Chapter 007

Mental Health and Mental Status Assessment Chapter 7

Mental Health/Status Assessment • Comprehensive assessment: mental and emotional health as well as physical health • Mental health: relative state of mind; healthy person copes/adjusts to stresses in acceptable ways • Data based on description of behavior – Persistence of behavior: when becomes mental illness?

• Changes in life/other factors influence mental health

Mental Health/Status Assessment • Mental status: degree of competence a person shows in intellectual, emotional, psychologic, personality functioning • Perception of event determines reaction – Culture influences perception/ways to respond

Anatomy and Physiology • Limbic system = emotional brain regulates memory/basic emotions – Structures surround corpus callosum – Linked to lobes of cerebral cortex (communication links) – Inhibit/initiate other parts of brain

• Neurotransmitters associated with mental health – Synthesized in neurons receptor sites on other neuron/effector cells

Anatomy and Physiology • Initiators of activity – Norepinephrine, serotonin: regulate mood and maintain arousal • Serotonin levels ↑ in schizophrenia

– Dopamine • Emotions/memory (midbrain) • Emotional responses/reactions (hypothalamus/ pituitary gland)

• Inhibitors – GABA: suppresses activity

Health History • General Health History – Compare client’s apperance/behavior to healthy personality characteristics – Begins when first see client • Dressed appropriately, mood, affect, posture, tone of voice, conversation logical/flowing

Health History • Present health status – Feel about self; present feelings a problem; temporary/curable? – Medical problems/medications

• Self-concept: describe self to others (what’s best/what like about self?)

Health History • Interpersonal relationships – Satisfaction, socialization, friends to talk about feelings/problems?

• Stressors – Changes, affects, major stressors – How to deal with; actions take/effective?

Health History • Anger: have been/feeling now,reaction, cause • Alcohol abuse – Ever drink alcohol, maximum number of drinks, how many drinks daily/weekly – CAGE, AUDIT

• Drug abuse: use, what, frequency – Adapt CAGE/AUDIT for drug use

Health History: Mental Health Questions • Past medical history – Experienced behaviors indicative of mental health problems • Describe, how coped, working?

• Family history – Relatives with behaviors indicative of mental health problems • Describe behavior

Problem-Based History: Depression (Symptom Analysis Not Appropriate for Behaviors and Feelings)

• • • • • • •

Risk factors? Mood ? Friends available? How long have had these feelings? Had them before? Want to escape; want to hurt self/end life/plan? What’s kept you from hurting yourself in past?

Problem-Based History: Anxiety • Difficulty concentrating/making decision; preoccupied/forgetful; sleeping (fall/stay asleep); change in energy; more irritable, tense muscles/tight throat? • Nausea, heart racing, frequent urination? • Change in feelings? (describe; cause/cope?) • Anxious/uncomfortable?

Problem-Based History: Altered Mental Status • Concerns about orientation, attention span, memory – do MMSE – Estimate/document changes in cognitive functions – Detect organic brain disease – Orientation, registration, attention, calculation, recall, language

Problem-Based History: Altered Mental Status • Orientation – Date/time first orientation to disappear • Only abnormal if person can’t remember day/date after reorientation

– Place: second orientation to disappear • Expected to remember after reorientation

– Person: last orientation to disappear • Don’t know who they are even after reorientation

– Orientation returns in opposite order of loss

Problem-Based History: Altered Mental Status • Memory – Short term – repeat 3 unrelated objects – Long term – during history

• Calculation – backwards from 100 by 7s • Language – naming, repetition, reading, writing, copying • Judgment/abstraction

Examination • Techniques depend on reason for exam, setting, condition/age of client, skill of nurse • History – long term memory, intellectual, emotional, psychological, personality functioning

Examination • Observe – Posture/movements – Appropriate dress/hygiene – Eye contact – Changes in voice tone, speech rate, perspiration, muscle tension, tremors

• Measure – Height, weight, blood pressure

Examination • Palpate brachial pulse (rate, rhythm, amplitude, contour) • Observe and count respirations (rate, breathing pattern)

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

Age-Related Variations: Infants • Examination – Narcotic abstinence syndrome: withdrawal from in utero drugs (passive addiction) – 48 to 72 hours post birth; last 6-8 weeks – ANS manifestations up to 3 to 4 months (tremors, restlessness, hyperactive reflexes, ↑ muscle tone, tachypnea, shrill cry) • Suck, rooting exaggerated; poor feeders [ineffective reflexes] • Regurgitation, vomiting, diarrhea

Age-Related Variations: Infants • Examination – Fetal cocaine exposure; crosses placenta – Mothers develop hypertension, decreased uterine blood flow – Infants may demonstrate cerebral infarcts, renal/cardiac defects, low birth weight/length, smaller head circumference – Risk for SIDS

Examination: Children • Health History – Child • Going to school/like, get in trouble; fears [what]?

– Parent • Change in behavior/teacher commented? • Child fainted, HAs, visual change, false seizures? (if yes—loss of parent from death, divorce, move?)

• Exam – normal with behavioral changes as reported

Age-Related Variations: Adolescents • Health history—”Present health Status” (self concept, IPR, stress, anger); if indicated questions on depression/anxiety • Questions – Adolescence rough time—how coping? – Belong to peer group? – School have drug problem? – Friends drink alcohol/do drugs? – Ill because of alcohol/drugs?

Age-Related Variations: Adolescents • Ask parents/guardians – Spend hours in bedroom doing nothing? – Resist talking/isolate from family members? – Change in attitude toward school? – Dropped out of community/school activities? – Mood swings/↑irritability, angry outbursts? – Unhappy/less able to cope with frustration? – Manipulative/lying – avoid confrontation, getting caught?

Age-Related Variations: Adolescents • Examination – Presenting symptoms of depression same as for adults; expression may be different • Sadness: black clothing, morbid thoughts expressed through poetry/stories • Not sleeping: watch TV, not wake up, sleeping during day, • Grades down: not sleeping, loss of concentration, slow thinking, less energy • Boredom: depression • Decreased appetite; anorexia, bulimia

Age-Related Variations: Older Adult • Anatomy and physiology – ↓Metabolic activity, ↓cerebral blood flow, ↓neurotransmitters contributes to depression – Depression may be overlooked—reported symptoms attributed to aging • Also caused by other illnesses, medications, loss

– Think it will go away or too old for help; sign of weakness – Encouraged to report

Age-Related Variations: Older Adult • Examination (normal/abnormal findings) – Depression assessed same as other adults – Yesavage Geriatric Depression Scale

Health Promotion: Mental Illness and Suicide Prevention • 20% of US affected by mental illness/year • Depression – major cause of disability; associated with 65% of suicides/year – 30,000 suicides/year (US); 650,000 care in ER for suicide attempts

Health Promotion: Goals/Objectives– Healthy People 2010 • Mental health – leading heath indicator • Goal – improve mental health and ensure access to appropriate, quality MH services – ↓suicide rates/attempts of adolescents – ↓proportion of homeless adults with mental illness – ↑employment for individual with mental illness – ↓relapse for those with eating disorders

Health Promotion: Goals/Objectives– Healthy People 2010 – ↑ proportion of adults/children with MI receiving treatment – ↑ proportion of persons with mental health/substance abuse problems receiving treatment

Health Promotion: Substance Abuse • Staggering problem—associated with other problems: injury (vehicular crash), violence (child/spouse abuse), STD, unwanted pregnancy, financial problems, homelessness • 20% adolescents use alcohol/10% report drug use • 17% adults binge drink; 6% use drugs • 3 million of 13-16 million individuals receive treatment

Health Promotion: Goals/Objectives– Healthy People 2010 • SA leading health indicator • Goal – ↓ SA to protect health, safety, quality of life, especially children • 25 objectives in 5 categories – ↓ vehicle crash deaths/injuries related to SA – ↓ drug/alcohol related visits to ER – ↓drug/alcohol related violence – ↓ use of illicit substances by adults/ adolescents

Health Promotion: Goals/Objectives– Healthy People 2010 – ↓ annual alcohol consumption/binge drinking – ↓ steroid/inhalant use by adolescents – ↑ proportion of adolescents who perceive risks and disapprove of SA – Improve treatment for SA – ↑ referrals from ER for SA treatment – Extend impaired driving laws

Common Problems and Conditions: Alterations of Mood and Affect • Major depression: sense of sadness, hopelessness, helplessness, worthlessness • Single/recurrent episode • Feeling depressed not same as depression – Depressed mood for 2 weeks with significant distress/impairment accompanied by four classic symptoms

• More common in females – Psychosocial factors/hormone fluctuations

Common Problems and Conditions: Alterations of Mood and Affect • Clinical findings – Depressed mood/lost interest in pleasure for 2 weeks, with significant distress/impairment and at least 4 classical clinical manifestations • • • • • •

Persistent sad, anxious, “empty” mood Feelings of hopelessness, pessimissism Feelings of guilt, worthlessness, helplessness ↓ appetite/weight loss;↑ appetite/weight gain Insomnia Fatigue, difficulty concentrating/making decisions, suicidal thoughts

Common Problems and Conditions: Alterations of Mood and Affect • Bipolar disorder: depression with mania, depression, or mixed moods – Mood switches dramatic/rapid; mostly gradual – Genetic role in cause – ↓ neurotransmitters also contribute – ↑ intracellular Na+/Ca++ related to cell membrane abnormalities – Steroid side effects can trigger mania

Common Problems and Conditions: Alterations of Mood and Affect • Clinical findings – Manic – excessive emotional displays, excitement, euphoria, hyperactivity with elation, boisterousness, impaired concentration ↓ need for sleep, energy; delusions of grandeur – Depression – apathy, feelings of profound sadness, loneliness, guilt, ↓ self esteem

Common Problems and Conditions: Alterations of Mood and Affect • Anxiety: feeling uneasy/discomfort; from mild to panic – No specific source or object – May mobilize to be constructive or immobilized – May be destructive – >19 million in US have anxiety disorders [panic disorder, obsessive/compulsive, PTSD, phobias, generalized anxiety disorder

Common Problems and Conditions: Alterations of Mood and Affect • Clinical findings – Mild – broad perceptual field (heightened awareness) produces learning • Sees/hears more, logical thinking

– Moderate – narrowed perception results in selective inattention (focus on concern) – Severe – reduced perception results in compulsive mechanisms to avoid anxiety • Impaired memory/attention/concentration, problem solving difficulty, unable to focus

Common Problems and Conditions: Alterations of Mood and Affect – Panic – complete perceptual disruption resulting in terror, unable to think logically/make decisions

• Physical manifestations from sympathetic stimulation – Muscle tension, tachycardia, dyspnea, hypertension, increased respirations/perspiration

Common Problems and Conditions: Alterations in Mood and Affect • Obsessive-compulsive disorder: anxiety disorder due to anxiety symptoms developing from resistance to obsession/ compulsion – Obsession – unwanted, intrusive, persistent ideas, thoughts, impulses, images that cause marked anxiety/distress – Compulsions – unwanted, repetitive behaviors/ mental acts intended to ↓ anxiety • Recognized as excessive/unreasonable– continued because of anxiety reduction

Common Problems and Conditions: Alterations of Mood and Affect • Clinical findings – Obsessions – repeated thought about contamination, repeated doubts, need for particular order, sexual imagery – Compulsions – praying, counting, repeating words silently

Common Problems and Conditions: Alterations of Mood and Affect • Post Traumatic Stress Disorder –anxiety disorder – Persistent symptoms develop after experiencing/witnessing traumatic event – Family members can also develop disorder

• Clinical findings – Nightmares, flashbacks, emotional numbing, depression, feeling angry, irritable or distracted, easily startled

Common Problems and Conditions Alterations of Thought Content • Phobia: two types – Social – disabling fear of scrutiny, embarrassment or humiliation in social situations leading to avoidance of activities that may be pleasurable – Specific – disabling, irrational fear of something with little to no actual danger

• Manifestations: faintness, fatigue, palpitations, perspiration, nausea, tremor, panic

Common Problems and Conditions: Psychotic Disorders • Schizophrenia – one of large group; gross distortion of reality, disturbances of language/communication, withdrawal, disorganization/fragmentation of thought perception and emotion reaction – >1.9 million with schizophrenia – Unknown etiology; biologic factors – genetic, excess dopamine-dependent neuron activity – Mild or prolonged hospitalization

Common Problems and Conditions: Psychotic Disorders • Clinical findings – Apathy/confusion; delusions/hallucinations – Rambling/stylized speech patterns – Withdrawn, regressive, and bizarre behavior – Emotional liability

Common Problems and Conditions: Psychotic Disorders • Delusions: persistent aberrant beliefs/ perceptions despite contrary evidence – One or more non-bizarre delusions persisting for 1 month

• Clinical findings – Feel controlled by external force – Delusions of grandeur– exaggeration of one’s importance, wealth, power (paranoid schizophrenia) – Persecution– being mistreated, harassed (paranoia, paranoid schizophrenia)

Common Problems and Conditions Substance Abuse Disorders • Alcohol withdrawal syndrome – Alcohol – CNS depressant measured by blood alcohol level (BAL) • 100 mg/dl (0.10%) legal intoxication level (most states) • 0.08 % some states

– Two phases of AWS

Common Problems and Conditions Substance Abuse Disorders – Early manifestations: tremors, sweating, nausea/vomiting, anxiety/agitation • 6 to 8 hours after last drink; peak at 24-36 hours; gone after 48 hours • 7% – hallucinations (visual/auditory); 5-10% develop seizures

– Delirium Tremors (5%): dysrhythmias, increased BP, increased respirations, profuse sweating, hallucinations/delusions

Common Problems and Conditions Delirium/Dementia • Delirium – disturbance of consciousness, change in cognition develops rapidly over short time period – Disturbance in cerebral function [metabolic disorders – Short duration (<1 month); reversible

• Clinical findings – attention deficits, disorganized thinking, confusion, disorientation, restlessness, incoherence, anxiety, excitement, illusions

Common Problems and Conditions Delirium/Dementia – Emotional instability – fear, anxiety, depression, irritability, anger, euphoria, apathy – ANS – tachycardia, sweating, flushed face, dilated pupils, ↑BP

Common Problems and Conditions Delirium/Dementia • Dementia: acquired progressive intellectual impairment; compromises memory, language, visual-spatial skills, emotion, personality cognition – Primary – Alzheimers – no other organic cause – Secondary – caused by other condition (AIDS, Cerebral trauma) – Not reversible – distinguishes from delirium

Common Problems and Conditions Delirium/Dementia • Clinical findings – Initial symptoms not apparent – As progresses – lose things/forgetfulness – Short term memory loss – Further progression – disorientation • Psychomotor symptoms – wandering, obsessivecompulsiveness, agitation/aggression

– Late stage – unable to recognize family; confined to bed