Mental Health Assessment Flashcards
symptoms of emotional problems or concerns
mild to moderate distress
mild or temp. impairment
symptoms of mental illness
marked distress
moderate to disabling or chronic impairment
the 11th leading cause of death in the US is suicide t or f
true
what percentage of the population suffer from severe mental illness
3-6%
what US mental health system has failed
De-institutionalization
role of the nurse in mental health
trusted front-line, often first person patient sees
assessment
common mental health problems
depression
substance abuse
schizophrenia
nurses must be comfortable asking highly sensitive questions t or f
true (hx of abuse, suicide, sexuality)
mental status exam includes
subjective and objective data
subjective data on mental assessment
hx, risk, symptoms
objective data on mental assessment
observation of patients physical appearance and behavior ABCT (appearance, behavior, cognition, thought process)
ABCT
appearance
behavior
cognition
thought process
risk fxrs for mental health problems
non modifiable (race, age, sex, family hx) environmental (housing, health care access, economics, support, literacy) physical conditions (cancer, HIV/AIDS)
substance abuse assessment
CAGE (Cut down, annoyed, guilty, eye-opener)
Current/previous use of alcohol/drugs
CAGE assessment (substance abuse)
Have you ever felt you need to Cut down on drinking/drug use?
Have you ever felt Annoyed by criticism of drinking/drug use?
Have you ever had Guilty feeling about drinking/drug use?
Have you ever taken a drink/used drugs first thing in the morning?(Eye-opener) to steady nerves or get rid of a hangover
Spirituality Assessment
HOPE
beliefs/needs
HOPE for spirituality assessment
H: sources of Hope, Meaning, Comfort, Strength, Peace,
Love, and Connection
O: Organized Religion
P: Personal Spirituality/Practices
E: Effect on Medical and End-of-Life Issues
suicidal ideation pneumonic
sad personas
mood is subjective affect is objective t or f
true
flat affect
no emotional tone or reaction
blunted affect
severe reduction in expression
assessing appearance
posture, hygiene, dress
assessing behavior
speech, expressions, cooperation, consciousness
assessing cognitive function
mmse (mini mental status exam)
memory, attention, judgment, orientation
MMSE (mini mental status exam)evaluates
orientation, registration, concentration, language,
short-term memory, and visio-spatial aspects
assessing thought process/perceptions
coherent/incoherent
relevant
abnormal thought processes
Word salad-disconnected and incoherent
combination of phrases, words, and sentences
Echolalia- repetitive imitation of another person’s
speech
Clanging-association of words based on sounds
rather than concepts; rhyming
Neologisms-creating and using new words
delirium is
SUDDEN onset, usually resolves
dementia is
SLOW onset, progresses
depression
slow onset
