Mental and Spiritual assessment Flashcards
Mental Status
is a person’s emotional and cognitive functioning
Optimal functioning aims toward simultaneous life satisfaction in work, caring relationships, and within the self
Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally
Defining mental status
Its functioning is inferred through assessment of an individual’s behaviors: Consciousness Language Mood and affect Orientation Attention Memory Abstract reasoning Thought process Thought content Perceptions
Role of the nurse
establish therapeutic relationship
exhibiting caring behaviors
Collect data for the client’s plan of care:
Use a variety of sources: clients, family, friends, old charts, other health care providers
Data can be elusive
Guard against interpretation or misinterpretation of behaviors
factors from health history that could affect interpretation of findings: known illnesses or health problems medications educational and behavioral level responses indicating stress
Remember that the goal is to be *****objective, rather than interpretive.
Mental Status Examination
is a systematic check of emotional and cognitive functioning
Four main headings: A-B-C-T Appearance Behavior Cognition Thought processes
Mental disorder
is apparent when a person’s response is much greater than the expected reaction to a traumatic life event. It is a behavioral/psychological pattern
It is only necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered or in certain situations:
anxiety or depression memory loss trauma tumor stroke mental illness
Objective data
are the main components of a mental status examination
MSE: Appearance
posture: erect and position relaxed
body movements: voluntary, deliberate, coordinated, and smooth and even
dress: appropriate for setting, season, age, gender, social group
grooming and hygiene: clean and well groomed; hair is neat and clean
MSE: Behavior
Level of consciousness: alert, awake, aware of surroundings, respond appropriately
Facial expression: comfortable eye contact, changes with topic
speech: pace, clear, understandable, makes sentences
mood and affect: body lang, facial, how are you feeling today?
MSE: Cognitive Function
Orientation: time, place, person, situation
Attention Span: ability to concentrate
Recent Memory: ask about 24 hour diet recall, ask what time they arrived
Remote Memory: verifiable past events, past health, first job, birthday, dates,
Judgment: he ability to compare and evaluate alternatives and reach an appropriate course of action, daily and long terms goals, capacity to be violent or suicidal,
Aphasia
the loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident.
ways to assess aphasia
reading: read available print
writing: make up a sentence, write a sentence
word comprehension: point to articles, make person name them
MSE: Thought Process
Thought processes: should be logical, goal directed, coherent
Thought content: consistent and logical
Perceptions: aware of reality,
Screen for suicidal thoughts
Screening for Suicidal Thoughts
When the person expresses feelings of sadness, hopelessness, despair, or grief, it is important to assess any possible risk of physical harm to himself or herself
assess lethality: more painful and lethal the plan, more serious
more lethal: guns, hanging, drowning, car crash, overdose
less lethal: cutting, house gas,
Infants and Children
Developmental Competence
Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are interdependent
aging adults
Developmental Competence
Older adulthood contains more potential for losses
Grief and despair surrounding theses losses can affect mental status and can result in disability, disorientation, or depression
Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of life
Developmental Care: Aging Adults
Check sensory status, vision, and hearing before any aspect of mental status
Assess Behavior and level of consciousness: glasgow coma scale (testing consciousness in aging persons)
Assess Cognitive functions: mainly orientation
Health
depends on a balance of physical, psychological, sociological, and cultural developmental and spiritual variables.
Spiritual distress
the impaired ability to experience and integrate meaning and purpose in life
Spirituality
requires open communication and establishment of trust
Spiritual Assessment
Assess patient’s viewpoints: deeply subjective, means different things to different people
Ask direct questions.
Utilize spiritual assessment tools:
BELIEF: belief, ethics, lifestyle, involvement, education, future events
FICA: faith, influence, community, address
Faith
An important part of spiritual assessment is learning who makes up the patient’s community of faith. Ask about faith and belief systems to understand culture and spirituality relationships.
Influence
Nurses also need to determine whether a patient’s religious beliefs conflict with medical treatment.
Community
ask about support networks
Address
Ritual and practice: ask about life practices used to assist in structure and support during difficult times
Vocation: ask whether illness or hospitalization has altered spiritual expression
Providing Spiritual Care
Look beyond isolated patient problems, and recognize the broader picture of a patient’s holistic need.
mobilize hope, help patient use social, emotional, and spiritual resources
Acute Care
display soothing presence and supportive touch.
restorative and continuing care
prayer can be an opportunity to renew personal faith and belief in a higher being.
stress and illness
can tip balance on mental status
Lethargic
sluggish, laziness, lack of energy
Stuporous
condition of greatly dulled or completely suspended sense or sensibility
