Health Assessment Week 3: Mental Status and Pain Assessment

mental status

describes how a person is thinking and feeling at a particular time = emotional + cognitive functioning

• Aims for balance in work, relationships, and self

• Shaped by biology, environment, and social factors

mental status example

during a nursing assessment, you might notice whether the patient is alert, knows where they are, remembers information, communicates appropriately, and shows appropriate emotions

emotional functioning

how the person feels and expresses emotions, such as happiness, sadness, anxiety, or anger

cognitive functioning

how well the brain is working, including memory, attention, thinking, judgment, and orientation.

mental health

refers to a person's overall emotional and psychological well-being, including their ability to handle stress and everyday challenges

stress

is the body's and mind's response to something that feels challenging, threatening, or overwhelming

• Triggered by traumatic events

• Short-term dysfunction can be a normal response: like trouble sleeping, concentrating, or managing emotions

• nursing assessment helps identify strengths, resources, and coping strategies

mental disorder

Emotional or cognitive condition causing distress or disability in daily life

• can function in daily life

• ex. depression or OCD

organic disorder

Due to known brain disease or cause (e.g., delirium, dementia, substance use/withdrawal)

• internal factors that caused altered mental status

psychiatric disorders

• No clear organic cause (e.g., anxiety, schizophrenia)

• Assessment shows dysfunction and its impact on daily self-care

• ex. depression, anxiety, OCD, bipolar disorder

mental status is assessed by behaviors

1. Consciousness, language, mood, affect

2. Orientation (person place and time) + attention

3. Memory + reasoning

4. Thought process, content, perceptions

components of the mental status examination

• Assessment of mental status can be integrated within the context of the health history interview.

• Four main headings of mental status assessment: A-B-C-T

  • Appearance - what does the patient look like?

  • Behavior - how does the patient act and interact?

  • Cognition - how well is the patients brain processing information? (orientation, attention, memory, ability to concentrate)

  • Thought processes - how does the patient think? (logical vs. confused thoughts, hallucinations, delusions)

when a full mental status examination is necessary

1. initial screening

2. behavioral changes

3. brain lesions

4. aphasia

5. symptoms of psychiatric mental illness

initial screening

suggest an anxiety disorder or depression

behavioral changes

Memory loss, inappropriate social interaction

brai lesions

Trauma, tumor, cerebrovascular accident, or stroke

aphasia

Impairment of language ability secondary to brain damage

symptoms of psychiatric mental illness

especially with acute onset

objective data: appearance

• Posture

  • Erect and position relaxed

• Body movements

• Body movements voluntary, deliberate, coordinated, and smooth and even

• Dress

  • Appropriate for setting, season, age, gender, and social group

• Grooming and hygiene

  • Congruence between grooming and age

• Pupils

  • Note pupil size and reaction to light

  • Document as PERRLA

objective data: appearances

• Level of consciousness

• Person is awake, alert, aware of environment and self Responds appropriately and in a timely way (Document as Awake, Alert, and Oriented X 3)

(AAOx3)

• Facial expression

  • Matches situation and topic

  • Comfortable eye contact (unless limited by culture)

• Speech

  • Clear, effortless, appropriate conversation

  • Normal pacing, articulation, and word choice

• Mood and affect

  • Judged by body language, expression, and questions

  • Should fit the situation and change with topics

  • Person is cooperative

objective data: cognitive function

orientation

• Time: day, date, year, season

• Place: address, city, building, location

• Person: name, age, who examiner is

***Note: hospitalized patients may miss exact date but still be oriented

attention span

• Ability to stay focused and complete a thought

• Often reduced in anxiety, fatigue, or intoxication

objective data: cognitive functions

Recent memory

• Ask about events from the past 24 hours (e.g., meals, time of arrival).

• Use questions you can verify to detect memory gaps

Remote memory

• Ask about verifiable past events (e.g., health history, first job, birthdays, historical events).

• Loss of remote memory may occur in Alzheimer’s, dementia, or brain disease.

aphasia

trouble speaking, writing, or understanding language (often after a stroke)

tests for aphasia

1. word comprehension: point to objects and ask patient to name them

2. reading: have patient printed material (consider education level)

3. writing: ask patient to write a sentence; check for clarity, spelling, and grammar

thought processes

the way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts

thought content

what person says should be consistent and logical

perceptions

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

screen for anxiety disorders

Anxiety and depression are the two most common mental health disorders seen in individuals seeking health care.

• Generalized anxiety disorder scale (GAD-7)

  • Consists of 7 itemized scale

  • Higher the score, greater the likelihood.

  • First 2 questions relate to core anxiety.

  • Greater or equal than 3 indicates diagnosis.

Types of generalized anxiety disorder scale

1. GAD-2 initial screen (score greater than equal to 3 is positive)

2. GAD-7 identifies probable anxiety + severity

screen for depression disorders

series of tools that can be used in clinical setting

1. patient health questionnaire-2 (PHQ-2)

2. PHQ-9

patient health questionnaire - 2

1. Asks 2 questions about depressed mood and anhedonia (lack of interest) - score is greater than or equal to 2 its positive

2. Serves as a initial screening tool to use full PHQ-9 tool

PHQ-9

• Series of 9 questions requiring adding column totals that relate to frequency of occurrence of symptoms

• Higher the score, the greater the likelihood of functional impairment or clinical diagnosis

  • 5-9: minimal depressive symptoms

  • 10-14 minor depressive symptoms

  • 15-19 major depression, moderate

  • ≥20 major depression severe

screening for suicidal thoughts

1. assess: if patient expresses sadness, hopelessness, or grief

2. begin: with general questions, then move to direct ones if needed

3. remember: asking about suicide does not increase risk, skipping questions can miss warning signs, ambivalent patients may still be helped with support

4. share: any concerns with a mental health profession

ask suicide screenings

• In the past few weeks have you wished you were dead?

• In the past few weeks have you felt that you or your family would be better off if you were dead?

• In the past few weeks have you had thoughts about killing yourself?

• Have you ever tried to kill yourself?

• Yes to any of these questions = positive screening

• Follow up with assessing for plans, safety

judgment

Ability to compare options and make appropriate

decisions

judgment assessment

• Ask about daily or long-term goals

• Note if responses are realistic and safe

• Watch for risk of acting on hallucinations, delusions, or harmful behavior

ex.

• Plans for job, family, or future — do they fit the person’s situation?

• Ask how they make health decisions or follow medical advice

mini mental state exam (MMSE)

11 questions, takes 5–10 minutes

Focuses on cognitive function only

Used to detect dementia or delirium

Score: 24–30 = normal

montreal cognitive assessment (MOCA)

• Requires certification to administer

  • 1 hour training

• Takes 10 minutes

• Total score 30

  • Score ≥ 26 normal

  • Score < 26 mild cognitive impairment

developmental competence children

• Covers behavioral, cognitive, psychosocial development

• Use A-B-C-T guidelines, adjusted for milestones

• Abnormalities = missing milestones

• Parent’s health & developmental history provides key data

infants and children

1. Denver II test (screening test)

2. Behavioral Checklist

Adolescents

see same ABCT framework as for adults

Denver II test

(birth–6 yrs):

1. screens for delays in behavior, language, cognition, and psychosocial development.

2. Not a diagnostic test, just a screening tool

Behavioral checklist

(ages 7–11): parent- completed tool covering mood, play, school, friends, and family; quick (5 min)

delirium

is an acute change in attention and awareness (a sudden confusion)

For example, an older adult who was talking normally yesterday develops an infection and today is confused, cannot focus, and doesn't know where they are.

Another important feature is fluctuation. The patient might seem relatively normal in the morning but become very confused later.

Key nursing clue: A sudden change in mental status is NOT normal aging and needs prompt evaluation for an underlying cause

Appearance (A)

Observe the patient's physical appearance.

You might ask yourself: Does their appearance seem appropriate for the situation?

Look at things such as age, clothing, cleanliness/hygiene, grooming, posture, facial expressions, and overall physical condition.

For example: Patient is appropriately dressed, clean, and well-groomed

Behavior (B)

Observe how the patient acts during the interview.

Look at eye contact, facial expressions, movements, speech, mood/emotional expression, and interaction with you.

For example, a patient may be calm and cooperative, or they may appear restless and repeatedly pace around the room.

Cognitive (C)

Cognition means the patient's ability to know, remember, understand, and process information.

A nurse may assess:

• Orientation → Does the patient know who they are, where they are, the date/time, and what is happening?

• Attention and concentration → Can they stay focused?

• Memory → Can they remember recent and past information?

• Ability to understand information

For example, asking “Can you tell me your name, where you are, and today's date?” helps assess orientation.

Thought process (T)

Here you're assessing how the patient's thoughts are organized and what they are thinking about.

You want to determine whether their thoughts are logical, organized, and connected.

You may also assess for unusual thought content or perceptions, such as delusions or hallucinations.

For example:

Normal: “I came to the hospital because I've had chest pain since this morning.”

Abnormal/disorganized: The patient's answers repeatedly jump between unrelated topics and are difficult to follow.

dementia

involves a progressive worse decline in cognitive abilities that interferes with independent daily functioning (gradual cognitive decline)

• alzheimers disease is one cause of dementia

• A person might initially:

  • Forget recent conversations repeatedly

  • Ask the same questions

  • Have difficulty managing medications or finances

  • Get lost in familiar places

  • Eventually need help with activities of daily living

normal aging

some changes in memory and thinking can occur with normal aging (mild changes without major loss of independence)

Normal aging:
“I can't remember her name right now.” → remembers it later.

Concerning for dementia:
“I don't remember who she is.” → forgets a familiar person or repeatedly forgets important recent information.

Another example:

Normal aging: Occasionally misplacing your keys.

Dementia: Putting your keys somewhere unusual, repeatedly losing important items, and being unable to retrace your steps.

The important distinction is that normal age-related changes generally don't substantially interfere with independent everyday functioning.

exam shortcut

Delirium = QUICK + FLUCTUATING + INATTENTIVE

Dementia = SLOW + PROGRESSIVE + MEMORY/COGNITIVE DECLINE

Normal aging = MILD changes + INDEPENDENCE maintained

testing aging adults

• Use same A-B-C-T guidelines as for younger adults

• Use Glasgow Coma Scale (GCS) in older adults

  • Provides a numerical score for:

  • Eye-opening

  • Verbal response

  • Motor response

• Helps avoid confusion when multiple providers assess the same patient

aging adults: supplemental mental status testing

1. mini cog

normal aging vs alzheimers

mini cog

• Quick screening tool for cognitive impairment

• Combines:

  • 3-word recall

  • Clock-drawing test

• Tests memory, planning, organization, and executive function

• Normal: recalls 3 words + draws a correct clock

documentation example

• Appearance: Posture erect, no involuntary movements noted. Dress and grooming appropriate for season and setting.

• Behavior: Alert, appropriate facial expression. Speech clear and appropriate.

• Cognitive function: Oriented x3 (person, place, time), cooperative with exam. Recent and remote memory intact. Able to recall 4 words at 5, 10, and 30 minutes.

• Thought processes: Perceptions and thought processes logical and coherent. Denies suicidal ideation. Score on MoCA 30.

types of pain

1. nociceptive

2. neuropathic

3. somatic

4. visceral

5. referred

nociceptive pain

painful sensations transmitted to the CNS (pain from tissue injury)

• Nociceptors located mainly in skin, joints, connective tissues, muscle, thoracic, abdominal, pelvic viscera

neuropathic pain

pain to lesion or disease in nervous system (pain from nerve damage)

• Abnormal processing of pain

• Difficult to assess and treat

• Can be a result of nociceptive pain

• Neuropathic pain conditions: diabetes, herpes zoster, HIV/AIDS, sciatica, trigeminal neuralgia, phantom limb pain, chemotherapy, CNS lesions

sources of pain

1. visceral

2. somatic

3. referred

visceral pain

where pain comes from: internal organs

what it feels like: deep, dull, squeezing, cramping

• direct injury to the organ

• type of nociceptive pain

somatic pain

musculoskeletal or body tissue (type of nociceptive pain)

• deep somatic:

  • where it comes from: blood vessels, joints, tendons, muscles, bones

  • what it feels like: aching and throbbing

• cutaneous somatic:

  • where it comes from: skin and tissue under the skin

  • what it feels like: sharp, burning, superficial

referred pain

starts in one place but is felt somewhere else (pain felt at a different site than originates

• both sites innervated by same spinal nerve

• type of nociceptive pain

deep somatic

• where it comes from: blood vessels, joints, tendons, muscles, bones

• what it feels like: aching and throbbing

cutaneous somatic

• where it comes from: skin and tissue under the skin

• what it feels like: sharp, burning, superficial

acute pain

short-term, self-limiting

1. Follows predictable trajectory

2. Self-protective

chronic (or persistent) pain

more than 6 months

1. Malignant: cancer related

2. Non-malignant usually musculoskeletal or neuropathic

3. Level of pain does not correspond with findings, abnormal processing

pain assessment tools

1. numeric pain intensity scales (0-10) (adults and older children who can self report)

2. Wong Baker FACES pain rating scale (children)

3. McGill Pain Questionaire

4. CRIES Neonatal postoperative pain measurement scale (infants)

5. FLACC behavioral Pain Scale (infants and toddlers)

numeric pain intensity scales

• adults and older children who can self report

• Patient chooses a number from 0 = no pain to 10 = worst pain imaginable

Wong Baker Faces

Children or people who have difficulty using numbers

• Patient chooses the face that best represents how much they hurt

McGill Pain Questionare

Patients able to describe their pain in detail

• Assesses quality and characteristics of pain, not just intensity (what is the pain like?)

CRIES neonatal post operative scale

Primarily newborns/young infants, especially postoperatively

• nurse observes 5 indicators of pain

• C = crying

• I = increased vital signs

• E = expression (such as grimacing)

• S = sleeplessness

FLACC

Infants, toddlers, and patients unable to verbally report pain

• Nurse observes 5 behaviors and gives a score from 0–10

• F = face = grimacing?

• L = legs = tense, kicking, restless?

• A = activity = relaxed or moving/restless?

• C = cry = quiet, moaning, crying?

• C = consolability = can the patient be comforted?

The critical care pain observation tool

used to assess pain in critically ill patients who cannot reliably tell you how much pain they have, such as patients who are intubated or mechanically ventilated

• Critically ill/nonverbal patients

• observes: facial expression, body movements, muscle tension, and vocalization or ventilator compliance

• score = 0-8

behavioral pain scale (BPS)

used to assess pain in critically ill patients who cannot reliably tell you how much pain they have, such as patients who are intubated or mechanically ventilated

• Critically ill, especially mechanically ventilated patients

• observes: facial expression, upper-limb movement, and ventilator compliance

• score = 3-12