Health assessment mental health and pain

What does it mean if a patient is alert?

awake and fully aware of environment

What does it mean if a patient is lethargic

drowsy, drifts to sleep when not stimulated

What does it mean if a patient is Obtunded

sleeps most of time, hard to rouse, confused

What does it mean if a patient is Stuporous

unconscious, responds to pain (e.g., Trapezius squeeze, nailbed pressure), moans

What does it mean if a patient is Comatose

unconscious, no response to pain

clinically, a change in level of consciousness is always important.

What is orientation test

Do they know person, place, time, purpose

What is attention span test

Attention span: concentration

Ask the patient to perform Serial 7s (100 − 7 repeatedly) or spell

WORLD backward.

How to test recent memory

Ask about recent events that can be verified, or give 3 unrelated words and ask the patient to recall them after several minutes.

How to test remote memory

Ask about verifiable events from the distant past

What happens to older adults response times

Older adults: slower response times but no decrease in

• Knowledge, memory, language

Describe how mental status changes in older adults and when to be concerned

Mental Status is mostly intact

• No decrease in knowledge or vocabulary

• Longer to process information

• Reaction time slows

• So, slow down when you deal with older adults!

• Perceptual losses… vision, hearing

• Put patient at risk for social isolation, suspicion

and depression

• Dementia (not a normal part of aging): A significant decline from the person's previous level of cognitive functioning (Early sign: loss of recent memory while long term memory is intact)

What is MMSE

Mini mental state exam tests for cognitive issues

Describe Mental health

State of well-being: copes w/ normal stress, works productively, contributes to

community

• Optimal mental health: satisfied w/ work, caring relationships, self

• We all have good and bad days

• Stress tips the balance toward mental disorder

Describe mental disorder

Response to stress is greater than would be expected

• Significant distress /impaired function involving social, occupational or other important

activities

Describe the two types of mental disorders

Types Mental Disorders

• Psychiatric: … depression, anxiety, schizophrenia

• Related to a medical condition or substance… ETOH intoxication, brain damage

How to access mood

durable display of feelings

• Assess by asking “‘How would you describe your mood today?’”

• Assess suicidal, homicidal ideation

How do you access affect and what are the types of affects

temporary, visible display of feelings

• Full/broad affect — normal range and intensity of emotional

expression.

• Constricted/restricted affect — range of emotional expression is

reduced.

• Blunted affect — markedly reduced intensity of emotional

expression.

• Flat affect — essentially no observable emotional expression.

• Labile affect — emotions change rapidly and abruptly

• Inappropriate/incongruent affect — emotional expression does not match the situation or stated mood, such as laughing while discussing a tragic event.

How do you access Thought processes (how the person's thoughts are organized)- do they make sense?

What are the types a person can have

• Flight of ideas- Rapid, continuous shifting of topics

• Incoherence- Speech makes no sense

• Confabulation- fills in gaps in memory with false/inaccurate information

• Clang associations: rhyming speech (chooses words because they

sound alike or rhyme)

How do you access thought content (what the person is thinking about) and what are the types of content

• Obsessions- persistent, intrusive thoughts

• Compulsions- repetitive, unwanted behaviors

• Phobias- irrational fears

• Delusions- fixed, false beliefs

• Perception- hallucinations

MENTAL DISORDERS PREVALENCE (what is the most common ones?)

• Depression: most common MD

• Anxiety: 2nd most common MD

• Somatic: 10-15%

• Substance abuse: 10-15%

• Bipolar: 3%

• Schizophrenia: 1%

• Personality Disorders (PD):

• Frequent users of HC & cause of burnout in HCP

• Antisocial PD

• Narcissistic PD

• Obsessive Compulsive PD (excessive

perfectionism, orderliness

SCREENING FOR MENTAL DISORDERS: DEPRESSION What is SIGE CAPS and PHQ-9

SIGE CAPS @ least 5 symptoms present QD x 2 weeks = depression

S: Sleep changes

I: interest loss

G: guilt (worthlessness)

E: energy loss (fatigue)

C: cognition/concentration difficulties

A: appetite loss and or weight loss

P: psychomotor (Agitation)

S: suicidal ideations

And Patient Health Questionnaire (PHQ-9) differentiates mild, moderate, severe depression

What is the GAD test

GAD-7 total score for the seven items ranges from 0 to 21. 0–4: minimal anxiety. 5–9: mild anxiety. 10–14: moderate anxiety. 15–21: severe anxiety.

What are the four questions of the CAGE questionnaire

C: have you ever felt the need to cut down your drinking

A: Have people annoyed you by criticizing your drinking

G: have you ever felt guilty about your drinking

E: Have you ever had a drink first thing in the morning to steady nerves or cure a hangover

How many questions in the CAGE questionnaire do you have to say yes too in order to cause concern

a yes to two or more suggests potential alchol dependences warranting further evaluation

Describe Pain and how it is determined

Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage

• Pain is whatever the patient says it is!!!!!

Describe acute pain

Short, self-limiting, follows predictable course

 Warns of actual or potential tissue damage

 Dissipates after injury heals

 Eg: Sprained ankle, Burns, Kidney stones

Describe chronic pain

Persists @ least 3 months… may last years

 Malignant: Tissue necrosis

 Non-Malignant: Arthritis, Low Back Pain

 Doesn’t stop when injury heals

 Patient is often not believed & labeled

 Drug seeker or Malingerer

What are the categories of Nocioceptive Pain

Cutaneous: originates from the skin or superficial tissues (relatively well localized; e.g., superficial burn, cut, abrasion,

needle stick); sharp, burning, or stinging

Somatic: originates from deeper structures of the body (e.g., muscles, tendons, joints, bones, and connective tissues); dull, deep ache, or throbbing

Visceral: originates from organs within the thoracic, abdominal, or pelvic cavities; tends to be poorly localized; deep, squeezing, cramping, pressure-like, or aching

What are the categories of Neuropathic Pain

Central: involving the brain or spinal cord (e.g., Encephalitis)

Peripheral: involving the peripheral nervous system (e.g., diabetic peripheral neuropathy )

burning,’‘shooting,’‘electric,’‘pins and needles,’‘tingling,’‘stabbing,’‘like an electric shock.’

What is reffered pain?

Pain originates in one location but is perceived somewhere else; due to sharing embryonic pathways:

• During early development, internal organs and certain areas of the skin become connected to the same

regions of the nervous system.

• Because their sensory nerves eventually enter the same areas of the spinal cord, the brain can sometimes become confused about where a pain signal is actually coming from.

• Referred pain is not the same thing as radiating pain!!!!

What do you do if reliable self-report for pain is not possible in an older adult

 facial grimacing,

 guarding,

 moaning or vocalizations,

 increased agitation,

 changes in mobility,

 resistance to movement or care,

 changes in sleep or appetite,

 a sudden change from the patient's usual behavior.

How do Gender Differences affect pain management

Social expectations…men stoic

 Women have more migraines during childbearing years

 Women more sensitive to pain during PMS

 Human genome project located pain gene (Future pain treatment based on genetic factors?)

How do Transcultural Differences affect pain management?

 How we express pain has a lot to do with our culture!

 Black & Latino people often prescribed less analgesia than Caucasian people, although difference is small

 Older adults may hide pain for fear of losing independence

Describe how pain is a subjective finding

 Pain is always a subjective finding

 Patient’s subjective report is most reliable indicator of pain

 Pain occurs @ neurochemical, cellular level, so can’t see it

 Ask: How does pain limit your function/activities?

 Ask: What does this pain mean to you?

 Use Pain Assessment Tool (1-10)

What questions must be asked about pain?

P — Provocation/Palliation: What brings it on? What makes it better or worse?

 Q — Quality/Quantity: What does it feel like? Sharp, burning, aching, throbbing?

 R — Region/Radiation: Where is it? Does it travel anywhere?

 S — Severity: How bad is it? 0–10.

 T — Timing: When did it start? How long does it last? Constant or intermittent?

 U — Understanding: What do you think it means to you? Pain assessment & reassessment

What are acute objective signs of pain

Guarding, grimacing, moaning, diaphoresis, restlessness, stillness, change in VS

What are chronic objective signs of pain

more variable than acute pain bracing, rubbing, diminished activity, sighing, decreased appetite

What are objective bodily signs that suggest pain

 Joints: size, contour, deformity, ROM

 Muscles and Skin: Color, swelling, visible or palpable mass

 Abdomen: Symmetry, masses, guarding

What are the Consequences of Undertreating Pain

 Catabolism (breakdown mode—breaking down stored fat, carbohydrates, muscle protein into energy to meet increased metabolic demands)

 Increased secretion of stress hormones

 Increased salt & water retention

 Reduction of natural killer cells

 Anxiety, depression, sleep deprivation

 Chronic pain syndromes

What are some pain treatments drug and not drug

Drugs:

• NSAIDS (e.g., ibuprofen and naproxen)

• Opioids (e.g., morphine, hydromorphone,

oxycodone, fentanyl)

• Antidepressants (SNRIs and tricyclic

antidepressants )

Non-drug interventions:

 Cold compresses (acute musculoskeletal injuries

or inflammatory conditions)

 Heat compresses (muscle tension, stiffness, or

chronic musculoskeletal discomfort)

 Relaxation techniques, Distraction, Music