MENTAL STATUS NCM 101

• Functional assessment


  Measures an individual's level of function and ability to perform specific tasks on a safe and dependable basis over a defined period
• Purpose of functional assessment


  For the nurse to learn how the client functions in terms of daily activities
• Two Categories of Functional Assessment

  • Physical Activities of Daily Living (ADLs)
  • Instrumental Activities of Daily Living (IADLs)
• Physical Activities of Daily Living (ADLs)


  A collective term for all the basic skills you need in regular daily life, indicating your ability to care for yourself without assistance
• Physical ADLs


  • Bathing
  • Dressing
  • Toileting
  • Transfers
  • Continence
  • Feeding
  • Managing Money
• Instrumental Activities of Daily Living (IADLs)

  More complex activities that are essential to live independently in the community, not needed every day unlike ADLs
• Instrumental ADLs


  • Using the telephone
  • Shopping
  • Preparing food
  • Housekeeping
  • Laundry
  • Transportation
  • Taking medicine
• Functional Assessment


  1. Is the client independent or dependent in doing his or her activities of daily living?

  2. How to elicit such data: Open-ended questions
• Mental status


  Refers to a client's level of cognitive functioning (thinking, knowledge, problem solving) and emotional functioning (feelings, mood, behaviors, stability)
• Mental status is reflected in one's appearance, behaviors, speech, thought patterns, decisions, and ability to function effectively in relationships
• 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 neurologic system
  • Psychosocial developmental level and issues
• Mental Status Examination (MSE)


  A structured assessment of client's behavioural and cognitive functioning, a vital component of nursing care that assists with evaluation of mental health conditions
• 4 Major Components of Mental Status Examination

  • Appearance
  • Behavior
  • Cognition
  • Thought Process
• Appearance


  Includes posture, body movements, dress, grooming and hygiene
• Behavior


  Includes level of consciousness, facial expression, speech, mood and affect
• Cognitive Function


  Includes orientation, attention span, recent and remote memory
• Thought Processes and Perceptions


  Includes thought process, thought content, perception, suicidal thoughts
• Erik Erikson's Stages of Psychosocial Development


  Personality develops in a predetermined order through eight stages, with each stage involving a psychosocial crisis that can positively or negatively affect personality development
• Erik Erikson's Stages of Psychosocial Development

  • Infant (Basic trust vs. mistrust)
  • Toddler (Autonomy vs. shame and doubt)
  • Preschooler (Initiative vs. guilt)
  • School-aged child (Industry vs. inferiority)
  • Adolescent (Identity vs. role confusion)
  • Young Adult (Intimacy vs. isolation)
  • Middle-aged adult (Generativity vs. stagnation)
  • Older adult (Ego integrity vs. despair)
• Jean Piaget's Stages of Cognitive Development


  A child's knowledge and understanding of the world develops over time as they interact with the world around them, with each stage having a goal a child should achieve
• Jean Piaget's Stages of Cognitive Development

  • Sensorimotor Stage (0-2 yrs) - Object Permanence
  • Pre Operational Stage (2-7 yrs) - Symbolic Thought
  • Concrete Operational Stage (7-11 yrs) - Operational thought
  • Formal Operational (12+ years) - Abstract Concept
• Sensorimotor stage (ages 0-2)


  A child uses sensory and motor abilities to experience and learn about the world, developing problem-solving skills and mental images, with the main goal being understanding object permanence
• Pre Operational stage (ages 2-7)


  A child continues to use mental representations, such as symbolic thought and language, but is egocentric with little awareness of others, the main goal being symbolic thought
• Concrete Operational stage (ages 7-11)


  A child develops an understanding of the outside world and others' perceptions, using logical operations when problem-solving, the main goal being operational thought
• Formal Operational stage (ages 12+)


  Adolescents develop abstract logical and moral reasoning, able to analyze their environment and grasp abstract concepts, the main goal being understanding abstract concepts
• Lawrence Kohlberg's Stages of Moral Development


  Focuses on the thinking process that occurs when deciding whether a behaviour is right or wrong, with three levels and six stages of moral development
• Pain is an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage
• Right


  That which is acceptable to and approved by the self. When actions satisfy one's needs, they are "right."
• Level II: Conventional


  Cordial interpersonal relationships are maintained (able to see victim's perspective)
• Age 10 to 13, but can go into adolescence


  Approval of others is sought through one's actions
• Stage 3: Good boy/girl orientation


  Authority is respected
• Stage 4: Law-and-order orientation


  Individual feels "duty-bound" to maintain social order. Behavior is "right" when it conforms to the rules.
• Level III: Postconventional


  Adolescence and beyond. Individual understands the morality of having democratically established laws (underlying ethical principles are considered that include societal needs).
• Stage 5: Social contract orientation


  It is "wrong" to violate others' rights
• Stage 6: Hierarchy of principles orientation


  Judgments based on principles of justice, respect for dignity or human beings as individuals – Do to others as you would have them do to you.
• Pain is whatever the person says it is (Mc Caffery and Pasero, 1999)
• Pain


  • An unpleasant sensory and emotional experience, which we primarily associated with tissue damage or describe in terms of such damage (International Association for the Study of Pain, 2011)
  • Most common form of discomfort that a human being may experience. It can have a significant impact on individual's health including physical well being, mental status, social status and spiritual dimension
• Factors Affecting Pain


  • Age
  • Sex
  • Childhood
  • Cultural Background
  • Psychological Factors
  • Religious Beliefs
  • Expected Response
  • Setting
  • Diagnosis
  • Physical/Mental Health
  • Previous Experience
• Pattern Theory


  It states that pain is perceived whenever the stimulus is intense enough
• Specificity Theory


  It states that there are specific nerve receptors for particular stimuli e.g. nociceptors for noxious stimuli,; thermoreceptors for heat or cold; mechanoreceptors for pressure, pulling or tearing sensation; chemoreceptors for chemicals