INTRODUCTION

According to international recommendations, the first step in the early detection of cognitive impairment is considered to be a brief assessment of mental state, supported by assessment instruments (Loureiro et. al. 2018). Cognitive functions are those characteristics of the person that cannot be directly observed, but interfere with behaviour, and can be conceptualised in three systems: cognitive, emotional, and executive. The cognitive refers to information, the emotional includes feelings and motivation, and the executive relates to behaviour.

Therefore, in the assessment of the cognitive state, the initial assessment is of utmost importance, depending on the cognitive state, help may be requested (Bacigalupe et al. 2020) from relatives, it is necessary to assess the premorbid functions, i.e. before the disease and all its antecedents, and risk factors. Therefore, for the assessment of cognitive functions, some instruments can be used according to their confidentiality, validity, sensitivity and specificity. Some instruments such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) are discussed (Loureiro et. al. 2018), while another review article talks about the Clock Test (TdR) and the Mini-Cog (Carnero et al. 2019). The following is a description of the most commonly used cognitive assessment tests: MoCA test. - Created to assess mild cognitive impairment and Alzheimer's disease, it requires between 10 and 15 minutes to run (Serrano et al. 2020).

Minimental state examination test. Indicates more severe cognitive problems, consists of 10 assessment items (Llamuca-Quinaloa et al. 2020).

Mini-mental cognitive test. This is the most widely used in clinical and epidemiological settings, due to its ease of time and application. A research article notes that this test showed similar results in people with low schooling to people with dementia, so its application is limited (Sánchez-Nieto & Mendoza-Núñez, 2021).

Clock test. It is a quick, easy and simple test to apply and helps in global cognitive assessment (Rodríguez-Vargas et al. 2021).

Mini Cog Test. A very useful instrument for detecting potential cases of cognitive impairment and postoperative delirium (Seitz et al. 2018).

From the above evidence, nursing care is a strategic part of prevention, promotion, recovery and rehabilitation. Its methodology is based on: assessment, diagnosis, planning, implementation and evaluation; this is supported by the nursing taxonomy (Martínez-Esquivel, 2020).

On the other hand, the main nursing diagnoses prevalent in patients with mental disorders have been summarised, which are: anxiety, ineffective health maintenance, ineffective management of the therapeutic regime, deficit in recreational activities, ineffective coping, low self-esteem. On the other hand, the most prevalent domains are: perception and cognition, coping and stress tolerance, activity and rest (Moreno et al. 2018).

So, we have that within nursing care it is necessary to prevent the development of mental disorders or the exacerbation of a previous disorder. At this point it is worth mentioning some points to consider within prevention, these are: communication, patient well-being, prevention of post-ICU syndrome, humanised infrastructure, end-of-life care (Flavia-Feron, 2019). However, nursing care includes care aimed at reducing the factors that contribute to the onset or exacerbation of mental disorders.

In this sense, the aim of the research was to analyse nursing care in adult patients with mental disorders.

METHOD

The research work was of a quantitative, non-experimental design, with a descriptive and cross-sectional scope.

For the inclusion criteria, nursing staff were taken into account; nursing graduates and assistants working in the different critical units of the Nuevo Ingles Hospital, located in the city of Quito, Ecuador, including emergency, operating theatre, intermediate care and adult intensive care. For the exclusion criteria, personnel who refused to participate in the research and personnel working in paediatric units were excluded. The population used consisted of 27 participants of which 16 were nursing graduates and 11 were auxiliary nurses.

A survey and a Likert-type questionnaire consisting of 33 items was used to assess the opinion of the nursing staff on the assessment of mental state, the assessment of risk factors and continuing education. The instrument was scored by expert judgement and Cronbach's alpha reliability with a high reliability rate of 0.89, with the permission of the study institution and the informed consent of the research population.

The data from the questionnaire were organised in a database and analysed in SPSS V25 using descriptive statistics.

RESULTS

The results of the research are described:

Table 1: Continuing education on mental disorders.

N.º	Ítems	Nunca	Casi nunca	Casi siempre	Siempre
1	En su institución ha recibido talleres relacionados a los trastornos mentales.	40,7	44,4	14,8	0
2	En su institución ha recibido cursos sobre trastornos mentales.	40,7	51,9	7,4	0
3	Ha recibido información sobre la depresión causada en el paciente hospitalizado en unidad de cuidado crítico.	37,0	44,4	18,5	0
4	Ha recibido información sobre la ansiedad causada en el paciente hospitalizado en unidad de cuidado crítico.	25,9	37,0	37,0	0
5	Ha recibido información sobre el delirio que provoca la hospitalización en unidad de cuidado crítico.	25,9	37,0	33,3	3,7
6	Ha recibido información sobre el estrés pos-trauma que experimenta el paciente hospitalizado en unidad de cuidado crítico.	22,2	33,3	37,0	7,4

Source: Own elaboration.

With regard to continuing education, 40.7% stated that they had never received workshops or courses on mental disorders, 44.4% of staff had almost never received any information on depression in hospitalised patients, while 37% said they had almost never received information on anxiety and delirium in critically ill patients, and 37% said they had almost always received some kind of information on post-traumatic stress disorder.

Discussion

According to the above results, a large number of staff value patient orientation in terms of time, place and person at all times. This is an activity that is carried out very frequently as part of the nursing assessment, especially in critical areas where there are a large number of patients with neurological impairment, as can be seen in an article on the main pathologies in the ICU, where it is shown that neurological diseases are in fourth place with 10.27%, as well as cranioencephalic traumas in eighth place (Delgado-Macías et al. 2019).

On the other hand, some research shows that most diseases are affected by a series of predisposing factors such as biological, psychological and environmental factors, which also affect mental and behavioural disorders.

In this sense, biological factors play an important role, since, depending on the genetic material, as well as biochemical imbalances can determine mental health (Rodríguez-Yunta, 2016). On the other hand, emphasis is placed on epigenetics and DNA sequence across generations, thus challenging that psychosis like other more complex disorders are entirely genetic. In this article he mentions that paternal age influences the development of mental illness in children of parents of older parents (Casavilca-Zambrano et al. 2019).

On the other hand, we have chemical imbalances as a participant in the onset of mental disorders. For example, decreased serotonin transmission is mentioned in depressive states (Pardo-Angulo et al. 2020). On the other hand, the neuro-biological response to stress can be activated in two neuroendocrine pathways of the sympathetic nervous system and the hypothalamic axis. Chronic activations of both systems cause biochemical imbalances in response to stress and when chronically regulated lead to an increased likelihood of developing a disorder (Capitán-Llamas & Artigue-Gómez, 2020). Similarly, brain injury is a predisposing factor for the development of mental illness or cognitive impairment. Taking into account that brain functions organise the brain network, the dysfunction of these can present alterations in this connectivity (Lubrini et al. 2018).

Meanwhile, in the psychological factors that determine the appearance of mental disorders within the critical areas we have anxiety, mood disorders, lack of information, recreational deficits, addictions, and the administration of sedative-narcotics. Based on the above, we have the lack of information in critical units, an acute event generates uncertainty, admission, and hospitalisation in a complex area, in a study the importance of the nursing assessment of the patient's uncertainty is raised (Flórez-Torres et al. 2018).

Another of the important factors for the appearance of mental disorders in the deficit of recreation in critical areas, this makes the patient more predisposed to suffering, these lack of recreation together with the dissociation with the external environment distances the patient from the social relationship, which causes stressors (Lana et al. 2018). In another important point, we have a history of addiction; addiction is a disorder caused by recurrent drug and/or alcohol dependence (Karila et al. 2020). Based on this context, addictions are an important factor taking into account that during hospitalisation the patient is deprived of the consumption of the substances on which he or she is dependent.

We can also mention the use of sedatives and analgesics as factors for the triggering of mental disorders. At this point we can mention that the most commonly used analgesics are opioids that help greatly in pain management, but bring with them a series of collateral effects that influence cognition, sedation, euphoria and delirium (Olmos et al. 2019).

On the other hand, we have environmental factors, where we can mention sleep disturbance, noise, ineffective thermoregulation.

In other words, high temperatures can contribute to the development of general mental disorders such as schizophrenia and bipolar disorders; on the other hand, noise is an important factor for mental illnesses, and several studies show the relationship between noise and mental disorders (Ordoñez-Iriarte, 2020). Considering all of the above, it is essential to develop a work guide that allows nursing staff to act in a timely and quality manner in the presence of symptoms of mental disorders. Therefore, in order to provide comprehensive care to patients and their families, it is necessary to acquire competencies through training and continuing education of professionals, as well as humanised care, generating awareness among nursing staff through strategies and improvement plans. Educational intervention is effective in increasing knowledge, so it is recommended that staff be kept trained (Díaz-Rodríguez et al. 2020).

For the assessment of risk factors, it is also important that in the initial nursing assessment, the presence of a personal history of previous mental illnesses, a history of addictions, the use of sedatives and analgesics, in a study on the use of psychotropic drugs where it is observed that more than a third present dependence (Verdaguer-Pérez et al. 2021) and with it all the complications resulting from addiction. It is also important to mention that the hospitalised patient does not always receive some kind of instrument that helps leisure during their hospitalisation, which on the other hand contributes to the development of some kind of disorder due to the lack of activities during their stay, as for example in a study it was observed that the application of music significantly reduced the levels of anxiety of hospitalised patients (Contreras-Molina et al. 2021), while in another analytical study it was observed that there is a large percentage decrease in anxiety, but also in stress and improved comfort not only in patients but also in the environment of health personnel and family (Ríos-Álvarez, 2018). On the other hand, we also found that the majority, but not all staff carry out some type of activity to reduce the noise or sound emitted by the equipment in critical care units, as is observed in a review article of 5 previous studies where a large percentage of sleep disorders are attributed to noise and brightness.

Finally, continuing education has not been directed towards the assessment of mental disorders, as well as the interventions that nursing staff should carry out to detect and act on patients with mental disorders, or those at risk of developing them. In a phenomenological study, training detected in the nursing staff of the intensive care unit, considering that the greater the preparation of the nursing staff, the greater the capabilities of such staff in the face of new problems (Santana et al. 2019).

Most recurrent mental disorders

Within this framework, we can mention anxiety, which is a psychological disorder, which depending on the symptoms is classified as emotional, it is related to fear, it can occur as real situations or in turn in imaginary elements, anxiety is stimulated by negative emotions and that our body is conceived as an alarm signal, and that these can originate by internal sensations or in turn by external stimuli that cause fear or a problem for interpersonal relationships (Kimelman, 2019).

At another point we refer to mood disorders where the main ones are depression and bipolar disorders (Cavieres & López-Silva, 2021). In depression, sadness, hopelessness, irritable mood and disinterest in common activities can be experienced, and there are somatic and biological changes such as sleep and eating disorders, agitation or abstention from movement, fatigue or loss of energy.

On the other hand, delirium or also known as acute confessional syndrome is a neuropsychiatric disorder of organic origin that presents with alterations in consciousness; it is characterised by its onset within hours or days (Torales et al. 2017). According to Mesa, delirium is one of the most frequent disorders within the Intensive Care Unit and its condition is underdiagnosed, but untreated, has high morbidity and mortality. The presence of delirium in the critically ill patient has a significant impact on patient management, as it can increase hospital costs and patient length of stay, leading to increased morbidity and mortality risks (Page & Gough, 2010).

On another point, post-traumatic stress disorder belongs to the group of anxiety disorders and is characterised by the appearance of characteristic symptoms following an event that represents a danger or threat to their integrity. It should be noted that the critical care syndrome is defined as the deterioration of the physical, cognitive or psychological state that occurs after a critical illness (Kosinski et al. 2020).

CONCLUSIONS

With regard to the assessment of risk factors, we can mention that nursing staff should participate in the initial assessment of the patient, inquiring about the patient's history, especially in relation to previous mental disorders or the use of addictive substances that may contribute to the appearance of new disorders or the development of previous ones, and in this way focus the strategies and interventions personalised for each patient. Finally, in terms of continuing education, institutions should plan in their educational activities the topic of mental disorders, especially in critical areas in which patients may experience changes.

FUNDING

Non-monetary

CONFLICT OF INTEREST

There is no conflict of interest with persons or institutions involved in the research.

ACKNOWLEDGEMENTS

To the participants of the critical care nursing course at the Universidad Regional Autónoma de Los Andes. UNIANDES.

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