assessment of mental status Flashcards
mental status
assessment of cognitive ability (thinking, knowledge, problem-solving), emotional status (feeling, mood, behaviors, stability)
What is included in mental status?
Glasgow coma scale, LOC, posture, gait, body movement
What do you assess in cognitive abilities?
orientation (know where are), concentration, recent memory (ex: eat for breakfast), remote memory (ex: first job?), use of memory to learn new information (remember three words), abstract reasoning (picture in mind, makes sense), judgment (ex: wanting to harm self), visual (imagination) perceptual (what color?) constructional ability
During mental health assessment, consider all these items:
LOC/mental status, hygiene, facial expressions, speech, mood/feelings/expressions, thought processes/perceptions
Glasgow coma scale
eye opening response, most appropriate verbal response, most integral motor response (arm) - spontaneous. highest 15, lowest 3
Scoring Glasgow coma scale
best = 15, comatose <8, totally unresponsive 3
Eye opening response
4 spontaneously
3 to speech
2 to pain
1 no response
Best verbal response
oriented 5
confused 4
inappropriate words 3
incomprehensible sounds 2
none 1
Best motor response
Obeys Commands-6
Localizes Pain-5
Withdraws Pain-4
Abnormal Flexion-3
Abnormal Extension-2
None-1
Mental health status
an essential part of total health, which is complete well-being not just the absence of disease. person can cope w/ normal stresses, and work productively.
Validate information
determine the validity of responses before doing the whole assessment, if thought processes are impaired need a new way to get subjective data
Risk factors for mental health disorders
history of behaviors, lack of parental supervision, history of substance abuse, availability of drugs, poverty
History includes
biographical data, history of present health concern, personal health history, family history, lifestyle/health practices
Mental health and risk for substance abuse assessment
behavior/affect, dress/grooming, CAGE assessment
CAGE assessment tool
CHave you ever tried to cut back on your use?
AHave you ever been annoyed/angered when questioned about your use?
G Have you ever felt guilt about your use?
E Have you ever had aneye-opened to get started in the morning?