NURS 301 Week 5 Mental health 2 PDF

THE PSYCHIATRIC MENTAL STATUS EXAMINATION Rae Marceau Gwen Keeler NURS 301 Health Assessment  OBJECTIVES Discuss history taking in mental health Describe the Mental Status Examination (MSE)  Defining Mental Status Mental status—emotional and c...

THE PSYCHIATRIC MENTAL STATUS EXAMINATION Rae Marceau Gwen Keeler NURS 301 Health Assessment  OBJECTIVES Discuss history taking in mental health Describe the Mental Status Examination (MSE)  Defining Mental Status Mental status—emotional and cognitive functioning Mental status is inferred through individual’s behaviours  MENTAL STATUS EXAMINATION The MSE is analogous to the physical examination and is used to evaluate an individual’s current cognitive, affective and behavioural functioning (Varcarolis, 2014). ASSESSING MENTAL HEALTH When assessing a client’s mental health, the nurse incorporates a variety of assessments, in addition to the traditional physical examination. Assessments may include the following: Performing a mental status examination Completing a psychosocial assessment Reviewing the client’s use of psychotropic medications (drugs that treat psychiatric symptoms) and/or other medications that can cause psychiatric symptoms as side effects Screening for suicidal ideation, exposure to trauma or violence, and substance misuse Incorporating a spiritual assessment while assessing the client’s coping status Incorporating life span, developmental, and cultural considerations Reviewing specific laboratory results related to the client’s use of psychotropic and other medications  WHEN IS A MENTAL STATUS ASSESSMENT DONE?  Family members express concern re person’s behavioural changes  Suspected or confirmed brain lesions  Aphasia  Symptoms of psychiatric mental illness  Suspected substance abuse  MENTAL STATUS EXAMINATIONS  Provide information about cerebral cortex function.  Cerebral abnormalities disturb pt’s intellectual ability, communication ability, or emotional behaviours.  Performed at beginning of head-toe assessment to provide clues re validity of subjective info provided by pt (eg. if thought processes distorted and memory impaired - must obtain info by another means or validate info with other sources) WHAT FACTORS AFFECT A MENTAL STATUS ASSESSENT? (OBTAINED FROM HEALTH HISTORY) Any know illnesses or health problems (eg. Alcoholism, chronic renal disease) Current medications whose side effects may cause confusion or depression The usual educational and behavioural level (ie. do not expect performance to exceed it) Responses to personal hx questions (perhaps indicative of current stress, social acceptance, sleep habits, drug and alcohol use)  DEVELOPMENTAL CONSIDERATIONS: INFANTS AND CHILDREN Diffi cult to differentiate development in each aspect of mental status Consciousness, use of language, attention span, and the ability to think abstractly all develop over time and must be considered from a developmental perspective when one is examining infants and children.  DEVELOPMENTAL CONSIDERATIONS: AGING ADULT Process of aging leaves the parameters of mental status mostly intact Slower response time may affect new learning. Be cognizant of the effect of age-related physical changes e.g. alterations in vision or hearing that may affect the mental status of the older adult. More potential for loss (e.g. spouse, job, income) mental status affects include grief and despair, disorientation, disability, depression  MENTAL STATUS ASSESSMENT (“ABCT”) Appearance: Behaviour: Cognition: Thought processes:  ASSESSING APPEARANCE Posture and position: erect & relaxed? Body movements: voluntary, deliberate, coordinated, smooth & even? Dress: appropriate for setting, season, age, gender? Proper fit? Put on properly? Grooming and hygiene: clean and well groomed? What do you notice about this photo in regards to appearance  ASSESSING BEHAVIOUR LOC: awake, alert, aware of environment Facial expression: appropriate for sit’n Speech: appropriate volume and pace of conversation; marticulation; word choice Mood and affect: observe body language or ask directly  LEVEL OF CONSCIOUSNESS Alert Awake or easily aroused, oriented, fully aware of environment, responds appropriately, has meaningful communications with others. Lethargic (A.K.A. Somnolent) Not fully alert, opens eyes when named called in normal voice, responds to questions/commands appropriately, falls back to sleep when not stimulated. Thinking seems slow; appears drowsy; inattentive; loses train of thought. Obtunded Transitional state between lethargy and stupor Opens eyes to loud voice or vigorous shake, responds slowly with confusion, seems unaware of environment. Speech may be mumbled, in monosyllables, or incoherent; requires constant stimulation to maintain PNUR/IEPN 126/Fall 2015/CMB cooperation.  LOC CONT’D Stupor or Semi-coma Awakens to vigorous shake or painful stimuli but returns to unresponsive sleep “spontaneously unconscious” Has appropriate motor response (eg. withdraws hand to avoid pain) reflex activity persists Groans, mumbles, moves restlessly Coma Remains unresponsive to all stimuli; eyes stay closed. May have some reflex activity but no purposeful movement (eg. when suctioned, does not try to push catheter away). May see decorticate posture (a.k.a. abnormal flexor posture = draws hands up to chest) when stimulated May see decerebrate posture (a.k.a. abnormal extensor posture = extends arms/legs, arches neck, rotates hands/arms internally)  COGNITION VS AFFECT Cognition = the mental process characterized by knowing, thinking, learning and judging Cognitive Function = an intellectual process by which one becomes aware of, perceives, or comprehends ideas. It involves all aspects of perception, thinking, reasoning, and remembering Affect = an outward manifestation of a person’s feelings or emotions WHAT DO YOU NOTICE?  ASSESSING COGNITION Orientation: to time, place, person Attention span Recent memory Remote memory New learning: 4 unrelated words test  ASSESSING COGNITION CONT’D Additional tests for persons with aphasia: – Word comprehension – Reading – Writing Insight and Judgement – Daily or long-term life goals: are they realistic considering person’s present health situation  ASSESSING COGNITION Attention: Ask pt to repeat increasingly long lists of numbers (eg. 2,3; 3,7,8; 9,1,4,7; 8,2,4,6,9; etc) Serial 7’s or 3’s subtraction (also assesses “calculation”) Memory: Recent memory: 3 or 4 unrelated words recall Remote memory: spouse’s name or b-day, mother’s maiden name Judgement Decisions based on sound reasoning Eg. “What would you do if you found an addressed envelope with correct postage?”, “What would you do if followed by police car with lights flashing?”  ASSESSING COGNITION Mini Mental State Exam (MMSE) Cognitive screening test using Initial and serial measurements Quick 10-15 minutes Questions about time & place orientation, serial 7’s, naming objects, repeating phrases, following 3-step directions, reading & responding, writing a sentence, drawing intersecting pentagons CONCENTRATES ON COGNITIVE FUNCTIONING NOT MOOD OR THOUGHT PROCESSES Maximum score = 30 Average score =27 No cognitive impairment = 24 – 30 Mild cognitive impairment = 18 – 23 Severe cognitive impairment = 0 - 17  ASSESSING COGNITION Montreal Cognitive Assessment (MoCA) – Quick (10 – 15 minutes) – Standardized set of questions and instructions – Useful for initial and serial measurements – Assesses visuospatial domain, memory, attention, language, abstract thought, orientation – Includes clock drawing test – Good screening tool for detecting dementia and delerium – Maximum score = 30 Scores >26 = no cognitive impairment 18-26 = mild cognitive impairment 10-17 = moderate cognitive imparement actual completed suicides Canadian Statistics – 11.3 deaths/100,000 – Leading cause death for ♂ 25-29 years and 40-49 yrs ♀ 30-34 years – ♂ 4x more likely to complete suicide than ♀  THOUGHT PROCESSES Suicidal ideation – SAD PERSONAS Suicide Risk Assessment Sex Age Depression Previous attempt Ethanol abuse Rational thought loss Social supports lacking Organized plan No spouse Access to lethal means Sickness  Remember Suicide risk assessment, like all risk assessments, gauges risk at a particular moment in time. A person’s suicide risk may change quite quickly.  SUICIDE ASSESSMENT LINKS Suicide assessment https://www.youtube.com/watch?v=Kw8vb8Dc48E  RISK OF SELF-HARM Self-harm: Any intentional damage to the person’s body, without a conscious intention to die Common behaviour in people with mental illness Means of regulating emotional distress Assess person for risk factors: ◦Low mood ◦Sense of abandonment ◦History of self-harm ◦Use of alcohol  RISK OF SELF-HARM If person is assessed as at increased risk of self-harm: Approach person with supportive attitude - encourage sharing of thoughts and feelings Remove harmful objects Assess for precipitating factors and suicide risk Remain available to person for emotional support/ provide close observation Explore alternative coping methods Develop mutually agreed plan for managing possible future episodes  RISK OF VIOLENCE Violence - a physical attack where the intent is to cause harm to an individual or object Aggression - action or behaviours that can range from violent physical acts (e.g. kicks and punches) through to verbal abuse, insults and nonverbal gestures Young males more likely to be involved in violence Previous history is the strongest predictor of violence  RISK OF VIOLENCE Assessing risk of violence involves consideration of multiple contributing factors Internal risk factors – relate to the individual ◦ Mental illness ◦ Age + gender ◦ Previous history External risk factors: ◦Environment-restrictive, crowded limited space ◦Treatment setting perceived as- coercive, controlling, threatening Situational factors ◦Stress, tired, unwell  RISK OF VIOLENCE Observable behaviours and cues indicating violence - STAMP Staring and eye contact – prolonged glaring/ absent eye contact Tone and volume of voice – sharp tone Anxiety – flushed appearance, rapid speech, grimacing, writhing, clenched fists Mumbling – criticising staff, talking under the breath Pacing – walking around confined spaces  RISK OF VIOLENCE If person is assessed as at increased risk of violence: Approach them calmly Speak softly and slowly Avoid prolonged eye contact Keep space between you and the client Always use non-threatening behaviours & speech Provide the person with choice if appropriate Listen to the person Use other staff wisely Follow protocol Use medication and seclusion if necessary DE-ESCALATION  DELERIUM VS DEMENTIA Delerium Disturbance of consciousness (ie. ↓ awareness of environment with ↓ ability to focus or sustain attention) +/- Change in cognition (eg. memory deficit, disorientation, lang. disturbance) +/- Development of perceptual disturbance  DELERIUM VS DEMENTIA CONT’D Dementia Memo ry impair ment + One or more cogniti ve disturb ances: A  DEPRESSION = 5 or more of symptoms listed are present during the same 2 week period & represents a change from previous level of functioning Depressed mood Diminished interest or pleasure in activities Unintentional significant weight loss/weight gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue Feelings of worthlessness or excessive/inappropriate guilt Diminished ability to think/concentrate or indecisiveness Recurrent thoughts of death + At least one symptom is either Depressed mood  MENTAL STATUS: NORMAL FINDINGS Posture erect, gait smooth, body movements symmetrical Clean, well-groomed, clothing appropriate for age and weather Facial expressions appropriate to conversation content, symmetrical  MENTAL STATUS: NORMAL FINDINGS Affect appropriate to situation and cultural norms Able to produce spontaneous, coherent speech Alert, oriented to person, place, time Intact cognitive abilities Documentati on  REFERENCES Butler, K. (2015). On the Frontline with voices - A grassroots handbook for voice- hearers, carers and clinicians. London, UK: Speechmark Publishing Limited. Erwin, E. H., & Colson, C. W. (2014). Disorders of children and adolescents. Adapted by R. J. Meadus. In M. J. Halter, Varcarolis’s Canadian psychiatric mental health nursing: A clinical approach. C. L. Pollard, S. L. Ray, & M. Haase (Eds.), (First Canadian ed., chapter 29, pp. 586–612). Toronto, ON: Elsevier Canada. Mental Status Exam (chapter 29, p. 592–593). Halter (2014). Mental Status Exam. In M. J. Halter, Varcaroli (Eds.). Canadian psychiatric mental health nursing: A clinical approach (1st ed.) (pp. pp. 138 & pp. 592 – 593). Toronto, ON: Elsevier Canada. Jarvis, C. (2014). Physical examination & health assessment. Toronto: Elsevier Canada. Lasiuk, G. (2015). The assessment process. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 10, pp. 148–164). Philadelphia, PA: Wolters Kluwer. Robinson, D. (2008). The Mental Status Exam Explained, 2nd Edition. London, ON: Rapid Psychler Press. ISBN (13) 978-1-894328-25-8 (2015).