Mental Status Assessment Flashcards

1
Q

Mental Health Assessment is Performed When: (5)

A

a. abnormalities on behavioural portion of the general survey
b. patient has brain lesions
c. patient presents with aphasia
d. patient has a diagnosed mental illness
e. family members are concerned about behavioural changes

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2
Q

Mental Health

A

the capacity for each person to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face

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3
Q

Cognition

A
  1. Orientation
  2. Gnosia
  3. Attention/ Concentration
  4. Memory
  5. Comprehension
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4
Q

Orientation

A

patient is oriented to person, place, and time (x3)

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5
Q

Gnosia

A

ability to recognize objects and their function

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6
Q

Memory

A

Immediate - recall an event that just happened
Recent - recall an event that happened recently
Remote - recall verifiable past events

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7
Q

Thinking

A
  1. Processes
  2. Content
  3. Perception
  4. Insight and Judgement
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8
Q

Older Adults and Cognition

A

Older adults appear to decrease in cognition as a result of aging

  • identify if the decrease in cognition is related or age or if it is a legitimate decline
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9
Q

Mini-Mental State Examination (MMSE)

A

used to examine a patient’s mental status when time is limited

Max score: 30 points
Score: 25+ = normal
Score: <24 = mental abnormality present

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10
Q

Montreal Cognitive Assessment (MOCA)

A

used to help detect cognitive impairments - does not diagnose, only indicates the need for advanced testing

Max Score: 30 points
Score: 26+ = normal
Score <25 = cognitive impairment suspected

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11
Q

Confusion Assessment Method (CAM)

A

confusion assessment
a. Delirium - confusion, agitated state (physical state)
b. delusion - impaired perceptions, confusion (thought processes, mental)

Diagnosis of delirium requires the presence of BOTH A and B, and C OR D

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12
Q

Risk Assessment

A
  1. Suicidal Thoughts
  2. Assaultive/ Homicidal Ideation
  3. Elopement Risk
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13
Q

Suicidal Thoughts

A

assess if the patient presents with signs of depression or suicidal thoughts
- if yes, identify immediate risks

have you ever thought about hurting yourself?
do you want to harm yourself? Or just think about it?
what is your plan?
is there a history of suicide in your family?

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14
Q

Assaultive/ Homicidal Ideation

A

assess if the patient is at risk of assulting (hurting) or killing another person
- if yes, you must break confidentiality and inform your supervisor

are you thinking of hurting someone?
who?
how?

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15
Q

Elopement (flight) Risk

A

assess if the patient is at risk of leaving without informing staff
if yes, precautions need to be implemented to ensure the safety of the patient and others

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16
Q

When should you break confidentiality

A

ONLY when someone actively or passively presents the risk of injuring themselves or another person
- get as much information as you can
- inform the appropriate people