Chapter 6 + 7 (assessing mental status including risk for substance use)

Factors affecting mental health

economic, social, lifestyle, exposure to violence, personality, spiritual, cultural, psychosocial developmental level and issues, etc.

Mental status

clients level of cognitive and emotiona lfunctioning.

Nurse health assessment (objective)

collect information on pt

• appearance

• general behavior

• cognitive function

• memory

• thought processes

Glasgow coma scale

used to rate ones response to stimuli. Score of 10 or less needs medical attention. Score of 7 or less is considered in a coma.

Dementia

loss of brain function.

Delirium

acute state of mental confusion

• cause: medication toxicity an interactions; acute disease; trauma; chronic disease exacerbation

• risk factors: pre exsiting cognitive impairment

• occurrence: 80% among people hospitalized

• onset: rapid, acute onset

• age of onset: any age, predominantly in older adults

Alzhemier disease

• cause: early onset is by genetics, late onset unknown

• risk factors: advanced age, genetics

• occurrence: 70% of dementia

• onset: slow

• age of onset: early/late

Vascular dementia

• cause: cardiovascular disease

• risk factor: pre exsiting cv disease

• occurrence: 10-20% of dementia

• onset: often abrupt

• age of onset: 50-70 years

Signs of alzhemier and dementia

• poor judgment and decision making

• inability to manage a budget

• losing track of date or season

• difficulty having a conversation

• misplacing things and being unable to retrace steps

Signs of typical age related changes

• making a bad decision once a while

• missing a monthly payment

• forgetting which day it is and remembering later

• sometimes forgetting which word to use

• losing tings from time to time

screen for suicidal thoughts

being with general questions then continue with specific probing questions

Lethargy

client open eyes, answer questoins, and falls back asleep

Obtunded

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

Stupor

client awakens to vigorous shake or painful stimuli, but returns to unresponsive sleep

Coma

client remains unresponsive to all stimuli

Dysphonia

voice volume disorder

cerebellar dysarthria

irregular, uncoordinated spech caused by MS

dysarthria

a defect in muscular control of speech

aphasia

difficulty producing or understanding language, affected dominant cerebral hemi

wernike aphasia

rapid speech that lacks meaning, affected posterior superior temporal

broca aphasia

slowed speech with difficult articulatoin, but with clear meaning, affected posterior inferior frontal