Health Assessment: Assessing Mental Status & Psychosocial Developmental Level

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Chapter 6

Mental Status

client's level of cognitive and emotional functioning and stability

Mental Status is reflected in:

speech, appearance, and thought patterns

Mental Health

state of emotional and psychological well-being in which an individual is able to use his cognitive and emotional capabilities, function in society, and meet ordinary demands of everyday life

Psychosocial Development

frequently used in nursing; refers to client's mental and emotional health as well as one's self-concept, role development, relationships, coping stress patterns, and spiritual beliefs

Neurological System

can affect mental and psychosocial status

Cerebral Abnormalities

disturb client's intellectual ability, communications ability, or emotional behaviors

Done Before Asking Questions to Determine Client's Mental and Psychosocial Status

explain purpose of this part of examination

Required Due to Subjective Nature of Mental Status and Psychosocial Development Level

in-depth nursing history to detect problems affecting activities of daily living (ADLs)

Can Affect Mental Status

problems w/ other body systems
(i.e. client w/ low blood sugar may report anxiety and other mental status changes)

Included in Complete Neurological Assessment

assessment of cranial nerves, motor and cerebellar function, sensory function, and reflexes

Advantage of Assessing Mental Status at Very Beginning of Head-to-toe Exam

provides clues re: validity of subjective information provided by client throughout exam

Done if Nurse Finds Client's Thought Processes are Impaired

another means of obtaining necessary subjective data must be identified

Cognitive Abilities

orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability

Dementia

loss of cognitive skills that occur because of brain diseases or trauma

Vascular Demential (Multi-infarct Dementia)

results from small strokes or brain blood supply changes usually caused by blood clots in small vessels

Done After Collecting Subjective and Objective Data Pertaining to General Survey

identify abnormals and cluster data to reveal significant patterns or abnormalities for use in clinical judgments (nursing diagnoses: wellness, risk, or actual)

Wellness Diagnoses

- health-seeking behaviors related to desire and request to learn more about health promotion
- readiness for enhanced communication

Risk Diagnoses

- risk for self-directed violence related to depression, suicidal tendencies, developmental crisis, lack of support systems, loss of significant others, poor coping mechanisms and behaviors
- risk for developmental delay related to lack of healthy environmental stimulation and activities

Actual Diagnoses

- impaired verbal communication related to international language barrier (inability to speak English of accepted dominant language)
- impaired verbal communication related to hearing loss
- impaired verbal communication related to inability to clearly express self or understand others (aphasia)

Lethargy

client opens eyes, answers questions, and falls back asleep

Obtunded

client opens eyes to loud voice, responds slowly w/ confusion, 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; eyes stay closed
- client w/ lesions of corticospinal tract draws hands up to chest (decorticate - abnormal flexor posture) when stimulated
- client w/ lesions of diencephalon, midbrain, or pons extends arms and legs, arches neck and rotates hands and arms internally (decerebrate - abnormal extensor posture) when stimulated

Middle-aged Adult / Assessment Findings

normal = generativity
abnormal = stagnation

Older Adult / Assessment Findings

normal = integrity
abnormal = despair

Glasgow Coma Scale

provides score in range 3-15;
scores of 3-8 indicate coma;
total score is sum of scores in three categories:
best eye response
best verbal response
best motor response

Eye Opening Response

Spontaneous - open w blinking at baseline 4 points
Opens to verbal command, speech, or shout 3 points
Opens to pain, not applied to face 2 points
None 1 point

Verbal Response

Oriented 5 points
Confused, but able to answer questions 4 points
Inappropriate responses, words discernible 3 points
Incomprehensible speech 2 points
None 1 point

Motor Response

Obeys commands for movement 6 points
Purposeful movement to painful stimulus 5 points
Withdraws from pain 4 points
Abnormal (spastic) flexion, decorticated 3 points
Extensor (rigid) response, decerebrated 2 points
None 1 point

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