Mental health Flashcards
Mental status assessment: A-B-C-T
- Appearance
- Behavior
- Cognition
- Thought processes
When to perform a full Mental Status Examination? 5
- Initial screening suggests anxiety or depression disorder
- Behavior changes
- Brain lesions
- Aphasia
- Symptoms of psychiatric mental illness
Developmental Competence-Aging adults
- Older adulthood contains more potential for losses
- These losses affect mental status and can result in is ability disorientation or depression
- Chronic diseases such as heart failure, cancer, diabetes, and osteoporosis include fear of loss of life
What is a MMSE?
Mini-mental state examination
- From 0 to 30 range
- Any score 25 or higher considered to be intact (normal)
- 21 to 24 indicate mild cognitive impairment
- 0 to 17 indicates severe cognitive impairment
Mental status examination can be assessed directly like the characteristics of skin or heart sounds.
True or False?
False
Aging Adults
What we must do before assessing mental states?
Check sensory status, vision, and hearing before any aspect of mental status
- Vision and hearing changes due to aging may alter alertness and leave the person looking confused
- Vision and hearing changes may affect testing results
-Confusion is common and is easily misdiagnosed
Impacts of losses - social isolation, job, change in residence, or some short-term memory loss – can affect mental status examination
What are the basic functions should the nurse test first in an assessment of mental status?
Consciousness
Dementia is a state of a)__________ and b)________ loss related to brain disease most commonly Alzheimer’s disease.
a) cognitive impairment
b) short term memory
Delirium is a temporary state of a)__________ usually related to another medical condition
Confusion
Peripheral Nervous System (PNS)
a) ____ pairs of cranial nerves
b) ____ pairs of spinal nerves
a) 12
b) 31
Afferent (stimulus) messages from sensory receptors to CNS
Efferent (response) messages from CNS to sensory receptors
Sympathetic nervous system starts in the a)__________.
Response for b)________
Peripheral Nervous System starts either c)________ or at the d)________.
Response for e)________
a) middle of spinal cord
b) FIGHT OR FLIGHT
c) brain stem
d) bottom of the spinal cord
e) rest and digest
- Sensory
- Sensory
- Motor
- Motor
- Both
- Motor
- Both
- Sensory
- Both
- Both
- Motor
- Motor
Cerebral cortex?
Frontal lobe?
Parietal lobe?
Occipital lobe?
Temporal lode?
Wernicke’s area?
Broca’s area?
Cerebellum?
- *Cerebral cortex**: outer layer of nerve cells
- *Frontal lobe:** personality, Behavior, Emotion,
- *Parietal lobe:** Sensation
- *Occipital lobe**: Visual reception
- *Temporal lode**: auditory function
- *Wernicke’s area**: Language comprehension (receptive aphasia)
- *Broca’s area:** Mediates motor speech expressive aphasia results
- *Cerebellum**: Motor coordination of voluntary movements, equilibrium, and muscle tone.
Thalamus?
Hypothalamus?
Pituitary gland?
Basal ganglia?
Brainstem?
Midbrain?
Pons?
Medulla?
Spinal cord?
Thalamus
-Sensory pathways of spinal cord, cerebellum, and brain stem form synapses
Hypothalamus
-Major control center for resp, temperature, heart rate, blood pressure, stress response, emotional status.
Pituitary gland
-Regulation, and coordination of autonomic nervous system
Basal ganglia
-Initiate and coordinate automatic associated movements of the body/legs move during walking.
Brainstem
-Central core of brain consists of nerve fibers
Midbrain
-Contains many motor neurons and tracts
Pons
-Enlarged area containing ascending sensory and descending motor tracts
Medulla
-Continuation of spinal cord in brain; contains all fiber tracts connecting brain and spinal cord
Spinal cord
-Occupies upper two-thirds of vertebral canal from medulla to lumbar vertebrae L1 to L2
Cranial nerves
Enter and exit a)__________ rather than b)________
c)__ pairs of cranial nerves supply primarily head and neck, except d)________, which travels to heart, respiratory muscles, stomach, and gallbladder
a) brain
b) spinal cord
c) 12
d) vagus nerve
CN I and II
Extend from a)_________
Cranial nerves III to XII
Extend from b)________
a) cerebrum
b) brain stem
a)___ pairs of spinal nerves
How many each?
Cervical
Thoracic
Lumbar
Sacral
Coccygeal
a) 31
b) 8
c) 12
d) 5
e) 5
f) 1
Reflexes are basic a)__________ mechanisms of the nervous system
Four types of reflexes?
a) defense
- Deep tendon reflexes (ex: knee jerk)
- Superficial (corneal reflex)
- Visceral (pupillary response to light)
- Pathologic (abnormal) (Babinski’s or Planter reflex)
Involuntary muscles are mainly controlled by the a)_______ nervous system
The b)________ nervous system, associated with the voluntary
a) autonomic
b) somaticc
Kenn jerk
a) Where to hit?
b) What response should occur?
The c)________ fiber carry the message from the receptor and travel through the d)________ into the spinal cord.
They synapse directly in the cord with the motor neuron in the e)________ .
f)__________ fibers leave via the g)__________and travel to the muscle, stimulating a sudden contraction
a) Right below the knee cap(tendon)
b) Leg will kick out(involuntary response-muscle)
c) sensory afferent
d) dorsal root
e)anterior horn
f) Motor efferent
g) ventral root
Health history question
Headache
Any unusually frequent or severe headaches?
A pt who says, “this is the worse HA of my life”
—needs emergency referral to screen cerebrovascular cause
Health history question
Head injury
Ever had any head injuries? Please describe.
Did you have a loss of consciousness?
Health history question
Syncope
Sudden loss of strength?
LOC (a faint), due to lack of cerebral blood flow (low BP)
Health history question
Weakness
Any weakness or problem moving any body part?
Is this generalized or local?
Syncope?
Sudden loss of strength, due to lack of blood flow to the cerebral blood flow (low BP)
Fainting, or a sudden temporary loss of consciousness
Vertigo?
Rotational sinning is caused by neurological disorders, inner ear problems, brain stem problems
Room spins (obj vertigo), you spin (sub vertigo)
Difference between vertigo and dizziness?
Vertigo is always due to a neurological problem,
Dizziness may have many causes and is less specific.
-inner ear disturbance, motion sickness and medication effects etc
Health history question
Seizures
Ever had any convulsions?
When did they start? How often do they occur?
Occurs with epilepsy
Involuntary muscle movement or sensory disturbance
Health history question
Tremors
Any shakes or tremors in the hands or face?
When did these start?
Does it get worse with anxiety, alcohol, gets better with rest?
Do they affect daily activities?
Involuntary shaking, vibrating, trembling
Paralysis
Loss of a)__________ function due to a lesion in b)________ or c)________ system or loss of d)________
a) motor
b) neurologic
c) muscular
d) snsory innervationse
Health question
Incoordination
Any problem with coordination?
Any problem with balance when walking?
Do you list to one side?
Any history of fall?
Do your legs seem to give way?
Health question
Difficulty swallowing/Dysphagia
Any problem swallowing?
Does it occur with solids or liquids?
Have you experienced excessive saliva, drooling?
Dysarthria is a)__________ in which the muscles that are used to b)________ are damaged, paralyzed, or weakened.
diff forming words
A)motor speech disorder
B)produce speech
Expressive dysphasia is a difficulty in expressing )__________
They b)________ the launguage, but hard to c)________
a) what you want to say
b) understand
c) produce
Receptive dysphasia?
difficulty in putting words together to make meaning
Equipment needed for the NEUROLOGICAL ASSESSMENT 6
Tongue blade
Cotton swab
Tuning fork
Percussion hammer
Penlight
Occasionally need: familiar aromatic substance
CN1 to CN6 function and how to assses
- *CN1:** small, check nasal patency first.
- *CN2:** visual acuity using Snellen’s Chart
- *CN3, 4, 6:** Pupil size, direct & consensual response, EOM by the 6 cardinal positions of gaze
- *CN5:** Assess muscle of mastication as person clenches the teeth, should feel equally strong on both sides-eyes closes, light touch sensation by touching a cotton wisp on person’s forehead, cheeks, and chin
CN7 to CN12
- *CN7:** facial symmetry as person respond to frown, smile, puff cheeks, lift eyebrows, show teeth—a sense of taste by applying something on the tongue
- *CN8:** one ear at a time, cover other ear by placing a finger over the tragus, shield your lips to prevent lip reading, 1-2 feet distance, whisper slowly a set of 3 random letters and numbers and ask the person to repeat it, assess other ear using yet another set of items, a passing score is correct repeating of at least 3 out of a possible 6 numbers and letters
- *CN 9 &10:** ask the person to yawn or say ahhh and see uvula and soft palate rise in the midline, touch posterior pharynx with a tongue blade to check for the gag reflex, don’t check it
- *CN11:** examine neck and shoulder muscles by asking the person to shrug the shoulders against resistance and the movement should feel equally strong on both sides.
- *CN12:** ask the person to stck out tongue, inspect the tongue, should be midline, no wasting, tremors…
Testing a motored system
- *Hand grip**
- offer your two fingers, one on top of the other, so that a strong hand grasp does not hurt your knuckles.
Gait
-observe person walk 10 to 20 feet, turn and returns to starting point
Tandem walking
-ask person to walk in a straight line in a heel-to-toe fashion
- *Romberg’s test**
- ask person to stand up with feet together and arms at side;
- once in a stable position,close eyes and hold that position
- wait 20 seconds
- Normally a person should maintain the posture, slight swaying may occur, stay close to catch the person in case he or she falls.
Coordination and Skilled Movements
- *Rapid alternating movement**
- Patting the knees with both hands, turn hands over and pat the knees with the backs of the hands
- Should be equal turning and a quick rhythmic pace
- *-Finger-to-finger test**
- With the person’s eyes open, ask that he or she use the index finger to touch your finger,
- then his or her own nose. After a few times, move your finger to a different spot.
- The person’s movement should be smooth and accurate
- *Finger-to-nose test**
- Asking the person to close the eyes and to stretch out the arms
- T touch the tip of his or her nose with each index finger
Stereognosis
Ability to recognize objects by feeling forms, sizes and weights. Place a familiar object (paper clip; key, coin, pencil) in the person’s hand
Graphesthesia
Ability to “read” a number or letter by having it traced in the hand
Two-point discrimination
Person’s ability to distinguish the separation of two simultaneous points on the skin
Plantar reflex /normal response
normal response is plantar flexion of the toes and inversion and flexion of the forefoot
The aging adult
General atrophy
Steady loss of neuron structure
Velocity of nerve conduction decreases
-as a result pain, touch, taste, smell sensation may be diminished
Muscle strength decreases
Muscle tremor may occur
Decrease in cerebral blood flow and o2 consumption—dizziness, fall, loss of balance with position change
Which clients are most at risk for depressive symptoms?
- Divorced clients
- Females
- Chronically ill clients
A nurse is assessing the speech of an older adult pt. Which of the following would the nurse characterize as an expected assessment finding?
Moderate pace
Normally, in older adults, responses may be slowed, but speech should be clear and moderately paced. Slow, repetitive speech is characteristic of depression or Parkinson’s disease. Loud, rapid speech may occur in manic phases of bipolar disorder.
The client’s daughter asks the nurse why the nurse is asking her mother depression-related questions.
The nurse explains?
depression often mimics signs and symptoms of dementia
The nurse is assessing a client’s immediate and short-term memory.
What of the test would be most appropriate?
Giving the client three words and asking him to recite them now and then in 5 minutes.
The nurse documents findings from the client’s Mini-Mental State Examination.
The following information will be documented as a result of this test.
Orientation, memory, and cognitive function
Neurological exam includes? 4
- Mental status
- -Sensory
- Motor and reflexes
Within the frontal lobe, what is the area that controls motor speech?
What condition may arise following trauma to this area?
Broca’s area
-Expressive aphasia (difficulty saying words)
Reflexes are graded on a 0-4 scale.
What number is given to an average reflex response?
2+ = average
4+ very brisk, hyperactive with clonus (disease)
3+ brisker than average, may indicate disease
2+ average, normal
1+ diminished, low normal, or occurs with reinforcement
0 = no response
If the nurse observes that a pt.’s gait is unsteady and assess a positive Romberg Sign
Which area of the brain is most likely affected?
cerebellum
What is the most common neurologic symptom?
Headache
How might a patient describe the feeling of paresthesia?
What should the nurse assess regarding paresthesia?
“pins and needles”
The source and progression of symptoms
During the history, a client tells the nurse that “it feels like the room is spinning around me.” The nurse would document this as:
vertigo
Afferent neurons, also called a)__________, are the nerve fibers responsible for bringing sensory information from the b)________ into the c)________
a) sensory neurons
b) outside world
c) brain
The dorsal roots carry a)__________, while the ventral roots carry b)_______
a) afferent sensory axons
b) efferent motor axons
Mental states assessment
APPEARANCE/example
- *POSTURE** - erect and position is relaxed
abn: restlessness w/HTN or anxiety; slumped w/depression or organic brain disease - *BODY MOVEMENTS** - voluntary, deliberate, coordinated, smooth and even
abn: bizarre gestures schizophrenia - *DRESS** - appropriate for season, age, gender, setting
abn: inappropriate dress w/organic brain syndrome; eccentric dress w/schizophrenia or mania - *GROOMING+HYGIENE**
abn: unilateral neglect post-CVA; lack of concern for appearance in depression and alzheimers;
Mental assessment
BEHAVIOR/example
LEVEL OF CONSCIOUSNESS - awake alert aware
- *FACIAL EXPRESSION** - appropriate
abn: masklike expression in parkinsonism, depression - *SPEECH MOOD+AFFECT** - appropriate
abn: mood swings with mania; bizarre w/schizophrenia
Mental assessment
COGNITIVE FUNCTIONS/examples
- *ORIENTATION** - knows date, location, etc
abn: w/delerium and dementia - *ATTENTION SPAN -**
abn: digression from initial thought, irrelevant replies to questions - *RECENT MEMORY** - can recall 24 hrs
abn: dementia, delerium, Korsakoffs syndrome - *REMOTE MEMORY -** recalls events in past
abn: lost when cortical storage area for memory is damaged (alzheimer, trauma to brain region) - *NEW LEARNING** - 4 unrelated words test
abn: alzheimers, dementia, anxiety, depression
Glascow Coma Scale
- alert - awake or readily aroused, oriented
- lethargic (somnolent) - not fully alert, drifts to sleep when not stimulated, answers questions but thinking is slow and fuzzy
- obtunded - sleeps most of the time, difficult to arouse
- stupor or semi-coma - spontaneously unconscious, responds only to persistent and vigerous shake/pain
- coma - completely unconscious, no response to pain
Components of Mental Status Exam (MSE) 7 factors
1) General Appearance, Behavior & Attitude
2) Level of Consciousness and Orientation
3) Speech and Language
4) Mood and Affect
5) Thought Process, Content, & Perceptions
6) Memory and Cognition
7) Judgment and Insight
MSE: General Appearance, Behavior & Attitude
This is your first impression of the patient:
- Pt. awake?
- Pt. clean, wearing appropriate clothing?
- Pt. cooperative with staff?
- Pt. moving around too much, or completely still?
- Pt. appears roughly stated age?
- Pt. with appropriate verbal responses?
- Pt. angry, suspicious, guarded?
MSE: Level of Consciousness
1) Alert - patient is able to open eyes, look at you, responds fully and appropriately
2) Lethargic - drowsy, but can open eyes, look at examiner and respond. Falls back to sleep easily
3) Obtunded - opens eyes when commanded to and looks at you, offers confused responses, has lack of interest in the environment
4) Stuporous - Wakens only with painful stimuli. Verbal responses slow or absent. Falls back into unresponsive state when stimuli ceases
5) Comatose - unarousable to any stimuli
MSE: Orientation
What is your name?
What is the day or date?
Where are we now?
If all normal, write “A and O x 3”
MSE: Speech & Lang.
Quantity: talkative or silent? Does the pt speak spontaneously or only when directly questioned?
Rate: Too fast, too slow, just right?
Volume: too loud, too quiet, just right?
Articulation: can you understand what the patient is saying physically? If not, why not
Mood (MSE)
To assess mood, you need to ask the patients how they are feeling
1) “How are your spirits these days?”
2) Labile mood?
3) Intensity of mood?
4) Is the patient suicidal?
5) Is the mood appropriate to the patient’s situation
MSE: Thought Content, Process, Peceptions
1) Processes: Assess the logic, relevance, organization and coherence of the patient’s thought processes
2) Content: Pay attention for abnormalities of thought content and ask questions designed to reveal these abnormalities
3) Interview the to discover if they have any abnormal perceptions
MSE: Memory
Remote Memory: Can the patient correctly remember things that happened or information from long ago
For recent and remote memory, ask patients questions to which the answers are verifiable!!
Remote memory is usually only impaired in severe dementia or in traumatic brain injury
Recent memory is asking them to repeat objects 5 mins. Later
Recent memory may be impaired because of delirium, depression, dementia.
MSE: Cognition
1) Attention: Can the patient focus enough to be able to perform tasks?
- Serial “7’s” & spell world backwards
2) Information and vocabulary: Assess patient’s apparent intelligence by assessing the degree to which they are informed and the complexity of their vocabulary
- Does their general knowledge (world events, local geography, etc) match what their stated educational achievement is? Trying to sort out baseline mental retardation (limited knowledge and vocabulary) from those with dementia (who will have well-preserved vocabulary)
3) Abstract Thinking
- Proverbs: Ask the patient to interpret a commonly used proverb
- Similarities: Ask the patient to tell you how two things are alike
MSE: Judgement
Judgment is the ability to evaluate a situation and form an appropriate response. Assess by:
1) Ask patients to propose a solution to their current problems
2) Ask patients to propose a solution to a hypothetical problem
MSE: Insight
1) ability of patients to understand and acknowledge their illness or situation
2) Patients who are mentally ill or have dementia often lack insight and may deny their illness. They may also refuse to take medications for their illness or engage in needed therapy
When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status
Sensory-perceptive abilities
The nurse is preparing to conduct a mental status examination.
Which phase(interview) the nurse should have mental states examination?
Gathering mental status information during the health history interview is usually sufficient.
The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to
Give him the Four Unrelated Words Test.
The pt is given the Four Unrelated Words Test
The nurse would be concerned if she could not a)____ four unrelated words b)____.
a) recall
b) after a 30-minute delay
During a mental status assessment, which question by the nurse would best assess a person’s judgment?
“Tell me what you plan to do once you are discharged from the hospital.”
Two types of mental disorders
- Organic mental disorder
- Psychiatric mental illness
Organic mental disorder
- Due to brain disease of known specific organic cause, such as delerium, dementia, alcohol and drug intoxication and withdrawal, physical insult)
Psychiatric mental illnesss
Autism
Attention deficit-hyperactivity disorder
Bipolar disorder
Schizophrenia
Speech
a) Parkinsons
b) Manic syndrome
a) slow, monotonous speech
b) rapid-fire, pressured, loud
Manic syndrome
Extremely elevated and excitable mood usually associated with bipolar disorder
Mood & affects- abnormal findings
- *- Flat:** lack of emotional response, face immobile
- *- Depression**: sad, gloomy
- Anxiety: worried of anticipated danger of unknown source
- Fear: worried, external danger is known and identified
aphasia vs dysphasia
Aphasia is the medical term for full loss of language
Dysphasia stands for partial loss of language
how would the nursing student assess abstract reasoning in an adult patient?
four-word test
recall words at 5, 10 and 30 minutes
abstract resoning=abstract thinking
involves the ability to understand and think with complex concepts
How would the nursing student differentiate between recent and remote memory in an adult patient?
recent memory: 24 hours diet recall
remote memory: verifiable past events: birthdays, anniversaries
What information would be included in a mental status assessment for an adult patient?
consciousness
language
mood and affect
orientation
attention
memory
abstract reasoning
thought process
through content
perceptions
An 89-year-old male has a urinary tract infection and is confused on admission to the hospital
dementia or delirium?
Delirium
A 65-year-old female has been having continued difficulty remembering phone numbers for several months’ duration and comes to the physician’s office
dementia or delirium?
Dementia
Mental status in infants and children
object permenance - 18-24 months
language as a social tool of communication coincides with cooperative play - 4-5 years
logical and systematic thinking - 7 yrs
hypothetical thinking - 12-15 years
Which of the following statements about mental status testing of children is correct?
Abnormal findings are usually related to not achieving an expected developmental milestone
What the most elementary of mental status functions
conciuouness
What is difficult in performing mental status exam on infants and children
Difficult to separate and trace development of just one aspect of mental status in children
All aspects are interdependent.
Around 18-24 months the kid knows they are separate from mom.
Type memory normal effected by aging
Recent memory
What causes loss remote memory?
Remote memory is lost when cortical storage area for that memory is damaged
- Alzheimer disease
- Dementia
The nurse is conducting a patient interview.
Which statement made by the patient should the nurse more fully explore during the interview?
I never did too good in school
In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression;
Using the Glasgow Coma Scale, what would be the score of a patient who is in a deep coma?
The Glasgow Coma Scale ranges from the lowest score of 3 to the highest score of 15
A score of 3 would indicate that the patient is in the deepest coma
3 Deepest coma
3-8 Sever
9-12 Moderate
13 or higher Oriented
Brisk reflexes refer?
Wernicke’s area
Broca’s area
a) Language comprehension (receptive aphasia)
b) Mediates motor speech expressive aphasia results
