Ch 6 Mental Status (Skills)

Vascular (Multi-Infarct) Dementia

etiology: Cardiovascular (CV) disease, Cerebrovascular disease, Hypertension risk factors: Pre-existing CV disease occurrence: 10-20% of dementias onset: Often abrupt, Follows a stroke or transient ischemic attack age of onset: Most commonly 50-70 years gender: Predominantly males course: Chronic, irreversible, fluctuating, stepwise progression duration: Variable; years symptoms progress: Depends on location of infarct and success of treatment; death attributed to underlying CV disease mood: Labile: mood swings speech/language: May have speech deficit/aphasia depending on location of lesion physical signs: According to location of lesion: focal neurologic signs, seizures Commonly exhibits motor deficits

Delirium

etiology: Drug toxicity and interactions; acute disease; trauma; chronic disease exacerbation, Fluid and electrolyte disorders risk factors: Pre-existing cognitive impairment occurrence: 7-61% among hospitalized people onset: Rapid, acute onset, A harbinger of acute medical illness age of onset: Any age, although predominantly in older persons gender: Males and females equally course: Acute onset, Hypoalert—hypoactive, Hyperalert—hyperactive, Mixed hypo—hyper duration: Lasts 1 day to 1 month symptoms progress: Symptoms are fully reversible with adequate treatment; can progress to chronicity or death if underlying condition is ignored mood: variable

Assess concentration. Note the client's ability to focus and stay attentive to you during the interview and examination. Give the client directions such as "Please pick up the pencil with your left hand, place it in your right hand, then hand it to me."

normal: - Client listens and can follow directions without difficulty. abnormal: - Distraction and inability to focus on task at hand are noted in anxiety, fatigue, attention deficit disorders, and impaired states due to alcohol or drug intoxication.

Observe facial expressions, eye contact, and affect.

normal: - Client maintains eye contact, smiles, and frowns appropriately. abnormal: - Reduced eye contact is seen in depression or apathy. Extreme facial expressions of happiness, anger, or fright may be seen in anxious clients. Clients with Parkinson disease may have a mask-like, expressionless face. Staring watchfulness appears in metabolic disorders and anxiety. Inappropriate facial expressions (e.g., smiling when expressing sad thoughts) may indicate mental illness. Drooping or gross asymmetry occurs with neurologic disorder or injury (e.g., Bell palsy or stroke).

If the client has difficulty with speech, perform additional tests: Ask the client to name objects in the room. Ask the client to read from printed material appropriate for his or her educational level. Ask the client to write a sentence.

normal: - Client names familiar objects without difficulty and reads age-appropriate written print. Client writes a coherent sentence with correct spelling and grammar. abnormal: - Client cannot name objects correctly, read print correctly, or write a basic sentence correctly. Deficits in this area require further neurologic assessment to identify any dysfunction of higher cortical levels.

Observe mood, feelings, and expressions. Ask client "How are you feeling today?" and "What are your plans for the future?" - Moods and feelings often vary from sadness to joy to anger, depending on the situation and circumstance.

normal: - Cooperative or friendly, expresses feelings appropriate to situation, verbalizes positive feelings regarding others and the future, expresses positive coping mechanisms (support groups, exercise, sports, hobbies, counseling). abnormal: - Flat affect, euphoria, anxiety, fear, ambivalence, irritability, depression, and/or rage are all examples of altered mood expressions. Depression, anxiety, and somatization are common mental disorders seen in at least 5% to 10% of clients (Kroenke et al., 2010). Expression of prolonged negative, gloomy, despairing feelings is noted in depression. Expression of elation and grandiosity, high energy level, and engagement in high-risk but pleasurable activities is seen in manic phases. Excessive worry may be seen in anxiety or obsessive-compulsive disorders. Eccentric moods not appropriate to the situation are seen in schizophrenia.

Assess visual, perceptual, and constructional ability. Ask the client to draw the face of a clock or copy simple figures (Fig. 6-7).

normal: - Draws the face of a clock fairly well. Can copy simple figures. abnormal: - Inability to draw the face of a clock or copy simple figures correctly is seen with mental retardation, dementia, or parietal lobe dysfunction of the cerebral cortex.

AD

physical signs: Early—no motor deficits Middle—apraxia (cannot perform purposeful movement), Late—Dysarthria (impaired speech), End stage—loss of all voluntary activity; positive neurologic signs orientation: Becomes lost in familiar places (topographic disorientation) Has difficulty drawing three-dimensional objects (visual and spatial disorientation) Disorientation to time, place, and person—with disease progression memory: Loss is an early sign of dementia; loss of recent memory is soon, followed by progressive decline in recent and remote memory

delirium cont.

speech/language: Fluctuating; often cannot concentrate long enough to speak, May be somnolent physical signs: Signs and symptoms of underlying disease orientation: May fluctuate between lucidity and complete disorientation to time, place, and person memory: Impaired recent and remote memory; may fluctuate between lucidity and confusion personality: Fluctuating; cannot focus attention to converse; alarmed by symptoms (when lucid); hallucinations; paranoid functional status: impaired attention span: Highly impaired; cannot maintain or shift attention psychomotor activity: Variable; alternates between high agitation, hyperactivity, restlessness, and lethargy sleep-wake cycle: Takes brief naps throughout day and night

The World Health Organization (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. - The person has a strong desire to take the drug, difficulty controlling its use, and the need to continue its use despite harmful consequences. - The abuse may become the person's priority in life, resulting in avoidance of responsibilities and leading to a physical withdrawal state

A healthy mental status is needed to

think clearly, respond appropriately, and function effectively in all activities of daily living (ADLs) - 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 settings. - One's mental health may vary from day to day depending on a variety of factors.

Severe warning signs of ALZHEIMER DISEASE

Asking the same question over and over again Repeating the same story, word for word, again and again Forgetting how to cook, or how to make repairs, or how to play cards—activities that were previously done with ease and regularity Losing one's ability to pay bills or balance one's checkbook Getting lost in familiar surroundings or misplacing household objects Neglecting to bathe, or wearing the same clothes over and over again, while insisting that they have taken a bath or that their clothes are still clean Relying on someone else, such as a spouse, to make decisions or answer questions they previously would have handled themselves (WebMD, 2005-2007)

Do you drink caffeinated beverages? If so, how many per day?

Caffeine is a psychostimulant with the potential to increase stress (Lande, 2011). In healthy people, caffeine promotes cognitive arousal and fights fatigue. However, caffeine can produce symptomatic distress in a small subset of the population. A person in this subset is at high risk if he or she consumes enough caffeine, is vulnerable to caffeine, and/or has a pre-existing medical or psychiatric condition (especially mood disorders) that is aggravated by mild psychostimulant use (Arria & O'Brien, 2011; Butt & Sultan, 2011). It has become common for young people to overdose on energy drinks, which can be an especially serious issue in itself but more so if combined with alcohol intake (Pomeranz et al., 2013).

What is your educational level and where are you employed?

Clients from higher socioeconomic levels tend to participate in more healthy lifestyles. They are less likely to smoke and more likely to exercise and eat healthfully. Healthy lifestyles may influence one's ability to more effectively cope with mental disorders.

Sources of Voice and Speech Problems

Dysphonia is voice volume disorder caused by laryngeal disorders or impairment of cranial nerve X (vagus nerve). Cerebellar dysarthria is irregular, uncoordinated speech caused by multiple sclerosis. Dysarthria is a defect in muscular control of speech (e.g., slurring) related to lesions of the nervous system, Parkinson disease, or cerebellar disease. Aphasia is difficulty producing or understanding language, caused by motor lesions in the dominant cerebral hemisphere. Wernicke aphasia is rapid speech that lacks meaning, caused by a lesion in the posterior superior temporal lobe. Broca aphasia is slowed speech with difficult articulation, but fairly clear meaning, caused by a lesion in the posterior inferior frontal lobe.

What is your marital status?

Either healthy or dysfunctional relationships will affect one's mental health status.

Describe a typical day. Does your present health concern affect your activities of daily living? Describe your energy level.

Neurologic and mental illnesses can alter one's responses to activities of daily living (ADLs). Clients with dementia or Alzheimer disease may have trouble performing ADLs. Anxious clients may be restless, while depressed clients may feel fatigued. Clients with eating disorders may exercise excessively. Obsessive-compulsive working habits may cause fatigue leading to impairment of one's mental health.

General Routine Screening

Observe the client's level of consciousness. Observe posture, gait, and body movements Observe behavior and affect Ask the client: Do you drink alcohol? What type, how much, and how often? Do you use illicit drugs? Type, how much and how often? Observe dress and grooming Observe facial expressions Assess speech Observe mood, feelings, and expressions. Observe thought processes and perceptions. Identify possibly self-injurious or suicidal tendencies Assess orientation Assess concentration Assess recent and remote memory

Sometimes the mental status examination is performed with a complete neurologic assessment

Of the neurologic assessments, the mental status examination assesses the highest level of cerebral integration. Many find assessing mental status at the very beginning of the head-to-toe examination advantageous, as it provides clues regarding the validity of the subjective information provided by the client throughout the examination.

substance abuse is

"a set of related conditions associated with the consumption of mind- and behavior-altering substances that have negative behavioral and health outcomes." The National Institute on Drug Abuse (NIDA, 2015) report lists the most abused drugs, which include alcohol and tobacco, cocaine and heroin, hallucinogens, methamphetamine, and many others medically prescribed, over-the-counter, or illegal. Causes for substance abuse are suspected to be a combination of environmental (such as family context, peer behaviors, etc.) and genetic predisposition (NIDA, 2010a).

There are several factors that may influence the client's mental health or put him or her at risk for impaired mental health. These include:

- Economic and social factors, such as rapid changes, stressful work conditions, and isolation - Unhealthy lifestyle choices, such as sedentary lifestyle or substance abuse - Exposure to violence, such as being a victim of child abuse - Personality factors such as poor decision-making skills, low self-concept, poor self-control - Spiritual factors - Cultural factors - Changes or impairments in the structure and function of the neurologic system: for example, cerebral abnormalities often disturb the client's intellectual ability, communication ability, or emotional behaviors - Psychosocial developmental level and issues

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?

- Tension headaches may be seen in clients experiencing stressful situations. - Clients with anxiety disorders may hyperventilate or have palpitations. - The sleep-wake cycle may be reversed in delirium. - - - Decreased sleep and a tendency to awaken early are seen with depression. - Rapid mood swings, anxiety, and fearfulness are seen in delirium. Agitation or a flat affect are seen in dementia, whereas sadness, apathy, irritability, and anxiety are seen in depression. - Fatigue is often seen in depression. - Suicide is between the 8th and 10th leading cause of death in the United States (Rockett & Caine, 2015). Persons at highest risk are those aged 45 years and older (followed by those from age 15 to 24 years, with only a small risk for those younger than 14 years) and white males (followed by Native American and Alaska Native males living in the Western United States), with Montana leading (American Foundation for Suicide Prevention, 2015). Risk for suicide may be seen with or without a psychiatric diagnosis. Sometimes clients with suicidal/homicidal thoughts are reluctant to talk or may even appear despondent. It is important for the client to understand that the nurse is ready to listen and comfortable with discussing any concerns in this area.

focused specialty assessment

- Use the Glasgow Coma Scale (GCS) for clients who have experienced a traumatic brain injury - Use the PHQ-9 (Maurer, 2012) to further assess a client who indicates depression using the PHQ - Use Quick Inventory of Depressive Symptomatology (Self-Report) Box 6-2 to determine whether the client is at risk for depression - Use the Columbia Suicide Severity Rating Scale (CSSRS) for clients to assess for suicide risk - Use the SBIRT (Screening, Brief Intervention, and Referral to Treatment) (SAMSA-HRSA, 2011) tool to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. - Use the CAGE Self-Assessment (Ewing, 1984) to detect alcohol dependence in trauma center populations. - Use the AUDIT questionnaire (Tool 6-1) to assess alcohol-related disorders - Use Geriatric Depression Scale (Chapter 32) if you suspect depression in the older client. - Use Assessment Guide 6-1, the SAD PERSONS Suicide Risk Assessment, to determine the risk factors - Assess abstract reasoning - Use the SLUMS Dementia/Alzheimer's Test Examination (Assessment Tool 6-3) - Assess judgment ability - Assess visual, perceptual, and constructional ability. - To distinguish delirium from other types of cognitive impairment, use the Confusion Assessment Method (CAM)Assessment Tool 6-4

notes

- When assessing the mental status of an older client, be sure first to check vision and hearing before assuming that the client has a mental problem.

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 identifying symptoms. The DSM-5 definition for a mental disorder is a disorder that has the following features

1. A behavioral or psychological syndrome or pattern that occurs in an individual 2. That reflects an underlying psychobiologic dysfunction 3. The consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) 4. Must not be merely an expectable response to common stressors and losses (e.g., the loss of a loved one) or a culturally sanctioned response to a particular event (e.g., trance states in religious rituals) 5. That is not primarily a result of social deviance or conflicts with society

The Confusion Assessment Method (CAM) 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?

Do you drink alcohol? Is so, what type, how much, and how often? Use the SBIRT (Screening, Brief Intervention, and Referral to Treatment) (SAMSA-HRSA, 2011) tool to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. This is the most current recommended tool to use when substance abuse is suspected. The tool is designed for use by physicians, other health workers, and mental health professionals and can be used with clients 12 years of age and older.

Excessive drinking over an extended period can lead to certain types of cancer, liver damage, immune system disorders, and brain damage. It can also aggravate some conditions such as osteoporosis, diabetes, high blood pressure, and ulcers. Drinking in some older adults may cause symptoms of forgetfulness or confusion, which could be mistaken for signs of Alzheimer disease. Sometimes clients try to self-medicate a mental health disorder that has not been diagnosed with drugs or alcohol, especially when they have not been able to afford treatment. The SBIRT tool can be used to assess the client's risk for substance abuse, teach the client about the risks, and make appropriate referrals for treatment.

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 is 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, overly sensitive to environmental stimuli, startled very easily]]; Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma [unarousable]) The diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4.

Mental disorders may affect other body systems when prompt assessment and intervention is delayed.

For example, clients with depression may have decreased or loss of appetite and over time may develop nutritional deficiencies that affect the gastrointestinal system as well as other body systems.

Abnormal Levels of Consciousness

Lethargy: Client opens eyes, answers questions, and falls back asleep. Obtunded: Client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment. Stupor: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. Coma: Client remains unresponsive to all stimuli; eyes stay closed.

Is there a history of mental health problems (anxiety, depression, bipolar disorder, schizophrenia) or Alzheimer disease in your family? How were they treated? Was the treatment effective?

Some psychiatric disorders may have a genetic or familial connection such as anxiety, depression, bipolar disorder and/or schizophrenia, or Alzheimer disease. Effectiveness of past family treatments may give direction for future treatments for this client.

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 the examination, which include assessment of the client's level of consciousness, posture, gait, body movements, dress, grooming, hygiene, facial expressions, behavior and affect, speech, mood, feelings, expressions, thought processes, perceptions, and cognitive abilities. Cognitive abilities include orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability.

What is your name, address, and telephone number?

These answers will provide baseline data about the client's level of consciousness, memory, speech patterns, articulation, or speech defects. Inability to answer these questions may indicate a cognitive/neurologic defect.

Normal aging has common forms of decline that are often mistaken for dementia or resemble dementia.

These include slower thinking, problem solving, learning, and recall; decreased attention and concentration; more distractedness; and need for hints to jog memory. It is important to differentiate dementia from common cognitive changes that occur with age.

How old are you? What is your date of birth? Note if the client is male or female. With which gender do you identify?

This information helps determine a reference point with which the client's psychosocial developmental level and appearance can be compared. Women tend to have a higher incidence of depression and anxiety, whereas men tend to have a higher incidence of substance abuse and psychosocial disorders. Apparent male or female characteristics may not reflect a person's gender identity.

Mental status refers to

a client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability). One cannot be totally healthy without "mental health." Mental health is an essential part of one's total health and is more than just the absence of mental disabilities or disorders.

The World Health Organization (WHO, 2014) states: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

WHO further defines mental health as "a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community."

Alzheimer Disease (AD)

etiology: Early-onset (familial, genetic [chromosomes 14, 19, 21]), Late-onset sporadic—etiology unknown risk factors: Advanced age; genetics occurrence: 70% of dementias onset: slow age of onset: Early-onset AD: 30s-65 years, Late-onset AD: 65+ years, Most commonly: 85+ years gender: Males and females equally course: Chronic, irreversible; progressive, regular, downhill duration: 2-20 years symptoms progress: Onset insidious: Early—mild and subtle, Middle and late—intensified, Progression to death (infection or malnutrition) mood: Depression common speech/language: Speech remains intact until late in disease: Early—mild anomia (cannot name objects); deficits progress until speech lacks meaning; echoes and repeats words and sounds; mutism

Assessment of mental status is accomplished by

interviewing the client and observing his or her behaviors - Important verbal and behavioral clues about mental status can be assessed from the very outset and throughout the entire duration of your interaction with the client.

Dementia

is not a disease but a set of symptoms associated with the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person's daily life. The cognitive changes occur because of brain diseases or trauma and can have a rapid or a gradual onset. Memory loss is a common symptom of dementia, although memory loss by itself does not mean a person has dementia. - Alzheimer disease, the most common cause of dementia of the elderly, results from gradual destruction of brain nerve cells and a shrinking brain. The Alzheimer's Association describes three states of Alzheimer disease: Stage 1, preclinical, Stage 2, mild cognitive impairment, and Stage 3, dementia of Alzheimer disease

Use the SLUMS Dementia/Alzheimer Test Examination (Assessment Tool 6-3) if time is limited and a quick measure is needed to evaluate cognitive function. If further assessment is needed to distinguish delirium from other types of cognitive impairment, use the Confusion Assessment Method (CAM; see Assessment Tool 6-4).

normal: - 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. abnormal: - For clients with a high school education, a score of 20-27 indicates mild cognitive impairment (MCI) and for clients with less than a high school education, a score of 14-19 indicates MCI. For clients with a high school education, a score of 1-19 indicates dementia and for clients with less than a high school education, a score of 1-14 indicates dementia. - Over half a million people in the United States have young-onset dementia and another half million have MCI, a precursor of dementia (Hunt, 2011). - A diagnosis of delirium by CAM requires the presence of features 1 and 2 and either 3 or 4 under the CAM Diagnostic Algorithm

Assess judgment. Ask the client, "What do you do if you have pain?" or "What would you do if you were driving and a police car was behind you with its lights and siren turned on?"

normal: - Answers to questions are based on sound rationale. abnormal: - Impaired judgment may be seen in organic brain syndrome, emotional disturbances, mental retardation, or schizophrenia.

Assess remote memory. Ask the client: "When did you get your first job?" or "When is your birthday?" Information on past health history also gives clues as to the client's ability to recall remote events.

normal: - Client correctly recalls past events. abnormal: - Inability to recall past events is seen in cerebral cortex disorders.

Assess abstract reasoning. Ask the client to compare objects. For example, "How are an apple and orange the same? How are they different?" Also ask the client to explain a proverb. For example, "A rolling stone gathers no moss" or "A stitch in time saves nine."

normal: - Client explains similarities and differences between objects and proverbs correctly. The client with limited education can joke and use puns correctly. abnormal: - Inability to compare and contrast objects correctly or interpret proverbs correctly is seen in schizophrenia, mental retardation, delirium, and dementia.

Observe thought processes and perceptions. Observe thought processes for clarity, content, and perception by inquiring about client's thoughts and perceptions expressed. Use statements such as "Tell me more about what you just said" or "Tell me what your understanding is of the current situation or your health."

normal: - Client expresses full, free-flowing thoughts; follows directions accurately; expresses realistic perceptions; is easy to understand and makes sense; does not voice suicidal/homicidal thoughts. abnormal: - Abnormal processes include persistent repetition of ideas, illogical thoughts, interruption of ideas, invention of words, or repetition of phrases, as in schizophrenia; rapid flight of ideas, repetition of ideas, and use of rhymes and punning, as in manic phases of bipolar disorder; continuous, irrational fears, and avoidance of an object or situation, as in phobias; delusion, extreme apprehension; compulsions, obsessions, and illusions are also abnormal. Confabulation (making up of answers to cover for not knowing) is seen in Korsakoff syndrome. Also seen in cognitive deficits/decline (Alzheimer's and other dementias).

Assess use of memory to learn new information. Ask the client to repeat four unrelated words. The words should not rhyme and they cannot have the same meaning (e.g., rose, hammer, automobile, brown). Have the client repeat these words in 5 minutes, again in 10 minutes, and again in 30 minutes.

normal: - Client is able to recall words correctly after a 5-, a 10-, and a 30-minute period. abnormal: - Inability to recall words after a delayed period is seen in anxiety, depression, or dementia—Alzheimer's is one type of dementia.

If the client does not respond appropriately, call the client's name and note the response. If the client does not respond, call the name louder. If necessary, shake the client gently. If the client still does not respond, apply a painful stimulus. - When assessing level of consciousness, always begin with the least noxious stimulus: verbal, tactile, to painful.

normal: - Client is alert and awake, with eyes open and looking at examiner. Client responds appropriately. abnormal: - Abnormal Findings 6-1 describes abnormal levels of consciousness. Client with lesions of the corticospinal tract draws hands up to chest (decorticate or abnormal flexor posture) when stimulated (Fig. 6-4). Client with lesions of the diencephalon, midbrain, or pons extends arms and legs, arches neck, and rotates hands and arms internally (decerebrate or abnormal extensor posture) when stimulated

Observe the client's level of consciousness. Ask the client his or her name, address, and phone number. Ask the client to identify where you currently are (e.g., hospital, clinic), the day, and the approximate time of day

normal: - Client is alert and oriented to person, place, time and events. Responds to your questions and interacts appropriately. Makes and maintains eye contact and conversation. Asks and answers questions appropriately. abnormal: - Client is not alert to person, place, day or time; does not make or maintain eye contact; does not respond appropriately.

Assess orientation. Ask for the client's name and names of family members (person), the time such as hour, day, date, or season (time), and where the client lives or is now (place) - When assessing orientation to person, place, time, and events, remember that orientation to time is usually lost first and orientation to person is usually lost last.

normal: - Client is aware of self, others, time, home address, and current location. Client is oriented to person, place, time and events. abnormal: - Reduced degree of orientation may be seen with organic brain disorders or psychiatric illness such as withdrawal from chronic alcohol use or schizophrenia. (Note: Schizophrenia may be marked by hallucinations—sensory perceptions that occur without external stimuli—as well as disorientation.)

Observe behavior and affect.

normal: - Client is cooperative and purposeful in his or her interactions with others. Affect is appropriate for the client's situation. Mild to moderate anxiety may be seen in a client who is apprehensive about having a health assessment performed. abnormal: - Uncooperative, bizarre behavior may be seen in the angry, mentally ill, or violent client. Anxious clients are often fidgety and restless. Some degree of anxiety is often seen in ill clients. Apathy or crying may be seen with depression. Incongruent behavior may be seen in clients who are in denial of problems or illness. Prolonged, euphoric laughing is typical of mania.

Observe dress and grooming. Keep the examination setting and the reason for the assessment in mind as you note the client's degree of cleanliness and attire. For example, if the client arrives directly from home, he or she may be neater than if he or she comes to the assessment from the workplace.

normal: - Dress is appropriate for occasion and weather. Dress varies considerably from person to person, depending on individual preference. There may be several normal dress variations depending on the client's developmental level, age, socioeconomic level, and culture or subculture. abnormal: - Unusually meticulous grooming and finicky mannerisms may be seen in obsessive-compulsive disorder. Poor hygiene and inappropriate dress may be seen with organic brain syndrome. Bizarre dress and exaggerated makeup/cosmetics may be seen in schizophrenia or manic disorders. Extreme unilateral neglect may result from a lesion due to a cerebral vascular accident (CVA). - Uncoordinated clothing, extremely light clothing, or extremely warm clothing for the weather conditions may be seen on mentally ill, grieving, depressed, or poor clients. This may also be noted in clients with heat or cold intolerances. Extremely loose clothing held up by pins or a belt may suggest recent weight loss. - Clients wearing long sleeves in warm weather may be protecting themselves from the sun or covering up needle marks secondary to drug abuse. Soiled clothing may indicate homelessness, vision deficits in older adults, or mental illness.

Use the Glasgow Coma Scale (GCS) for clients who have experienced a traumatic brain injury - The GCS 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 (ICU) comatose patients

normal: - GCS score of 15 indicates an optimal level of consciousness. abnormal: - GCS score of less than 15 indicates some impairment in the level of consciousness. A score of 3, the lowest possible score, indicates deep coma.

Use Box 6-1: Quick Inventory of Depressive Symptomatology (Self-Report) to determine whether the client is at risk for depression and needs to be referred to a primary care health provider for further evaluation.

normal: - Inventory scores of 0-5 = No risk of depression abnormal: - Inventory scores of 6-10 = Mild 11-15 = Moderate 16-20 = Severe 21-27 = Very severe

Use Assessment Guide 6-1, the SAD PERSONS Suicide Risk Assessment, to determine the risk factors the client may have that may put him or her at risk for suicide.

normal: - No risk factors present on the SAD PERSONS factors. abnormal: - Evaluate any risk factors on the SAD PERSONS. Suicide is the 10th leading cause of death in the United States for all ages and is four times more prevalent in men. Firearms accounted for 17,352 deaths, suffocation 8,161 deaths, and poisoning 6,358 deaths (CDC, 2015). Women attempt suicide more frequently. Men are more successful. - Older, single/widowed, Caucasian males are at greatest risk for suicide.

Assess recent memory. Ask the client "What did you have to eat today?" or "What is the weather like today?"

normal: - Recalls recent events without difficulty. abnormal: - Inability to recall recent events is seen in delirium, dementia, depression, and anxiety.

Assess speech. Note tone, clarity, and pace of speech. - Speech is largely influenced by experience, level of education, and culture. First, always assess the client's skill with English or the language being used for the assessment.

normal: - Speech is in a moderate tone, clear, with moderate pace, and culturally appropriate. abnormal: - Slow, repetitive speech is characteristic of depression or Parkinson disease. Loud, rapid speech may occur in manic phases of bipolar disorder. Disorganized speech, consistent (nonstop) speech, or long periods of silence may indicate mental illness or a neurologic disorder (e.g., dysarthria, dysphasia, speech defect, garbled speech).

Observe hygiene. Consider normal level of hygiene for the client's developmental level, socioeconomic status, and ethnic/cultural background.

normal: - The client is clean and groomed appropriately for occasion. Stains on hands and dirty nails may reflect certain occupations such as mechanic or gardener. abnormal: - A dirty, unshaven, unkempt appearance with a foul body odor may reflect depression, drug abuse, or low socioeconomic level (i.e., homeless client). Poor hygiene may be seen in dementia or other conditions and may indicate a self-care deficit. If others care for the client, poor hygiene may reflect neglect by caregiver or caregiver role strain. Breath odors from smoking or from drinking alcoholic beverages may be noted.

Observe posture, gait, and body movements.

normal: - The client is relaxed, with shoulders and back erect when standing or sitting. Gait is rhythmic and coordinated, with arms swinging at sides. abnormal: - Slumped posture may reflect feelings of powerlessness or hopelessness characteristic of depression or organic brain disease. Bizarre body movements and behavior may be noted in schizophrenia or may be a side effect of drug therapy or other activity. Tense or anxious clients may elevate their shoulders toward their ears and hold the entire body stiffly. - In the older adult, purposeless movements, wandering, aggressiveness, or withdrawal may indicate neurologic deficits.

Use the PHQ-9 (Maurer, 2012) to further assess a client who indicates depression using the PHQ 2.

normal: - Using the PHQ-2, a threshold score of less than 2. abnormal: - Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression (Arroll et al., 2010).

AD cont.

personality: Apathy, indifference, irritability: Early disease—social behavior intact; hides cognitive deficits, Advanced disease—disengages from activity and relationships; suspicious; paranoid delusions caused by memory loss; aggressive; catastrophic reactions functional status: Poor judgment in everyday activities; has progressive decline in ability to handle money, use telephone, use computer and other electronic devices, function in home and workplace attention span: Distractible; short attention span Psychomotor activity: Wandering, hyperactivity, pacing, restlessness, agitation sleep-wake cycle: Often impaired; wandering and agitation at nighttime

Identify possibly self-injurious or suicidal tendencies in client's thought processes and perceptions by asking, "How do you feel about the future?" or "Have you ever had thoughts of hurting yourself or doing away with yourself?" or "How do others feel about you?" Have you ever thought about hurting yourself or someone else? If suicidal thoughts seem evident, use the Columbia Suicide Severity Rating Scale (CSSRS) to assess for suicide risk if not used during the interview

normal: - Verbalizes positive, healthy thoughts about the future and self. Answers no to all questions related to suicidal ideation, suicidal behaviors, and both suicidal ideation and behavior. abnormal: - Clients who are suicidal may share past attempts at suicide, give plan for suicide, verbalize worthlessness about self, joke about death frequently. Clients who are depressed or feel hopeless are at higher risk for suicide. Clients who have depression early in life have a twofold increased risk for dementia Clients undergoing hemodialysis often have depression and suicidal ideation (Andrade et al., 2015). Suicidal ideation: A "yes" answer at any time during treatment to any one of the five suicidal ideation questions (categories 1-5) on the C-SSRS. Suicidal behavior: A "yes" answer at any time during treatment to any one of the five suicidal behavior questions (categories 6-10) on the C-SSRS. Suicidal ideation or behavior: A "yes" answer at any time during treatment to any one of the 10 suicidal ideation and behavior questions (categories 1-10) on the C-SSRS.