neurological mental health nursing assessment

causes of mental illness

trauma

hormonal imbalance

genetics

brain chemistry

depression

s+s - social isolation, irritability, prolonged sadness, negative thought patterns, sleep patterns, changes in appetite, loss of interest

causes: trauma, genetics, hormonal imbalance, brain chemistry, substance abuse, stress, loss

CAGE

C - have you ever felt the need to cut down on your drinking?

A - has anyone ever annoyed you by criticising your drinking?

G - have you ever felt guilty about drinking?

E - eye opener: have you ever had a drink first thing in the morning?

MSE

mental status examination - comprehensive examination of a patient’s mental state

components of MSE

B - behaviour and general appearance

E - emotions

S - speech

T - thought content and processes

P - perceptual disturbances

I - impulse control

C - cognition

K - knowledge

behaviour and general appearance

age, sex, gender, grooming, dress, alertness, posture, eye contact

emotions

mood, emotional state, facial expression

speech

tone, volume, rate, amount

thought content and processes

suicidal and homicidal ideations, negative thoughts, abnormalities, obsessions, delusions

perceptual disturbances

hallucinations, illusions

impulse control

ability to control, regulate, inhibit, delay, modulate certain behaviours

cognition

consciousness, orientation, concentration, memory

knowledge

understanding of condition, anticipate consequences, choose appropriate behaviours

what is most commonly used for substance use

CAGE

what is most commonly used for delerium

PRISME, CAM

what is most commonly used for dementia

SMMSE

what is most commonly used for depression

PHQ-9, depression screening