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Lippincott Nursing Pocket Card - August 2023

Mental Health Assessment

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Introduction

Mental health assessment is a critical component in the neurologic assessment and changes may have pathologic or pharmacologic causes. While the sequence of certain parts of this assessment is important, we must also be flexible in structuring this exam, being sure to include all six components: appearance and behavior; speech and language; mood; thoughts and perceptions; insight and judgment; and cognitive function. Much of the mental health assessment is done simultaneously during the health history and head-to-toe physical assessment.
 

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Appearance and behavior

  • Assess the patient’s level of consciousness.
    • Is the patient awake and alert?
    • Does the patient understand your questions and respond appropriately and reasonably quickly? If the patient doesn’t respond to questions, escalate the stimulus in steps to elicit a response.
  • Note the patient’s posture and motor behavior.
    • Does the patient sit or lie quietly or prefer to walk around?
    • Are movements voluntary and spontaneous? Are any limbs immobile?
    • Do posture and motor activity change based on what is being discussed or who is in the room?
  • Observe the patient’s dress, grooming, and personal hygiene.
    • Is the clothing clean and presentable? Is it appropriate for age?
    • How do the grooming and hygiene compare with that of peers of comparable age and lifestyle?
    • Are there differences from one side of the body to the other?
  • Assess the patient’s facial expression at rest and during conversation.
    • Are there appropriate changes in expression for the topics being discussed or is the expression relatively unchanged throughout?
  • Assess the patient’s manner, affect, and relationship to people and things.
    • Are they appropriate to the topics being discussed or is the affect labile, blunted, or flat? Does it seem exaggerated at certain points?
    • Does the patient hear or see things not present or converse with someone who is not there?

Speech and language

  • Is the patient talkative or unusually quiet? Are comments spontaneous, or limited to direct questions?
  • Is speech fast or slow? Loud or soft?
  • Are words clear and distinct? Is there a nasal quality to the patient’s speech?
  • Are there any abnormalities in fluency, such as gaps in the flow and rhythm of words; disturbed inflections; circumlocutions (phrases or sentences are substituted for a word the person cannot think of); or paraphasias, in which words are malformed, incorrect, or invented?

Mood

  • Ask the patient to describe their mood, including usual mood level and changes due to life events.
  • If the patient tells you they are depressed or you suspect depression, assess its severity and suicide risk, by asking further questions, for example:
    • Do you feel discouraged or depressed?
    • Have you had thoughts of death?
    • Have you thought about killing yourself?
    • Have you thought about how or when you would try to kill yourself? Do you have a plan?

Thoughts and perceptions

  • Listen for patterns of speech that suggest disorders of thought processes.
  • To assess thought content, follow the patient’s cues by asking them to expand on something you’ve already discussed, for example, “Can you tell me more about that?”
  • Perception includes sensory awareness of objects in the environment and their interrelationships (external stimuli), as well as internal stimuli such as dreams or hallucinations. When false perceptions are present, explore them further. For example, ask, “When you heard the voice speaking to you, what did it say?”

Insight and judgment

  • Assess if the patient is aware that symptoms or disturbed behaviors are normal or abnormal; for example, distinguishing between daydreams and hallucinations that seem real.
  • Note whether the patient is aware that a particular mood, thought, or perception is abnormal or part of an illness.
  • Assess judgment by noting the patient’s responses to certain situations, such as family circumstances, jobs, or use of money.

Cognitive function

  • Is the patient oriented to self, place and time?
  • Assess attention by using digit span (have the patient repeat a series of numbers back to you); serial 7s (ask the patient to count backward from 100 by 7s); spelling backward (say and spell a five-letter word, then ask the patient to spell it backward.)
  • Assess remote memory by asking about important dates or events in the patient’s past.
  • Test recent memory by asking about events of the day.
  • Assess the patient’s ability to learn new things by telling them three or four words, having them repeat them, then asking them to repeat them again three to five minutes later.
  • If indicated, tests for higher cognitive functions may be performed.

PEARLS

  • Studies show that asking at-risk individuals if they are suicidal does not increase suicides or suicidal thoughts (Mathias et al., 2012).
  • Patients with psychotic disorders often lack insight into their illness.
  • When assessing memory, be sure you can validate responses.
  • Remote memory is usually preserved in early stages of dementia but may be impaired in its later stages. Recent memory is impaired in dementia and delirium.
References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
 
Mathias, C. W., Michael Furr, R., Sheftall, A. H., Hill-Kapturczak, N., Crum, P., & Dougherty, D. M. (2012). What's the harm in asking about suicidal ideation?. Suicide & life-threatening behavior, 42(3), 341–351. https://doi.org/10.1111/j.1943-278X.2012.0095.x

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