Mental Status and Neurological System Assessment

 

The human nervous system is a unique system that allows the body to interact with the environment as well as to maintain the activities of internal organs. It is composed of structures that transmit electrical and chemical signals between the body’s systems and the brain. The multiple functions of the nervous system are so automatic that most people are unaware of their magnitude until a problem occurs. An impaired nervous system can manifest in many ways, from subtle weakness to drastic loss of mobility. The nervous system acts as the main “circuit board” for every body system.Because the nervous system works so closely with every other system, a problem within another system or within the nervous system itself can cause the nervous system to “short-circuit.” A major goal of nursing is early detection to prevent or slow the progression of disease. So it is important for nurses to accurately perform a thorough neurologic assessment and to understand the implications of subtle changes in assessment findings. By doing so, you can initiate timely interventions that can save lives. Because of the complexity of this system, assessment can be challenging, especially for beginning nurses. All body organs and most tissues are innervated; therefore, neurologic activity affects functioning within all body systems. For example, the nervous system responds to stress by increasing the heart rate, resulting in increased blood pressure (BP), whereas it responds to the sight or smell of food by increasing the production of digestive juices. Furthermore, a seemingly straightforward neurologic symptom such as headache, insomnia, or forgetfulness can have a wide range of causes, contributing factors, and consequences. Another assessment challenge may be interacting with the patient. Neurologic impairment can reduce the ability to communicate, cause confusion, alter personality, and otherwise confound your attempts to obtain an accurate health history. Finally, factors such as drug and alcohol use, medication interactions, diet, amount of sleep, and other self-care factors can influence neurologic health. Therefore, careful sleuthing is required when taking the health history and gathering and evaluating the physical findings. The previous chapter discussed neuromuscular function, just one aspect of the highly complex neurologic system.This chapter presents the sensory-neurologic assessment, including information on assessing cerebral function, cranial nerves (CNs), sensation, and reflexes. Throughout the assessment, you will identify risk factors for neurologic impairment and health promotion teaching needs. Remember to document all findings, including normal data, precisely and thoroughly, to provide a baseline against which future neurologic function can be measured. These baseline data are critically important for evaluating degeneration in patients with progressive neurologic disease, as well as for evaluating patients’ progress toward rehabilitation after neurologic trauma and other acute problems.

 Anatomy and Physiology Review

Before beginning the neurologic assessment, you need to understand the anatomy and physiology of the system, including its anatomic and functional divisions and the type and extent of its interaction with other body systems. In addition to the motor aspects discussed in Chapter 20, general functions of the neurologic system include:

 ■ Cognition, emotion, and memory.

 ■ Sensation, perception, and the integration of sensoryperceptual experience.

 ■ Regulation of homeostasis, consciousness, temperature, BP, and other bodily processes.

 

 Structures and Functions of the Sensory-Neurologic System

There are two types of nerve cells:neuroglia and neurons.

 Neuroglia act as supportive tissue, nourishing and protecting the neurons. They also maintain homeostasis in the interstitial fluid around the neurons and account for about 50 percent of the central nervous system (CNS) volume. Neuroglia have the ability to regenerate and respond to injury by filling spaces left by damaged neurons.

 Neurons have the ability to produce action potentials or impulses (excitability or irritability) and to transmit impulses (conductivity).They are composed of a cell body, dendrites, and axons.

 The cell body contains the nucleus. Dendrites are short, branchlike structures that receive and carry impulses to the cell body. Axons are long fibers that carry the electrical impulses generated by the cell bodies.Some axons are covered with a myelin sheath that allows rapid impulse transmission. For neurons to communicate with one another, the axon of one neuron has to convey its impulse to the dendrite of the next neuron across a space called a synapse. It does this with the help of neurotransmitters, chemicals released by the axon that carry the impulse to the receiving dendrite. The impulses conveyed by neurons include sensory data about what the body is seeing, hearing, feeling, and so on, as well as motor data telling the muscles how to respond. Sensory impulses are transmitted to the brain through afferent, or ascending,pathways.Motor impulses are transmitted from the brain to muscles through the efferent, or descending, pathways (Fig. 21.1). Neurons band together into peripheral nerves,spinal nerves, the spinal cord, and the tissues of the brain.These structures make up the neurologic system,which is divided into the CNS and the peripheral nervous system (PNS).  

 

 

The Central Nervous System

The CNS consists of the brain and spinal cord.

The Brain

 The brain is composed of gray matter, made up of neuronal cell bodies, and white matter, composed of axons and dendrites.The brain consists of four major structures: the cerebrum, diencephalon, cerebellum, and brainstem. These and other components of the brain are shown in Figure 21.2 and described in Structures and Functions of the Brain.

 

 The Spinal Cord

The spinal cord descends through the foramen magnum (large aperture) of the occipital bone of the skull, through the first cervical vertebra (C1), and through the remainder of the vertebral column to the first or second lumbar vertebra. At this point, the cord itself terminates and its roots branch off into the cauda equina (“horse’s tail”). A cross-section of the spinal cord reveals gray matter composed of neuronal cell bodies clustered into an “H” shape, with two anterior and two posterior “horns.” This gray matter is surrounded by white matter composed of myelinated axons and dendrites. Cord fibers associate into ascending tracts, which carry sensory data to the brain, and descending tracts, which carry motor impulses from the brain.

 Sensory Pathways

Sensory pathways,either ascending or afferent,allow sensory data, such as the feeling of a burned hand, to become conscious perceptions.The pathways by which a variety of somatic sensations travel to the cerebral cortex are illustrated in Figure 21.3.The two major sensory pathways are the lateral and anterior spinothalamic tracts and the posterior column. The lateral and anterior spinothalamic tracts  

 

transmit nerve impulses for pain, temperature, itching, tickling, pressure, and crude touch, whereas the posterior column transmits nerve impulses for proprioception, discriminative sensations, and vibrations. Some visceral sensory neurons also enter the spinal cord as shown in the figure; however, other visceral stimuli are carried by the vagus nerve or another of the cranial nerves and enter the brainstem directly, bypassing the spinal cord. All somatic sensory stimuli—for example, sensations of pain, heat, or pressure—are conveyed from the body periphery into the spinal cord via the posterior root of the appropriate spinal nerve. At that point, sensations of fine touch, proprioception, and vibration continue into the posterior column of the spinal cord and into the brainstem. Here they cross to the opposite side of the brainstem before they continue into the thalamus and from there to the sensory areas of the cerebral cortex.

 

 

 

 In contrast to this, sensations of pain, temperature, crude touch, and pressure enter the posterior horn and cross the spinal cord into the opposite side of the cord before they begin their ascent. Pain and temperature are carried in the lateral spinothalamic tract, whereas crude touch and pressure are carried in the anterior spinothalamic tract. These tracts continue to ascend straight upward, entering the thalamus and then the cerebral cortex. As you might imagine,a patient with a particular type of sensory loss may have a neurologic impairment affecting a particular column or tract. For example, someone who loses the ability to perceive vibration and changes in positioning may have a lesion in the posterior column.  

 

Motor Pathways

 Motor pathways (descending or efferent) transmit impulses from the brain to the muscles. The three major motor pathways of the CNS are the corticospinal (pyramidal or direct), including the corticobulbar; the extrapyramidal or indirect; and the cerebellum.The descending pathways can be direct or indirect.

Direct (pyramidal) pathways carry impulses from the cerebral cortex to lower motor neurons that innervate the skeletal muscles, resulting in voluntary movement. The direct pathways include the anterior and lateral corticospinal and corticobulbar tracts. The corticospinal tracts control voluntary skilled movement of the extremities and fine movement of the fingers.The corticobulbar tract connects the motor cortex to lower motor neurons of the cranial nerves.

The indirect (extrapyramidal) pathways carry impulses from the brainstem and other parts of the brain, resulting in automatic movement,coordination of movement, and maintenance of skeletal muscle tone and posture. The indirect pathways consist of the reticulospinal, rubrospinal, tectospinal, and vestibulospinal tracts.The possible pathways of the corticospinal system are shown in Figure 21.4. The cerebellar system, which is involved primarily in coordination, equilibrium, and posture, is not shown.Also note that this discussion pertains to somatic,not visceral,motor neurons. From the motor cortex, all somatic motor impulses descend via one of three tracts through the thalamus and into the brainstem, at which point the configuration of the three tracts resembles a pyramid.The anterior corticospinal and corticobulbar (uncrossed pyramidal tract) .And the reticulospinal and vestibulospinal (uncrossed extrapyramidal tract) continue straight down into the spinal cord. There, the impulse must cross over to the opposite anterior horn before it can exit the spinal cord via the anterior root of the spinal nerve.The lateral corticospinal (crossed pyramidal tract) and the rubrospinal (crossed extrapyramidal tract) both cross to the opposite side of the brainstem before descending directly into the anterior horn and exiting into the anterior root of the spinal nerve. Motor impulses from the motor cortex to the periphery are controlled by upper and lower motor neurons. The upper motor neurons are located in the cerebral cortex and brainstem and regulate the responses of the lower motor neurons.The lower motor neuron cell bodies lie in the anterior horn of the spinal cord, then exit the cord through the nerve roots.The lower motor neurons are the final link between the CNS and the skeletal muscles. An upper motor neuron lesion causes increased muscle tone (spasticity) and hyperreflexia. A lower motor neuron lesion causes decreased tone, flaccidity, and absent reflexes or hyporeflexia.

 

 Spinal Reflexes

Spinal reflexes do not depend on conscious perception and interpretation of stimuli, nor on deliberate action; in other words, they do not involve the brain. They occur involuntarily, with lightning speed, and are identical in all healthy children and adults, although they are less developed in infants.When we experience a spinal reflex, we are not aware of the reflexive activity itself, only its result. The simplest spinal reflexes are known as deep tendon reflexes (DTRs). They are monosynaptic, involving just one sensory neuron communicating across a single synapse to one responding motor neuron. A reflex arc is shown in Figure 21.5.

 The classic example of a DTR is the patellar reflex, commonly called the knee-jerk reflex. The patellar reflex is an example of a stretch reflex. The patellar tendon is tapped with a reflex hammer, triggering a stretch response in the sensory fibers of the quadriceps femoris muscle. This stimulus is received by a sensory neuron,which carries it to the anterior horn of the spinal cord, where it is conveyed across a synapse to a motor neuron that then causes the muscle to contract.

 

Because of the simplicity of the reflex arc, this contraction occurs within less than 1 second after the hammer tap. Slow or absent DTRs could indicate a health problem affecting the peripheral nerves, such as a degeneration of their myelin sheaths. Spinal cord trauma or lesions also commonly affect reflexes; therefore, it is helpful to know the specific spinal cord segment associated with each specific reflex.The box entitled Spinal Reflexes identifies the five DTRs, as well as superficial reflexes involving stimulation of the skin, along with the segmental level at which they occur.Assessment of these reflexes is discussed later in the chapter. In addition to the monosynaptic reflexes, the body exhibits protectiveflexor (or withdrawal) reflexes, which help minimize trauma from harmful stimuli. For example, these reflexes allow speedy, involuntary withdrawal from a heat source. Flexor reflexes require a sensory neuron to interact with an intermediate neuron or interneuron in the spinal cord.This interneuron, in turn, sends the impulse across a synapse to the receiving motor neuron.

 Peripheral Nervous System

The peripheral nervous system consists of the cranial and spinal nerves and the peripheral autonomic nervous system.The PNS can also be divided into the somatic and the visceral nervous systems.The somatic system has both afferent and efferent divisions. The afferent division receives, processes, and transmits sensory information from the skin and the musculoskeletal system,eyes,tongue, nose, and ears.The efferent division has lower motor neurons and regulates voluntary muscle contraction. The visceral system also has afferent and efferent divisions.The afferent division is responsible for processing information from the visceral organs.The efferent division is responsible for the motor responses of the smooth muscle, cardiac muscle, skin glands, and viscera.The efferent system is known as the autonomic nervous system.

 Cranial Nerves

The 12 pairs of cranial nerves originate from the brain and are called the peripheral nerves of the brain. As shown in Figure 21.6, these nerves originate from the cerebrum, diencephalon, and brainstem.The function of each of the cranial nerves is indicated in Function of Cranial Nerves.

 Spinal and Peripheral Nerves

Branching from the spinal cord are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal (Fig. 21.7). The spinal nerves contain both ascending and descending fibers, and although there is some overlap,each is responsible for innervation of a particular area of the body. As shown in Figure 21.8, dermatomes are regions of the body innervated by the cutaneous branch of a single spinal nerve. For example, nerve C6 innervates a portion of the lateral (thumb) side of the arm and hand. Although there is some individual variation, it is useful to know which spinal nerves typically innervate which segments of the body so that neurologic deficits can be more easily associated with lesions of particular nerves. Each spinal nerve emerges from the spinal cord from two distinct roots. The posterior (dorsal) root contains afferent fibers that receive sensory information   from the body periphery and convey it to the CNS.

 

 

The anterior (ventral) root contains efferent fibbers that convey motor impulses from the CNS to the muscles of the body, directing and refining movement. These anterior and posterior roots then merge just distal to the cord to form one mixed spinal nerve capable of both sensory and motor functioning. Spinal nerves branch further to form theperipheral nerves of the body, most of which also carry both sensory and motor fibers. The autonomic nervous system is divided into the sympathetic and parasympathetic, with efferent fibers to muscle, organs, or glands. Usually, the two systems work opposite each other.The sympathetic allows the body to respond to stressful situations.

The parasympathetic functions when all is normal. The sympathetic nerves exit the spinal cord between the level of the first thoracic and the second lumbar vertebrae.The preganglionic nerves descend the cord and exit, and then enter a relay station known as the sympathetic chain. The impulse is then transmitted to a postganglionic neuron that goes to the target organ to stimulate a response. Sympathetic responses include vasoconstriction; increased BP, heart rate, and contractility; increased respiratory rate; smooth muscle relaxation of bronchioles, gastrointestinal (GI) tract, and urinary tract; sphincter contraction; pupillary dilation; increased sweat, and decreased pancreatic secretion. The parasympathetic fibers leave the CNS by way of the cranial nerves from the midbrain and medulla, and between the second and the fourth sacral vertebrae. A long preganglion fiber exits to an area near the target organ, and then synapses to form a postganglionic nerve, which in turn leads to a response. Parasympathetic responses include decreased heart rate, contractility, and velocity; smooth muscle constriction of bronchioles; increased GI tract tone and peristalsis with sphincter relaxation; urinary sphincter relaxation and increased bladder tone; vasodilation of external genitalia causing male erection; pupillary constriction, and increased pancreatic, lacrimal, and salivary secretions. There is little effect on mental and metabolic activity. Figure 21.9 illustrates the autonomic nervous system

. Interaction With Other Body Systems

Because the nervous system is the main circuit board for the body, all body systems interact with it in some way.  

 

 

 

The Cardiovascular System

Although the conduction system of the heart is completely independent of extrinsic neural control, cardiac centers in the medulla influence heart rate. Also, the vagus nerve can exert significant influence over both heart rate and vessel constriction,thereby influencing BP.

 The Respiratory System

Respiratory centers in the medulla of the brainstem regulate inspiration and expiration. Centers in the pons regulate respiratory drive. The vagus nerve relays data on blood gas levels to the medulla.Voluntary regulation of breathing can be achieved via motor neurons,which can stimulate the respiratory muscles

. The Endocrine System

The secretion of some endocrine glands, such as the adrenal glands, is regulated by nerves. Some neurons in the hypothalamus actually act as endocrine cells, secreting antidiuretic hormone, which stimulates the kidneys to reabsorb water and oxytocin, a reproductive hormone. Some other hormones, notably parathyroid hormone, affect metabolism of electrolytes, which in turn affects neurologic function.

 The Musculoskeletal System

Somatic and visceral motor neurons receive impulses from the cerebral cortex to carry out both voluntary and reflexive movements.

 

Performing the Sensory-Neurologic and Cranial Nerve Assessment

 A complete assessment of the patient’s neurologic system requires you to take a detailed health history, perform a mental status examination, assess the cranial nerves, assess the sensory system, and test deep tendon and superficial reflexes.

 Health History

Before you begin the health history, keep in mind that the patient may be experiencing confusion, impaired verbal communication, memory loss, personality changes, or other deficits.This may affect her or his ability to provide reliable information, so verifying subjective data with a family member or friend may be wise.  

 

Rather than asking a long series of questions, it may be best to encourage the patient to tell her or his story without interruption.You can learn a great deal from the content of the story and also by listening to the way it is told. If time is an issue and you are unable to perform a complete health history, perform a focused history on the sensory-neurologic system.

 Biographical Data

As always, review the patient’s biographical data for clues that relate to the neurologic system. Obviously, the patient’s age and educational level will influence the questions you ask and the type and extent of teaching you provide. Keep in mind that certain neurologic disorders are age related.For example, the incidence of stroke increases with age,and neurologic diseases such as myasthenia gravis (MG) and multiple sclerosis (MS) usually attack young women with a peak age between 20 and 30 years. Spinal cord injuries occur more frequently in young people because of the higher rate of accidents. Also, some neurologic disorders are gender related. For example,women have a higher incidence of hemorrhagic stroke, whereas men have more thrombic strokes; before age 40, MG occurs in women two to three times more often than in men; and the incidence of MS is higher in women than in men. Even geographical locale influ influences some types of neurologic diseases.For instance,MS occurs most often in colder climates such as the northeastern,Great Lakes, and Pacific Northwestern states. Also, the incidence of stroke is higher in the “stroke belt” states of Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana,Mississippi, North Carolina, South Carolina, Tennessee, and Virginia. Ask adolescents and adults about their job history. Could they have been exposed to neurotoxins? Have they had a head or back injury? Marital status, such as a recent divorce or death of a spouse, can certainly influence neurologic findings.A patient’s spiritual beliefs may also influence how he or she perceives illness (e.g., as a punishment) and how he or she deals with illness (e.g., the Christian Science belief in healing through mental and spiritual means).

 Current Health Status

The current health status focuses on the patient’s chief complaint. If she or he has a neurologic problem, begin with the chief complaint. Major neurologic symptoms to watch for are headache, memory loss, confusion, dizziness, loss of consciousness, numbness, sensory loss, and problems with any of the five senses. Explore these complaints using the PQRST format.  

 

Symptom Analysis

Symptom analysis tables for all the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book.

 Headache

Headache is the most common neurologic symptom.The causes are many.The pain may be mild or severe, acute or chronic, localized or generalized. Ninety percent of all headaches are benign in nature, caused by muscle contraction (tension) and/or vascular (migraine and cluster); the other 10 percent have underlying pathology.Because a headache may be a symptom of a serious medical problem, a careful, thorough symptom analysis is needed to determine the cause. Mental Status Changes

Mental status changes are an early indication of a change in neurologic status. The changes may be very subtle and difficult to detect.They may begin slowly as forgetfulness, memory loss, or inability to concentrate, or rapidly proceed to unconsciousness. Causes include neurologic problems, fluid and electrolyte imbalance, hypoxia, low perfusion states, nutritional deficiencies, infections, renal and liver disease, hyper- or hypothermia, trauma, medications, and drug and alcohol abuse. If your patient’s mental status is severely impaired, ask family members to describe the changes that have occurred.

 Dizziness, Vertigo, and Syncope

Dizziness, vertigo, and syncope are common neurologic signs and symptoms that warrant further investigation. Dizziness is a “fainting” sensation, whereas vertigo is a sensation that the surroundings are spinning around (objective vertigo) or that the person is spinning around (subjective vertigo).Vertigo is often accompanied by nausea and vomiting, nystagmus, and tinnitus. Dizziness can lead to syncope,which is a temporary loss of consciousness. The patient may say that he or she “blacked out” or “had a spell.” Although the underlying cause of these signs and symptoms may be benign, they may also indicate a serious problem, such as an impending stroke, and need to be investigated thoroughly.Numbness or Loss of Sensation

Numbness or tingling is referred to as paresthesia. Possible causes include diabetes and neurologic, metabolic, cardiovascular, renal, and inflammatory diseases. Determine the area affected and the onset and progression of symptoms.  

Deficits in the Five Senses

Assess changes in any of the five senses. Intact cranial nerves are essential for many of the senses. CN I (olfactory) is responsible for the sense of smell; CN II (optic), III (oculomotor), IV (trochlear), and VI (abducens) are responsible for visual acuity, pupillary constriction, and extraocular movement (EOM); CN VII (facial) and IX (glossopharyngeal) control taste; CN VIII (acoustic) controls hearing; and CN V (trigeminal) and dermatomes control somatic sensations. Visual problems are a frequent symptom associated with neurologic disorders and should be further assessed. Visual changes can result from ocular, neurologic, or systemic problems, eye or head trauma, or adverse effects from drugs.The anatomic position of the cranial nerves that control the eye makes the nerves vulnerable to increases in intracranial pressure (ICP). These visual changes can be total loss of vision, visual field cuts,blurred vision, diplopia (double vision), photosensitivity, and amaurosis fugax (unilateral vision loss, as if a shade were being pulled down, resulting from insufficient blood supply to the retina and lasting up to 10 minutes). The visual deficit may have an acute or gradual onset and be permanent or temporary.

 Past Health History

The purpose of the past medical history is to compare it with the patient’s present neurologic status or uncover risk factors that might predispose the patient to neurologic disorders. The following questions will guide you in exploring specific areas related to the sensory-neurologic system.  

 

 

Family History

The family history identifies any predisposing or causative factors for neurologic problems.

 

Review of Systems

The review of systems (ROS) allows you to assess how the neurologic system affects or is affected by every other system. Often, you may uncover an important fact that your patient failed to mention earlier.

 

 

Psychosocial Profile

The psychosocial profile reveals patterns in the patient’s life that may affect the neurologic system and put her or him at risk for neurologic disorders. It may also identify teaching needs.  

 

Physical Assessment

Once you have obtained the subjective data, focus on collecting the objective data by performing the physical examination.

 The components of the neurologic examination include tests of the patient’s:

■ Mental status.

 ■ Cranial nerve function.

 ■ Sensory function.

 ■ Reflex function.

As a nurse, you will perform an abbreviated screening neurologic examination more often than the comprehensive neurologic examination described here.

 

Although it is briefer, the screening examination still addresses each area of the neurologic assessment and includes:

 ■ Evaluation of loss of consciousness (LOC) with brief mental status examination and evaluation of verbal responsiveness.

 ■ Testing of selected cranial nerves (usually CNs II, III,IV, and VI)

. ■ Motor screening,including strength,movement,and gait (see Chapter 20,Assessing the Musculoskeletal System).

 ■ Sensory screening, including tactile and pain sensations on upper and lower extremities

. ■ Reflexes.  

If the patient’s condition warrants it, continue to assess neurologic status by performing rapid, repeated checks to evaluate LOC, pupil size and reaction, responsiveness, extremity strength and movement,and vital signs.

 Approach

The neurologic physical assessment sequence is different from that for other body systems, but you still use inspection, palpation, and auscultation. The main difference is that this examination consists of a series of tests. Even though the physical assessment establishes the objective database,many of the findings are still somewhat subjective, based on the patient’s perception. Because the exam is lengthy, make sure that the patient is seated comfortably, preferably in a chair with back support rather than on an examination table.Check from time to time to be sure that he or she is not becoming fatigued. The patient with a neurologic disorder may find it difficult to understand instructions and participate fully in the exam. In these cases, limit tests that require a lengthy explanation and active cooperation.If the patient is lethargic or exhibits any other possible alteration in LOC,then it is critical to perform an assessment for LOC. When assessing older adults, keep in mind that their responses to questions and directions may be slower and that you may need to adjust the pace of the examination. Because of the normal changes of aging and the possibility of paresis, stay close to patients to prevent them from falling, and help with position changes.  

 

Performing a General Survey

Before you begin the specific neurologic assessment, perform a general survey, including scanning your patient from head to toe and taking vital signs. Look at every system as it relates to the neurologic system.If you detect any changes, investigate further as you perform the specific neurologic examination. The general survey can provide immediate and important information about the patient’s neurologicneurologic status.Affect, hygiene, grooming, speech, posture, and body language can provide clues to your patient’s general level of functioning, as well as any pain or impairment.Ask yourself:  

■ Does the patient appear her or his stated age?

■ Is her or his affect or mood appropriate for the situation?

■ Are her or his responses appropriate?

■ Is she or he following the interview?

■ Is she or he well groomed and neatly dressed?

■ Are her or his clothes stained with food?

■ Is a female patient’s make-up appropriately applied?

 

Scan for symmetry, especially in the face.Ask your patient to smile, and look for symmetry of facial features. Are there any abnormal movements? Shake your patient’s hand and note muscle strength. Look at facial expression and eye contact. Is his or her speech clear or slurred? Are responses slow and deliberate or one-word? Poor grooming, food on clothing, or inappropriate make-up can reflect visual deficits such as visual field cuts; motor deficits, such as weakness or paralysis; impaired cerebral function, such as confusion; and affective problems such as depression. Poor posture or facial asymmetry (ptosis or droopy smile) may be a sign of weakness or hemiparesis. Abnormal movements or balance and coordination problems may indicate a cerebellar dysfunction.Weak hand grip may reflect weakness of a neurologic nature. Inappropriate responses, short attention span, or poor eye contact may indicate an underlying cerebral function disorder or a psychiatric problem.

 

Vital Signs

Because the neurologic system plays a vital role in the regulation of vital signs, a change in vital signs can reflect a change in the neurologic system.

For example:

■ BP: HTN is a risk factor for stroke. A widened pulse pressure is a Cushing’s sign of increased ICP.

■ Pulse: Bradycardia is a Cushing’s sign indicating increased ICP; atrial fibrillation increases the risk for stroke.

■ Respirations: Irregular breathing patterns with periods of apnea are a Cushing’s sign of increased ICP.

■ Temperature: A temperature elevation may be associated with infection, meningitis, or brain abscess.A slight temperature elevation may occur after a stroke as a result of the inflammatory response, and a high temperature can occur as a result of a brainstem stroke.

Performing a Head-to-Toe Physical Assessment

The neurologic system affects the functioning of all other body systems. Therefore, it is essential to examine the patient from head to toe to note any unusual findings. Although not every abnormality you note will be related to neurologic dysfunction, you should consider a variety of possibilities.For example,a bruise on the forehead may be caused by an injury sustained when a patient with a preexisting neurologic impairment experienced an LOC. On the other hand, the patient may have been healthy before the injury, and the injury may be causing the current symptoms of pain and disorientation.  

 

 

Performing a Neurologic Assessment

Once you have completed the head-to-toe scan,zero in of the specifics of the sensory-neurologic examination. Begin by assessing cerebral function, and then assess cranial nerve function, sensory function, and reflexes. The motor-musculoskeletal system was assessed in the previous chapter.

Cerebral Function

Assessment of cerebral function includes LOC, mental status and cognitive functioning, and communication. (See Assessing Cerebral Function.)

Level of Consciousness

Evaluating LOC involves assessing arousal (wakefulness) and orientation (ability to receive and accurately interpret sensory stimuli).

 Assessing Arousal

Determine the arousal state first, using minimal stimuli and increasing intensity as needed. Start with auditory stimuli,move to tactile stimuli, and then use painful stimuli as a last resort

. Auditory and Tactile Stimuli.

 To assess auditory stimuli, determine whether the patient is sleeping or awake. If the patient is awake, what is she or he doing?

 

 

If the patient is sleeping, call her or him by name in a normaltone of voice. If she or he does not respond, speak louder.If auditory stimuli fail, try tactile. Gently touch thepatient’s hand. If she or he does not respond, gentlyshake her or his shoulder.

Painful Stimuli. If your patient does not respond to tactilestimuli, you will have to resort to painful stimuli.There are acceptable and unacceptable ways to elicit aresponse to pain. Never perform a nipple twist. Avoidusing a pin or needle, because if the skin breaks, you riskinfection.Also remember to rotate sites—repeated stimulationat the same site may cause bruising.Painful stimuli may be central or peripheral.Centralpainful stimuli include the trapezius squeeze, the sternalrub, supraorbital pressure, and mandibular pressure.Peripheral painful stimuli include nail pressure and theAchilles tendon squeeze.Apply the stimulus for 15 to 30seconds.

 A responsive patient will experience pain andmove in response to these stimuli

:■ Trapezius squeeze: Pinch 1 to 2 inches of the trapeziusmuscle and twist.

■ Sternal rub: With the knuckles or the palm of yourdominant hand, apply pressure in a grinding motion tothe sternum. Do not use this site repeatedly because itwill cause bruising.

■ Supraorbital pressure: Apply firm pressure with yourthumbs at the notch at the center of the orbital rimbelow the eyebrows. Because a nerve runs in thenotch, pressure to this area will cause sinus pain. Usethis stimulus carefully to avoid damage to the eyes.

■ Mandibular pressure:With your index and middle finger,apply inward and upward pressure at the angle ofthe jaw

.■ Nail pressure: Apply pressure over the moon of thenail with a pen or pencil.

■ Achilles tendon squeeze: Squeeze the Achilles tendonbetween your thumb and your index finger.

 

Documenting Arousal

When documenting your findings, record how yourpatient responds rather than simply giving the responsea label. For example, charting that a patient respondsslowly to verbal stimuli but drifts back to sleep is muchmore descriptive than simply writing “lethargic.”Becausea change in LOC is an early sign of a neurologic problem,you need to be able to detect subtle changes in yourpatient. Describing the response to the stimuli is moreobjective and allows better comparisons during followupassessments.The Glasgow Coma Scale (GCS) provides a moreobjective way to assess the patient’s LOC. It evaluatesbest eye response, best motor response, and best verbalresponse on a scale of 3 to 15. Fifteen (highest score)indicates that the patient is awake, alert, oriented, andable to follow simple commands. Three (lowest score) indicates that the patient does not respond to any stimulusand has no motor or eye response, reflecting a veryserious neurologic state with poor prognosis. (SeeGlasgow Coma Scale.)

 

 

 

 

 

Assessing Orientation

Next, test orientation to time,place, and person. Purposeis also sometimes included as a fourth area of orientation.Avoid asking questions that require only a “yes” or “no”response. Start with specifics; then be more general, ifnecessary.For example,if your patient does not know thespecific date, ask him or her what month it is,and if he orshe does not know the month, ask what season it is. If heor she was once oriented to place and is not the nexttime you ask, this may be an early sign of a deterioratingneurologic status.

Time.

Ask the patient to state the date, including the yearand day of the week. Hospitalized patients—especiallyolder adults—can easily become disoriented to time, butthey usually reorient easily. Be sure your documentationreflects this.

Place.

 Ask your patient to state where he or she is.Can heor she identify environmental cues (e.g., bed, equipment,sound of bells or buzzers) to determine location? A personwho is usually oriented but becomes confused when hospitalizedoften temporarily mistakes the hospital room forhome. You will need to address safety concerns withpatients who are disoriented both at home and in the hospital;for example, those with Alzheimer’s disease, whotend to wander.

Person. Ask the patient to state her or his name.Self-identityusually remains intact the longest, making disorientationto person an ominous sign.

Mental Status and Cognitive Function

Once you have determined that your patient is arousableand oriented, assess level of awareness.Level of awarenessreflects mental status and cognitive function.It is the functionalstate of the mind as judged by a person’s behavior,appearance, response to stimuli, speech, memory, andjudgment. It reflects the person’s connection with his orher environment.These areas are at a higher level of functioningthan LOC and reflect the cerebral cortex’s abilityto process and respond. Be sure to explain to your patientthat you need to ask questions that have obvious answersto accurately assess his or her neurologic status.Like the general survey, a mental status screening isoften integrated into the health history interview.A typicalscreening consists of 10 questions that address eacharea of the detailed mental status examination. Anotherinstrument that can be used to assess cognitive functionis the Mini-Mental State Examination (MMSE) (Folstein, 1975). It is used to screen for and monitor dementia.

Youwill need to perform a rigorous mental status examinationin the following situations:

■ If data from patient or patient behavior during thehealth history interview suggests an abnormality.

■ If family members or caregivers report changes in thepatient’s personality or behavior.

■ If the patient has a history of head injury, stroke, dysphasiaor aphasia, or mental illness.A mental status and cognitive function assessmentincludes: memory, general knowledge and vocabulary,mathematical and calculative skills, and thought process/abstract reasoning/judgment.

 

Memory

Assess immediate, recent, and remote memory. Testimmediate memory by asking your patient to repeat aseries of numbers.Test recent memory by asking whatthe patient had for breakfast or by asking her or him toname three objects—for example, a pen, a tree, and aball—and then asking her or him to recall them later.Totest remote memory, ask birth dates or anniversary datesif someone can validate the information; if not, ask datesof major historical events.

General Knowledge and Vocabulary

Before you assess general knowledge and vocabulary,youneed to consider the developmental level, educationallevel, and cultural background of your patient so that youcan phrase and direct your questions accordingly.To testgeneral knowledge,ask about current events,the name ofthe president of the United States, or common knowledgequestions, such as the number of months in a yearor days in a week.To test vocabulary, ask the patient todefine words. Begin with easy, familiar words, such as“orange,”and proceed to more difficult or abstract words,such as “dictatorial.”

Mathematical and Calculative Skills

To test mathematical and calculative skills, have yourpatient solve a simple math problem.Counting backwardfrom 100 by 7s (serial 7s) is frequently used, but this isdifficult for many people, especially those dependent oncalculators.As an alternative,have the person count backwardby 3s or 4s,or ask him or her to solve a simple problem.An example is: “If you purchased a magazine for$1.50, and you have $2.00,how much change would youget back?”Whichever method you use, make sure theproblem is appropriate for the patient’s educationallevel.

Thought Process/Abstract Reasoning/Judgment

To assess thought process, examine the appropriateness,organization, and content of your patient’s responsesthroughout the entire assessment. Be alert for any sensory-perceptual experiences, feelings, or false beliefs thatare not based on reality and may indicate illusions, hallucinations,or delusions.Assess abstract reasoning by asking your patient toexplain a simple proverb, such as “People in glass housesshouldn’t throw stones.” If the person’s age or culturalbackground makes using proverbs inappropriate, use aphrase such as “It’s raining cats and dogs!”Note the degreeof concreteness or abstractness of her or his interpretation.You can further assess abstract ability by asking her orhim to group similar objects; for example,ask “What do anapple,an orange,and a pear have in common?”Then determinewhether the responses are appropriate.Sound judgment involves considering options andchoosing appropriate actions. Assess your patient’s judgmentby observing his or her response to the currentsituation or by giving him or her a hypothetical situation.For example,say:“If you were walking down the street andwitnessed a car accident,what would you do?”Then decidewhether the response is appropriate and reasonable.

Assessing Communication

When assessing speech, evaluate not only the ability tospeak but also the content, appropriateness, speed, andquality of speech. Identify the patient’s primary language,and solicit an interpreter if needed.Various speech problemsare associated with neurologic disorders, and thetype of problem depends on which area of the brain isaffected. Increasing language difficulties may reflect aturn for the worse in your patient’s neurologic status thatwarrants further medical evaluation.The inability to communicatecan be frustrating for both of you,so be patient,allow your patient time to respond, and make referrals tospeech therapy as needed.To pinpoint the exact location of the neurologicproblem, assess further for spontaneous speech, soundrecognition, auditory-verbal comprehension, visualrecognition, visual-verbal comprehension,motor speech,automatic speech, naming, vocabulary,writing, and copyingfigures.This assessment can also be used to developan effective speech therapy plan for your patient.

Cranial Nerve Function

Evaluation of the cranial nerves is an essential part of theneurologic examination. However, like other portions ofthe exam, it depends upon an alert patient who is emotionally,cognitively, and physically able to participate.Assessment techniques are described in the following section.See Chapter 12, Assessing the Eye and the Ear, forassessment techniques for CNs II, III, IV,VI, and VIII. (SeeAssessing the Cranial Nerves.)

 

 

 

Sensory System Function

Assess the patient’s sensory function using tests of light(superficial) touch, pain, temperature, vibration, positionsense, stereognosis (ability to recognize the form ofsolid objects by touch), graphesthesia (ability to recognizeoutlines, numbers, words, or symbols written onskin), two-point discrimination, point localization, andextinction. Light touch, pain, and temperature are super-ficial sensations and travel the spinothalamic tracts of theanterolateral system.Vibration, position sense, stereognosis,graphesthesia, two-point discrimination, point localization,and extinction are highly localized and travel thedorsal column–medial lemniscal pathway of the posteriorcolumn-medial lemniscal pathway.Before beginning this portion of the examination,inform the patient that you will apply various stimuli,andthat she or he should close the eyes during the entireexam. Instruct her or him to say “now” whenever she orhe perceives a sensation.Avoid asking leading questions,such as, “Can you feel anything here?”Also avoid usingany recognizable pattern, but do test symmetricalregions. If you notice an area of altered sensation, stimulateareas close to it until you have delineated its borders.Record your findings with a diagram of the area.The extent of the sensory assessment depends onyour findings. For screening purposes, include the upperand lower extremities and the trunk. If you detect adeficit, perform a more thorough assessment.

Reflexes

Reflex assessment evaluates the intactness of thespinal cord. Intact sensory and motor systems arerequired for a normal reflex response. Normal reflexesinclude DTRs and superficial reflexes. There are alsoprotective reflexes that are responses of intact cranialnerves.The protective reflexes include the gag, coughand swallow, blink and corneal. CNs IX and X areresponsible for the gag, cough and swallow, and CNs Vand VII are responsible for the blink and cornealreflexes. Reflexes that normally occur in newborns aretermedpathological or primitive reflexes when theyoccur in adults.Deep Tendon and Superficial Reflexes

DTRs include the biceps (C5, C6), triceps (C7, C8), brachioradialis(C5, C6),patellar (L2, L3, L4) and Achilles (S1,S2). Superficial reflexes include the plantar (L4 to S2),abdominal (T8,T9,T10), anal (S3, S4, S5), cremasteric (L1,L2), and bulbocavernous (S3, S4).To test DTRs, use a rubber percussion hammer toswiftly tap a slightly stretched tendon to elicit contraction ofan associated skeletal muscle.Keep your wrist loose so thatimmediately upon impact, it swings back spontaneously.Aswith other neurologic assessments, test reflexes bilaterally.Then grade DTRs on a scale from 0 to 4. Stick figures areoften used to chart DTR findings (Fig. 21.10).

Because the normal response for a DTR is musclecontraction, eliciting a response may be difficult if yourpatient is tense and the muscles are contracted. Through cognitive inhibition, the patient can override and suppressthe peripheral reflex response.Tell your patient torelax and let you support the limb being tested. If you arestill having difficulty eliciting a DTR response, use a reinforcementtechnique to enhance the response. One technique,distraction maneuvers, allows the patient to concentrateon something other than the reflex being tested,thereby relaxing the area and eliminating unintentionalcognitive inhibition. The other technique, isometricmaneuvers, overrides the inhibitory message from thebrain and increases reflex response. Two isometricmaneuvers are having your patient clench his or her teeth(enhances upper extremity reflexes) and having thepatient interlock his or her hands and push (enhanceslower extremity reflexes).These techniques are shown inFigure 21.11. If you use a reinforcement technique, besure to document it.When assessing superficial reflexes, use a tongueblade, the base of the reflex hammer, or the back ofyour thumbnail and stroke the body briskly, withoutpressing into the underlying organs.

Superficial reflexesare graded as positive or negative. DTRs are gradedas follows:

■ 0: No response detected.

■ 1: Response present but diminished (hypoactive).

■ 2: Response normal.

■ 3: Response somewhat stronger than normal.

■ 4: Response hyperactive with clonus.

Grades 1 and 3 are usually considered normal.Evengrade 0 may occur symmetrically in some patients in theabsence of any underlying neurologic disorder.For example,a patellar reflex may be difficult to elicit on a patientwho has had knee surgery. Grade 4 usually indicatespathology. Clonus is the presence of rhythmic involuntarycontractions, most often at the foot and ankle.Sustained clonus confirms CNS involvement.

Pathological or Primitive Reflexes

Pathological or primitive reflexes usually indicate asevere underlying neurologic problem.They reflect cerebraldegeneration or late-stage dementia and are referredto as primitive reflexes because they are normally seenin a newborn with an immature neurologic system.Family members may be misled by these reflexes, whichmay seem like a sign of improvement.Therefore, be sureto explain that these are reflexive responses and providesupport for the family.Primitive reflexes include the following:■ Grasp: Place your fingers in palm of patient’s hand.Patient will close her or his fingers and grasp yours.

              

 

■ Sucking: Gently stimulate patient’s lips with a mouthswab. Patient will start sucking.

■ Snout: Gently tap oral area with finger. Patient’s lipswill pucker.

■ Rooting: Gently stroke side of patient’s face. Patientwill turn toward stimulated side

■ Glabellar: Gently tap on patient’s forehead.Patient willblink.

■ Babinski: Stroke lateral aspect of sole of foot. Dorsi-flexion of great toe and fanning of toes will occur.

Meningeal Signs

Classic signs of meningitis include nuchal rigidity (extensionof neck with resistance to flexion), fever, photosensitivity,headache, nausea, and vomiting. If you suspectthat your patient has meningitis, assess for Kernig’s andBrudzinski’s signs.To assess for Kernig’s sign (Fig. 21.12), have thepatient lie supine with one leg flexed.Tell him or her totry to extend the leg while you apply pressure to theknee.Contraction and pain of the hamstring muscles andresistance to extension are positive signs of meningitis.To assess for Brudzinski’s sign (Fig. 21.13), have thepatient lie supine with her or his head flexed to her or hischest. Flexion of the hips is a positive sign of meningitis.

 

 

SUMMARY

 

■ This chapter taught you how to perform a thoroughsensory-neurologic assessment, including a health historyand physical examination. Before you begin theassessment, you an understanding of the anatomy ofthe neurologic system is essential. Because the neurologicsystem is the main circuit board for the entirebody, a problem in the neurologic system can affect aperson’s well being and ability to function

■ Begin by taking a detailed health history looking forclues related to the neurologic system.

■ The physical examination of the neurologic system differsfrom other assessments.The exam includes assessmentof cerebral function, cranial nerve function, sensoryfunction, and reflexes.

■ After you complete your assessment,analyze your findingsto identify actual and potential health problems,as well as write nursing diagnoses and plan of care.

 

 

Mental Assessment and Disorders

 

After you have successfully completed this chapter, you should be able to:

■ Describe the various theories in understanding mental health/illness

■ Describe developmental influences on mental health/illness

■ Discuss various cultural influences on mental health/illness

■ Identify history data as they relate to mental health/illness

■ Identify physical assessment data as they relate to mental

■ Describe additional assessment components specific to mental health/illness assessment

■ Perform a mental health assessment

■ Document assessment findings

■ Identify actual/potential health problems stated as nursing diagnoses with supporting data

Learning Outcomes

 A biological risk factor could be a family history of mental illness with a genetic link such as

schizophrenia.A person’s developmental level may be  psychosocial risk factor. External stressors are examples

of environmental factors.

Assessment entails not only identifying your client’s weaknesses but also identifying his or her strengths. So, you need to assess not only for risk factors but also for

protective factors, such as coping mechanisms andresources.

 

 

Mental health is a “state of successful performance of mental function, resulting in productive activities,fulfilling relationships with other people, and the ability to adapt to change and to cope withadversity”(Healthy People 2010).Jahoda (1958) identified six characteristics of positive mental health that address positive self-perception, personality integration, autonomy and independence,perception and reality,and growth and development leading to self-actualization. Mental

health or wellness affects every aspect of one’s life, and the impact of this can be seen when mental illness occurs.The effects are not only mental but also physical.

Current research is providing more and more evidence that there are organic and neurochemical bases for some mental illnesses and behaviors. Be sure to review

the anatomy and physiology section in Chapter 21, Assessing the Sensory-Neurological System. Genetic links have been identified for certain braindisorders such as schizophrenia. Although schizophrenia, depression, bipolar disorder, anxiety disorders, and Alzheimer’s are classified as mental illnesses, biological bases have been identified. Biochemical factors, specifically neurotransmitters, have been identified in depression and mania (Fig.5.1).Another part of the brain is the limbic system,which is called the emotional brain and is associated with fear, rage, love, anger, aggression, hope, sexuality, and social behavior (Fig. 5.2).

 

Biological Basis of Mental Illness

Understanding Mental Disorders

 

Mental disorders affect thinking, mood, or behavior or a combination of all three, leading to impaired function, disability, pain, and even death.The term mentalillness is applied to diagnosable mental disorders. All age groups, gender, racial, and ethnic groups are ffected regardless of education or socioeconomic evel.A goal of Healthy People 2010 is “to improve mental ealth and ensure access to appropriate, quality ental health services.”As a nurse, you are well positioned to assess the mental health status of your atients at every level of health prevention and in very area of healthcare.

Prevention

Primary prevention entails decreasing the incidence f mental disorders by identifying those at risk, those ho are vulnerable to developing mental disorders.

Secondary prevention involves reducing theprevalence of mental disorders through screening andinitiating prompt treatment of mental disorders.

Tertiary prevention aims at reducing the severity ofthe illness by providing follow-up and rehabilitativeservices.

 Effects

Understanding Assesment

Cognitive theories provide an understanding by looking ot only at behavior but also at an individual’s cognitions and howa person processes thoughts (distorted

cognitions and maladaptive behaviors). Bandura and Back are cognitive theorists. Cognitive theory is of value when teaching patients new coping skills; individual

collaboration with the therapist and active involvement of the patient are needed for change to take place

(Townsend, 2006).

Developmental theories provide an understanding of the individual’s growth and development over one’s lifetime. Erikson, Piaget,Gilligan, and Miller are developmental theorists.

.

Psychological Theories

Behavioral Theories

Developmental Theories

Social Theories

Cognitive Theories

Developmental, Cultural, and

Ethnic Variations

Psychodynamic theories focus on intrapersonal concepts. These theories look at the development of themind over the course of a lifetime. Freud, the “Father of

Psychiatry,” introduced the psychoanalytic model of the conscious and unconscious mind.Various interpersonal and humanist models followed. Freud identifieddefense mechanisms, which served to protect the individual from unwanted anxiety.

Behavioral theories focus on normal behaviors rather than the causes of mental illness. Pavlov, Watson, Thorndike, and Skinner are behavioral theorists. The goal is to change behavior through conditioning, behaviorism (which includes frequency and recency), and positive reinforcement (Boyd, 2005).

Social theories include family dynamics, role theories, and sociocultural perspectives; thus, the assessment of

Developmental Level

Mental disorders can occur with any age group,with the incidence of certain disorders higher for specific age groups. For example, learning and behavioral problems are seen with children. Adolescents, known risk takers, have a high incidence of substance abuse. Bipolar illness or psychoses such as schizophrenia more commonly become apparent during young adulthood. Depression is often seen in the older adult.

Children

Because rapid growth and developmental changes occur during childhood, delays are readily detectable. Learning disorders and behavioral disorders often become apparent by the time the child reaches school age.

Mental Health Assessment for Children

Assessing the mental health of children should include both a detailed history and a physical examination.The assessment should include an interview with the child. If abuse is suspected, be sure to interview the child alone without the parents or caregiver present.

Health History

The health history should include a family history with attention to a history of mental health problems. A maternal history is also needed and should identify:

■ Age and health of mother during pregnancy.

■ Exposure to medications, alcohol or drugs during

pregnancy.

■ Course of labor and type of delivery.

■ Infant’s state of health at birth.

Assess the child’s normal growth and development milestones, such as motor development, bowel and bladder control, speech and language development, and social development. Also, assess the child’s medical health, noting any major illness or injury.

The assessment should also include a current developmental assessment, a mental status examination, and a physical examination. Various instruments are available to assess a variety of mental health disorders in children. Be sure to select the one best suited to meet the child’s

needs.

Scales for Mental Health Disorders

Child Abuse

Child abuse affects all areas of a child’s life and may manifest as a mental or physical disorder. Child abuse takes many forms from physical abuse, neglect, sexual abuse, emotional abuse, factitious disorders by proxy (Munchausen syndrome), and secondary abuse (children of battered women). The assessment should include an interview with the child. If abuse is suspected, be sure to interview the child alone without the parents

or caregiver present.

 

Risk Taking

Adolescents are known risk takers. Experimenting with drug and alcohol is common, and suicide is the second leading cause of death among adolescents. Mental and substance abuse disorders or a combination of disorders are more often than not associated with suicide. A goal of

Healthy People 2010 is to decrease the attempted suicide rate among adolescents from a 12-month average of 2.6 percent of adolescents in grades 9 through 12, to a 12- month average of 1 percent.

Another popular form of risk taking during childhood is the choking game,which produces a high or a state of euphoria by cutting off the blood supply to the brain. If the blood supply is compromised for too long, the child will pass out and feel a “rush” as consciousness returns. Depriving the brain of oxygen may result in permanent and cumulative death to brain cells, stroke, seizures, retinal damage, or death.

This behavior, which is also known as fainting, American dream, flatliner, space cowboy, knockout, gasp, rising sun, airplaning, pass out,blackout, andspace monkey, is most common among children ages 10 through 16. It can be performed either alone or with others.

Use of ligatures and performing this alone increases the risk of death.

Approach to the Mental Assessment

Children who “play” the choking game are usually not troubled children and generally have no history

of drug or alcohol abuse.

 

• Learning disorders and behavioral disorders often

become apparent by the time the child reaches

school age.

• Depending on the age of the child, play or drawing

can be very helpful in eliciting the child’s perceptions.

INSTRUMENT

Behavior Assessment System for Children (BASC)

Child Behavior Checklist (CBCL)

Children’s Depression Inventory (CDI)

Pediatric Anxiety Rating Scale (PARS)

Yale-Brown Obsessive Compulsive Scale (YBOCS)

Swanson, Nolan, Pelham (SNAP)-IV

ASSESSES FOR

Behavior and emotions for children ages 2–18

Psychopathology and competencies for children ages 4–16

Physical symptoms, harm avoidance, social anxiety, and

separation/panic disorders for children ages 7–17

Severity of anxiety for children ages 6–17

Obsessive compulsive disorder (OCD) for children ages 6–17

Inattention and overactivity (attention deficit hyperactivity disorder [ADHD]) and oppositional defiant disorders

Adapted from Boyd, M.A. (2005). Psychiatric Nursing Contemporary Practice. Philadelphia: Lippincott, Williams & Wilkins.

Risk Factors for Teen Suicide

■ Depression

■ Social isolation

■ History of abuse

■ Drug and alcohol abuse

■ Not fitting in with peers

■ School pressure

Source: Gorman, L., Raines, M., and Sultan, D. (2005). Psychosocial

Nursing for General Patient Care, ed. 2. Philadelphia: F.A. Davis.

Signs and Symptoms of the Choking Game

■ Unexplained marks or bruises on neck

■ Severe headaches

■ Red eyes

■ Belts, leashes, ropes, and shoelaces tied in strange

knots or in unusual locations

■ Disorientation after being alone

■ Locked bedroom doors

Pregnant Women

Although the birth of child is seen as a happy event, mental health disorders can occur, affecting not only the mother but also the entire family.Many mothers experience mild depression, also known as baby blues, usually within 4 weeks following childbirth. If the baby bluespersist for more than a few weeks, postpartum depression may have developed. The depression is more serious and results in postpartum depression with or without

psychosis.The mother may experience severe mood swings and pervasive sadness.The mother often has feelings of guilt and inadequacy as a mother. In addition to the feelings associated with postpartum depression, with postpartum psychosis, the mother experiences delusions and thoughts of harming herself or her baby. If you detect at-risk mothers or postpartum depression,be sure to make the appropriate referrals for followup care.Assessment for postpartum depression is important. Screening tools for postpartum depression include the Postpartum Check List (Beck, 1995) and the Edinburgh Postpartum Depression Scale (Cox,Holden,& Sagovsky, 1989).

Older Adults

Older adults are more at risk for the development of mental health problems for several reasons, ranging from the normal physiological changes associated with aging to acute and chronic illness to side effects associated with polypharmacy. Risk factors may be developmental, situational, internal, or external in nature.

Mental Health Assessment of the Older Adult

Approximately 25 percent of all older adults experience some type of mental disorder (depression, anxiety, substance abuse,and dementia) that is not related to the normal changes associated with aging (Healthy People2010). Alzheimer’s affects 8 percent to 15 percent of older adults over the age of 65 and accounts for 69 percentto 70 percent of all dementia (Healthy People 2010). Assessing the mental health of the older adult shouldinclude both a detailed history and a physical examination. The assessment should focus on mental status,behavioral responses, functional ability, general health,

and social supports of the client. Mental status assessment should include a Mini-Mental State Examination (MMSE), a mental status examination, and assessment for depression, anxiety, and psychosis.A change in mental status has to be carefully evaluated. Changes are often attributed to normal

changes associated with aging. Changes in mental status may be physiological or psychological in nature. Because dementia increases with age, care must betaken to differentiate dementia from delirium and depression.

 Understanding Assesment

Risk Factors for Postpartum Depression

■ History of mood disorders

■ Low self-esteem

■ Unwanted pregnancy

■ Unemployment of mother or head of household

■ Poor marital relationship

■ Father depressed

■ Poor support systems

■ External stressors

■ Physical changes associated with aging that may affect functional ability

■ Cognitive changes and memory loss

■ Chronic medical illness

■ Psychosocial changes, such as retirement, that occur with aging

■ Limited financial resources

■ Polypharmacy

■ Loss and bereavement

■ Loss of social supports

Delirium should be treated as an emergency because its acute onset may have an underlying life-threatening cause. The MMSE and the Clock Scoring Test are screening instruments used to assess cognitive impairment and screen for dementia.

 

Assessment of behavioral responses includes description of behavior and triggers, with special attention to behavioral changes and problem behaviors. A functional assessment should focus on the client’s ability to perform activities of daily living, physiological functioning,

mobility, and risk for fall assessment. A nutritional assessment and history of substance abuse is included in the assessment of the client’s general

health. Finally, the assessment should identify social supports, family-patient interactions, and caregiver concerns.

Depression

Depression is a major mental health problem for older adults, but it can be easily missed. If left untreated, depression can lead to suicide or self-neglect. In theUnited States, the suicide rate is highest among older adults, with older men over age 80 at highest risk and guns the most frequent method (Gorman, Raines, & Sultan, 2005). But the suicide rate is probably higher, because older adults can easily commit passive suicideby not complying with medical regimens or failing to eat.

Elder Abuse

Elder abuse, if taking place, affects all areas of the patient’s life and may manifest as a mental or physical disorder.

Elder abuse can take many forms: physical abuse, neglect, sexual abuse, emotional abuse, and financial

Abuse.

Approach to the Mental Assesment

Characteristics of Dementia, Delirium, and Depression

FEATURE DEMENTIA DELIRIUM DEPRESSION

Onset

Prognosis

Course

Attention

Memory

Perception

Psychomotor

behavior

Cause

Abrupt (hours to a few

weeks)

Reversible

Worse in P.M.

Impaired

Impaired recent and

immediate

Impaired

Hypo-/hyperkinetic

Caused by acute illness,

fever, infection,

dehydration, electrolyte

imbalance, medications,

and alcoholism

Gradual (months to years)

Irreversible

Progressive

Normal

Impaired recent and remote

Normal

Normal/apraxia

Caused by many diseases,

including alcoholism,

acquired immunodeficiency

syndrome (AIDS), cerebral

anoxia, and brain infarcts

Either

Variable

Possibly worse in A.M.

Variable

Impairment

Normal

Retardation/agitation

May coincide with life

event, such as death in

the family, loss of a

friend or a pet, or a

move

Risk Factors for Suicide Among Older Adults

■ Lives alone

■ Widower

■ Lack of financial resources

■ Poor health

■ Social isolation

■ Drug and alcohol abuse

Geriatric Depression Scale

Are you basically satisfied with your life? YES/NO

Have you dropped many of your activities and interests?

YES/NO

Do you feel that your life is empty? YES/NO

Do you often get bored? YES/NO

Are you in good spirits most of the time? YES/NO

Are you afraid that something bad is going to happen to

you? YES/NO

Do you feel happy most of the time? YES/NO

Do you often feel helpless? YES/NO

Do you prefer to stay at home rather than going out and

doing new things? YES/NO

Do you feel you have more problems with memory than

most? YES/NO

Do you think it is wonderful to be alive now? YES/NO

Do you feel pretty worthless the way you are now?

YES/NO

Do you feel full of energy? YES/NO

Do you feel that your situation is hopeless? YES/NO

Do you think that most people are better off than you

are? YES/NO

Bold answers _ depression

GDS Scoring:

12–15 Severe depression

8–11 Moderate depression

5–8 Mild depression

0–4 Normal

Source: Yesavage, et al., 1983, pp. 37–47.

GDS website: http://www.stanford.edu/~yesavage/

 

 

 

Cultural Perceptions of Mental Health/Illness

CULTURAL GROUP PRACTICES/BELIEFS

Amish

Appalachian

Arab American

Chinese American

Cuban American

Egyptian American

Filipino American

French Canadian

Greek American

Iran American

Irish American

Jewish American

Mexican American

Native American

Vietnamese American

 

Undrstanding Assessment

Atypical

Signs and Symptoms of Depression in the Older Adult

Typical

■ Changes in appetite

■ Decreased self-esteem

■ Changes in sleep patterns

■ Social withdrawal

■ Feelings of helplessness

■ Loss of motivation

■ Constipation

■ Hostility

■ Pessimism

■ Agitation

■ Guilt

■ Aggression

■ Vague somatic complaints—such as constipation, joint pain, fatigue, and memory changes—that seem to be out of proportion to the actual

problem.

■ Client may become obsessed with the problems and feel that if the problems are relieved, she or he will be fine.Cultural and ethnic variations often influence a patient’s view of mental health. Cultural beliefs influence perceptions, understanding, and treatment of mental illness.

■ Children with mental or physical differences are seen as “hard learners.”

■ The mentally ill are generally cared for at home.

■ Usually takes care of own, so mentally deficient and handicapped are readily accepted.

■ Mentally handicapped are not crazy, but rather have “bad nerves” or are “quiet

turned” or “bad turned.”

■ Behaviors that would warrant psychiatric treatment are seen as lazy, mean,immoral, criminal, or psychic and treated by punishment or tolerance.

■ Mental illness is seen as a social stigma, therefore psychiatric symptoms may be denied, attributed to “bad nerves” or supernatural beings, or caused by a physical ailment or emotional trauma.

■ Somatic orientation leads to patients’ tolerance of emotional suffering and relatives’ tolerance of behavioral disorders.

■ Patients with mental distress will somatize symptoms. Somatic treatment for psychiatric disorders is preferred over psychotherapy.

■ Balance between yang and yin explains mental health/illness.

■ Mental illness results from metabolic imbalance and organic problem.

■ Stigma is associated with mental illness, so patient will seek folk healer first.

■ Does not readily seek treatment for emotional or nervous disorders.

 

■ Emotional crises are treated by santero, a practioner of santeria (a 300-year-old

Afro-Cuban religion that combines Roman Catholic elements with ancient Yoruba

tribal beliefs and practices).

■ May act out emotional problems in a non–threatening way, allowing person to

maintain self-esteem.

■ Mental illness is considered a stigma.

■ More tolerance for emotional problems.

■ View mental health problems with a supernatural framework, including “curse”

and “devil.”

■ Emotional problems of grief and losses are due to wrongdoings of others or

weakness and inability to control and snap out of distress.

■ Mental and emotional issues are expressed somatically so therefore treated with

psychosomatic interventions.

■ Seeks family and friends for advice.

■ Stigma is associated with mental illness.

■ Mental illness is caused by heredity.

■ Takes care of mentally ill family member rather than seek mental

healthcare.

■ Federal Canadian laws protect the mentally disabled from discrimination.

■ Stigma is associated with mental illness.

■ Mental illness is seen as hereditary linked, therefore “polluting” the blood line,

bringing shame to family.

■ Families of mentally ill may experience loss of friends and social isolation.

■ Mental illness often somatisized. Wide range of acceptable behavior leads to delay

of seeking treatment.

■ Folk model for “nerva” (nerves) is socially acceptable and treated with medication

rather than with psychotherapy.

■ Stigma is associated with mental illness.

■ Mental illness is caused by genetic problem; more likely to be labeled a

“neurological” problem.

■ Avoids psychotherapeutic treatment.

■ Symptoms somatasized and treated with psychopharmacology.

■ High rate of mental illness.

■ Difficulty expressing emotions and feelings.

■ Family may take care of mentally ill family member.

■ Some attribute mental illness to sin and guilt.

■ Mental health is as important as physical health.

■ Mental incapacity relinquishes one from all responsibilities.

■ Mental illness is seen as God’s will.

■ Family prefers to care for patient at home.

■ Mental illness is caused by witches; treated by healers.

■ May wear turquoise to ward off evil.

■ Some tribes view mentally ill as having special problems.

■ Mental illness results from offending a deity.

■ Brings disgrace to family and is therefore concealed, which delays treatment.

■ Emotional disturbances are caused by malicious spirits, bad luck, or family

inheritance.

■ Buddhists see mental illness as bad karma from previous misdeeds.

■ Sometimes nervous system is seen as cause of mental problems.

 Mental Health

Assessment

A thorough assessment includes assessment of the psychological health of the patient.Mental health reflects aperson’s positive attitudes toward self, growth and development,self-actualization, integration, autonomy, reality perception, and environmental mastery (Stuart & Laraia,

2005). As you perform your assessment, look for clues that reflect the mental health status of your patient. Realize that your patient may prefer to have you believe she or he has a physical problem rather than a psychological problem by somatizing feelings. Also,medical problems or drug use (prescribed, over-the-counter[OTC], illegal) may present as mental disorders, such as hyperthyroidism, which may produce signs and symptoms

of anxiety. Comorbidities can also result with patients. Chronic illness can lead to depression, especially as the disease progresses.

Report any suspected abuse or any threat of child or elder abuse. Also report threats of suicide orhomicide. Threats to self or others must always be taken seriously.

Health History

When obtaining a health history, ask yourself,“What can the health history reveal about the mental health of thepatient?” Identify factors that may affect mental health in either a positive or a negative way. Ensure patient confidentiality, but confidentiality should be breached if there is suspected abuse or a threat of child or elder abuse or if the patient poses a threat to herself or himself or others.

Health History as It Relates to Mental Health

RISK/FACTORS/

QUESTIONS TO ASK RATIONALE/SIGNIFICANCE

■ Response to stressors differs with age.

■ Identifies possible maturational crises related to

developmental changes.

■ Women have greater incidence of depression and

affective and anxiety disorders.

■ Men have greater incidence of psychosocial and

substance abuse disorders.

■ Age of onset of schizophrenia occurs later in

women than in men.

■ Men are more likely to be aggressive and selfdestructive

than women.

■ The higher the socioeconomic and

educational level, the lower the incidence of

depression.

■ The higher the educational level, the more likely

the individual is to use mental health services if

needed.

■ The lower the income, the higher the incidence of

psychological symptoms.

■ African Americans and Hispanics have twice the rate of

being diagnosed with severe mental illness than other

groups.

■ African Americans are diagnosed with the most

severe types of psychopathology and fewer affective

disorders and are overdiagnosed with schizophrenia.

■ Ethnic groups have three times more

hospitalizations for mental illness than the general

population.

■ Married and partnered adults report less stress

than single or divorced adults.

■ Can affect mental health in either a positive or a

negative way.

■ Influences perceptions of mental illness.

■ Identifies supports.

■ Identifies any signs or symptoms that may reflect

mental illness.

■ Identify any past mental health problems and

treatments.

■ Identifies previous psychiatric hospitalization.

■ Identifies familial/genetically linked psychiatric

disorders. Familial/genetically linked disorders

include:

■ Schizophrenia.

■ Depression.

■ Bipolar disorders.

■ Anxiety and panic disorders.

■ Identifies any psychiatric drugs.

■ Identifies any possible drug interactions.

■ OTC medications such as pseudoephedrine can

cause anxiety symptoms.

■ Herbal supplements such as St. John’s wort,

ephedra, ginseng, kava kava, and yohimbe can

interact with psychotrophics or other

medications, or cause anxiety, drowsiness, or

other adverse psychological effects (Pedersen,

2005). (See Psychotropic Drugs and Some

Related Side Effects.)

■ Identifies possible source of stressor related to

post-traumatic stress syndrome

 

Biographical

Age

■ How old are you?

Gender

■ Is the patient male or female?

Socioeconomic and Educational Levels

■ What is your educational level?

 

Ethnicity

■ What is the patient’s cultural background?

Marital Status

■ Are you single, married, or divorced?

Religion

■ What is your religious affiliation?

Contact Person

■ Who is your contact person?

Current Health Status

■ How is your health?

Past Health History

Childhood Illnesses

■ Did you have any major health problems

(physical or mental) while growing up?

Past Hospitalizations

■ Have you ever been hospitalized for mental

health problems?

Family History

■ Does anyone in your family have mental health

problems?

Medications

■ Are you taking any medications, either

prescribed, OTC, or herbal? If yes, what are you

taking? (See Drugs That May Adversely Affect

Mental Health.)

Military Service

■ Are you now or did you ever serve in the military?

If yes, when and what was your tour of duty?

General Health Survey

■ How have you been feeling?

Integumentary

■ Do you have any problems with your skin? If yes,

describe.

Head, Eyes, Ears, Nose, and Throat (HEENT)

■ Do you have headaches? If yes, describe.

■ Do you have thyroid disease?

Respiratory

■ Do you have any breathing problems? If yes, describe.

Cardiovascular

■ Do you have any CV problems? If yes, describe.

■ Fatigue may be associated with depression.

■ Restlessness may be associated with anxiety.

■ Sweating, itching associated with anxiety

■ Headaches associated with depression.

■ History of migraines and tension headaches

affected by psychological factors.

■ History of hyperthyroidism and diabetes can be

affected by psychological factors, manifest with

psychological signs or symptoms, or mimic

psychological disorders.

■ History of breathing problems, such as

hyperventilation, associated with anxiety disorders.

Sighing associated with depression.

■ Hypertension, angina affected by psychological

factors

■ Palpitations, racing heart associated with anxiety

■ Heterocyclic antidepressants—use with caution with

cardiovascular disease

Drugs That May Adversely Affect Mental Health

Drugs Effect

Antihypertensives Depression

■ Reserpine

■ Beta blockers

■ Methyldopa

Oral contraceptives

Corticosteroids

Benzodiazepine

Cancer chemotherapeutic agents

■ Vincristine

■ Vinblastine

■ Interferon

■ Procarbazine

Psychoactive agents

■ Alcohol

■ Amphetamine or cocaine withdrawal

■ Opioids

Corticosteroids Manic states

Levodopa

Amphetamines

Tricyclic antidepressants (TCAs)

MAO inhibitors

Methylphenidate

Cocaine

Thyroid hormone

Amphetamines Psychotic reactions

Antidepressants (particularly tricyclics)

Anticholinergics (atropine)

Anticonvulsants (carbamazepine, valproic acid)

Antiparkinsonians (levodopa)

Antituberculars (isoniazid)

Antivirals (acyclovir, amantadine)

Antiarrhythmics (lidocaine)

Alcohol

Beta blockers (propranalol)

Corticosteroids

H2-receptor blockers (cimetidine)

Cyclosporine

Disulfiram (Antabuse)

Anesthetics (ketamine)

Antibiotics (cephalosporins, ciprofloxacin, sulfonamides)

Opioids (morphine, hydromorphone)

Lithium Nausea, diarrhea, polyuria, acne, rashes, alopecia, tremors; weight

gain, hypothyroidism; can also precipitate psoriasis and psoriatic

arthritis.

Anticonvulsants Sedation, hepatotoxicity, rash, and Stevens-Johnson syndrome (SJS),

which is a life-threatening mucocutaneous reaction.

Anticholinergics Blurred vision, constipation, dry mouth

TCAs Sedation, blurred vision, dry mouth, constipation, life-threatening

arrhythmias and electrocardiogram (ECG) changes

Selective serotonin reuptake inhibitors Gastrointestinal (GI) symptoms, insomnia, and agitation

Antipsychotics Movement disorders (akathisia) and tardive dyskinesia (especially

conventional antipsychotics [chlorpromazine]), dystonia,

parkinsonism, gynecomastia, and lactation, and possibly treatmentemergent

diabetes

 

A L E R T

Neuroleptic malignant syndrome (NMS) is a potentially fatal side effect from antipsychotic drugs, characterized by fever, tachycardia, sweating, muscle rigidity, tremors, incontinence, stupor, leukocytosis, elevated creatine phosphokinase (CPK), and renal failure

 

Review of Systems

As you proceed with the review of systems, note

any problems that may affect your patient’s mental

health.

Review of Systems

Psychotropic Drugs and Some Related Side Effects

 

Psychosocial Profile

CATEGORY/QUESTIONS TO ASK RATIONALE/SIGNIFICANCE

Health Practices and Beliefs

■ How would you describe your mental health?

■ Do you or would you use mental health services?

Typical Day

■ Can you tell me what your typical day is like?

Nutritional Patterns

■ Can you tell me what you ate yesterday (24-hour

recall)?

Activity and Exercise Patterns

■ Do you exercise regularly? If yes, describe.

Recreation, Pets, Hobbies

■ What do you do for fun?

■ Do you have pets?

■ Do you have hobbies?

Sleep/Rest Patterns

■ How many hours of sleep do you get a night?

■ Do you have any problems falling asleep, staying asleep?

■ Do you take or do anything to help you sleep?

Personal Habits

■ Do you use alcohol, drugs, caffeine, or nicotine? If, yes,

how much?

Occupational Health Occupation?

■ How do you feel about your work? Your coworkers?

■ Do you find your work stressful? If yes, how do you

deal with it?

■ Are there any health risks associated with your work? If

yes, describe.

Environmental

■ Where do you live?

■ Are you exposed to any pollutants or toxins?

Roles, Relationships, Self-Concept

■ How do you see yourself?

■ Can you identify your various roles and relationships?

Cultural Influences

■ What is your cultural background?

■ What influences your perception of health?

Religious/Spiritual Influences

■ What is your religious background?

■ What influence does your religious beliefs have on your

perception of health?

■ Identify perceptions of mental health, mental health

practices, and use of mental health services.

■ Identifies ability to maintain activities of daily living

(ADLs). Mental health problems such as depression and

schizophrenia, compulsive disorders may affect ability

to perform ADLs.

■ Nutritional disorders are associated with eating

disorders, anxiety, and depression.

■ Excessive exercise is associated with eating disorders.

■ Inactivity is associated with depression.

■ Inactivity is associated with depression.

■ Problems with sleep and rest are associated with many

psychological disorders, such as anxiety, depression,

bipolar disorders, and substance abuse.

■ Identifies history of substance abuse (use of alcohol,

drugs, caffeine, nicotine).

■ Identify ability to maintain job. Work can be a source of

stress.

■ Identify risk for head injury, such as construction work

■ Identifies risk for exposure to toxic substances, such as

lead, mercury, herbicides, solvents, cleaning agents, and

lawn chemicals, that can affect cognitive ability.

■ Identifies sense of worth and value, which may be

affected by psychological factors such as low self-image

associated with depression and eating disorders.

■ Roles and relationships may affect or be affected by

psychological factors.

■ Identifies culture’s perception of mental health and

illness.

■ Identifies religious/spiritual influences on mental health

and illness.

Gastrointestinal

■ Do you have any GI problems? If yes, describe.

■ Have you experienced changes in weight? If yes,

describe.

■ Have you experienced changes in appetite? If yes,

describe.

Genitourinary (GU)

■ Do you have any GU problems? If yes, describe.

■ If your patient is female, ask if she has experienced any

irregularities in her menstrual cycle.

■ Do you have any concerns about your sexual

performance? If yes, describe.

Musculoskeletal (MS)

■ Do you have any MS problems? If yes, describe.

Neurological

■ Do you have any neurological disorders?

■ Have you experienced seizures, concentration, or

memory problems?

■ Have you experienced depression, anxiety? If yes,

describe.

■ Changes in appetite associated with depression,

anxiety, eating disorders, substance abuse

■ History of peptic ulcer, irritable bowel syndrome,

colitis affected by psychological factors

■ GI complaints such as nausea, abdominal pain,

diarrhea seen with anxiety

■ Indigestion and constipation seen with depression

■ Nausea is a common side effect of many

psychotrophic medications.

■ History of sexual dysfunction, such as impotence,

frigidity, and premenstrual syndrome (PMS),

affected by psychological factors

■ Menstrual irregularities associated with eating

disorders

■ Pressure and frequency of urination associated with

anxiety

■ Use TCAs (amitriptyline), cautiously with benign

prostatic hyperplasia (BPH)

■ History of rheumatoid arthritis and idiopathic low

back pain affected by psychological factors

■ Weakness associated with anxiety

■ Osteoporosis associated with eating disorders

■ Use of antipsychotics contraindicated with

myasthenia gravis.

■ Seizures associated with eating disorders, use TCAs

cautiously with seizures and buproprion is

contraindicated with seizures.

■ Neuroleptic malignant syndrome and movement

disorders are a side effect of antipsychotic

medications

■ Cognitive problems, difficulty focusing, inability to

concentrate associated with anxiety, depression,

dementia, and schizophrenia

Family Roles and Relationships

■ What is your role in your family?

■ How is your relationship with your family?

Sexuality Patterns

■ Do you have any concerns about sexual patterns? If yes,

describe.

■ Do you practice safe sex?

Stress and Coping Patterns

■ How do you deal with stress?

■ What do you do when you are upset?

■ Identifies sources of support or stress on patient’s

mental health.

■ Mental illness may affect patient’s role and relationship

in family.

■ Sexual problems are often associated with mental

illness such as depression.

■ Unprotected sexual activity is associated with substance

abuse.

■ Identifies current coping skills.

■ Determines effectiveness of coping skills.

 

 

 

Psychosocial Profile

As you perform the psychosocial assessment, look for clues that would reflect your patient’s mental health.

 

Mental Status Assessment

A mental status assessment, involving a systematic approach to various components, is done to assess and evaluate a patient’s cognitive and mental functions. Each assessment provides information about that patient atthat point in time. (See Mental Status Assessment as it

Relates to Mental Health/Illness.) Additional assessments will demonstrate improvement, regression, or stabilization and will provide a “progress report” as well as “patterns” of functioning. The components of the mental status assessment include:

■ General appearance.

■ Behavior/activity.

■ Speech and language.

■ Mood and affect.

■ Thought process and content.

■ Perceptual disturbances.

■ Memory/cognitive.

■ Judgment and insight.

Additional Assessments

Depending of your assessment findings, additional mental health screening may be indicated.Various mental health problems and assessment instruments are available to assess for a variety of mental health problems. Additional mental health assessments are presented below.

Physical Assessment

As you perform a head-to-toe physical examination, consider how your patient’s physical findings reflect his or her mental health.

Head-to-Toe Physical Examination as It Relates to Mental Health/Illness

SYSTEM ABNORMAL FINDINGS/RATIONALE

General Health Survey ■ Poor grooming and personal hygiene: Associated with depression

■ Bright colors or unusual dress: Associated with mania

■ Poor eye contact: May indicate depression

■ Inability to maintain attention: Associated with schizophrenia and depression

■ Labile affect: May reflect mania

■ Flat, incongruent affect: May reflect schizophrenia

■ Stooped posture: Associated with depression

■ Restlessness, tension: Associated with anxiety

■ Malnourished appearance: May indicate an eating disorder

■ Slurred speech: May indicate drug and alcohol abuse

■ Pressured speech: Seen with mania

■ Disorganized speech: Seen with schizophrenia

■ Irritability: Associated with anxiety

■ Suspiciousness: Associated with paranoia

Integumentary ■ Flushed or pallid skin color: Seen with anxiety

■ Excessive sweating: Seen with anxiety

■ Injury or scarring: From self-injury or past suicide attempts or self-mutilation

HEENT ■ Dilated or constricted pupils: Seen with drug abuse

■ Poor eye contact: Seen with depression

■ Dental caries, parotid swelling: Seen with eating disorders

■ Erosion of nasal or oral mucosa: May be secondary to drug use

■ Rope marks on neck: In children, associated with “choking game”

Respiratory ■ Increased respiratory rate and hyperventilation: Seen with anxiety

Cardiovascular ■ Increased pulse rate and blood pressure: Seen with anxiety

Abdominal ■ Increased bowel sounds: Seen with excessive use of laxatives in eating

disorders

■ Abnormal liver size: Associated with substance abuse

Musculoskeletal ■ Generalized weakness and tremors: Seen with anxiety

■ Abnormal muscle movement: May be adverse effect of psychotropic drugs

■ Excessive body movements: Associated with anxiety, mania, or stimulant

abuse

■ Minimal or no body movement: Associated with depression, catatonic states, or

drug-induced stupor

■ Repeated movements: Associated with compulsive disorders

■ Repeated picking at clothes: May be associated with hallucinations, delirium, or toxic

conditions

Neurological ■ Cognitive changes, thought process disorders: Seen with schizophrenia

■ Loose association: Associated with schizophrenia

■ Flight of ideas: Associated with mania

■ Preservation: Associated with brain damage and psychotic disorders

■ Auditory hallucinations: Associated with schizophrenia

■ Visual hallucinations: Often organic in nature

■ Tactile hallucinations: Seen with organic problems, drug abuse, or delirium tremens

(DTs)

■ Changes in mental status: Seen with mental illness such as schizophrenia, substance

abuse, bipolar disorder

■ Increased reflexes: Seen with anxiety

■ Movement disorders: Adverse effect associated with antipsychotic medications

Mental Status Assessment as It Relates to Mental Health/Illness

AREA/QUESTIONS ABNORMAL TO ASK NORMAL FINDINGS/RATIONALE

Grooming/dress

■ Does the patient dress appropriate for age, gender,season, and situation?

Hygiene

■ Are the patient and his or her clothing clean?

■ Does the patient present with any unusual odors?

Eye Contact

■ Does the patient maintain eye contact?

Posture

■ Does the patient assume a specific position?

■ Is posture erect?

Identifying Marks/Scars/Tattoos

■ Are there any obvious marks or scars?

Appearance vs. Stated Age

■ Does the patient appear stated age, or younger or older?

Behavior/Activity

■ Do you notice any unusual activity?

■ Is patient’s behavior appropriate for the situation?

■ What is the patient’s level of consciousness?

■ Dress neat and appropriate

■ Clean, no unusual odors

■ Maintains eye contact

■ Comfortably positioned, posture erect

■ No obvious marks or scars

■ Appears stated age

■ Calm, relaxed, no unusual behavior or movements

■ AAO _ 3 (awake, alert, and oriented to time, place,person)

■ Disheveled appearance: Associated with depression

■ Bright-colored clothing: Associated with mania

■ Poor hygiene: Associated with depression or schizophrenia

■ Poor eye contact: Associated with depression

■ Slumped posture: Associated with depression

■ Defensive posture: Associated with paranoia

■ Scars: May indicate self-mutilation or past suicide attempts

■ Older appearance than stated age: May be associated with depression

■ Hyperactivity: Associated with anxiety,mania, or stimulant abuse

■ Hypoactivity: Lethargic, thinking slowed; associated with depression, alcohol or drug abuse.

■ Altered orientation: May be seen with organic disorders or schizophrenia

■ Agitation: May be seen with dementia or delirium

■ Psychomotor retardation, slow movements: May be associated with depression

■ Tremors: May indicate drug/alcohol withdrawal

■ Tics: May be an adverse effect of psychotropic medications

■ Unusual movements such as jaw/lip smacking: May be associated with tardive dyskinesia, an adverse effect of antipsychotic medications

■ Catatonia: May be seen with schizophrenia

■ Akathisia (restlessness): Seen with extrapyramidal adverse effect from antipsychotic medications

■ Rigidity: May be a sign of NMS

 

Speech

■ What are the quality, tone,

volume, fluency, and pace of

speech?

Attitude

■ What is the patient’s attitude? Is it friendly? Hostile?

Mood (Including Self-Report of Emotional State)

■ How does patient appear?

■ How does the patient describe

her or his mood?

Affect (Apparent Emotional

State)

■ What is the patient’s affect facial expression)?

Thought Process

■ Can you follow the patient’s thinking? Is it coherent and logical?

■ Quality and pace of speech normal with no exaggeration

■ Fluent, pleasant tone

■ Cooperative

■ Appropriate for situation

■ Appropriate for situation

■ Thought process intact

■ Responds appropriately

■ Slow speech: Associated with depression

■ Rapid and pressured speech: Associated with mania

■ Mumbling: Seen with Huntington’s chorea

■ Slurred speech: Seen with alcohol intoxication

■ Suspicious tone: Associated with paranoia

■ Volume: Soft associated with depression

■ Poor fluency (mute/hesitation/latency of response): Less likely to talk with depression

■ Hesitancy: Seen with mistrust or paranoia

■ Uncooperative: Associated with paranoia

■ Warm/friendly/distant: Seen with personality disorders

■ Suspicious/combative: Seen with paranoia

■ Guarded/aggressive: Seen with psychosis

■ Hostile/aloof: Seen with psychosis

■ Apathetic: Seen with depression

■ Sad: Associated with depression

■ Elated: Associated with mania

■ Irritable/anxious: Associated with anxiety

■ Fearful/guilty: Seen with phobias

■ Worried/angry: Seen with personality disorder

■ Hopeless: Associated with depression

■ Labile: Associated with mania

■ Mixed (anxious and depressed): Seen with depression

■ Flat affect: Seen with schizophrenia

■ Blunted or diminished affect: Seen with psychosis

■ Inappropriate/incongruent (sad and smiling or laughing): Associated with schizophrenia

■ Thought process disturbances: Often seen with psychosis or organic brain disorders.Examples of thought process disturbances

are:

■ Concrete thinking: Unable to abstract; thinks in concrete terms

■ Circumstantiality: Excessive, irrelevant detail, but eventually gets to the point

l Status Assessment as It Relates to Mental Health/Illness (continued)

Thought Content

■ Does the patient’s content of thought make sense and seem reality based?

■ Does the patient have thoughts about hurting self or someone else?

Perceptual Disturbances

■ Does the patient haveperceptual disturbances? Auditory disturbances? Visual

disturbances? Olfactory disturbances? Tactile disturbances?

■ Thought content (what the patient is thinking) reality based

■ No hallucinations, illusions, or depersonalization.

■ Tangentiality: Digresses from topic to topic, never getting to the point

■ Loose association: Loose connection between thoughts that are unrelated

■ Echolalia: Repetition of words spoken by another

■ Flight of ideas: Rapidly going from one topic to another

■ Preservation: Involuntary, excessive repetition of a single response to different questions

■ Clang association: Association of words by sound

■ Blocking: Draws a blank

■ Word salad: Combination of words that have no meaning

■ Derailment: Off track

■ Delusions (grandiose/persecution/reference/ somatic): Associated with psychosis

■ Suicidal/homicidal thoughts: Associated with depression, anxiety, or schizophrenia

■ Obsessions: Seen with OCD

■ Paranoia: Seen with schizophrenia

■ Phobias: Seen with anxiety disorders

■ Magical thinking (primitive form of thinking

that thinking about something will make it

happen)

■ Poverty of speech

■ Visual hallucinations: Often organic in nature

■ Auditory hallucinations (commenting/ discussing/commanding/loud/soft/other): Associated with schizophrenia

■ Tactile hallucinations: Seen with organic problems, drug abuse, or DTs

■ Illusions (misperception of a real external stimulus): Common with dementia of

Alzheimer’s and schizophrenia

A L E R T

If the patient is having homicidal thoughts, identify those toward whom those thoughts are directed.

 

Memory

Immediate

■ Can patient repeat objects named minutes before?

Remote

■ Can patient recall anniversaries, past important, historical events?

Insight (Awareness of the Nature of Illness) and Judgment

■ Does patient have insight into his or her problem? (Ask, “Can you tell me what the problem is?”)

■ Is judgment appropriate? (Ask the patient to respond to a hypothetical situation, such as,

“If you were walking down the street and saw smoke coming from a window of a home, what would you do?”)

■ Immediate, recent, and remote memory intact

■ No confabulation

■ Insight and judgment intact and appropriate

■ Depersonalization (altered perception or experience that causes temporarily loss of self or personal identity): Seen with panic

disorder

■ Memory problems and confabulation: Seen with organic, dissociative, and conversion disorders

■ Level of alertness: Altered with substance abuse

■ Poor insight: Seen with psychosis

■ Poor judgment: Seen with psychosis

■ Poor impulse control: Seen with OCD, psychosis, mania

Crisis

A crisis results from an acute event that stresses a person’s resources and ability to cope; a crisis can also result from a perceived threat to self. Crises may be maturational or developmental and situational. An example of amaturational crisis would be a child becoming an adolescent.

An example of a situational crisis might be the loss of a loved one. A situational crisis could also be a major disaster, such as a hurricane or a terrorist attack. An event that may be a crisis for one person may not be for another.A stressful event causes disequilibrium forthe person. It is the ability of the person to restore equilibrium that determines the outcome. Whether or not a person adapts to the crisis or not depends upon several

factors:perception of event,situational supports,and coping mechanisms.Once you have performed a crisis assessment,you can then develop interventions that will help your patient deal with the crisis and regain equilibrium.

 

BATHE Technique

When you have only limited time to perform an assessment, it is important to keep the interview focused.The BATHE technique helps the patient identify problems and coping strategies and is supportive of the patient.The acronym is representative of the interview’s components

(Stuart & Lieberman, 1993):

■ Background—What is going on? What brought you here?

■ Affect—How does this make you feel?

■ Trouble—What troubles you most in this situation?

■ Handling—How are you able to handle this situation/problem?

■ Empathy—Empathize with client, shows an understanding of client’s view of situation.

A L E R T

The BATHE technique is not intended for use with patients with severe problems, such as patients who are suicidal or those who have suffered severe abuse.

Crisis Assessment

Perception of event

Supports

Coping mechanisms

■ Can you tell me what has happened? Please be specific.

■ What caused the crisis?

■ How has this affected you?

■ How did this make you feel?

■ Is there anyone I can call?

■ Do you live alone?

■ Do you have family or friends who support you?

■ Are you active in any religious or community groups?

■ How have you handled stressful events in the past?

■ Can you talk about the stressful event?

■ What do you do to relieve tension? Cry? Talk? Exercise?Use alcohol?

■ Sleep (increase/decrease)

■ Interest (diminished)

■ Guilty/low self-esteem

■ Energy (poor/low)

■ Concentration (poor)

■ Appetite (increase/decrease)

■ Psychomotor (agitation/retardation)

■ Suicidal ideation

■ Past suicide of family member, close friend, or peer

■ Impulsivity

■ Mood disorders

■ Substance abuse

■ Recent loss of a spouse, partner, friend, or job

■ Expressed hopelessness (patient sees no future)

■ Social isolation (patient lives alone, has few friends

or supports)

■ Stressful life event

■ Previous or current abuse (emotional, physical, sexual)

■ Sexual identity crises/conflict

■ Available lethal methods (guns)

■ Legal issues/incarceration

 

A depressed mood plus four or more SIGECAPS for 2 weeks or longer indicates a major depressive disorder.A depressed mood plus three SIGECAPS most days for 2 years or longer indicates dysthymia, which is a depressive neurosis with no loss of contact with reality.

 

 

Assessing Depression

Depression poses a major health problem. Major depression has been identified by the World Health Organization as the leading cause of disability for adults in developed countries,such as the United States (Healthy People 2010). In any given year, approximately 6.5 percent of women and 3.3 percent of men will have a major depressive episode.The incidence of major depression is twice as great in women as in men. Identification of

those at risk and accurate assessment of depression can lead to prompt intervention and promotion of mental health.

If you suspect that your patient is depressed, use the mnemonic SIGECAPS to easily recall and review theDSM-IV criteria for major depression:

Suicide Assessment

In the United States, suicide is a major public health problem (Healthy People 2010). It is often the end result of mental illness.More women attempt suicide than do men, but men are four and a half times more likely to succeed at suicide than are women.If you suspect that your client is suicidal,perform a suicide assessment. It is important to identify those at risk for suicide and intervene promptly.

 

Symptoms of dysthymia are similar to those of a major depressive disorder, but milder.

A L E R T

Suicide attempts are more likely to occur as the patient’s symptoms improve because the patient now has the energy to commit suicide.

Feelings of hopelessness

Suicidal ideations

Plan for suicide

Possessions

Auditory hallucinations

Lack of support network

Alcohol or substance abuse

Precipitating event

Media

A key element in assessing for feelings of hopelessess is determining whether the patient is able to see a future with herself or himself in that future.

ASSESSMENT AREA QUESTIONS TO ASK

A L E R T

For many people, holidays can be a precipitating event to a suicidal episode.

■ Take note if the local media has reported on the suicide of a famous

person or local teenager.

Assessing Substance Abuse

Substance use includes use of prescribed or OTC drugs, alcohol, caffeine, nicotine, steroids, and illegal drugs.

Abuse and addiction exist when substance use has social,professional, or legal consequences.There are two types of substance abuse disorders, substance use disorders and substance-induced disorders.

 Substance use disorders include:

■ Substance dependence: Repeated use despite substance-related cognitive, behavioral, and psychological problems.Tolerance,withdrawal,and compulsive drugtaking can result.

■ Substance abuse: Recurrent, persistent substance

use with significant adverse consequences during a 12-month period.

Substance-induced disorders include:

■ Substance intoxication: Overuse of a substance that

results in a reversible, substance-specific syndrome;can

be indicated by behavioral and psychological changes.

■ Substance withdrawal: Symptoms differ upon the

substances being used and develop upon their withdrawal

(Pederson, 2005;APA, 2000).

If substance abuse is a concern with your client, it is

important to ask the right questions and obtain an accurate

history. If there is no time to obtain a detailed assessment,a

focused assessment tool such as the CAGE questionnaire

can also identify a possible substance abuse problem.

 

Groups at Risk for Suicide

■ Elderly persons who are isolated or widowed or who have experienced multiple losses

■ Males who are widowed and without close supports

■ Adolescents and young adults

■ Persons with serious or terminal illness who become depressed or hopeless

■ Persons with mood disorders,depression,and bipolar

■ Persons with schizophrenia, either newly diagnosed or those experiencing auditory command hallucinations

■ Persons who abuse drugs or alcohol, especially persons with a mental disorder

■ Persons under stress (sometimes multiple stressors) with recent loss or losses

Performing a Suicide Assessment

Substance Abuse History and Assessment Tool

1. When you were growing up, did anyone in your family use substances (alcohol or drugs)? If yes, how did the substance

abuse affect the family?

2. When (how old) did you use your first substance (e.g., alcohol, cannabis) and what was it?

3. How long have you been using a substance(s) regularly? Weeks? Months? Years?

4. What is your pattern of abuse?

a. When do you use substances?

b. How much and how often do you use?

c. Where are you when you use substances and with whom?

5. When did you last use, what was it, and how much?

6. Has substance use caused you any problems with family, friends, job, school, the legal system, other? If yes, describe.

7. Have you ever had an injury or accident because of substance abuse? If yes, describe.

8. Have you ever been arrested for a DUI because of your drinking or other substance use?

9. Have you ever been arrested or placed in jail because of drugs or alcohol?

10. Have you ever experienced memory loss the morning after substance use (can’t remember what you did the night

before)? Describe the event and feelings about the situation.

11. Have you ever tried to stop your substance use? If yes, why were you not able to stop? Did you have any physical

symptoms such as shakiness, sweating, nausea, headaches, insomnia, or seizures?

12. Can you describe a typical day in your life?

13. Are there any changes you would like to make in your life? If so, what are they?

14. What plans or ideas do you have for making these changes?

15. History of withdrawal:

Other comments:

Source: Pedersen, D. (2005). PsychNotes. Philadelphia: F.A. Davis; and modified from Townsend, M. (2005).

Psychiatric Mental Health Nursing, ed. 5. Philadelphia: F.A. Davis.

CAGE Questionnaire

■ Have you ever felt you should Cut down on your drinking/drug use?

■ Have people Annoyed you by criticizing your drinking/drug use?

■ Have you ever felt bad or Guilty about your drinking/drug use?

■ Have you ever had an Eye opener (use of alcohol or drugs first thing in the morning) to steady your nerves or get rid of

a hangover?

A positive (yes) response to two or more questions suggests that there is an alcohol/substance problem.

Note: The need to cut down is related to tolerance (needing more substance for same effect), and the eye

opener is related to withdrawal syndrome (reduction/cessation of substance).

 

Abused Substances: Effects From Use and Withdrawal

SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL

Depressants

■ Alcohol (booze, brew, juice, spirits)

■ Sedatives, hypnotics, and anxiolytics, including barbiturates (barbs, beans,black beauties, blue angel, candy, downers,goof balls, BB,nebbies, reds,sleepers, yellowjackets, yellow)

■ Benzodiazepine(downers)

Stimulants

■ Amphetamines(A, AMT, bam, bennies, crystal, diet pills, dolls, eye-openers, pep pills, purple hearts, speed, uppers, wakeups)

■ Cocaine

(Bernice, bernies, big C, blow, C, Charlie,coke, dust, girl,heaven, jay, lady, nose candy, nosepowder, snow,sugar, whitelady)

■ Crack (Conan, freebase, rock,toke, white cloud, whitetornado)

■ Unconsciousness

■ Respiratory depression

■ Coma

■ Death

■ Hypotension

■ Nystagmus

■ Stupor

■ Cardiorespiratory depression

■ Coma

■ Death

■ Ataxia

■ High temperature

■ Seizures

■ Respiratory distress

■ Cardiovascular collapse

■ Coma

■ Death

■ High temperature

■ Seizures

■ Transient vasospasms (may cause myocardial infarction [MI], cerebrovascular accident[CVA], coma, death)

■ Depressed cognitive functioning

■ Impaired psychomotor functioning

■ Decreased reaction time

■ Decreased balance and coordination

■ Decreased REM sleep

■ Slurred speech

■ Labile mood

■ Inappropriate sexual behavior

■ Loss of inhibition

■ Drowsiness

■ Impaired memory

■ Euphoria

■ High energy

■ Impaired judgment

■ Anxiety

■ Aggressive behavior

■ Paranoia

■ Delusions

■ Euphoria

■ Grandiosity

■ Sexual excitement

■ Impaired judgment

■ Insomnia

■ Anorexia

■ Nasal perforation

(inhaled route)

■ Psychosis

■ Tremors

■ Diaphoresis

■ Anxiety

■ Hallucinations

■ Delusions

■ Increased pulse andblood pressure

■ DTs

■ Sleep disturbances

■ Insomnia

■ Hand tremor

■ Agitation

■ Nausea and vomiting

■ Anxiety

■ Tinnitus (withbenzodiazepines)

■ Seizures

■ Cardiac arrest

■ Depression

■ Agitation

■ Confusion

■ Vivid dreams followed by lethargy

■ Fatigue

■ Depression

■ Anxiety

■ Suicidal behavior

Marijuana

■ Cannabis (marijuana,hashish, Acapulco gold, Aunt Mary, broccoli, dope, grass, weed,grunt, hay, hemp,J, joint, joy stick, killer weed, pot, ragweed, reefer,smoke weed)

Opiates

■ Heroin (H, horse, harry, boy, scag,shit, smack, stuff, white junk, whitestuff)

■ Morphine

■ Hydromorphone

■ Meperidine

■ Codeine

■ Oxycodone

■ Opium

■ Methadone

Hallucinogens

■ Hallucinogens

(LSD, DMT, Mescaline, acid, big D, blotter, blue heaven, cap, D, deeda, flash, L, mellow yellow, microdots, paper acid, sugar, ticket,

yello)

■ Club drug, MDMA (ectasy)

Phencyclidine

■ Phencyclidine (PCP, angel dust, DOA, dust,elephant, hog,peace pill,supergrass, tictac)

■ Extreme paranoia

■ Psychosis

■ Dilated pupils

■ Respiratory depression

■ Seizures

■ Cardiopulmonary arrest

■ Coma

■ Death

■ Panic

■ Psychosis with

hallucinations

■ Cerebral damage

■ Death

■ Confusion

■ Hallucinations

■ Severe anxiety

■ Hypertension

■ Seizures

■ High temperature

■ Hallucinations

■ Psychosis

■ Seizures

■ Respiratory arrest

■ Death

■ Euphoria

■ Intensified perceptions

■ Impaired judgment and motor ability

■ Increased appetite, weight gain

■ Sinusitis and bronchitis with chronic use

■ Anxiety, paranoia

■ Red conjunctiva

■ Euphoria

■ Drowsiness

■ Impaired judgment

■ Constricted pupils

■ Dilated pupils

■ Diaphoresis

■ Palpitations

■ Tremors

■ Enhanced perceptions of colors and sound

■ Depersonalization

■ Grandiosity

■ Euphoria

■ Muscle relaxation

■ Impulsive behavior

■ Impaired judgment

■ Belligerent, violent behavior

■ Ataxia

■ Muscle rigidity

■ Nystagmus

■ Hypertension

■ None

■ Yawning

■ Insomnia

■ Anorexia

■ Irritability

■ Rhinorrhea

■ Muscle cramps

■ Chills

■ Nausea and vomiting

■ Feelings of panic and doom

■ None

■ Psychological dependence can causedepression, flashbacks

■ None

SUBSTANCE INTOXICATION OVERDOSE WITHDRAWAL

Inhalants

■ Gasoline, glue, aerosol sprays,paint thinners(spray, rush, bolt,huffing, bagging,sniffing)

■ Nicotine(Cigarettes, cigars, bidis, kreteks, pipe tobacco, chewing tobacco, snuff,nicotine gum or patches)

■ Psychosis withhallucinations

■ Cardiac arrhythmias

■ Central nervous system depression

■ Coma

■ Cerebral damage

■ Death

■ None

■ Numbness or diminished response to pain

■ Euphoria

■ Impaired judgment

■ Blurred vision

■ Unsteady gait

■ Sense of anxiety reduction

■ Relief from depression

■ Satisfaction

■ None

■ Insomnia

■ Depression

■ Irritability

■ Anxiety

■ Poor concentration

■ Increased appetite

 

RESEARCH TELLS US

Worldwide,mental health problems,with depression and anxiety being the most frequent, occur in approximately 24 percent of patients in primary care (WHO, 2005).Mood disorders with increasing rates of depression and anxiety may be associated with physical illness. Deteriorating physical health and cognitive functioning that is often associated with aging is a major risk factor for developing depression later in life. The purpose of the following study was to examine staff contact and input with mental health problems and to determine their experience, training, and

attitudes to mental health problems.A cross-sectional design was used in the United Kingdom.A 40-item questionnaire was mailed to over 300 staff members in primary care.The return rate was 66 percent (n _ 217, 95 percent confidence interval,with two-thirdsof the respondents RNs).The questionnaire focused on depression in identifying mental problems, interventions,and mental health training.Demographics

were obtained to describe the sample.The Depression Attitude Questionnaire (DAQ), a 20-item instrument,was used to assess staff attitude toward depression. The findings reported that 16 percent of their patients had associated mental health problems,with dementia, depression, and anxiety being the most common.The staff reported a willingness to develop an understanding and skills needed to address mental

health problems with patients, but reported little training in the past 5 years that addressed this issue.

The staff, as revealed by the DAQ,was optimistic about treating depression. The study supports the need for mental health training in primary care as evidenced by the limited detection and treatment of mental health problems. The staff was willing and eager to develop the knowledgeand skills to assess and treat mental health problems. The areas identified included recognition of mental disorders, anxiety management, crisis intervention,

and pharmacologic treatment for depression. Although this study was limited to the United Kingdom, the problem is universal.A better understanding

of assessment and treatment of mental health problems would provide a holistic approach to meeting the patient’s needs.

HEALTH CONCERNS

Healthy People 2010 has identified specific objectives that address mental health/disorders.

Improving Mental Health

■ Improve mental health and ensure access to appropriate,

quality mental health services.

■ Reduce the suicide rate.Target: 5 per 100,000 from

11.3 per 100,000 in 1998.

■ Reduce the rate of suicide attempts by adolescents.

Target: 1 percent over 12 months from 2.6 percent

from grades 9 through 12 in 1999.

■ Reduce the proportion of homeless adults who

have serious mental illness.Target: 19 percent from

25 percent age 18 and older in 1996.

■ Increase the proportion of persons with serious mental

illness who are employed.Target:51 percent from

43 percent age 18 and older in 1994.

Improving Treatment

■ Reduce the relapse rates for persons with eating

disorders.

■ Increase the number of persons seen in primary

healthcare who receive mental health screening

and assessment.

■ Increase the proportion of children with mental

health problems who receive treatment.

■ Increase the proportion of juvenile justice facilities

that screen new admissions for mental health problems.

■ Increase the proportion of adults with mental disorders

who receive treatment.

■ Increase the proportion of persons with cooccurring

substance abuse and mental disorders

who receive treatment for both disorders.

Improving State and Local Involvement

■ Increase the proportion of local government with

community-based jail diversion programs for adults

with serious mental illness.

■ Increase the number of states (including the

District of Columbia) that track consumers’ satisfaction

with the mental health services they receive.

■ Increase the number of states and territories

(including the District of Columbia) with an operational

mental health plan that addresses cultural

competence.

■ Increase the number of states and territories

(including the District of Columbia) with an operational

mental health plan that addresses mental

health crisis interventions, ongoing screening, and

treatment services for elderly persons.

Asessment of Common Mental Health Problems

Anxiety

■ Diffuse feelings of apprehension with feelings of

uncertainty, helplessness

■ Ranges from mild to panic state that can be paralyzing

■ Restlessness

■ On edge

■ Easily fatigued

■ Concentration problems

■ Irritability

■ Sleep disturbances

■ Dizziness

■ Palpitations

■ Hot/cold flashes

■ Tightness of chest

■ Nausea

■ Decrease appetite

■ Abdominal pain

Affect

■ Nervous

■ Anxious

■ Fearful

Physical Findings

■ Sweating

■ Tremors, rigidity, spasms

■ Dilated pupils

■ Increased respirations

■ Wheezes due to bronchial spasms

■ Tachycardia, increased blood pressure

■ Diarrhea

■ Vomiting

■ Increased reflexes

■ Muscle tension

■ Pacing, clumsy movements

■ Confusion

■ Easily distracted

■ Short attention span

 

Anxiety differs from fear in that fear has an identifiablesource, anxiety may not.

Types: (DSM-IV)

Panic Disorders

■ Extreme, overwhelming anxiety in response to real or

perceived life-threatening situation

■ Can lead to phobias, avoidance, and agoraphobia

Phobias

■ Unreasonable fear response to a specific object or

situation

■ Causes anxiety

■ Person realizes fear is unreasonable

Social Anxiety Disorder

■ Fear of social or performance situations that may cause

embarrassment

OCD

■ Recurrent thought or ideas (obsession)

■ Action person cannot refrain from doing

(compulsion)

■ Obsession and compulsion interfere with social and

occupational functioning

■ Recognizes thoughts and behaviors are unreasonable

PTSD

■ Traumatic event

■ Threat of harm or death, actual death, and helplessness

■ Re-experiences event (flashback)

■ Hypervigilant

■ Recurring nightmares

■ Anniversary reactions related to trauma

■ Persistent anxiety

■ Acute _ 3 mo, chronic _ 3 mo, delayed _ 6 mo

Acute Stress Disorder

Anxiety, dissociation, and other symptoms after exposure

to recent stressors

Anxiety Disorder related to Medical Condition

Generalized anxiety disorder

■ Excessive worry and anxiety for at least 6 mo

■ Difficult to control worry

■ Hypervigilant

Substance-induced anxiety

 

Assessment of Common Mental Health Problems (continued)

Personality Disorders

■ Pattern of relating and perceiving the world that is

inflexible and maladaptive

Types:

Cluster A includes paranoid, schizoid, schizotypal

personality disorders

■ Paranoid: Distrustful and suspicious of others,

preoccupied with doubts of loyalty, holds grudges,

unwilling to forgive, quick to react and counter

perceived insults

■ Schizoid: Detached from social interaction, restricted

expression of emotions, lacks desire for intimacy,

emotionally cold

■ Schizotypal: Social and interpersonal deficits, odd

beliefs or magical thinking, perceptual alterations, odd

or eccentric behavior

Cluster B includes antisocial, borderline, histrionic, and

narcissistic personality disorders

■ Antisocial behavior: Pattern of disregard and violation

of rights of others

■ Borderline: Unstable behavior with changes in

relationships, self-image, and mood

■ Histrionic: Excessive expression of emotion and

attention-seeking behavior

■ Narcissistic: Inflated sense of self, need for attention

and admiration, no concern for others

Cluster C includes avoidant, dependent, and obsessive

compulsive personality disorders

■ Avoidant: Avoids social interaction for fear of criticism

and feelings of inadequacy

■ Dependent: Needs to be taken care of, submissive, fear

of separation, low self-confidence, difficulty making

decisions and voicing disagreement

■ Obsessive compulsive: Rigid way of functioning,

excessive detail or controlling ways

Psychotic Disorders

Schizophrenia

■ Caused by neurobiological factors; influenced by social

and environmental factors

Four “A”s of Schizophrenia

■ Inappropriate Affect

Cluster A

■ Distrustful, emotionally detached, eccentric

personalities

Cluster B

■ Disregard for others, unstable and intense interpersonal

relationships, excessive attention seeking, entitlement

issues with lack of empathy for others

Cluster C

■ Avoider of social situations, clinging, submissive

personality; and person preoccupied with details, rules,

and order

Borderline Personality Disorder

■ Pattern of unstable relationships

■ Fear of abandonment

■ Splitting: Idealize and devalue (love/hate)

■ Impulsive (in two areas: sex, substance abuse, binge

eating, reckless driving)

■ Suicidal gestures/self-mutilation

■ Intense mood changes lasting a few hours

■ Chronic emptiness

■ Intense anger

■ Transient paranoid ideation

Positive Symptoms _ Excessive function/distortion inbehavior

■ Delusions

■ Hallucinations (auditory/visual)

■ Hostility

■ Disorganized thinking and behavior

Obsessive compulsive personality disorder differs from OCD in that the person with obsessive compulsive personality disorder has no problem with behavior, whereas the person with OCD is anxious and wants to change

• Auditory hallucinations usually begin distant and soft, then become louder, but become softer and distant as client’s condition improves.

• In North America, most hallucinations auditory. Not likely to have both auditory and visual together.

Negative Symptoms _ Deficits in behavior, such as reduced function or self-care deficits

At least for 1 mo, two or more:

■ Delusions

■ Hallucinations

■ Disorganized speech

■ Disorganized behavior

■ Negative symptoms

■ Functional disturbances at work or school disturbance

continues for 6 mo

Mood Disorders

■ Extremes of moods (mania or depression)

Types

Depressive

■ Major depressive disorder (unipolar depression): At

least 2 wk of depression/loss of interest and four

additional symptoms with one or more major depressive

episodes.

■ Dysthymic disorder: On-going, low-grade depression of

at least 2 years’ duration for more days than not and

does not meet the criteria for major depression

■ Depressive disorder not otherwise specified (NOS): Does

not meet criteria for depressions described above.

Bipolar Disorders

■ Bipolar I disorder: One or more manic or mixed episodes

with a major depressive episode

■ Bipolar II disorder: One or two major depressive

episodes and at least one hypomanic episode

■ Cyclothymic disorder: At least 2 years of hypomanic

episodes that do not meet the criteria for other

disorders

■ Bipolar disorder NOS: Does not meet any of the other

bipolar criteria

Eating Disorders

Types

Anorexia Nervosa

■ Terrified of gaining weight

Depressive

Depressed mood or loss of interest for at least 2 wk and five or more of:

■ weight loss/gain

■ insomnia or hypersomnia

■ psychomotor agitation or retardation

■ fatigue

■ worthless feelings or inappropriate guilt

■ problem concentrating

■ recurrent thoughts of death

Mania

Persistent elevated, irritable mood for 1 wk or more, plus three or more (irritable, four or more):

■ high self-esteem

■ decreased sleep

■ increased talking/pressured speech

■ racing thoughts/flight of ideas

■ distractibility

■ extreme goal-directed activity

■ excessive buying/sex/business investments (painful

consequences)

Anorexia Nervosa

■ Emaciated appearance

■ Below normal weight

■ Hair loss, dry skin

■ Loose Association

■ Autistic thoughts

■ Ambivalence

A L E R T

When working with patients who have depression, it is important to identify any suicidal/homicidalideations.

 

 Common Mental Health Problems (continued)

■ Weight below minimally accepted (weight _ 85% of

what would be expected for age and height)

■ Disturbed self-perception of size and shape of body;

even though underweight, still fears becoming

overweight

■ Self-esteem and self-evaluation based on weight

■ Introverted, socially isolated, high achiever

Bulimia Nervosa

■ Recurrent binge eating of large amounts of food over

short period

■ Lack of control

■ Self-induced vomiting, use of laxatives, purging,

fasting, excessive exercising

■ Weight normal, under-/overweight

■ Fluid and electrolyte imbalance

■ Impulsive, acting out, more histrionic (pervasive,

excessive expression of emotions and attention-seeking

behaviors)

■ Amenorrhea

■ Pedal edema

Bulimia

■ Normal or overweight

■ Weight fluctuations

■ Dehydration

■ Hoarseness

■ Parotid gland enlargement (chipmunk facies)

■ Tooth enamel erosion

■ Finger or pharynx bruising

 

S U M M A R Y

■ Holistic nursing care includes assessment of the psychological health of your patient.The developmental level and cultural background of your patient needs to be considered when assessing your patient’s mental health.

■ When obtaining a health history and physical assessment, look for clues that reflect the mental health of your patient.

■ A thorough mental health assessment includes a detailed mental status assessment. Specific mental health assessment instruments are available to further assess the mental health needs of your patient.

■ Identify supports and resources and make referrals as needed to meet the mental healthcare needs of your patient.