Transcript Mental Health Assessment

Mental Health and
Abusive Behavior Assessment
DSN
Kevin Dobi, MS, APRN
Copyright © 2013 by Mosby, an imprint
of Elsevier Inc.
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Mental health:
 State of well-being – ability to realize one’s own
abilities.
 Can cope with normal stresses of life.
 Able to contribute to community.
Changes in people’s lives may affect mental health:
 Periodic assessment of mental health and mental
status is required.
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Mental status:
 Degree of competence that a person shows:
 Intellectual
 Emotional
 Psychological
 Personality
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Abusive experiences may influence a person’s mental
health:
 Alcohol abuse
 Drug abuse
 Personal abuse
Interpersonal violence:
 Is not an illness, but is a crime.
 Is a human rights violation.
Can have negative impacts on mental health.
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Limbic system called emotional brain because it regulates
memory and basic emotions such as fear, anger, and sex
drive.
Structures of limbic system:
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Limbic lobe
Cingulate gyrus
Hippocampus
Amygdala
Thalamus
Portions of the hypothalamus
These structures enable communications between
limbic system and cerebral cortex.
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Neurotransmitters have an essential role in human
emotion and behavior
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Several neurotransmitters affect mental health:
 Norepinephrine (excites or elevates)
 Serotonin (stablises)
 Dopamine (feel good)
 Histamine (numbs)
 Acetylcholine (tremors)
 Gamma-aminobutyric acid (GABA) (sedating)
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Because data needed for mental health assessment are
collected by talking with patient, nurse collects data
about mental status during history:
 This is a deviation from assessments of specific body
systems when data collection for history is
performed prior to examination.
During history, nurse determines patient’s appearance,
behavior, and cognitive function compared with
characteristics of a healthy personality.
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Data collection begins upon first seeing patient:
 Is patient dressed appropriately for weather?
 Does his or her mood seem appropriate? Is affect
(emotional state) appropriate?
 What is patient’s body posture? Slumped over and
looking at ground with a sad facial expression, or
walking tall with a brisk step and a smiling face?
 What is tone of voice? Monotone or happy,
expressive tone?
 Does conversation flow in logical sequence?
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Are you having any medical problems?
What medications are you taking?
 Side effects of some medications may cause changes
in mood and behavior; also, nurse needs to know if
patient is taking medications for mental disorders.
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In the past, have you experienced any behaviors that
could indicate a mental health problem?
 If yes, how have you coped in the past?
 Did these strategies work for you?
Do you have any blood relatives who have behaviors
that could indicate a mental health problem?
 If yes, describe the behavior they experience.
Some people have witnessed violence at home:
 Did you have any experience with violence?
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How have you been feeling about yourself?
 Do you consider your present feelings as being a
problem in every day life?
How would you describe yourself to others?
 What are your best characteristics?
 What do you like about yourself?
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How satisfied are you with your interpersonal
relationships?
 Are there people you feel you can talk to about your
feelings?
Because abuse or violence have become more common,
all patients should be asked these questions:
 Have you been physically injured by someone in
your home over the last year?
 Are you fearful of anyone you have had a
relationship with?
 Do you feel safe?
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Stressors:
 Have there been any recent changes in your life?
 Have these affected your stress level?
 What are major stressors in your life? How do you
deal with stress?
 Are those methods effective for you?
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Anger:
 Have you been feeling angry?
 Do you feel angry now?
 How do you react when angry?
 Verbally, physically, or do you keep anger inside?
Can you talk about what causes your anger?
We all fight at home:
 What happens when you and your partner fight?
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Every adult and adolescent should be asked about
alcohol and recreational drug use to determine if it is a
health problem.
Alcohol use:
 How often do you drink alcohol, including beer,
wine, or liquor?
Recreational drug use:
 Do you ever use recreational drugs? If yes, tell me
about your drug use.
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Commonly reported problems of mental health
include:
 Depression
 Anxiety
 Altered mental status
Common problems of abusive behaviors include:
 Alcohol abuse
 Drug abuse
 Interpersonal violence
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Note gender and age of patient:
 Women are at risk for depression 2:1 over men.
 It is most common between the ages of 25 and 44.
Pay special attention to:
 Facial expression
 Eye contact
 Body language
 Tone of voice
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During past month, have you been feeling down,
depressed, or hopeless?
 Have you had little interest or pleasure in activities?
Are you able to fall asleep and stay asleep?
 Have you lost or gained weight recently?
Describe your mood:
 Do you have crying spells?
 Is it hard to concentrate?
 Have you been more irritable?
How often have you had those feelings?
 How long did they last?
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Do you have friends you can trust and who are
available when you need them?
Have you had feelings like this before?
 What did you do about depressive feelings then?
Have you ever thought of escaping by hurting yourself
or ending your life?
 If yes, do you feel like this now?
 Do you have a plan for hurting yourself?
 Have you told anyone else about your plan?
 What would happen if you were dead?
 What has kept you from hurting yourself in the past?
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Have you had difficulty concentrating or making
decisions?
 Are you able to fall asleep and stay asleep?
 Have you been more irritable?
 Are your muscles tense? Do you feel a tightening in
your throat?
Have you felt nauseated?
 Does your heart race?
 Do you have to urinate more?
Have you noticed a change in your feelings?
 If yes, describe.
 What initiated those feelings?
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Changes in mental status may become evident when
there is change in patient’s orientation to time, place or
person, attention span, or memory.
When orientation becomes a concern while taking
history, nurse asks questions to collect additional data.
Long-term memory can be assessed during history by
asking patient where he or she was born or about
previous surgeries.
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Orientation:
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Memory:
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Ask patient to repeat three unrelated objects.
Calculation ability:
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What year is it?
Where are you?
You buy fruit that cost $2.50. You give the cashier $3.00. What
should your change be?
Communication skills:
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Repetition
Reading
Writing
Copying
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If the patient answered “yes” during earlier screening
questions about interpersonal violence, follow up in
private.
You are asked about violence because so many women
are dealing with this in their homes:
 If abuse is a problem for you, you may talk to me
about it safely.
 Are you in a relationship in which you have been
hurt or threatened?
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Nobody deserves to be afraid in their home:
 Has your partner destroyed things you care about?
 Has your partner ever threatened or abused your
children?
 Has your partner ever forced you to do something
you did not want to do?
 Has your partner prevented you form leaving home,
seeing friends, getting a job, or continuing your
education?
 Do you have guns in the home?
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Variations for neonates and infants include asking
about drug and alcohol use of the mother during
pregnancy.
Children are asked about experiences in school, if they
like school, if they get into trouble, and fears about any
aspects of their lives.
Adolescents are asked about school experiences, drug
and alcohol use, and feelings of depression or anxiety;
assessing the self-esteem of those in this age group is
important.
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Indications of depression in older adults may be
misinterpreted as expected manifestations of aging:
 Decrease in appetite or fatigue may be a decrease in
metabolism or a loss of taste buds.
 Problems concentrating or sleeping may be
interpreted as expected change of advanced age.
 Many think depression will go away without
intervention, that they are too old to get help, or that
reporting sadness may be seen as a sign of weakness.
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Delirium is characterized by disturbance of
consciousness and rapidly developing change in
cognition.
 Manifestations are 1 or more weeks.
 Reversible with treatment.
Clinical findings:
 Altered level of consciousness.
 Impaired memory.
 Fluctuating attention span.
 May have hallucinations or delusions.
 “Sundowning” may increase.
 Speech may be rapid, inappropriate, or rambling.
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Dementia is characterized by memory impairment:
 Aphasia
 Apraxia
 Agnosia
 Disturbance of executive function
Dementia is not reversible.
Clinical findings:
 Onset slow
 Consciousness intact but memory, judgment, and
calculation impaired
 Flat affect
 May have delusions
 Speech is slow and incoherent
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During the initial intake, the nurse asks the patient a series of
questions. When asked how long he has been working in real
estate, the patient responds by saying, “I think 5 years. My dad
was in real estate, but my mom worked in an office. I like offices
because they are usually organized and neat. My son is very
messy, but he is good at guitar. Do you play any musical
instruments?” The nurse should document that the patient:
A.
B.
C.
D.
Appears concerned about son.
Suffers from manic disorder.
Demonstrates flight of ideas.
Is able to multitask but struggles with echolalia.
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After completing a dressing change and tidying up the room, the
nurse asks the patient if she needs anything. The patient
responds, “I am just tired of being tired. Ever since my husband
died, I can’t seem to sleep more than 3 to 4 hours a night. I can’t
find anything fun to do, and all my friends seem to have
disappeared.” The nurse discloses this information to the social
worker and recommends that the patient:
A.
B.
C.
D.
Start taking diphenhydramine at bedtime.
Be assessed on the Beck short form.
Undergo AUDIT assessment.
Undergo CAGE assessment.
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