Components of mental status
What does the ABCT stand for
Appearance
Behavior
Cognition
Thought process
stupor/semi-coma
spontaneously unconscious but responds to pain or stimulation
Dysphonia
abnormal volume/pitch horse and whisper only
Blocking
Word salad
sudden interruptions
mix of words or phrases
what is important to know about screening
Happens during the health history
Integration dysfunction (effects daily living) and daily living
Organic (have you had a traumatic brain injury, hormone imbalances) vs. Psychiatric (feelings, cognitive behavior)
Mental statues is not only mental health
What should be looked for when assessing A
Posture
body movements
dresses
grooming/hygiene
pupils
lethargic/somnolent
Slow moving, overly tired
Dysarthria
distorted speech but basic language is intact
Confabulation
Echolalia
fabricates events, gaps in memory so brain fills in the missing parts
imitation or repetition of words like an echo
What is asked/looked for in a comprehensive exam (done if needed after the screening)
Personal and other concerns
Physiological
Signs and symptoms of disorders
Substance abuse of violence
What should be looked at when assessing B
LOCs
facial expression
speech
mood/affect
obtunded
sleepy, confused when aroused, needs to have continuous stimulation to stay awake
Aphasia (global)
global=absent/reduced speech
Neologism
person comes up with new words for everything
Developmental competence with aging
You do not get stupider when you grow old
Longer response time
Recent memory may be impacted (decreased)
Age-related sensory changes (vision and hearing decreases)
What should be looked at when assessing C
Orientation
attention span
memory
new learning
abstract reasoning
coma
unconscious, no response to pain or stimulation
Aphasia (broca/expressive)
Broca/expressive=understands, cannot express or talk back
Circumlocution
roundabout way to come to the word you are thinking when can't think of the word (pass me that thingy that is round filled with water)
What is a mental status assessment and key points to know
Emotional , feelings cognitive function
Relative and ongoing
Everyone gets a mental assessment!!!
What should be looked at when assessing T
Judgement
Hallucinations
List abnormal LOC from less serious to most serious
1.lethargic/ somnolent
2. obtunded
3.stupor/semi-coma
4.coma
Aphasia (wernicke/receptive)
Wernicke/receptive= cannot relate words or speech to their meaning but may be able to speak
Flight of ideas
skipping from one topic to another rapidly
Screen for suicidal thoughts
When a person exhibits S/S of depression you need to assess for suicidal ideations
Need to be confrontational and direct w/ patient (do you feel like hurting yourself, do you have plans...)
Asking does not increase thoughts
24-48 hours is the highest risk time
Always report SI
Implement suicide precautions to facility guideline