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159 Cards in this Set

  • Front
  • Back

Significance of Mental Health Assessment For Canadians

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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

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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

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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

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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

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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


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


Telephone numbers

Birthdate and birthplace


Relationship status




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

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Past Illness, Injury, Hospitalization

Note childhood diseases


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


Record the exact time and date of the mental status examination because the mental status can change quickly, as in delirium

Equipment Needed



Reading material (occasionally)


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Posture is erect

Position is relaxed

Body Movements

Body movements are voluntary, deliberate, coordinated, smooth, and even


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


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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


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

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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

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Word Comprehension

Point to articles in the room, and ask the patient to name them


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


Ask the patient to compose and write a sentence

Note coherence


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

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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?"


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

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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



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)


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


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


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


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


Walking in the home and community


Home heating

Transportation to health care clinics

Social and commercial services

Social events

Risk Assessment

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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

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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)


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Level of Consciousness

Scales such as the Glasgow Coma Scale avoid ambiguity when numerous examiners care for the same person

Cognitive Functions

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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
Performance improves at 10 to 30 minutes after being reminded by verbal cues

Supplemental Mental Status Examination

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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

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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


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


(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


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)


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


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"


Joy and optimism, overconfidence, increased motor activity, not necessarily pathological

"I'm feeling very happy"


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"


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"


Worried, uneasy, apprehensive

External danger is known and identified

Fear of flying in airplanes


Annoyed, easily provoked, impatient

Internalizing a feeling of tension, so that a seemingly mild stimulus "sets off" the patient


Furious, loss of control

Expressing violent behaviour toward self or others


The existence of opposing emotions toward an idea, object, person

Feeling love and hate toward another person at the same time


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


Sudden interruption in train of thought, seems related to strong emotion

Unable to complete sentence, saying, "Forget what I was going to say"


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


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"


Roundabout expression, substituting a phrase when patient cannot think of name of object

Saying, "the thing you open the door with" instead of "key"


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


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."


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."


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


Strong, persistent, irrational fear of an object or situation

Feeling driven to avoid it

Cats, dogs, heights, enclosed spaces


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


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)


Unwanted repetitive act thought to neutralize or prevent discomfort or some dreaded event

Hand-washing, counting, checking and rechecking, touching


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"