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NR 509 Final Study Guide
Behavior/Mental Health Assessment and Modification for Age
- Assessmen t: a. b. Many mental health d_is_orders are masked by other clinical conditions; 20% of primary care outpatients have mental d_is_orders(50-70% go undetected and untreated) c. Physical symptoms account for approx 50% of office v_is_its d. ⅓ of physical symptoms are unexplained; in 20-25% those symptoms become chronic e. Symptoms and Behaviors: i. Sorting symptom is a challenge; can be unexplained symptoms 1. Patients who have unexplained symptoms depression and anxiety exceeds 50% ii. Physical or “somatic” symptoms account for 50% of U.S. office v_is_its
- Pain, fatigue, palpitations, GI symptoms, sexual dysfunction, dizziness or loss of balance
- Symptoms that present as clusters are called “functional syndromes” such as IBS, fibromyalgia, chronic fatigue, TMJ d_is_order, and multiple chemical sensitivity
- The presence of symptom overlap is high in the common functional syndromes such as fatigue, headache, sleep d_is_turbance, pain, GI upset iii.Patients with unexplained and somatic symptoms are often frequent users of the health care system and termed “difficult patients” iv.Patients with symptoms that last longer than 6 weeks are recognized as chronic and should be screened for depression and anxiety. a. A two tiered approach is recommended for screening. A brief screening with questions that yield high sensitivity then a more detailed investigation when indicated V. Patient who warrant a mental health screening include:
- medically unexplained physical symptoms
- Multiple physical or somatic symptoms
b. Abnormal: unaware of person, place, or time
- Perception: a. Normal: Sensory awareness of objects in the environment b. Abnormal: hallucinations
- Thought Process: a. Normal: logic, coherent, and relevant thoughts b. Abnormal: irrational thought
- Thought Content: a. Normal: Has insight and judgement b. Abnormal: impaired judgement and irrational behaviors
- Insight a. Normal: able to d_is_tingu_is_h normal vs. abnormal b. Abnormal: Unable to d_is_tingu_is_h normal vs. abnormal
- Judgement a. Normal: good judgement b. Abnormal: poor or bad F· Speech Patterns
- Note characters of speech a. Slow speech= depression b. Accelerated and Loud speech= mania c. Articulation: are the words clear and d_is_tinct; does the speech have a nasal quality i. Dysarthria(defective articulation) ii. Dysphonia-impaired volume, quality or pitch iii. Aphasia-d_is_order of speech d. Fluency: reflects rate, flow and melody of speech and the content and words used. Abnormalities include i. Hesitancies and gaps in flow ii. D_is_turbed inflections such as monotone iii. Circumlocutions, in which phrases or sentences are substituted for a word the person cannot think of ie. “what you write with” instead of “pen” iv. Paraphrasias, words are mal_for_med(“I write with a den”), wrong (I write with a bar) or made up (I write with a dar) v. Fluency abnormalities indicate aphasia from cerebrovascular infarction. vi. Aphasia may be receptive(impaired comprehension with fluent speech) OR expressive(with preserved comprehension and slow nonfluent speech)
vii. A person who can write a correct sentence does NOT have aphasia e. Testing for Aphasia i. Word Comprehension: Ask the patient to follow one-stage commands such as “Point to your nose” ii. Repetition: Ask the patient to repeat a phrase of one- syllable words “ No ifs, ands, or buts” iii. Naming: Ask the patient to name the parts of a watch iv. Reading Comprehension: Ask the patient to read a paragraph aloud v. Writing: Ask the patient to write a sentence · Mental Status Examination
- Five components of the mental status examination a. Appearance and Behavior i. Note level of consciousness: is the patient awake and alert, does the patient understand your questions and respond appropriately 1. If the patient does not respond then speak to the patient by name in a loud voice 2. Lethargic patients are drowsy but open their eyes and look at you, respond to questions, then fall back asleep 3. Obtunded patients open their eyes and look at you but respond slowly and are somewhat confused ii. Note posture and motor behavior:does the patient sit or lie quietly or prefer to walk around; note the pace, range, and type of movement 1. Look for tense posture, restlessness, and anxious fidgeting; the crying, pacing, and hand wringing of agitated depression 2. The hopeless slumped posture and slowed movement of depression 3. The agitated and expansive movements of manic ep_is_odes iii. Note Dress, Grooming, and Personal hygiene: how is the patient dressed, clean and presentable?, how is grooming compared to those of similar age, compare one side to the other 1. May deteriorate in depression, schizophrenia, and dementia 2. Excessive fastidiousness may be seen OCD 3. One-sided negligence may result from a lesion in the opposite parietal cortex; usually the non-dominant side
3. Flight of Ideas: a continuous flow of accelerated speech with abrupt changes from one topic to the next; most frequently seen in manic ep_is_odes 4. Neolog_is_ms: Invented or d_is_torted words, or words with new and highly idiosyncratic meanings; observed in schizophrenia, psychotic d_is_orders, and aphasia 5. Incoherence: Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or d_is_ordered grammar or word use. Flight of ideas, when severe, may produce incoherence. Seen in severe psychotic d_is_turbances usually schizophrenia 6. Blocking: Sudden interruption of speech in mid sentence or be_for_e the idea is completed, attributed to “losing the thought.” Blocking occurs in normal people. May be striking in schizophrenia 7. Confabulation: Fabrication of facts or events in response to ques- tions, to fill in the gaps from impaired memory. Seen in Korsakoff syndrome from alchol_is_m 8. Perseveration: Pers_is_tent repetition of words or ideas Occurs in schizophrenia and other psychotic d_is_orders 9. Echolalia:Repetition of the words and phrases of others. Occurs in manic ep_is_odes and schizophrenia 10. Clanging: Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. for example, “Look at my eyes and nose, w_is_e eyes and rosy nose. Two to one, the ayes have it!” Seen in schizophrenia and manic ep_is_odes ii. Thought Content: to assess follow patients cues rather than asking direct questions; “Can you tell me more about that” or “What do you think about times like these?” Abnormalities in content include 1. Compulsions: Repetitive behaviors that the person feels driven to per_for_m in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation; these behaviors are excessive and unreal_is_tically connected to the provoking stimulus 2. Obsessions: Delusions 3. Recurrent pers_is_tent thoughts, images, or urges experienced as intrusive and unwanted that the person tries
to ignore, suppress, or neutralize with other thoughts or actions (for example, per_for_ming a compulsive behavior)
4. Phobias :Pers_is_tent irrational fears, accompanied by a compelling desire to avoid provoking stimulus 5. Anxieties: Apprehensive anticipation of future danger or m_is for_tune accompanied by feelings of worry, d_is_tress, and/or somatic symptoms of tension 6. Feelings of Unreality: A sense that the environment is strange, unreal, or remote 7. Feelings of Depersonalization:A sense that one’s self or identity is different, changed, unreal; lost; or detached from one’s mind or body 8. Delusions: False fixed personal beliefs that are not amenable to change in light of conflicting evidence; types of delusions include: a. ● Persecutory ● Grandiose ● Jealous ● Erotomanic— the belief than another person is in love with the individual ● Somatic—involves bodily functions or sensations ● Unspecified—includes delusions of reference without a prominent persecutory or grandiose component, or the belief that external events, objects, or people have a particular and unusual personal significance (for example, commands from the radio or telev_is_ion) 9. Compulsions, obsessions, phobias, and anxieties often occur in anxiety **d_is_orders.
- Delusions and feelings of unreality or** depersonalization are often associated with **psychotic d_is_orders
- Delusions may also occur in delirium,** severe mood d_is_orders, and dementia iii. Perceptions: Purse false perceptions, “When you heard the voice speaking to you, what did you say?” Abnormalities in perception include 1. Illusions: M_is_interpretations of real external stimuli, such as m_is_taking rustling leaves for the sound of voices. Illu_is_ions may occur in grief reactions, delirium, acute and posttraumatic stress d_is_orders, and schizophrenia 2. Hallucinations: Perception-like experiences that seem real but, unlike illusions, lack actual external stimulation. The person may or may not recognize the experiences as false. Hallucinations may be auditory, v_is_ual, olfactory, gustatory, tactile, or somatic. False perceptions associated with dreaming, falling asleep, and awakening are not classified as hallucinations. Hallucinations may occur in
Start with simple questions, then move to more difficult questions. Note the person’s grasp of in_for_mation, complexity of the ideas, and choice of vocabulary. In_for_mation and vocabulary are rela- tively unaffected by psychiatric d_is_orders except in severe cases. Testing helps d_is_tingu_is_h adults with life-long intellectual impairment (whose in_for_- mation and vocabulary are limited) from those with mild or moderate dementia (whose in_for_mation and vocabulary are fairly well preserved). ii. Calculating Ability: Test ability to do arithmetical calculations; start with simple addition, or pose practical functionally important questions such as if something cost 78 cents and you give the clerk $1 how much change should your receive Poor per_for_mance suggests dementia or aphasia, but should be measured against the patient’s fund of knowledge and education. iii. Abstract Thinking: ask the patient about what certain proverbs mean or explain the similarity between two things such as an apple and orange. Concrete responses are common in people with intellectual d_is_ability, delirium, or dementia, but may also reflect limited education. Patients with schizophrenia may respond concretely or with personal and bizarre interpretations iv. Constructional Ability: ability to copy figures of increasing complexity onto a piece of blank unlined paper. With intact v_is_ion and motor ability, poor constructional ability suggests dementia or parietal lobe damage. Intellectual d_is_ability can also impair per_for_mance. i. Special Techniques for the Mental Exam i. Mini-Mental State Examination: brief test used to screen for cognitive dysfunction or dementia, and follow the patients course over time j. Recording Your Findings i. Example of normal findings: The patient is alert, well- groomed, and cheerful. Speech is fluent and words are clear. Thought processes are coherent, insight is good. The patient is oriented to person, place, and time. Serial 7s accurate; recent and remote memory intact. Calculations intact. ii. Example of findings that suggest dementia : “The patient appears sad and fatigued; clothes are wrinkled. Speech is
slow and words are mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed. Clock drawing is good. · Screening for Depression: BECKY PECK Generalized Anxiety D_is_order: WONGEL MARKOS Depressive D_is_orders: CRYSTAL SHAGENA/Ada Ejimadu Depressive D_is_orders ( pg 156) Ada Ejimadu Depression and anxiety d_is_orders are a common cause of hospitalization in the United States, and mental illness is associated with increased r_is_ks for chronic medical conditions, decreased life expectancy, d_is_ability, substance abuse, and suicide. About 19million adult American or almost 7% have major depression with other co- ex_is_ting anxiety d_is_order or substance abuse. Depression is as common in women as men, and the prevalence of postpartum depression is about 7% to 13%. Most patients with chronic medical conditions have depression. Symptoms of depression in high-r_is_k patients may be subtle and may include; I. Low self-esteem II. Loss of pleasure in daily activities (Anhedonia) III. Sleep d_is_order, IV. Difficulty concentrating or making dec_is_ions. Look carefully for symptoms of depression in vulnerable patients, especially those who are young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have other psychiatric d_is_orders, including substance abuse. A personal or family h_is_tory of depression also places patients at r_is_k. Asking two simple questions about mood and anhedonia appears to be as
interviews. Failure to diagnose depression can have fatal consequences— the presence of an affective d_is_order is associated with an 11-fold increased r_is_k for suicide. Depression screening · Over the past 2 weeks, have you felt down, depressed, or hopeless? · Over the past 2 weeks, have you felt little interest or pleasure in doing things ·(anhedonia)? Depression tends to be long-lasting and can recur. Because of these two factors, a wait- and-see approach to treatment is not desirable and timely treatment is necessary.
Suicide
I. Suicide is the second leading cause of death among 15- to 24-year olds. II. Suicide rates are highest among those ages 45 to 54 years, III. followed by elderly adults ≥age 85 years. IV. Men have suicide rates nearly four times higher than women, though women are three times more likely to attempt suicide. V. Men are most likely to use firearms to commit suicide, VI. while women are most likely to use po_is_on. VII. Overall, suicides in non-H_is_panic whites account for about 90% of all suicides. VIII. American Indian/Alaska Native women ages 15 to 24 years have the highest suicide rates of any racial/ethnic group.
Substance Use D_is_orders, Including Alcohol and Prescription
Drugs.
The harmful interactions between mental d_is_orders and substance use d_is_orders also present a major public health problem. Rates of drug-induced deaths continue to increase and are highest among whites and American Indian/Alaska Natives. The Centers for D_is_ease Control and Prevention reports that prescription drugs have replaced illicit drugs as a leading cause of
drug-induced deaths. Every
to volume in the venous system. The JVP is best assessed from pulsations in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium. The internal jugular veins lie deep to the SCM muscles in the neck and are not directly v_is_ible. (See Figure 9-24 pg375) Pulsations in the right external jugular vein can also be used, but the route from the vena cava is more tortuous, and examination can be impaired by kinking and obstruction at the base of the neck and by obesity. Note that the jugular veins and pulsations are difficult to see in children under 12 years of age, so inspection is not useful in th_is_ age group. The DOMINENT MOVEMENT of the JVP is INWARD vs the CAROTID PULSE MOVEMENT is OUTWARD!
- Identify the highest point of pulsation in the right jugular vein. Extend a long rectangular object or card horizontally from th_is_ point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical d_is_tance in centimeters above the sternal angle where the horizontal object crosses the ruler and add to th_is_ d_is_tance 5 cm, the d_is_tance from the sternal angle to the center of the right atrium. The sum is the JVP. -JVP measured at >3 cm above the sternal angle, or more than 8 cm in total d_is_tance above the right atrium, is considered elevated above normal. -Carotid Upstroke- View figure 9-27 on page 379. The first elevation, the presystolic a wave, reflects the
slight r_is_e in atrial pressure that accompanies atrial contraction. It occurs just prior to S1 and be_for_e the carotid upstroke. The normal upstroke is br_is_k; it is smooth, rapid, and follows S1 almost immediately. The timing of the carotid upstroke in relation to S1 and S2. Note that the normal carotid upstroke follows S1 and precedes S2. -Carotid Bruits- The carotid pulse provides valuable in_for_mation about cardiac function, especially aortic valve stenos_is_ and regurgitation. Press just inside the medial border of a relaxed SCM muscle. Never palpate both carotid arteries at the same time. Th_is_ may decrease blood flow to the brain and induce syncope. Auscultate both the carotid arteries to l_is_ten for a bruit, a murmur- like sound ar_is_ing from turbulent arterial blood flow. Ask the patient to stop breathing for ∼15 seconds, then l_is_ten with the diaphragm of the stethoscope, which generally detects the higher frequency sounds of arterial bruits better than the bell. 3.) Palpate and describe the apical impulse (PMI). -To assess the PMI and extra heart sounds such as S3 or S4, ask the patient to turn to the left side, termed the left lateral decubitus position—th_is_ brings the ventricular apex closer to the chest wall. To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic
increases the interval between A2 and P2, and d_is_appears on expiration. In some patients, especially younger ones, S2 may not become single on expiration until the patient sits up. -Paradoxical Splitting: Paradoxical or reversed splitting refers to splitting that appears on expiration and d_is_appears on inspiration. Closure of the aortic valve is abnormally delayed so that A2 follows P2 in expiration. Normal inspiratory delay of P2 makes the split d_is_appear. The most common cause is left bundle branch block. 7.) Auscultate and recognize abnormal sounds in early diastole, including an S3and OS of mitral stenos_is_. -The opening snap (OS) is a very early diastolic sound caused by abrupt deceleration during the opening of a stenotic mitral valve. It is best heard just medial to the apex and along the lower left sternal border. If loud, an OS radiates to the apex and to the pulmonic area, where it may be m_is_taken for the pulmonic component of a split S2. Its high pitch and snapping quality help to d_is_tingu_is_h it from an S2, but it becomes less audible as the valve leaflets become more calcified. It is heard better with the diaphragm. -You will detect physiologic S3 frequently in children and young adults to the age of 35 or 40 years, and often during the last trimester of pregnancy. Occurring early in diastole during rapid ventricular filling, it is later than an OS, dull and low in pitch, and heard best at the apex in the left lateral decubitus position.
The bell of the stethoscope should be used with very light pressure. -A pathologic S3 or ventricular gallop sounds like a physiologic S3. An S3 in adults over age 40 years is usually pathologic, ar_is_ing from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts. The term gallop comes from the cadence of three heart sounds, especially at rapid heart rates, which sounds like “Kentucky.” 8.) Auscultate and recognize an S4 later in diastole. -An S4 (atrial sound or atrial gallop) occurs just be_for_e S1. It is dull, low in pitch, and best heard at the apex with the bell. L_is_ten at the lower left sternal border for a right ventricular S4 (or in the subxiphoid area if obstructive lung d_is_ease). An S4 is occasionally normal, especially in trained athletes and older age groups. More commonly, it is due to ventricular hypertrophy or fibros_is_ causing stiffness and increased res_is_tance (or decreased compliance) during ventricular filling following atrial contraction. -Causes of a left-sided S4 include hypertensive heart d_is_ease, aortic stenos_is_, and _is_chemic and hypertrophic cardiomyopathy.. A left-sided S4 is heard best at the apex in the left lateral decubitus position, with a cadence like “Tennessee.
