficult to arouse: needs loud shout or vigorous shake, acts confused when aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation |
|
|
Stupor or Semicoma |
Spontaneously unconscious, responds only to persistent and vigorous shake or pain Has appropriate motor response (i.e., withdraws hand to avoid pain) Otherwise can only groan, mumble, or move restlessly Reflex activity persists |
|
|
Coma |
Completely unconscious, no response to pain or to any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away) In light coma, has some reflex activity but no purposeful movement In deep coma, has no motor response |
|
|
Acute Confusional State (Delirium) |
Clouding of consciousness (dulled cognition, impaired alertness) Inattentive Incoherent conversation Impaired recent memory and confabulatory for recent events Often agitated and having visual hallucinations Disoriented, with confusion worse at night when environmental stimuli are decreased |
|
|
Abnormalities of Mood and Affect
|
nothing to put here |
|
|
Flat affect (blunted affect) |
Lack of emotional response No expression of feelings Voice monotonous and face immobile Topic varies, expression does not |
|
|
Depression |
Sad, gloomy, dejected Symptoms may occur with rainy weather, after a holiday, or with an illness If the situation is temporary, symptoms fade quickly "I've got the blues" |
|
|
Depersonalization (lack of ego boundaries) |
Loss of identity, feeling estranged, perplexed about own identity and meaning of existence "I don't feel real" or "I feel as if I'm not really here" |
|
|
Elation |
Joy and optimism, overconfidence, increased motor activity, not necessarily pathological "I'm feeling very happy" |
|
|
Euphoria |
Excessive well-being, unusually cheerful or elated, that is inappropriate considering physical and mental condition, implies a pathological mood "I am high"; I feel like I'm flying"; or "I feel on top of the world" |
|
|
Anxiety |
Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown "I feel nervous and high strung"; "I worry all the time"; or "I can't seem to make up my mind" |
|
|
Fear |
Worried, uneasy, apprehensive External danger is known and identified Fear of flying in airplanes |
|
|
Irritability |
Annoyed, easily provoked, impatient Internalizing a feeling of tension, so that a seemingly mild stimulus "sets off" the patient |
|
|
Rage |
Furious, loss of control Expressing violent behaviour toward self or others |
|
|
Ambivalence |
The existence of opposing emotions toward an idea, object, person Feeling love and hate toward another person at the same time |
|
|
Lability |
Rapid shift of emotions Person expresses euphoric, tearful, angry feelings in rapid succession |
|
|
Inappropriate affect |
Affect that is clearly discordant with the content of the person's speech Laughing while discussing admission for liver biopsy |
|
|
Examples of Abnormalities of Thought Process |
nothing to put here |
|
|
Blocking |
Sudden interruption in train of thought, seems related to strong emotion Unable to complete sentence, saying, "Forget what I was going to say" |
|
|
Confabulation |
Fabricating events to fill in memory gaps Giving detailed description of a long walk around the hospital although the patient is known to have remained in their room all afternoon |
|
|
Neologism |
Coining a new word Invented word has no real meaning except for the patient Several words may be condensed Saying "I'll have to turn on my thinkilator" |
|
|
Circumlocution |
Roundabout expression, substituting a phrase when patient cannot think of name of object Saying, "the thing you open the door with" instead of "key" |
|
|
Circumstantiality |
Talking with excessive and unnecessary detail, delay in reaching point Sentences have a meaningful connection but are irrelevant (this occurs normally in some people) Saying "When was my surgery? Well I was 28, I was living with my aunt, she's the one with psoriasis, she had it bad that year because of the heat, the heat was worse then than it was the summer of '92...." |
|
|
Loosening associations |
Shifting from one topic to an unrelated topic Person seems unaware that topics are unconnected Saying "My boss is angry with me and it wasn't even my fault. [pause] I saw that movie too, Lassie. I felt really bad about it. But she kept trying to land the airplane and she never knew what was going on. |
|
|
Flight of ideas |
Abrupt change, rapid skipping from topic to topic, practically continuous flow of accelerated speech Topics usually have recognizable associations or are plays on words Saying "Take this pill? The pill is blue. I feel blue. [sings] she wore blue velvet" |
|
|
Word salad |
Incoherent mixture of words, phrases, and sentences Illogical. disconnected, includes neologisms Saying "Beauty, red based five, pigeon, the street corner, sort of |
|
|
Preservation |
Persistent repeating of verbal or motor response, even with varied stimuli Saying "I'm going to lock the door, lock the door. I walk every day and I lock the door. I usually take the dog and I lock the door." |
|
|
Echolalia |
Imitation, repeats others' words or phrases, often with a mumbling, mocking, or mechanical tone [In response to the nurse's request to take a pill] Saying mockingly, "Take your pill. Take your pill." |
|
|
Clanging |
Word choice based on sound, not meaning Includes nonsense rhymes and puns Saying "My feet are cold. Cold, bold, told. The bell tolled for me." |
|
|
Abnormalities of Thought Content |
nothing to put here |
|
|
Phobia |
Strong, persistent, irrational fear of an object or situation Feeling driven to avoid it Cats, dogs, heights, enclosed spaces |
|
|
Hypochondriasis |
Morbid worrying about own health Feeling sick with no actual basis for that assumption Preoccupation with the possibility of having cancer Belief that any symptom or physical sign means cancer |
|
|
Obsession |
Unwanted, persistent thoughts or impulses experienced as intrusive and senseless Logic does not purge them from consciousness Violence (parent having repeated impulse to kill a loved child) Contamination (becoming infected by shaking hands) |
|
|
Compulsion |
Unwanted repetitive act thought to neutralize or prevent discomfort or some dreaded event Hand-washing, counting, checking and rechecking, touching |
|
|
Delusions |
Fixed, false beliefs Irrational beliefs Clinging to delusion despite objective evidence to contrary Grandiose delusion: belief that one is God, a famous person, a historical figure, a sports figure, or another well-known person Persecution: saying, "They are out to get me" |
