Mental Status
Assessment
By InnaKorda, MD,
Institute of Nursing, TSMU
Mental Health
Mental status definition: A person’s emotional and cognitive
function
Mental disorder definition: “A significant behavioral or
psychological pattern associated with distress or
disability and has a significant risk of pain, disability, or
death, or a loss of freedom” (APA, 1994)
Can a mental disorder
be assessed? How?
•You must believe what your pt. tells you, must take
them seriously if they say they want to kill themselves.
•Suicide precautions may be implemented by having a
sitter or restraints.
How do you know
if a person has a
mental disorder or
is just having a crisis
in his or her life?
You don’t know, that’s
why we assess
mental health.
Theoretical vs. Practical
Assessing Mental Health
1.
2.
3.
4.
Appearance
Behavior
Cognitive function
Thought process and perceptions
Assessing mental health
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Appearance
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Posture
 Anxiety – sitting on edge of bed, tense muscles, frowning,
restless, pacing (Hyperthyroidism?)
 Depression – sitting slumped in a chair, slow walk, dragging
feet
Body movements
 Normal – voluntary, deliberate, coordinated, smooth and even
 Anxiety – restless, fidgety
 Depression – apathy, slow movements
 Schizophrenia – bizarre gestures, facial grimaces
Dress
 Eccentric dress occurs with schizophrenia or manic syndrome
Hygiene
 Note change from previously well-groomed appearance to one
that is disheveled - depression
 Obsessive compulsive disorder – meticulously dressed and
groomed
Assessing Mental Health
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Behavior
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Consciousness (LOC)
Facial expression
 Look is appropriate for the situation
 Flat, masklike expression in Parkinson’s and
depression
Language – physical ability to speak, word choice
Mood and affect
 Mood – more temporary expression of emotions
 Affect – more permanent display of feelings
Assessing Mental Health
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Cognitive Function
 Orientation – person, place, time (A&O x 3)
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Attention – give orderly instructions and ask pt. to perform
Memory – short and long term
Abstract reasoning
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Disorientation occurs with dementia, delirium
Problem solving and reasoning abilities
Must keep in mind patient’s education level
Thought Processes and Perceptions
 Thought process – Logic. How a person thinks.
 Thought content – What a person thinks.
 Perceptions
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How do people treat you? What do people say when they talk about
you?
Assessing Mental Health
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Suicide precautions
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Risk factors
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Prior suicide attempts
Depression
Verbal messages to kill self
Death themes in talk, jokes
Giving away possessions
Assessing
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“Have you ever thought about hurting yourself?”
“Do you plan to hurt yourself now?”
“Have you ever hurt yourself in the past?
Mini-Mental State Examination
LOC Abnormalities
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GCS – Glasgow Coma Scale
Common terms when assessing
consciousness
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Alert – to person, place, and time
Lethargic – drifts off frequently. Must be
aroused. Frequently effect of sedation
Obtunded – frequent sleep, difficult to
arouse, incoherent speech
Stupor – responds only to vigorous
shaking and pain, groans and mumbles
Coma – unconscious with little or no
response to stimuli. Little or no reflex
response.
GCS 15 – normal person
GCS <7 – coma
Speech Disorders
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Dysphonia – difficulty or
discomfort using voice to talk
Dysarthria – disorder of
articulation in which the speech
sounds are distorted.
Aphasia – language defect in
processing
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Global aphasia – little or no speech and
comprehension
Broca’s aphasia – can understand
language, but difficulty speaking.
Grammar problems.
Wernicke’s aphasia – problem
comprehending words. Can still
articulate well.
Mood and Affect Abnormalities
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Flat affect – no emotional response
Inappropriate affect – wrong emotion for the situation
Depression – sadness
Depersonalization – loss of identity. “I don’t feel real”
Elation – joy and optimism, overconfidence
Euphoria – inappropriate elation
Anxiety – worried, uneasy, nervous
Fear – worried, uneasy, apprehensive
Irritability – annoyed, easily provoked
Rage – furious, loss of control
Lability – rapid shift of emotions
Thought abnormalities
Process
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Confabulation – make up
events
Loose associations –
shifting between unrelated
ideas
Flight of ideas – unrelated
ideas but connected usually
by a play on words
Word salad – incoherent
mixture of words
Content
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Phobia – irrational fear of
an object
Hypochondrias – phobia of
having diseases.
Obsession – unwanted and
persistent thoughts
Compulsion – unwanted
and persistent actions.
Delusions – False beliefs,
often of persecution or
grandiose
Abnormalities of Perception
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Hallucination – Sensory perception for which
there are no external stimuli. May be visual,
auditory, tactile, olfactory, gustatory.
Delusion – Misperception of an actual
existing stimulus, by any sense.
Schizophrenia
Delirium, Dementia, and Amnesia
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Delirium
 Consciousness change – reduced awareness of environment with
reduced ability to focus, sustain, or shift attention
 Cognition change
 Develops over a short period of time (hours to days)
Dementia
 Memory impairment
 One or more of the following:
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Alzheimer’s, Parkinson’s, HIV, cerebrovascular disease
Amnesia
 Memory impairment without other disorders
 May be caused by trauma or substance induced
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Aphasia – language disturbance
Apraxia – impaired ability to carry out motor activities despite intact motor
function
Agnosia – impaired ability to recognize or identify objects despite intact
sensory function
Executive functioning disturbance – planning, organizing, sequencing,
abstracting
Substance Use Disorders
Substance: agents taken nonmedically to alter
mood or behavior
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Intoxication – ingestion of substance produces
maladaptive behavior changes due to effects on
CNS
Abuse – Daily use needed to function. Inability to
stop. Impaired social and occupational functioning
Dependence – physiologic dependence on
substance
Tolerance – requires increased amount of substance
to produce same effect
Withdrawal – cessation of substance produces
physiologic symptoms
Effects of Common
Substances
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Alcohol, sedatives, and hypnotics (CNS depressants)
 Symptoms – unsteady gait, incoordination, impaired judgement
 Withdrawal – tremor of hands, eyelids. Tachycardia, elevated BP,
sweating, headache, insomnia, anxiety, N&V, hallucinations,
delusions
Nicotine (mild stimulant)
 Symptoms – increased systolic BP, increase HR,
vasoconstriction, loss of appetite, dizziness
 Withdrawal – vasodilation, headaches, irritability, anxiety,
nervousness
Marijuana
 Symptoms – reddened conjunctivae, tachycardia, dry mouth,
increased appetite, euphoria, anxiety, slowed time perception
 Withdrawal – ? restlessness, decreased appetite
Effects of Common
Substances
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Cocaine and Amphetamines (psychostimulants)
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Symptoms – Pupillary dilation, tachycardia or bradycardia,
elevated or decreased BP, N&V, weight loss, euphoria,
agitation, aggressiveness
Withdrawal – Anxiety, depression, irritability, fatigue
Opiates (morphine, heroin)
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Symptoms – pinpoint pupils, decreased BP, pulse,
respirations, and temperature, lethargy, psychomotor
retardation, inattention, impaired memory
Withdrawal – Dilated pupils, lacrimation, tachycardia,
elevated BP, sweating, diarrhea, irritability, depression
Anxiety Disorders
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Panic attack
 Intense fear or discomfort develops within 10 minutes
 Symptoms
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Agoraphobia
 Anxiety about being in a place or situation where escape might be difficult
or where help might not be available
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Palpitations, sweating, trembling, SOB, feeling of choking, chest pain, nausea,
dizziness
Being outside of home, in a crowd, on a bridge, in a car, bus, or train
Specific phobias
 Phobias of specific objects provokes an anxiety response
OCD (Obsessive-Compulsive)
PSD (Posttraumatic Stress Disorder)
 Experience or witness of actual or threatened death or serious injury of
self or others
 Recurrent recollections of event followed by distress
Generalized Anxiety Disorder
 Persistent general anxiety
Mood Disorders
Depression
 5 or more present during
the same 2 week period
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Depressed mood
Diminished interest
Weight loss
Insomnia
Psychomotor agitation
Fatigue
Feelings of worthlessness
Diminished ability to think
Thoughts of death
Mania
 Persistently elevated or
irritable mood lasting 1
week or more with:
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Grandiosity
Decreased sleep
Talkativeness
Flight of ideas
Distractibility
Agitation
Pleasurable activities
Isn’t everyone suffering
from a mental disorder???
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Mental Status Assessment