GROUP 1

Assessing Mental Status

Including Risk for
Substance Abuse
1
Conceptual
Foundations
Factors Affecting Mental
Health
Mental Disorders
-Substance Abuse


MENTAL STATUS - refers to a client's level of cognitive

functioning and emotional functioning.

MENTAL HEALTH - is an essential part of one's total health and is

more than just the absence of mental disabilities or disorders.

The WHO (World Health Organization, 2014) states that "HEALTH

IS A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL-
BEING AND NOT MERELY THE ABSENCE OF DISEASE OR
INFIRMITY".
- a healthy mental status is needed to think clearly,
respond appropriately, and function effectively in all
activities of daily living.

- it is reflected in one's appearance, behaviors,

speech, thought patterns, decisions, and in one's
ability to function in an effective manner in
relationships in home, work, social, and recreational
setting.

- one's mental health may vary from day to day

depending on a variety of factors.
FACTORS AFFECTING MENTAL HEALTH:
- Economic and Social factors
- Unhealthy lifestyle choices
- Exposure to Violence
- Personality Factors
- Spiritual factors
- Cultural factors
- Changes or impairments in the structure
and function of the Neurologic System
- Psychosocial developmental level and
issues
 MENTAL DISORDERS
The National Institute of Mental Health (NIMH) reports
that in 2013, 18.5% of US adults suffered from some form of
mental illness. The Diagnostic and Statistical Manual of
Mental Disorders (DSM) is published by the American
Psychiatric Association and is widely used for defining
mental disorders and symptoms.

The DSM-5 definition for a mental disorder is a disorder

that has the following features:
 MENTAL DISORDERS
A behavioral or psychological syndrome or pattern at
occurs in an individual
That reflects an underlying psychobiologic dysfunction
The consequences of which are clinically significant
diseases or disability
Must not be merely an expectable response to
common stressors and losses or a culturally sanctioned
response to a particular event
That is not a primarily result of social deviance or
conflicts with society
 SUBSTANCE ABUSE
The WHO describes substance abuse as the "harmful or
hazardous use of psychoactive substances, including
alcohol and illicit drugs."

This abuse can lead to a dependence syndrome, which

manifests itself in a cluster of behavioral, cognitive, and
physiologic phenomena that develop after repeated
substance use.
2
Health Assessment
Biographical Data
History of Present Health
Concern
Personal Health History
Family History
Lifestyle and Health Practices
2
Assessment
Step one of nursing process
Collecting subjective and objective data
Analyzing and synthesizing the data
Making judgements about the effectiveness of nursing
interventions
Ongoing and continuous throughout all the phases of nursing
process
What are the things that need to be considered during the conduct of
interview?

✓ Establish rapport.
✓ Maintain a quiet and calm environment that is comfortable for the
patient being interviewed.
✓ Maintain the client’s privacy and ensure confidentiality.
✓ Ask the questions in an open and close-ended format accordingly.
✓ Listen carefully to the client’s verbal descriptions and quote the terms
used.
✓ Watch for the client’s facial expressions and grimaces during the
interview.
✓ DO NOT put words in the client’s mouth.
What happens if we do not document?

• Errors are made

• There is confusion
• No record of what happened with the patient on a shift
by shift, day by day basis.’
• No legal basis on which to stand and support what nurses
have done to care for a
patient
• Do not effectively communicate
 BIOGRAPHICAL DATA
What data are obtained under the biographical information section
of a patient health history form
Name
Address
Age
Birthday
Occupation
Relationships
Contact number
Nationality or spiritual practices
Language spoken
Education Level
 HISTORY OF PRESENT HEALTH CONCERN
QUESTION RATIONALE:
What is your most urgent health This information willhelp the
concern at this time? Why are examiner determine the client's
you seeking health care?
perspective and ability to
prioritize the reality of
symptoms related to the
current health status.
 HISTORY OF PRESENT HEALTH CONCERN
Are you experiencing any other
health problems?
Do you have headaches? Describe.
Do you ever have trouble breathing
or have heart palpitations?
Do you have insomnia?
Do you have irritability or mood
swings?
Do you suffer from fatigue?
Do you have suicidal thoughts?
 HISTORY OF PRESENT HEALTH CONCERN

Do you have Signs of violent behavior include

thoughts of wanting to loud aggressive speech, aggressive
hurt or kill anyone? actions, tense posture, pacing,
throwing object, hitting the wall,
pounding fists, or heating self.
Consider any angry client potentially
violent and take action to protect
yourself and others.
 PERSONAL HEALTH HISTORY
QUESTION
Have you ever received medical treatment or
hospitalization for a mental health
problem or received any type of counseling services?
please explain
RATIONALE
Some clients may had a positive or a negative
past experience with mental health care services
or counseling that may influence their decision to
seek help in this area again. A past hospitalization
for mental health may indicate a more serious
problem than if the client received outputpatient
services.
Some mental health disorders may recur or
symptons may intensify. clients who have
depression early in life have a twofold increased
risk for dementia.
 Have you ever had any type of head injury, These conditions can affect the developmental level and
meaninggitis,encephalitis,or stroke? the mental status of the client

Changes behaviour, communication patterns, and sleep habits,

What changes did you notice as a result of these aswell as other physical changes, may occur with these
conditions

Have you ever served on actice duty in the armed Posttraumatic syndrome may be seen in veterans who
forces? explain experienced traumatic conditions in militart combat.
 FAMILY HISTORY
QUESTION
Is there a history of mental health problems (anxiety,
depression, bipolar disorder, schipherenial or aizhermer
disease in your family
How were they treated ? was the treatment effective?
RATIONALE
Some psychiatric disorders may have a genetic or
familiar connection such as anxiety ,depression,
bipolar disorder and/ or schinophrenia, or
alzheimer disease , Effectiveness of past family
treatments may give direction for future
treatmentss for this clients
 LIFESTYLE AND HEALTH PRACTICES
QUESTION
Do you eat at the right time and
three times a day?
What are the foods in daily eating?
RATIONALE
Healthy diet is essential for good health and
nutrition. It protects you against many
chronic noncommunicable diseases, such as
heart disease, diabetes and cancer.
Exercise helps people lose weight and
lower the risk of some diseases. Exercising
regularly lowers a person's risk of
developing some diseases, including
obesity, type 2 diabetes, and high blood
pressure
 LIFESTYLE AND HEALTH PRACTICES
QUESTION
Do you drink 8-10 glasses of water in a day?
Do you have a regular sleeping
routine?
easily by maintaining the internal clock of your
RATIONALE
Drinking enough water may offer health benefits,
including: Weight loss. Drinking enough water may
help you burn more calories, reducing appetite if
consumed before a meal and lowering the risk of
long-term weight gain. Better physical
performance.
Maintaining a consistent sleep routine, even on
weekends, helps you fall asleep and get up more
body. Making just a few minor modifications can
substantially enhance your sleep, even if life gets
in the way of reaching the perfect sleep pattern.
3

Assessment Tool
The Alcohol Use Disorders
Identification Test
(AUDIT)
INTRODUCTION
The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item
screening tool developed by the World Health Organization (WHO) to
assess alcohol consumption, drinking behaviors, and alcohol-related
problems. Both a clinician-administered version (page 1) and a self-report
version of the AUDIT (page 2) are provided. Patients should be encouraged
to answer the AUDIT questions in terms of standard drinks. A chart
illustrating the approximate number of standard drinks in different alcohol
beverages is included for reference. A score of 8 or more is considered to
indicate hazardous or harmful alcohol use. The AUDIT has been validated
across genders and in a wide range of racial/ethnic groups and is well-suited
for use in primary care settings
 Questions:

1. How often do you have a drink containing alcohol?

(0) never
(1) monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week

2. How many drinks containing alcohol do you have on

a typical day when you are drinking?

(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7,8, or 9
(4) 10 or more
3. How often do you have six or more drinks on
one occasion?

(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

4. How often during the last year have you found that
you were not able to stop drinking once you had
started?

(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to do
what was normally expected from you because of
drinking?

(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
6. How often during the last year have you needed a first
drink in the morning to get yourself going after a heavy
drinking session the night before?

(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

7. How often during the last year have you had a feeling
of guilt or remorse after drinking?

(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
8. How often during the last year have you been unable to
remember what happened the night before because you
had been drinking?

(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily

9. Have you or someone else been injured as a result of

your drinking?

(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
10. Has a relative or friend or a doctor or another health
worker been concerned about your drinking or
suggested you cut down?

(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
1

Collecting Objective Data:

Physical Examination
General Routine
Screening vs. Focused
Specialty Assessment
A comprehensive mental status examination is lengthy
and involves great care on the part of the examiner to
put the client at ease. There are several parts of
examination, which include assessment of the client's level
of consciousness, posture, body movement, grooming,
hygiene, facial expressions, speech, mood, feelings and
expressions, thought processes, perception, and cognitive
abilities.

Cognitive abilities include orientation, concentration,

recent and remote memory, abstract reasoning,
judgment, visual perception, and constructional ability.
2

Physical Assessment
Level of Consciousness
and Mental Status
Cognitive Abilities
 Level Consciousness and Mental Status
Assessment Procedure:
Observe the clients level of consciousness.
✓name, address, phone number
✓ask where you currently are (e.g. hospital or clinic)
Normal findings:
✓client is alert and oriented to person, place, time and
events.
✓interacts properly
✓makes and maintain eye contact and conversation.
 Level Consciousness and Mental Status

Abnormal Findings:
✓client is not alert to person, place, day or time
✓does not make or maintain eye contact or respond
appropriately
 Level Consciousness and Mental Status

Assessment Procedure:
Use the glasgow coma scale for clients who have
experienced a traumatic brain injury.
✓ the glasgow coma scale cannot be used to assess a
verbal score in intubated or aphasic clients however, it is
still the most widely used scoring system for intensive
care unit comatose patients.
 Level Consciousness and Mental Status
Normal findings:
✓glasgow coma scale 5:15 indicates an optimal level of
consciousness.

Abnormal findings:
✓glasgow coma scale score of less than 15
✓a score of three the lowest possible score indicates deep
coma
Cognitive Abilities
3

Assessment Tool
Glasgow Coma Scale
Seven Warning Signs of Alzheimer
Disease
SLUMS Mental Status Examination
The Confusion Assessment Method
(CAM)
SEVEN WARNING SIGNS OF
ALZHEIMER DISEASE
1. Asking the same question over and over again
2. Repeating the same story, word for word, again and again
3. Forgetting how to cook, or how to make repairs, or how to play
cards-activities that were previously done with ease and regularity
4. Losing one's ability to pay bills or balance one's checkbook
5. Getting lost in familiar sorroundings or misplacing household
objects
6. Neglecting to bathe, or waering the same clothes over and over
again, while insisting that they have taken a bath or that their
clothes are still clean
7. Replying on someone else, such as a spouse, to make decisions or
answer questions the previously would hav handled themselves
Assessment Procedure

Use the SLUMS Dementia/Alzheimer Test Examination if time

is limited and a quick measure is needed to evaluate function.

If further assessment is needed to distuinguish delirium from

other types of cognitive impairment, use the Confusion
Assessment Method.
 Normal Findings
A score between 27 and 30 for clients with a high
school education and a score of 20-30 for clients with
less than a high school education is considered
normal.
OLDER ADULT CONSIDERATIONS

See differences between signs of

ALzheimer disease and typical age-
related changes in the table within
Evidence-Based Practice
 Abnormal Findings

For clients with a high school education, a score of

20-27 indicates mild cognitive impairment (MCI) and
for clients with the less than a high school
education, a score of 14-19 indicates MCI.
The Confusion Assessment
Method Instrument
1. [Acute Onset] Is there evidence of an acute change in mental status from the
patient’s baseline?
2A. [Inattention] Did the patient have difficulty focusing attention, for example, being
easily distractible, or having difficulty keeping track of what was being said?
2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is,
tend to come and go or increase and decrease in severity?
3. [Disorganized thinking] Was the patient’s thinking disorganized or incoherent, such
as rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?
4. [Altered level of consciousness] Overall, how would you rate this patient’s level of
consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental
stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to
arouse]; Coma; [unarousable]; Uncertain)
5. [Disorientation] Was the patient disoriented at any time during the
interview, such as thinking that he or she was somewhere other than the
hospital, using the wrong bed, or misjudging the time of day?
6. [Memory impairment] Did the patient demonstrate any memory problems
during the interview, such as inability to remember events in the hospital or
difficulty remembering instructions?
7. [Perceptual disturbances] Did the patient have any evidence of perceptual
disturbances, for example, hallucinations, illusions or misinterpretations (such as
thinking something was moving when it was not)?
8A. [Psychomotor agitation] At any time during the interview did the patient
have an unusually increased level of motor activity such as restlessness, picking at
bedclothes, tapping fingers or making frequent sudden changes of position?
8B. [Psychomotor retardation] At any time during the interview did the patient
have an unusually decreased level of motor activity such as sluggishness, staring
into space, staying in one position for a long time or moving very slowly?
9. [Altered sleep-wake cycle] Did the patient have evidence of disturbance of the
sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night?
The Confusion Assessment Method
(CAM) Diagnostic Algorithm
Feature 1: Acute Onset or Fluctuating Course
This feature is usually obtained from a family member or nurse and
is shown by positive responses to the following questions: Is there
evidence of an acute change in mental status from the patient’s
baseline? Did the (abnormal) behavior fluctuate during the day, that
is, tend to come and go, or increase and decrease in severity?
Feature 2: Inattention
This feature is shown by a positive response to the following
question: Did the patient have difficulty focusing attention,
for example, being easily distractible, or having difficulty keeping
track of what was being said?
Feature 3: Disorganized thinking
This feature is shown by a positive response to the following question:
Was the patient’s thinking disorganized or incoherent,
such as rambling or irrelevant conversation, unclear or illogical flow
of ideas, or unpredictable switching from subject to subject?
Feature 4: Altered Level of consciousness
This feature is shown by any answer other than “alert” to the
following question: Overall, how would you rate this patient’s level
of consciousness? (alert [normal]), vigilant [hyperalert], lethargic
[drowsy, easily aroused], stupor [difficult to arouse], or coma
[unarousable])
1

Difference between
Dementia and
Delirium
 Application

Interdisciplinary Verbal
Communication of Assessment
Finding Using SBAR
 Situation:
Today, Mrs. Wilson came to the clinic
with concerns of anxiety, fearfulness,
SBAR
anorexia, insomnia, fatigue, inability
to concentrate, and "being very
nervous and unable to think straight"
over the last 3 months.
 Background:
She is a 61 year old Caucasian female employed as a
secretary with a family history of alzheimer disease.
Lost 10 pounds, has erratic bowel pattern with

SBAR episodes of constipation, followed by diarrhea self

treated with Correctol and Imodium once every two
weeks, and headaches treated with Tylenol. Takes
multivitamin daily. has experienced difficulty recalling
people's names and other information, which has led
to less frequent socialization in church activities, in
difficulty keeping up at work and with family activities.
 Assessment:
Thin and frail (but BMI 19), has brief i contact and often
stares at the floor, flat affect, frequently wrings hands.
Does not initiate conversation. Questions must often be
repeated do to her difficulty concentrating. Recent
SBAR memory not intact, remote memory intact. Judgment and
reasoning intact. Scored 22/30 on the SLUMS
examination. SLUMS: mild neurocognitive disorder.
Consciously look at husband for reassurance. Able to
name familiar objects in examination room. explain the a
meaning of common proverbs and what to do in an
emergency situation.
 Recommendation:
I believe Mrs. Wilson needs a comprehensive
SBAR physical and psychiatric examination.
 ANALYSIS OF DATA:
DIAGNOSTIC REASONING
After collecting subjective and objective data pertaining to
the mental status examination, identify abnormal findings
and client strengths using diagnostic reasoning.
SELECTED NURSING DIAGNOSES

HEALTH PROMOTION DIAGNOSES

readiness for enhanced health management related to
desire and request to learn more about health
promotion
readiness for enhanced coping
SELECTED NURSING DIAGNOSES
RISK DIAGNOSES
Risk for self-directed violence related to depression,
suicidal tendencies, developmental crisis, lack of
support system, loss of significant others, for coping
mechanisms, and behaviors
Risk for developmental delay related to lack of healthy
environmental simulation and activities
Risk for powerlessness related to prolonged disability
SELECTED NURSING DIAGNOSES
ACTUAL DIAGNOSES
Anxiety related to awareness of increasing memory loss
Impaired verbal communication related to intl. lang. barrier
Impaired verbal comm. related to hearing loss
Impaired verbal comm. related to inability to clearly express self
or understandable others (aphasia)
Impaired verbal comm. related to aphasia, psychological
impairment, or organic brain disorder.
SELECTED NURSING DIAGNOSES
ACTUAL DIAGNOSES
Acute or chronic confusion related to dementia, head injury,
stroke, alcohol, or drug abuse
Impaired memory related to """
dressing or grooming self care deficit related to confusion and
lack of resources or support from caregivers
disturbed thought processes related to alcohol or drug abuse
psychotic disorder or organic brain dysfunction
social isolation related to inability to relate or communicate
effectively with others
complicated grieving related to suicide of child and increasing
isolation from support system
 SELECTED COLLABORATIVE
PROBLEMS
After you group the data, it may become apparent that
certain collaborative problems emerge. Remember that
collaborative problems differ from nursing diagnosis in
that they cannot be prevented by nursing interventions.
Following is a list of collaborative problems that may be
identified when obtaining a general impression. These
problems are worded as risk for complications (RC)
followed by the problem.

RC: STROKE
RC: INCREASED INTRACRANIAL PRESSURE (ICP)
RC: SEIZURES
RC: MENINGITIS
RC: DEPRESSION
 MEDICAL PROBLEMS

After you group the data, it may become

apparent that the client has signs and
symptoms that require psychiatric medical
diagnosis and treatment.
 REPORTERS:
✓ ABAD, REALYN ✓ ARROYO, JAN DIETHER
✓ ALVARADO, JOYCECLEA ✓ BAYONITO, JAY ADRIAN
✓ BAETA, ANN KATHLYN
✓ BAGALACSA, LORIE ROSE
✓ BAGAPORO, ANTOINETTE PAULINE
✓ BANCASO, NICOLA JAN
Thank You!