Chapter 5 - Jarvis

MENTAL STATUS ASSESSMENT

Mental Status

 Mental status is a person’s emotional and

cognitive functioning
 Optimal functioning aims toward simultaneous
life satisfaction in work, caring relationships, and
within the self
 Usually, mental status strikes a balance between
good and bad days, allowing person to function
socially and occupationally

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2 Inc.
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Question

The nurse understands that all of the following

are components of the mental status
assessment except?
1. Known illness or health problem
2. Current medications known to affect mood
or cognition
3. Cultural background
4. Personal history; current stress, social habits,
sleep habits, and drug and alcohol use
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Mental Status

 Emotional and cognitive function

 Mental disorder: person’s response is much
greater than the expected reaction to a
traumatic life event
 Organic disorder: brain disease with a known
specific cause
 Psychiatric mental illness: no organic etiology has
been established
Defining Mental Status

 Mental status cannot be scrutinized directly

like the characteristics of skin or heart sounds
 Its functioning is inferred through assessment
of an individual’s behaviors:
 Memory
 Consciousness
 Abstract reasoning
 Language
 Thought process
 Mood and affect
 Thought content
 Orientation
 Perceptions
 Attention
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Copyright © 2012, 2008, 2004, 2000, 1996, 1993 by Saunders, an affiliate of Elsevier Inc. 5
Components of Mental Status
Exam
 Usually mental status can be assessed
throughout the health history
 Four components of mental status
assessment:
 A = Appearance
 B = Behavior
 C = Cognition
 T = Thought Process
Question

Which of the following basic functions should

the nurse test first in an assessment of mental
status?
1. Behavior
2. Consciousness
3. Judgment
4. Language

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Question

 When would a full mental status exam be

warranted?
 What data from the health history would
have to be considered when interpreting
mental status findings?
OBJECTIVE DATA
Appearance

 Posture
 Body movements
 Dress
 Grooming and hygiene
Behavior

 Level of consciousness
 Orientation to Person, Place, Time
 Facial expression
 Speech
 Mood and affect
 Cognitive Function
 Orientation
 Attention span
 Recent memory
 Remote memory
 New learning
 The Four Unrelated Words Test
 Person with Aphasia
 Word comprehension, reading, and writing
 Higher Intellectual Function
 Judgment
Thought Processes and
Perceptions
 Thought processes
 Thought content
 Perceptions
 Screen for anxiety disorders
 Screen for depression
 Screen for suicidal thoughts
 Mini-Mental Status Exam
 Simplified scored form of the cognitive functions
of the mental status examination
 11 questions
 Quick and easy to administer
 Initial and serial measurement
 Maximum score is 30
 People with normal mental status average 27
 Scores between 24-30 indicate no cognitive
impairment
DEVELOPMENTAL CONSIDERATIONS
 Infants and Children
 Emotional and cognitive function mature
progressively
 Consciousness and language develop by 18-24
months
 Abstract thinking develops by 12-15 years
 Consideration should be taken for
developmental milestones
 Denver II Screening
 Behavioral Checklist
 Aging Adult
 General knowledge remains intact
 Response time is slower
 Recent memory will decrease with age
 Vision loss may occur; hearing loss of high-
frequency sounds
 Check sensory before mental status
 People in their 80’s will have an age related
decline in mental function
 Mini-Cog – 3 item recall and clock drawing
ABNORMAL FINDINGS
 Levels of Consciousness
 Alert
 Lethargic (or somnolent) – not fully alert;
drowsy; awakes when stimulated
 Obtunded – sleeps most of time; difficult to
arouse
 Stupor or Semi-Coma – spontaneously
unconscious
 Coma – completely unconscious
 Acute Confusional State (Delirium)
 Speech Disorders
 Dysphonia – voice problem
 Dysarthria – articulation problem
 Aphasia – language comprehension problem
 Expressive (producing) Aphasia or Receptive
(understanding) Aphasia
 Global Aphasia – most severe; speech and
comprehension impaired
 Broca’s Aphasia – understand language but cannot
express self
 Wernicke’s Aphasia – can speak (sometimes
incomprehensible) but cannot understand
 Mood and Affect
 Flat Affect (blunted affect) – lack of emotion
 Depression – sad, gloomy, depression
 Depersonalization (lack of ego boundaries) – loss of
identity
 Elation – joy and optimism
 Euphoria – excessive well-being
 Anxiety – worry, uneasy, apprehensive; source unknown
 Fear – worry, uneasy, apprehensive; danger known
 Irritability – annoyed, impatient
 Rage – furious, loss of control
 Ambivalence – existence of opposing emotions
 Lability – rapid shift of emotions
 Inappropriate Affect – affect discordant with speech
 Thought Process
 Blocking – sudden interruption in train of thought
 Confabulation – fabricates events to fill memory gaps
 Neologism – coining a new word
 Circumlocution – round-about expression
 Circumstantiality – talks with excessive and
unnecessary detail
 Loosening associations – shifting to unrelated topics
 Flight of ideas – abrupt change; topics usually have
associations
 Word salad – incoherent mix of words
 Thought Process
 Perseveration – persistent repeating of verbal or
motor response
 Echolalia – imitation; repeating
 Clanging – word choice based on sound, not meaning
 Phobia – strong, persistent, irrational fear
 Hypochondriasis – morbid worrying about health
 Obsession – unwanted, persistent thoughts or
impulses
 Compulsion – unwanted, repetitive, purposeful acts
 Delusions – firm, fixed, false beliefs; unrational
Perception

 Hallucination – sensory perceptions for which

there are no external stimuli, may be any
sense

 Illusion – misperception of an actual existing

stimulus, by any sense
 Schizophrenia
 Two or more of the following symptoms present
for a significant part of a 1-month period
 Delusions
 Hallucinations
 Disorganized speech
 Grossly disorganized or catatonic behavior
 Negative symptoms
 One or more major areas of functioning are
decreased
 Signs persist for at least 6 months (including
initial month)
Delirium, Dementia, and
Amnestic Disorder
 Delirium
 Disturbance of consciousness
 Change in cognition
 Develops over a short period of time
 Dementia
 Memory impairment
 Aphasia, Apraxia, Agnosia, &/or disturbance in
executive functioning
 Amnestic Disorder
 Memory Impairment
 Impairment in social or occupational functioning
 Mood Disorders
 Table 5-11
 Major Depressive Episodes
 Manic Episodes
 Major Depressive Disorder – 1 or more major
depressive episode
 Dysthymic Disorder – 2 years of depressed
mood for more days than not
 Bipolar Disorder – one or more manic episode
accompanied by major depressive episodes
Anxiety Disorders – Table 5-12
 Panic Attack – intense fear or discomfort
 Agoraphobia – places & situations
 Panic Disorder – recurrent panic attacks with
worry
 Specific Phobia – marked & persistent fear
 Social Phobia – fear in social situations
 Obsessive-Compulsive Disorder
 Posttraumatic Stress Disorder
 Generalized Anxiety Disorder – excessive anxiety
and worry for 6 months