Mental Status Assessment Flashcards
Mental Health Assessment is Performed When: (5)
a. abnormalities on behavioural portion of the general survey
b. patient has brain lesions
c. patient presents with aphasia
d. patient has a diagnosed mental illness
e. family members are concerned about behavioural changes
Mental Health
the capacity for each person to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face
Cognition
- Orientation
- Gnosia
- Attention/ Concentration
- Memory
- Comprehension
Orientation
patient is oriented to person, place, and time (x3)
Gnosia
ability to recognize objects and their function
Memory
Immediate - recall an event that just happened
Recent - recall an event that happened recently
Remote - recall verifiable past events
Thinking
- Processes
- Content
- Perception
- Insight and Judgement
Older Adults and Cognition
Older adults appear to decrease in cognition as a result of aging
- identify if the decrease in cognition is related or age or if it is a legitimate decline
Mini-Mental State Examination (MMSE)
used to examine a patient’s mental status when time is limited
Max score: 30 points
Score: 25+ = normal
Score: <24 = mental abnormality present
Montreal Cognitive Assessment (MOCA)
used to help detect cognitive impairments - does not diagnose, only indicates the need for advanced testing
Max Score: 30 points
Score: 26+ = normal
Score <25 = cognitive impairment suspected
Confusion Assessment Method (CAM)
confusion assessment
a. Delirium - confusion, agitated state (physical state)
b. delusion - impaired perceptions, confusion (thought processes, mental)
Diagnosis of delirium requires the presence of BOTH A and B, and C OR D
Risk Assessment
- Suicidal Thoughts
- Assaultive/ Homicidal Ideation
- Elopement Risk
Suicidal Thoughts
assess if the patient presents with signs of depression or suicidal thoughts
- if yes, identify immediate risks
have you ever thought about hurting yourself?
do you want to harm yourself? Or just think about it?
what is your plan?
is there a history of suicide in your family?
Assaultive/ Homicidal Ideation
assess if the patient is at risk of assulting (hurting) or killing another person
- if yes, you must break confidentiality and inform your supervisor
are you thinking of hurting someone?
who?
how?
Elopement (flight) Risk
assess if the patient is at risk of leaving without informing staff
if yes, precautions need to be implemented to ensure the safety of the patient and others
