Mental Health Assessment

Assessment of Mental Health Status: Learning Objectives

• Categories used in assessment of a client's mental health should be identified
• Key physiologic functions that are frequently impaired in people with mental illness, should be recognised.
• Psychosocial assessment data is needed to plan nursing care
• Feelings about discussing suicide, homicide, or self-harm behaviors with a client should be examined.

General Appearance, Motor Behavior, and Communication

• Overall appearance should be assessed, including: dress, hygiene, and grooming.
• Determine if the client is appropriately dressed for age and weather
• Check if the client is unkempt or disheveled
• Observe posture, eye contact, facial expression, and any unusual tics or tremors
• Self-care deficits should be noted

Terms Used

• Automatism is repeated purposeless behaviors indicative of anxiety
• Psychomotor retardation is overall slowed movements
• Catatonia is when the client appears unmoving
• Echolalia is imitation of movements and gestures of someone whom the client is observing.
• Waxy flexibility is maintenance of posture or position, even when it is awkward or uncomfortable.

Assessing Speech

• Determine if the client talks nonstop
• Establish if the client perseverates
• Establish if responses are minimal “yes” or “no” without elaboration
• Check if the content of speech relevant to the questions being asked
• Determine if the rate is fast or slow, and the tone audible or loud
• Decide if the client speaks in a rhyming manner
• Detect if the client use neologisms
• Note any speech difficulties such as stuttering or lipsing

Unusual Speech Patterns

• Clang associations are ideas that are related to each other based on sound or rhyming rather than meaning, for example: “I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill.”

• Neologisms are words invented by the client.

• Verbosely is the stereotyped repetition of words or phrases that may or may not have meaning to the listener.

• Echolalia is the client's imitation or repetition of what the nurses says.

• Stilted language is use of words or phrases that are flowery, excessive, and pompous

• Perseveration is the persistent adherence to a single topic/idea and verbal repetition of a sentence, phrases, or words even when another person attempts to change the topic

• Word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener

Mood and Affect

• Mood refers to the client's pervasive and enduring emotional state
• Affect refers to the outward expression of the client's emotional state.
• Client's mood may be described as happy, sad, depressed, euphoric, anxious, or angry.
• Labile mood is when the client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no-apparent stimuli.

Common terms used in assessing affect:

• Normal affect
• Constricted affect
• Blunted affect is showing little or a slow-to-respond facial expression
• Broad affect is displaying a full range of emotional expressions
• Flat affect means showing no facial expression
• Inappropriate affect is displaying a facial expression that is incongruent with mood or situations and is often silly or giddy regardless of circumstances
• Restricted affect means displaying one type of expression, usually serious or somber

Thought Process and Thought Content

• Thought process refers to how the client thinks, and can be inferred from speech and speech patterns

Common terms used in thought process:

• Thought broadcasting is a delusional belief that others can hear or know what the client is thinking
• Thought insertion is a delusional belief that others are putting ideas or thoughts into the client's head, and that the ideas are not those of the client
• Thought withdrawal is a delusional belief that others are taking the client's thoughts away and the client is powerless to stop it
• Ideas of reference is a Client's inaccurate interpretation that the general events are personally directed to him/her, such as hearing a speech on the news and believing the message had personal meaning
• Delusion is a fixed false belief in reality

Types of Delusions

• Persecutory/paranoid delusions involve the client's belief that “others” are planning to harm the client or are spying, following, ridiculing, or belittling the client in some ways;
• Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or their belief that he/she is famous or capable of great power;
• Religious delusions often center the second coming of Christ or another significant religious figure or prophet, and they appear suddenly as part of the client's psychosis but are not part of his/her religious faith;
• Somatic delusions are generally vague and unrealistic beliefs about the client's health or bodily functions;
• Referential delusions or ideas of reference involve the client's belief that TV broadcasts, music or newspaper articles have special meaning for him/her

Thought Content

• Thought content is what the client actually says
• Circumstantial thinking is when a client eventually answers a question but only after giving excessive unnecessary detail
• Flight of ideas refers to an excessive amount and rate of speech composed of fragmented or unrelated ideas
• Loose association is disorganized thinking that jumps from one idea to another with little or no evident relation between thoughts
• Tangential thinking is wandering off the topic and never providing the information requested
• Thought blocking means stopping abruptly in the middle of a sentence or train of thought, they might be unable to continue the idea
• Word salad is the flow of unconnected words that convey no meaning to the listener

Sensorium and Intellectual Processes

• Orientation refers to the client's recognition of person, place, and time, and their knowledge of who and where they are and the correct day, date, and year, and is documented as “Oriented x3".
• Absence of correct information about person, place and time is referred to as disoriented, or "Oriented x 1" (person only), or “Oriented x 2" (person and place)
• When a person is disoriented, they first lose track of time, then place, and finally person
• Orientation returns in the reverse order: person, place and time

Memory

• Directly assessed by asking questions with verifiable answers

Questions To Assess Memory

• What is the name of the current president?
• Who was the president before that?
• In what country do you live?
• What is your phone, social security number?

Sensory-Perceptual Alterations

• Some clients experience hallucinations, which are considered false sensory perception or perceptual experiences that do not really exists
• Can involve the five senses and bodily sensations

Types of Hallucinations

• Auditory Hallucinations: The client hears voices that accuse them of an immoral act, command action or condemn them and considered the most common hallucination

• Visual Hallucinations: The client sees a person or object that is not present

• Olfactory Hallucinations: The client perceives an odor that actually not present

• Gustatory Hallucinations: The client experiences a taste that is not present and frequently is bitter or strong

• Tactile Hallucinations: The client experiences the feeling of touch

• Cenesthetic Hallucinations: Involve the client's report that they feel bodily functions that are usually undetectable

• Kinesthetic Hallucinations: Occur when the client is motionless but reports the sensation of bodily movement

• Illusions are false interpretations of external sensory stimuli and inappropriate response to the perception

Types of Illusions

• Visual: Seeing an object or person in a different form

• Auditory: Hearing a sound and believing that it is another type of sound

• Depersonalization is A form of extreme disorientation in which the client feels detached from his/her behavior

• Although a client can state their name correctly, he or she feels as if his/her body belongs to someone else, or that his/her spirit is detached from the body

Judgement and Insight

• Judgement refers to the ability to interpret one's environment and situation correctly, and to adapt one's behavior and decisions accordingly

• Problem with judgment may be evidenced as the client describes recent behavior and activities that reflect a lack of reasonable care for self or others

• Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation

• Poor insight would be a client who places all blame on others for his own behavior