mental assessment Flashcards
Mental Status
Refers to a person’s emotional (feeling) and cognitive (knowing) function.
Mental Health
A state of well-being in which individuals realize their own potential, cope with normal life stresses, work productively, and contribute to their community.
Level of Consciousness
- Lethargic: Drowsy, not fully alert; drifts to sleep when not stimulated.
- Obtunded: Sleeps, difficult to arouse with loud/vigorous stimuli; acts confused when aroused.
- Stupor: Semi-comatose; responds only to shaking or pain; has appropriate motor responses.
- Coma: Completely unconscious; no response to pain or external stimuli.
Emotional State
- Labile: Rapidly shifting emotions.
- Flat Affect: No emotional response; very monotone.
Lethargic
Drowsy, not fully alert; drifts to sleep when not stimulated.
Obtunded
Sleeps, difficult to arouse with loud/vigorous stimuli; acts confused when aroused.; sternal rub to wake them up
Stupor
Semi-comatose; responds only to shaking or pain; has appropriate motor responses.
Coma
Completely unconscious; no response to pain or external stimuli.
Labile
Rapidly shifting emotions.
Flat Affect
No emotional response; very monotone.
CAGE Questionnaire
A subjective tool used to screen for alcohol history and psychosocial associations. Questions include:
1. Cut down?
2. Annoyed?
3. Guilty?
4. Eye-opener? (drink when they wake up)
CIWA Scoring
An objective tool (Clinical Institute Withdrawal Assessment) used to assess/treat alcohol withdrawal and detox; assesses the level of risk and type of treatment given.
Alcohol (Depressant)
- Unsteady gait
- Slurred speech
- Labile emotions
- Tremors (with withdrawal)
Marijuana (Depressant)
- Tranquility
- Paranoia, suspiciousness
- Increased appetite
- Nausea, vomiting (with CHS - cannabis hyperemesis syndrome)
Opioids (Depressant)
- Lethargy
- Depressed vital signs
- Pinpoint pupils
- Impaired occupational function
NARCAN
An opioid antagonist used to reverse opioid overdose.
Cocaine (Stimulant)
- Hypervigilance
- Weight loss
- Pupillary dilation
- Tachycardia
MDMA, Ecstasy/Molly (Stimulant)
- Extroversion
- Emotional warmth
- Seizures
- Often mixed with other drugs (e.g., stimulants)
PCP, Angel Dust (Stimulant)
- Increased strength
- Seizures, possible death
- Reduced perception of pain
Glasgow Coma Scale (GCS)
A tool used to assess a patient’s level of consciousness and neurological functioning.
Eye Opening Response
- 4: Spontaneous (eyes open spontaneously)
- 3: To verbal command (eyes open to verbal stimuli)
- 2: To pain (eyes open in response to painful stimuli)
- 1: No response (no eye opening)
Verbal Response
- 5: Oriented (responds appropriately to questions)
- 4: Confused (disoriented but able to answer questions)
- 3: Inappropriate words (random or exclamatory speech)
- 2: Incomprehensible sounds (moaning but no words)
- 1: No response (no verbal response)
Motor Response
- 6: Obeys commands (follows simple commands)
- 5: Localizes pain (moves toward painful stimuli)
- 4: Withdrawal (withdraws from pain)
- 3: Flexion (abnormal flexion to pain)
- 2: Extension (abnormal extension to pain)
- 1: No response (no motor response)
Total GCS Score
3-15:
- 3: Deep coma or death
- 8 or less: Severe head injury (coma)
- 9-12: Moderate head injury
- 13-15: Mild head injury (fully conscious)
GCS Interpretation
- A lower score indicates a more severe level of impaired consciousness and neurological function.
- Used frequently in emergency settings to assess brain injury severity.
Level of Consciousness (LOC)
Assessed first to gauge overall mental status before using the ABCT framework.
ABCT Framework
A: Appearance, B: Behavior, C: Cognition, T: Thought processes.
Appearance
- Posture: Stance and body positioning.
- Body movements: Are movements purposeful?
- Dress: Appropriate for setting and situation?
- Hygiene and grooming: Indicators of self-care behaviors.
- Pupils:
- Dilated pupils → cocaine use
- Pinpoint pupils → opioid use
Behavior
- Facial expression: Is it appropriate for the situation?
- Eye contact: Level of engagement.
- Speech: Pace, articulation, and word choices.
- Cultural awareness: Consider cultural variations in behavior.
Mood and Affect
- Body language/facial expression: Observe non-verbal cues.
- Ask: “How do you feel today?”
- Mood abnormalities:
- Depression: Sad, gloomy.
- Flat affect: Lack of emotion.
- Elation: Joy, optimism.
- Lability: Rapid shifts in emotions.
- Anxiety: Worrying.
- Euphoria: Excessive well-being.
Cognition
- Orientation:
- Person, place, time (O x 3); situation (O x 4).
- Attention span:
- Serial commands to assess focus.
- Recent memory: Recall events from the last 24 hours.
- Remote memory: Long-term memory questions (anniversaries, first jobs).
- New memory: 4 unrelated words tested after 5/10/30 minutes.
- Judgment: Evaluate future plans, realistic expectations.
Thought Processes and Perceptions
- Thought processes: Are thoughts logical and coherent?
- Perceptions:
- Ask about feelings of being watched, followed, or controlled.
- Screen for anxiety:
- Questions from the Generalized Anxiety Disorder Scale (GAD).
- Suicidal thoughts:
- Directly ask about feelings of self-harm, hopelessness, and plans for suicide.
Abnormal Perceptions
- Hallucinations: Sensory perceptions with no external stimuli (e.g., visual, auditory).
- Illusions: Misrepresentation of actual stimuli (e.g., faces on money appearing to move).
The Aging Adult
- Aging adults should not exhibit decline in general knowledge and abilities; response time may be slower.
- Delirium: Acute confusional state, often reversible when the underlying cause is treated.
- Dementia: Gradual decline in cognitive function, not reversible and not part of normal aging.
Possible Contributing Factors to Cognitive Deficits
- Medications: (e.g., antipsychotics, sedatives, cocaine).
- Illnesses: Acute or chronic conditions.
- Delirium/Dementia: Recognize baseline behavior and assess changes.
- Age and Culture: Consider cultural norms in behavior and communication.
- Education: Impact on cognitive function and responses.
- Sensory deficits: Vision and hearing impairments may affect communication and assessment.
Body language/facial expression
Observe non-verbal cues to assess emotional state.
How do you feel today?
Question to gauge the individual’s current emotional state.
Mood abnormalities
Variations in emotional responses that may indicate mental health issues.
Depression
Characterized by feelings of sadness and gloominess.
Flat affect
A lack of emotional expression, appearing very monotone.
Elation
Feelings of joy and optimism.
Lability
Rapid shifts in emotions.
Anxiety
Persistent feelings of worry and nervousness.
Euphoria
Excessive feelings of well-being and happiness.
Orientation
Awareness of person, place, time (O x 3), and situation (O x 4).
Attention span
Assessed through serial commands to evaluate focus and concentration.
Recent memory
Recall of events from the past 24 hours.
Remote memory
Long-term memory recall (e.g., anniversaries, first jobs).
New memory
Recall of 4 unrelated words tested after 5, 10, and 30 minutes.
Judgment
Evaluation of future plans and realistic expectations.
Hallucinations
Sensory perceptions that occur without external stimuli, such as visual or auditory experiences.
Illusions
Misrepresentations of actual existing stimuli, for example, seeing faces on moving money.
Delirium
Acute confusional state, often reversible when the underlying cause is treated.
Dementia
Gradual decline in cognitive function, not reversible and not part of normal aging
Medications
Examples include antipsychotics, sedatives, and cocaine that may affect cognitive function.
Illnesses
Refers to both acute and chronic conditions that can impact cognitive abilities.
Delirium/Dementia
Importance of recognizing baseline behavior and assessing changes over time.
Age and Culture
Consideration of cultural norms in behavior and communication styles during assessments.
Education
The impact of educational background on cognitive function and responses to assessments.
Sensory deficits
Vision and hearing impairments that may affect communication and the effectiveness of assessments.
