Which level of awareness would the nurse evaluate in a patient with emotions related to trauma?

Function

The mental status examination is organized differently by each practitioner but contains the same main areas of focus. For the purposes of this activity, the mental status examination can be divided into the broad categories of appearance, behavior, motor activity, speech, mood, affect, thought process, thought content, perceptual disturbances, cognition, insight, and judgment. Cognition can subdivide into different cognitive domains depending on what areas the practitioner determines necessary to assess. Each section below will detail the definition, the proper method of assessment, and how that information has a use in the diagnosis and monitoring of mental illness.

Appearance

This is a description of how a patient looks during observation. It can be determined within the first seconds of clinical introduction as well as noted throughout the interview. Details to be included are if they look older or younger than their stated age, what they are wearing, their grooming and hygiene, and if they have any tattoos or scars. If a patient looks more youthful than their stated age, they may have a developmental delay or dress in an age-inappropriate manner. Patients that look older than their stated age may have underlying severe medical conditions, years of substance abuse, or often years of poorly controlled mental illness. Grooming and hygiene can give an idea of a patient’s level of functioning. Those with poor hygiene and grooming generally denote that in the context of their mental illness that they currently have poor functioning. Those with poor grooming or hygiene may be severely depressed, have a neurocognitive disorder, or be experiencing a negative symptom of a psychotic disorder such as schizophrenia.[2][4] Tattoos and scars can paint a picture of a patient’s history, personality, and behaviors. Scars tell stories about old, significant injuries from accidental trauma, harm caused by another individual, or self-inflicted harm. Self-inflicted injuries frequently include superficial cutting, needle tracks from IV drug use, or past suicide attempts.[2] Tattoos often are the name of a family member, significant other, or lost loved one. They can also depict gang marks, vulgar imagery, or extravagant artwork. If a certain level of trust has been established through the interview, the interviewer can ask about the significance of the tattoos or scars and what story they tell about the patient.

Behavior

This is a description obtained by observing how a patient acts during the interview. First, it is essential to note whether or not the patient is in distress. If a patient is in distress it may be due to underlying medical problems causing discomfort, a patient having been brought against their will to the hospital for psychiatric evaluation, or due to the severity of their hallucinations or paranoia terrifying the patient. Next, a description of their interaction with the interviewer should be noted.[2] For example, is the patient cooperative, or are they agitated, avoidant, refusing to talk, or unable to be redirected? A patient that is not cooperative with the interview may be reluctant if the psychiatric evaluation was involuntary or are actively experiencing symptoms of mental illness. Patients that are unable to be redirected often are acutely responding to internal stimuli or exhibit manic behavior. Lastly, it is important to note if the behavior the patient is displaying is appropriate for the situation. For example, it can be considered appropriate for a patient who was brought in via police for involuntary evaluation to be irritable and not cooperative. However, if in that same scenario, the patient was laughing and smiling throughout the interview, it would be considered inappropriate.

Motor Activity

This describes how a patient is moving and what kinds of movements they have. Motor activity can indicate an underlying mental illness or neurological disorder. Furthermore, as the dopamine system targeted by medications plays a vital role in the movement, it is especially essential in monitoring for medication side effects. 

One aspect of monitoring is the speed of movements. This can be described as normal, psychomotor retardation/bradykinesia, or psychomotor agitation/hyperkinesia. A patient with depression or a neurocognitive disorder may have psychomotor retardation.[5] On the other hand, psychomotor agitation may indicate that a patient is acutely under the influence of a stimulant or exhibiting manic behavior. It is important to note a patient’s gait. For example, if the gait is stiff, shuffling, or ataxic, this may point to an underlying neurological condition. One such neurological disorder is Parkinson's disease, which is indicated by the cardinal triad of rigidity, bradykinesia, and resting pill-rolling tremor. If these symptoms are noted early by astute observation from the clinician, this can help lead to earlier diagnosis and treatment for such conditions. 

A patient’s posture is important to note, as this may indicate underlying issues. Sustained posturing may point to catatonia, a type of psychomotor immobility/stupor/inflexibility, and a feature of psychotic disorders. Practitioners unfamiliar with the condition often overlook catatonia but is critical to differentiate as it requires a separate treatment than the underlying psychosis.[5] If the patient displays akathisia, a restless urge to move/inability to stay still, they may exhibit hyperactivity/impulsivity, which often presents in patients with attention deficit hyperactivity disorder (ADHD). Alternatively, a patient with akathisia may be experiencing a side effect from an antipsychotic.[6] Other aspects of movement that may indicate extrapyramidal side effects (EPS) from antipsychotics are rigidity, tremors, and tics such as teeth grinding, lip-smacking, or tongue protrusions. Severe sudden rigidity seen after antipsychotic administration is considered an acute dystonic reaction. Although rare, in its most extreme form this can be life-threatening if it involves laryngeal muscles. Thus, the practitioner needs to monitor and treat the slightest of reactions before they become more serious. Tardive dyskinesia is the neurological condition that arises from long-term antipsychotic administration that sustains these extrapyramidal side effects. These symptoms and their severity can be monitored more extensively with the Abnormal Involuntary Movement Scale (AIMS).

Speech

Speech is evaluated passively throughout the psychiatric interview. The qualities to be noted are the amount of verbalization, fluency, rate, rhythm, volume, and tone. It is of key importance to note the amount a patient speaks. If the patient speaks less than normal, they may be experiencing depression or anxiety. Conversely, an increased/hyperverbal amount of speech may also indicate some level of anxiety or that a patient is currently manic. Fluency refers to the patient’s language skills. English may not be a patient’s first language, and they may not be fluent. Alternately, English may be their first language, but they may have word-finding difficulty due to an altered mental status or a neurocognitive disorder. The rate of speech may be slow in depressed patients or those with a neurocognitive disorder. The pressured rate may indicate acute substance intoxication or that the patient is experiencing a manic episode.[6] A delayed speech response time may also indicate a neurocognitive disorder or that the patient is experiencing a thought process disorder such as thought blocking seen in psychosis. The rhythm of speech can provide clues to a number of diagnoses. Slurred speech may indicate intoxication. Dysarthria may indicate a possible motor dysfunction when speaking. Volume can be quiet if a patient is depressed/withdrawn or loud if they are agitated. Some patients have a neurocognitive disorder or hearing difficulties that may make them unable to control the volume of their voice. Lastly, the tone may indicate a patient’s mood. Additionally, a child-like tone may suggest a developmental delay depending on the patient’s age.

Mood

This is a patient’s subjective description of how they are feeling. It is determined by directly asking the patient to describe how they are feeling in their own words.[5] It is documented with quotations transcribing the patient’s response verbatim.

Affect

This is how the practitioner describes a patient’s observed expression through their non-verbal language.[2] Terms often used are euthymic, happy, sad, irritated, angry, agitated, restricted, blunted, flat, broad, bizarre, full, labile, anxious, bright, elated, and euphoric.[6] In addition to these terms, the range of affect may be described. For example, a patient may be minimally irritated versus extremely agitated. Some practitioners will also specify whether the affect is appropriate to the situation.[6] A patient who is smiling and laughing after being brought into the hospital for involuntary evaluation is considered to have an inappropriately elated affect. Another descriptor clinicians may use to describe affect is whether the affect is congruent or incongruent with what the patient says their mood is. If a patient says their mood is “great” and they are smiling, then their affect is happy and therefore congruent. However, if that patient said “great” while they are crying, then their affect would be tearful and incongruent.

Thought Process

This is a description of the organization of the thoughts expressed by a patient.[5] For a normal thought process, the thoughts are described as linear and goal-directed. Common descriptions of irregular thought processes are circumstantial, tangential, the flight of ideas, loose, perseveration, and thought blocking. A circumstantial thought process describes someone whose thoughts are connected but goes off-topic before returning to the original subject. On the other hand, a tangential thought process is a series of connected thoughts that go off-topic but do not return to the original topic. Flight of ideas is a type of thought process that is similar to a tangential one in that the thoughts go off-topic, but the connection between the thoughts is less obvious and more difficult for a listener to follow. In a loose, disorganized thought process, there is no connection between the thoughts and no train of thought to follow.[5] Perseverations are a type of thought process where no matter the topic or question, the patient goes back to the same subject. The content of these perseverations will be important to note in the next section. Lastly, thought blocking is seen in psychosis when a patient has interruptions in their thoughts that make it difficult to either start or finish a thought. This was previously discussed in speech as these patients often have pauses in their speech pattern and delays in response to questions.

Thought Content

This is essentially the subject matter of the thoughts that are in the patient’s mind. It is determined by listening throughout the interview and through direct questioning. If a patient has a particular preoccupation, they may have a perseveration-type thought process for which it is important to document the topic. When assessing a patient’s thought content, it is imperative to determine suicidal ideations, homicidal ideations, and delusions. 

The practitioner may ask the patient if they have suicidal ideations or homicidal ideations. Suicidal ideations need to be further clarified by passive thoughts of wishing to be dead versus active thoughts of wanting to take one’s own life. Furthermore, practitioners need to be able to ascertain whether the patient has a plan and intent to act on such thoughts. This can be difficult to determine as patients are rarely forthcoming about such details. If there is any concern for suicidal intent, a more thorough suicide risk assessment is warranted. Assessing homicidal ideations follows a similar pattern of needing to determine if the thoughts are passive ones of wishing someone was dead versus active thoughts of killing someone with or without a plan and/or intent to act.[7] It is also vital to try to obtain from the patient towards whom they have homicidal ideations. According to the Tarasoff ruling following the California Supreme Court case Tarasoff v. Regents of the University of California, it is a mental health professional’s duty to warn a person if a patient has made a threat against their life.[8]

Delusions are firmly held false beliefs of a patient which are not part of a cultural belief system and persist despite contradicting evidence.[6] These can be plausible or fantastical in nature. Types of delusions include bizarre, grandiose, paranoia, persecutory, and somatic types. Evidence of these delusions is often hard to extract from a patient because they may know that others do not believe them and fear persecution. It takes practice from mental health care clinicians to elicit these delusions from patients in a subtle, open-minded manner. For example, one would not ask a patient, “Are you paranoid?”, but rather, “Are you worried someone has been following or spying on you?” Some commonly held persecutory delusions are paranoia that someone is following them or spying on them with a camera. Others are grandiose beliefs of being God, royalty, famous, or wealthy. Somatic delusions often derive from a sensation that the patient feels. For example, a common somatic delusion is that a patient is pregnant (common in males and females) or that there is a parasite or alien inside of them because they are constipated or bloated. When determining if something is a delusion, it is important to compare what the patient believes to objective collateral reports from outsiders or laboratory data. For example, an older, disheveled patient that states that they are a famous model may actually have been one in the past. Other types of delusions include thought insertion, thought broadcasting, thought withdrawal, mind reading, and ideas of reference. These refer to when patients believe they have control over others’ thoughts or vice versa. Ideas of reference refer to when a patient believes that they are receiving a special message from a TV, radio, or the internet that is not there.

Perceptions

This section describes some of the various kinds of hallucinations that a patient may be experiencing. This is assessed by asking a patient what they are perceiving. A hallucination is the perception of something in the absence of any external stimuli. It is important to contrast an illusion, which is a misperception based on an actual stimulus such as thinking one hears their name called in a crowd. Contrarily, hallucinations that occur when going to sleep (hypnagogic), waking up from sleep (hypnopompic), or sleep paralysis are non-pathological and may be considered to be normal.[6] The most prevalent hallucinations are auditory and visual, but they can also be olfactory, tactile, and gustatory. When asking about auditory hallucinations, it is important to note what sort of sound is heard or if it is a voice. If the patient hears one or more voices, ask if the patient recognizes the voice or voices, what gender they appear to be, and what the voices are telling them. An auditory hallucination of God telling the patient to have a good day can potentially fall within the realm of normal depending on a patient’s religious and ethnic culture. Auditory hallucinations that are not considered to be normal can be negative and antagonistic towards the patient or give them commands to hurt themselves or others. Even if the patient believes it is God, such dangerous auditory hallucinations are considered to be pathological and a symptom of mental illness. When asking about visual hallucinations, it is important to get as much detail as possible. If a patient sees snakes, ask them to describe the snakes. How many are there? What are they doing? Additionally, as noted with auditory hallucinations, some visual hallucinations can be considered within the realm of normal, such as seeing the ghost of a deceased loved one shortly after they have passed. 

Frequently a patient will deny having any hallucinations despite experiencing them. This may either be due to paranoia or fear generated by what they are experiencing. Even if a patient denies experiencing hallucinations, it is important to note whether the patient appears to actively respond to internal stimuli by talking to someone not present or looking at something not present.

Cognition

The most common areas of cognition evaluated on a mental status examination are alertness, orientation, attention/concentration, memory, and abstract reasoning. If when assessing cognition or any other part of the mental status examination the practitioner finds symptoms of a possible neurocognitive disorder, more thorough screening is possible with additional evaluation tools such as Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), or Mini-Cog.[3][5]

Alertness is the level of consciousness of a patient. This can be described as alert, somnolent, obtunded, in a stupor, or comatose. Alert means that the patient is fully awake and can respond to stimuli. Somnolent means that the patient is lethargic or drowsy. Somnolence is considered to be a reduced level of consciousness, but the patient is still able to perceive stimuli and can be awakened fairly easily. Obtunded means that mild to moderate stimuli may not arouse the patient, and when the awoken patient will be drowsy with delayed responses. A patient in a stupor is unresponsive to almost all stimuli and when aroused may quickly go back to sleep without continued stimulation. A comatose patient is unresponsive to all stimuli, including vigorous and noxious stimuli.[6] An altered level of consciousness or sensorium may indicate that a patient may have had a head injury, ingested a substance, or have delirium from another medical condition.[9]

Orientation refers to the patient’s awareness of their situation and surroundings. This is assessed by asking the patient if they know their name, current location (including city and state), and date. Someone who is normally oriented fully but is acutely not oriented may be experiencing substance intoxication, a primary psychiatric illness, or delirium. Delirium can be easily missed and miscategorized as a primary psychiatric illness. It is important to be able to differentiate this altered mental state because it may mean there is a critical medical condition that needs to be evaluated and treated.[10]

Attention/concentration is assessable throughout the interview by observing how well a patient stays focused on the questions asked.[3] Alternatively, this can be directly tested in a multitude of ways. One way is to ask a patient to tap their hand every time they hear a certain letter in a string of random letters. If they have good math skills, then another method is to ask the patient to count back from 100 by 7. Additionally, a practitioner may ask a patient to spell a word forwards and backward or ask them to repeat a random string of numbers forward and backward.[2][6] Impairment in attention/concentration may be a symptom of anxiety, depression, poor sleep, or a neurocognitive disorder.[3] When describing the patient’s performance, a practitioner may document the performance as poor, limited, fair, or in the case of a previous comparison worsening versus improving. Additionally, a practitioner can specifically describe the task and the patient’s performance.

Memory subdivides into immediate recall, delayed recall, recent memory, and long-term memory. A practitioner can choose to assess one or all types of memory during evaluation. Immediate recall is asking the patient to repeat something back to you. This determines if a patient can register new information.[3] It can be a list of random words, random numbers, or a sentence.[6] The delayed recall is asking the patient to repeat the same thing to you after a certain amount of time (usually 1 to 5 minutes) after performing another task that prevents the patient from doing repetitions to practice the answer.[3] Even if a patient does not have delayed recall, they may be able to remember the information if given hints. In this case, a patient’s delayed recall would not be intact but prompted recall would.[3] Recent memory is an assessment of how well a patient remembers recent events. This can be determined during the interview by asking about the history of present illness, what they ate earlier in the day, or what they have been doing with their time. Long-term memory assesses a patient’s memory of long-past events. Examples of this are asking a patient about when they had a child, what high school they went to, their childhood home, or their wedding.[6] If a patient has impaired responses to recall testing and/or memory, this may point to a neurocognitive disorder that requires further screening with one of the assessments mentioned at the beginning of this section.

Abstract reasoning is a patient’s ability to infer meaning and concepts. This is assessable by asking a patient what two objects have in common or how to interpret a common saying, adage, or proverb. Literal interpretations and answers indicate concrete thinking, which is seen in many psychiatric disorders but also some intellectual disabilities and neurocognitive disorders.[6]

Insight

This refers to a patient’s understanding of their illness and functionality.[2] It is usually described as poor, limited, fair, or if there is a previous comparison worsening versus improving. If a patient can acknowledge that their auditory hallucinations are not real, then that patient has fair insight. If a patient does not realize that their paranoia about all food being poisoned cannot be true, then their insight is poor.

Judgment

This refers to a patient’s ability to make good decisions. A way to directly assess judgment is to ask a patient what they would do in specific scenarios. Often this is assessed through a patient’s history during an interview and their observed actions.[2] This, like insight, is also rated as poor, limited, fair, or if there is a previous evaluation to compare to, worsening versus improving. Patients that repeat the same mistakes over and over or refuse to take medications show poor judgment. It is not uncommon to have an encounter with a patient who does not believe their medications affect them positively or have any affect at all. Regardless of their poor insight, some patients show fair judgment by taking their medications because they know that when they do not take them, they return to the hospital for inpatient treatment. Those with poor judgment tend to have poor functioning due to the severity of their psychiatric illness. Patients with this kind of poor judgment and functioning are usually gravely disabled and often require inpatient psychiatric treatment.[4]

Example Documentation for Patient Charting

Appearance: 25-year-old African American female, appears stated age, wearing paper hospital scrubs that have been cut to reveal abdomen with vertical abdominal scar visible, and multiple tattoos of various names visible on forearms bilaterally.

Behavior: Not in acute distress, difficult to redirect for interviewing, inappropriately laughing and smiling

Motor Activity: Minimal psychomotor agitation present. Regular gait. Regular posturing. No tics, tremors, or EPS present.

Speech: Hyperverbal, fluent, pressured rate, regular rhythm, regular volume, happy tone

Mood: “Fantastic”

Affect: Elated, inappropriate, congruent

Thought Process: Flight of ideas

Thought Content: Denies suicidal ideations, denies homicidal ideations. Grandiose delusions elicited of being “an angel on a mission.”

Perceptions: Endorses auditory hallucinations of God commanding her to go to California. Denies visual hallucinations. Does not appear to be actively responding to internal stimuli.

Cognition: 

Sensorium/orientation: Alert and oriented to person, place, and date 

Attention/concentration: Poor. Unable to spell WORLD forward and backward.

Memory: Able to recall 3/3 objects immediately and after 1 minute. Recent memory - Intact to breakfast this morning. Long-term memory - Intact to what high school she attended.

Abstract reasoning: Intact with the ability to identify a bird and tree as both living.

Insight: Poor

Judgment: Poor

What characteristic of mental health allows people to adapt to tragedies trauma and loss?

Which stage of Freud's psychosexual stages of development would the nurse analyze for in a patient with destructive tendencies?

Which personality system would the nurse identify in a patient who is impulsive and lacks control?

Which statement indicates that a patient is motivated by the highest level on Maslow's hierarchy of needs pyramid?