Study sets, textbooks, questions
Upgrade to remove ads
Health Assessment: Mental Health
Terms in this set (40)
A person's emotional and cognitive function
full mental status examination
is a systematic check of emotional and cognitive functioning
Mental status can be assessed when?
During the health history interview
Components of the Mental Status Examination
Observe dress and hygiene
Observe posture, gait, and body movement
-Posture: Erect and position relaxed? slumped position?
-Gait: Rhythmic? Coordinated?
-Body Movement: Body movements voluntary, deliberate, coordinated, and smooth and even? Bizarre body movement?
Is the patient dressed appropriate for the occasion and weather
Is the patient clean and well groomed?
Hair is neat and clean?
Does the patient have a dirty, unkempt, unshaven appearance?
Does the patient have a foul smell?
-Keep in mind how you interpret a person's appearance because this may reflect a person's economic status or deliberate fashion trend
-Disheveled appearance in a previously well-groomed person is important
-Look is appropriate for the situation
-Flat, masklike expression in Parkinson's and depression
-Mood and affect
physical ability to speak, word choice
more temporary expression of emotions
Patient cooperates with what is being said
Patient does not cooperate with what is being said
Patient seems worried, concerned, and unease
A lack of emotional responsiveness
A feeling of great happiness or well-being
Changing rapidly and often, unstable
more permanent display of feelings
Difficulty or discomfort using voice to talk
Disorder of articulation in which the speech sounds are distorted
language defect in processing
little or no speech and comprehension
can understand language, but difficulty speaking. Grammar problems.
problem comprehending words.
Can still articulate well.
GCS (Glasgow Coma Scale)
Common terms when assessing consciousness
-GCS 15 - Normal person
-GCS >7 - Coma
* A change in LOC is the earliest and most sensitive indicator of neurological changes
to person, place, and time
drifts off frequently.
Must be aroused.
Frequently effect of sedation
difficult to arouse,
a state of near-unconsciousness or insensibility
responds only to vigorous shaking and pain, groans and mumbles
unconscious with little or no response to stimuli. Little or no reflex response.
Ask patient about time, place, situation, and date to access their cognitive reasoning.
* many people in the hospital normally have trouble with exact date, but are fully oriented on remaining items.
Disorientation occurs with
delirium and dementia. Orientation is usually lost in this order—first to time, then to place, and rarely to person
Check person's ability to concentrate by noting whether they complete a thought without wandering
-Attention span commonly is impaired in people who are anxious, fatigued, or intoxicated
Spell "WORLD" backward or "Can you count backward form 20 to 1?"
-The ability to recall events of the past few days
-Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency
-Ask questions you can corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss
In the context of the interview, ask the person verifiable past events
- ask to describe past health, the first job,
birthday and anniversary dates, and historical
events that are relevant for that person
Ability to compare and evaluate alternatives and reach an appropriate course of action
Infant and Children
All brain cells are present at birth but it takes the first years of life for cells to fully develop and myelinize.
-Brain insults, such as infection, trauma, or metabolic imbalance, can damage brain cells, leading to potentially serious dysfunction in mental status.
Intellectual maturation continues with greater capacity for information and vocabulary development.
Abstract thinking in adolescents
-Ability to develop theories
-Ability to use logical reasoning
-Ability to make future plans
-Ability to use generalizations
-Ability to consider risks and possibilities
--Judgment begins to develop with education, intelligence, and experience
Cognitive functions most sensitive to aging include the speed at which new information is:
**Minimal decline in cognitive and daily functioning should occur unless systemic or neurologic disorder develops
Older Adults (Cont.)
*Loss of recent memory, delayed response time, and diminished ability to learn complex information may occur.
**Remote memory may be more efficient than short-term memory.
***Some studies suggest that higher education attainment has been associated with better memory and cognitive function later in life
Sets with similar terms
Mental and Spiritual Assessment (NUR 310)
Chapter 5 mental status assessment
Evolve Chapter 5
HEALTH ASSESSMENT CH5
Other sets by this creator
Health Assessment: Ears
Health Assessment: Thorax & Lung
Health Assessment: Eyes & Ears
Health Assessment: Skin, Hair, and Nails