Assessment Chapter Seven

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Mental Health and Mental Status Assessment

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Mental Health: a realtive state of mind in which a person who is healthy is able to cope with and adjust to daily stresses in an acceptable way
anger: ar you , are you right now, how do you react when you are angry verbally physically or do you keep it inside, can you talk about what has caused it
Drug Abuse: can use cage and audit adapted to ask questions about
Probelm Based history: common health probelms that are reported related to mental health are depression, anxiety, and altered mental status
Measure: the blood pressure, height weight
general health history: compare client's apperance/behavior to healthy personality characteristics; This begins as soon as we see the client is dressed appropriately, their mood, affect (emotional state) appropriate, their posture, tone of voice, is convo app. is the convo in a logical sequence
stressors: recent changes, have these affected stress level, what are they, how do you deal with them, are those methods of stress relief currently effective for you
Three neurotransmitters facilitate or initiate activity: norepinephrine, serotonin, and dopamine
Each culture influences how: a stressful event is perceived and the acceptable way that people of that culture are expected to respond
How to test long term memory: during the history part of examination
alcohol abuse: do you ever, what is max number of drings had on any given occasion during the last month, how much on a typical day, on average how many days a week do you drink,
GABA (gamma aminobutyric acid): an inhibitory neurotransmitter that suppresses activity, insufficient GABA may contribute to anxiety
Examination techniques depend on: reason for exam, setting, condition/age of clients, skill of nurse
Serotonin: Similar to norepinephrine; levels are elevated in schizophrenia contributing to delusions, hallucinations, and withdrawal
Dopamine: acts in the midbrain on emotions and memory and in the hypothalamus and pituitary gland affecting emotional responses and stress reactions
Absract reasoning is tested by: asking the meaning of a proverb such as, tell me the meaning of a bird in the hand is worth than two in the bush
How to test short term memory: nurse says three unrelated objects slowly, patient repeats back to nurse
Limbic system: emotional brain; regulates memory, and basic emotions such as fear, anger, and sex drive
Language can be tested by: naming, repetition, reading, writing, and copying
Age related variations:Infants: Health History (mother take alcohol, drugs during pregnancy, what, how much, how often;examination expected normal parameters of growth/development; fetal alcohol syndrome;mothers who drink growth deficiency, heart defects, facial malformation, retardation, low birth weight, learning problems, hyperactivity, evident at birth may be undetected until older, irreversible
altered mental status: changes may become evident when there is a change in the client's oreientation to time place or person attention span or memory; Date and Time are the first orientation to disapear(even if client does not know date, they should be able to remember it after nurse has reoriented them); Orientation to Place is the second to disapper; Orientation to person is the last to disappear (client will not know who they are after reorientation)
Data collected also includes: vital signs, height, weight, and observations of clients to determine if physiologic changes are associated with the mental health problems
During the distory portion of the mental health assessmenta nurse collects data about the client's: recent and long term memory, intellectual emotional ppsychologic and personality functioning
Past Medical History: Have you experienced any behaviors that oculd indicate mental health problems in the the past, if so describe your experience, how have you coped in the past with this, are these coping strategies still working for you?
Risk factors for depression: Gender (femals are at greater risk), Age (adolescents are at risk for d and a in adults the onset is typically between 22 and 44) Psychosocial environment (people with history of trauma, sexual and physical abuse, diability, alcoholism, loss of a spouse), Personal characteristics (low self esteem, distorted perception of others views, inability to acknowledge personal accomplishment, pessimistic outlook
Mental Status: the degree of competence that a person shows in intellectual emotional psychologic and personality functionings
AUDIT: Alcohol use Disorders Identification Test
Orientations return: in the opposite order that they were lost. They return as person, place, and time
Observe: posture and movements of client during the examination; also if they are dressed appropriately and their hygiene, if the client keeps eye contact, changes in their voice tone, speech rate, perspiration, muscle tension, and tremors
present health status: how do they feel about themself, are your feelings a problem in daily life, if so do you feel the problem is temporary or curable (is there any medical problems, what meds are you taking)
Norepinephrine: regulates mood and maintains arousal; cocaine and amphetamines increase relase and block the reuptake of norepinephrine causing overstimulation
Observe and count respiratations: should be 12 to 20 respirations
Anxiety: do you have difficulty concentrating or making decisions, have you been preoccupied or forgetful, able to fall asleep and stay without difficulty, noticed a change in amount of energy (fatigued), more irritable than usual, do your muscles seem tense, feel a tightening in throat, have you felt nauseated, does heart feel as if it is racing, have you had to urinate more often than usual, have noticed a change in feelings describe, what inititated those feelings, howdo you handle or cope with these feelings, you seem anxious or uncomfortable
Depression: What is their mood, eating habits, weight loss, change in amount of energy, fatigued, have crying spells, experienced a loss, have difficulty making decisions, less interest in life, spend time alone, have friends who you can trust and are there when need, how long have you had these feelings (2 weeks is a criterion for depression), have you felt like this before what did you do. do you want to escape at times, have ever thought of escaping by hurting self or ending life, Do you have a plan for doing this, What has kept you from hurting yourself in the past?
Neurotransmitters: substances that carry messages from neuron to neuron or from neuron to muscle cell
Family History: Do you have any blood relatives who have behaviors that could indicate a mental health problem? If so can you describe the behavior they experienced?
Self Concept: how would you describe yourself to others, what are you best characteristics, what do you like about yourself?
CAGE: Have you ever felt you should cut down, Have people annoyed you by criticizing. have you ever felt bad or guilty, have you ever had a drink first thing in the morning (eye opener) to steady your nerves, get rid of hangover, or get the day started
Palpitate the brachial pulse: observe the rate, rhythm, amplitude, and contour, 60 to 100 beats per minute
Interpersonal Relationships: how satisfied are you, do you have friends that you socialize with, are there people whom you can talk about feelings and problems
Judgement is tested by: asking questions such as, what would you do if a car was speeding towards you
Calculation can be tested by: asking the client to count backwards from 100 by 7

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