Mental Status, Substance Abuse, Violence Assessment- HA(for final)

WHO mental health statement:

“there is no health without mental health… it [is a] state of wellbeing in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”

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

Stress surrounding a traumatic life event or illness can

tip the balance and can cause transient dysfunction.

A 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.

Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Instead, its functioning is inferred through assessment of

an individual’s behaviors

Consciousness is

the most elementary of mental status functions

Language is

a basic tool of humans, and its loss has a heavy social impact on the individual.

Both mood and affect deal with

prevailing feelings.

Orientation means being able to name one’s own

person, place, location, and time

Attention is

the ability to focus on one specific thing without being distracted by many environmental stimuli

M emory has two types.

Recent memory evokes day-to-day events, whereas remote memory brings up years’ worth of experiences.

Abstract reasoning:

The ability to ponder a deeper meaning beyond the concrete and literal

Thought process:

The way a person thinks; the logical train of thought.

Thought content:

What the person thinks; specific ideas, beliefs, and use of words.

Perceptions:

An awareness of objects through the five senses

The role of the nurse in caring for clients with known or suspected mental disorders includes:

1. Establishing a therapeutic relationship
2. Introducing yourself and exhibiting caring behaviors
3. Knowing yourself and your prejudices
4. Taking age, sex, cultural, developmental, and educational levels into account
5. Making it clear that the nurse and client are equal partners

Collect the data necessary to develop a plan of care. Use a variety of sources, including:

the client, family, friends, old charts, other health care providers

1. Remember that data can be elusive, especially if the client is psychotic.
2. Guard against interpretation or misinterpretation of behaviors.

Note these factors from the health history that could affect interpretation of findings:

1. Known illnesses or health problems, such as alcoholism or chronic renal disease
2. Medications with side effects, such as confusion or depression.
3. Educational and behavioral level: note these factors as normal baseline, and do not expect performance on mental status exam to exceed them.
4. Responses indicating stress in social interactions, sleep habits, drug and alcohol use

Remember that the goal is to be objective, rather than interpretive.

Symptom Check:

• Headaches?

• Insomnia?

• Irritability or mood swings?

• Fatigue?

• Suicidal thoughts?

• Thoughts of hurting or killing others?

Ask if the client has ever had:

• Head injury, meningitis, encephalitis, or stroke

• Experience on active duty in the military

Family History

• Any mental health disorders or Alzheimer’s disease in the family?

Describe a typical day.

• Does your current health issue affect your daily activities?

• Describe your energy level.

Substance Use:

• Do you drink alcohol?

  • Type, amount, and frequency?

• Do you use recreational drugs?

  • (e.g., marijuana, tranquilizers, barbiturates, crack, cocaine, meth)

Environmental Exposure:

• Any exposure to pesticides, herbicides, or occupational chemicals?

Psychosocial Assessment:

• How do you feel about yourself and your relationships?

• What support systems do you have and are you using them?

Stress & Mental Health:

• Current stressors in life? (e.g., loss, financial issues, role changes, language barriers, illiteracy, school stress)

• How do you feel about the future?

• Ever had thoughts of hurting yourself or ending your life?

Integrating a mental status examination into the health history interview is

enough for most people.

It is only necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered or in certain situations:

1. Clients whose initial screening suggests an anxiety disorder or depression
2. Behavioral changes, such as memory loss, inappropriate social interaction
3. Brain lesions: trauma, tumor, cerebrovascular accident, or stroke
4. Aphasia: impairment of language ability secondary to brain damage
5. Symptoms of psychiatric mental illness, especially with acute onset

In the older adult, assess

sensory status, vision, and hearing before any other aspect of mental status. Vision and hearing changes may alter alertness and leave the person looking confused. When older people cannot hear your questions, they may test worse than they are. Confusion is common in older adults and is easily misdiagnosed.

There are four main headings of mental status assessment:

A-B-C-T

Appearance

Behavior

Cognition

Thought processes and Perceptions

Level of Consciousness: Person should be

awake, alert, aware of stimuli from environment and within self, and respond appropriately and reasonably soon to stimuli.

Lethargy/lethargic:

client opens eyes, answers questions, and falls back asleep.

Obtunded:

client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment

Stupor/stuporous:

Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep

Coma/comatose:

Client remains unresponsive to all stimuli; eyes stay closed

When assessing level consciousness, always begin with the least noxious stimulus:

verbal, tactile, painful.

Verbal stimulus

• Ask the client their name, address, and phone number.
• Ask the client to identify where you currently are (i.e. hospital or clinic), the day, and the approximate time of day.
• If the client does not respond appropriately, called the client’s name and note the response. If the client does not respond, call the name louder

Tactile stimulus

If necessary, shake the client gently.

Painful stimulus

If the client still does not respond, apply a painful stimulus

the Glasgow Coma Scale is useful in testing

consciousness in clients who have experienced a traumatic brain injury or in aging persons in where confusion is common.

he GCS gives a numerical value to the person’s response in three areas:

eye-opening, best verbal response, and best motor response.

GCS score

Best: 15

Comatose: 8 or less

Totally unresponsive: 3

Facial Expression Normal Findings

• Expression matches topic and situation.

• Comfortable eye contact (unless culturally different).

• Smiles, frowns, and other expressions appear appropriate.

Facial Expression Cultural Considerations

• Eye contact may vary (based on status, gender, or culture).

• Smiling may not imply friendliness or agreement.

Facial Expression

• ↓ Eye contact → may indicate depression or apathy.

• Extreme expressions → may occur in anxious individuals.

• Mask-like face → possible in Parkinson’s disease.

• Staring/watchfulness → can be seen in metabolic issues or anxiety.

• Inappropriate expressions (e.g., smiling when sad) → possible mental illness.

Speech Normal Findings

• Speech is effortless, clear, and articulate.

• Conversation is fluent, with moderate pace and appropriate pauses.

• Word choice is suitable for education level.

• Can complete full sentences

Speech Abnormal Findings

• Slow, repetitive speech → Depression or Parkinson's

• Loud, fast speech → Mania

• Disorganized or nonstop speech → Mental illness or neurologic disorder

• Long silences → possible cognitive or mental health issue

↓ Eye contact

may indicate depression or apathy.

Extreme expressions

may occur in anxious individuals.

Mask-like face

possible in Parkinson’s disease

Staring/watchfulness

can be seen in metabolic issues or anxiety.

Inappropriate expressions (e.g., smiling when sad)

possible mental illness.

Slow, repetitive speech

Depression or Parkinson's

Loud, fast speech

Mania

Disorganized or nonstop speech

Mental illness or neurologic disorder

Long silences

possible cognitive or mental health issue

Aphasia

loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident.

Test for Aphasia:

• Word Comprehension: Ask to name items in the room

• Reading: Ask to read print material

• Writing: Ask to write a sentence (check grammar, spelling, coherence)

Mood and Affect Normal Findings

• Mood fits the situation and changes with topics

• Willing to engage and cooperate

• Described feelings match expression & behavior

Mood and Affect Ask:

• “How do you feel today?”

• “How do you usually feel?”

Mood

The client’s stated emotional experience

Affect

The observable emotional response

Euthymic

a normal, steady, tranquil mental state

Constricted

a mildly diminished range or intensity of emotional expression

Blunted

Markedly diminished emotional expression.

Flat

a severely reduced emotional expressiveness

Labile

irregular and severe mood swings

Inappropriate

emotional responses that are not in keeping with the situation or are incompatible with expressed thoughts or wishes, such as smiling when told about the death of a friend

Prolonged sadness

Depression

Elation, risky behavior

Mania

Constant worry

Anxiety or OCD

Odd or mismatched emotions

Schizophrenia

Time

day of week, date, year, season. Many hospitalized people normally have trouble with exact date, but are fully oriented on remaining items

Place

where person lives, address, phone number, present location, type of building, name of city and state

Person

own name, age, who examiner is, type of worker

Special Consideration for Older Adults:

• May have difficulty with exact date (normal)

• Considered oriented if they know:

  • General time (e.g., year and month)

  • Type of place they’re in (e.g., hospital, town)

Attention Span Normal findings

Can complete tasks or follow multi-step instructions like: “Pick up the pencil with your left hand, place it in your right, then hand it to me.”

Attention Span Abnormal Findings:

• Easily distracted, can’t follow directions

• Seen in:

  • Anxiety

  • Fatigue

  • ADD/ADHD

  • Substance use

Recent Memory

• Ask about:

  • 24-hour diet recall

  • Time of arrival at the agency

• Confirm with facts to detect confabulation (making up answers)

✅ Normal: Accurate answers
🚩 Abnormal: Memory loss in:

• Delirium

• Dementia

• Depression

• Anxiety

Remote Memory

• Ask about verifiable long-term events:

  • First job

  • Health history

  • Birthdays or anniversaries

  • Historical events relevant to person’s era

🚩 Lost in conditions that affect cortical memory storage:

• Alzheimer’s

• Dementia

• Other cerebral cortex damage

Judgment

Assesses ability to make sound decisions and evaluate consequences.

Ask About:

• Job plans → Are they realistic?

• Social or family responsibilities

• Future plans

• Reactions to hallucinations, delusions, or thoughts of harm

✅ Normal: Reasonable, thoughtful responses
🚩 Abnormal: Poor insight, impulsivity, unrealistic goals; possible in:

• Psychosis

• Cognitive disorders

• Mania

Thought processes:

The way the person thinks should be logical, goal directed, coherent, and relevant; should be a complete thought

Thought content:

What person says should be consistent and logical

Perceptions

Person should be consistently aware of reality; perceptions should be congruent with yours

Thought process should be

• Logical

• Goal-directed

• Coherent

• Relevant

• Contain complete thoughts

Abnormal thought processes

• Illogical or disorganized thinking

• Tangential or circumstantial responses

• Invention of words (neologisms)

• Repetition of phrases or ideas (perseveration)
  ➤ Common in schizophrenia and other psychotic disorders

• Rapid flight of ideas, rhyming, punning
  ➤ Seen in manic states of bipolar disorder

Rapid flight of ideas, rhyming, punning

• ➤ Seen in manic states of bipolar disorder

Repetition of phrases or ideas (perseveration)

• Common in schizophrenia and other psychotic disorders

neologisms

Invention of words

Repetition of phrases or ideas

perseveration

Thought Content should be

• Consistent

• Logical

• Reality-based

Delusions

false beliefs despite evidence (e.g., paranoia, grandiosity)

Obsessions

intrusive, repetitive thoughts

Compulsions

repetitive behaviors to relieve anxiety

Phobias

irrational fears/avoidance

Extreme apprehension

without clear cause

Normal perceptions

• Perceptions align with reality and match the interviewer’s understanding.

Hallucinations

sensory perceptions without external stimuli (auditory, visual, tactile, etc.)