NRS103 General Survey: Mental Status Chapter 7 Nancy Sanderson MSN, RN.

NRS103 General Survey: Mental Status

Chapter 7 Nancy Sanderson MSN, RN

General Survey

Gives an overall impression of patients healthProvides information about :• Hygiene (body & breath)• Body structure• Mobility• Behavior

Be careful about “assumptions” and stereotyping

Interviewing a patient

• Nurses interview a patient to collect subjective data about their present and past health experiences.

• Nurses ask patients about their self concept, interpersonal relationships including domestic violence, stressors, anger, alcohol and drug use. All which affects their mental health.

Mental Status/ Cerebral Function

Main components of a mental status exam– Mental Status• Appearance• Behavior• Language• Level of Consciousness– Intellectual Function • Memory• Knowledge• Abstract Thinking

Physical Appearance & Behavior

Gender and RaceDifferent physical features are related to gender and race

AgeAge influences normal physical characteristics and a

person’s ability to participate in some parts of the examination

Assess if appears stated ageSigns of acute distress

i.e. pain, difficulty breathing, anxiety

“Pt is 34 y/o Hispanic male in no apparent distress.”

Physical Appearance & Behavior• Body build/Contour– Fit, muscular, well nourished, obese,

overweight, excessively thin– Body type reflects level of health, age, and

lifestyle• Posture– Erect, slumped, bent– Often reflects mood or pain

“Pt is well nourished and sitting comfortably erect. “

DressClothing appropriate to climate, looks clean &

fits the body, & is appropriate to the patient’s culture & age group

Appropriate for setting, season, age, gender & social group

Personal hygiene & GroomingPatient appears clean & groomed appropriately

for his/her age, occupation, & socioeconomic group. Hair & nails neat and clean Hair groomed, brushed. Make-up appropriate.

Body odor Unpleasant odor may result from exercise,

poor hygiene or certain disease statesNo body odor present

Physical Appearance & Behavior

Appearance & Behavior.

Mood & AffectAffect is person’s feelings as they appear to othersAssess if affect and facial expressions are appropriate to

situationIf depressed assess for suicidal thoughts

Patient is comfortable and cooperative & interacts pleasantly

Patient abuseAssess for obvious physical injury or neglect

i.e. Evidence of malnutrition or bruising on trunkAssess for patient’s fear of spouse, partner, caregiver,

parent, or adult child.

Physical Appearance & Behavior

GaitBase as wide as shoulders width,

smooth, even, well balanced with symmetrical arm swing

Body movements/ROMFull mobility for each joint.

Deliberate, accurate, smooth & coordinated. No involuntary movements

“Gait and body movements are smooth and coordinated.”

Level of Consciousness Alert

Opens eyes, looks at you, and responds appropriateLethargic

Drowsy, but opens the eyes and looks at you, responds to questions then falls asleep

ObtundedDifficult to arouse-needs loud shout or vigorous shake.

Opens eyes and looks at you, responds slowly, confusedStupor

Arouses from sleep only after painful stimuli. Coma

Un-arousable-no response to any stimuli

Level of Consciousness

• Orientation– Time, place and person–Oriented to person, place and

time• One Step Command–Able to follow one step command

Level of Conscious

Glasgow Coma Scaleobjective tool often used with head injury

pt’sFlexion (formerly decorticate)

Flexion of arms, adduction of upper extremities, extension of lower extremities

Extension (formerly decerebrate) Arcing of back, backward flexion

of head, adduction & hyperpronation of arms, extension of feet

“GCS= 15”

LanguageSpeech

Assess rate, articulation of words, fluencySpeech fluent, understandable & appropriate

AphasiaSensory (receptive)

Inability to understand written or verbal speechWernicke’s aphasia

Motor (expressive)Understands, but cannot write or speech appropriately

Broca’s aphasiaMixed

Combination of the twoGlobal aphasia

Intellectual Function

• Memory• Knowledge• Abstract Thinking• Association• Judgement

More difficult to assess in

Elderly with sensory deficits

and people from other

cultures/languages

Mini-Mental Status Examination (MMSE)

Measures orientation and cognitive functionStandard set of 11 questions and requires only 5-10

minutes to administerUsed to:

Demonstrate worsening/improving cognition over time (obtain both initial and serial measurements)

Identify organic disease (dementia, delirium, intoxication) vs. psychiatric mental illness (anxiety, schizophrenia, depression)

Scores24-30, no cognitive impairment18-23, mild cognitive impairment0-7, severe cognitive impairment

Mini-Mental Status Examination (MMSE)

MMSE ComponentsTime OrientationPlace OrientationRegistration of 3 wordsSerial 7s as a test of attention and calculationRecall of 3 wordsNamingRepetitionComprehensionReadingWriting Drawing

Thought Processes & PerceptionsAssess for abnormal thought content/ perceptions

ie. Phobia, hypochondriasis, obsession, compulsion, delusions, hallucinations, illusions

Never argue with the patient about these…they are real for them, instead point out inconsistencies

Screen for suicidal thoughtsRisk Factors: Past attempts, substance use, close

friend/relative suicide, successful, lethality, means, losses, chronic health issues, unwillingness to verbal contract *Elderly males*

“Thoughts intact, no psychosis or suicidal ideation present”

Problem based history & conditions

• Depression-women are at risk for depression 2:1 over men depression can occur at any age, but is most common in women in ages 25-44 years of age. After puberty depression rates are higher in females than males. This gender gap lasts until after menopause. Note facial expressions, eye contact, body language, and tone of voice of the patient.

• Altered mental status- may become evident when there is a change in a patient's orientation to person, place or time, attention span or memory. Long term memory can be assessed by asking questions about where they were born or about previous surgeries.

Continued: problems

• Assessed mental status by determining orientation, memory, calculation ability, communications skills, judgment, and abstraction. (very good examples of how to present questions in assessing AMS is described in text on pg. 70 & 71)

• Alcohol and substance abuse- patients with these types of abuse are most likely to deny, minimize their disorder to avoid being judged by others. Thus the nurse uses the matter of fact and nonjudgmental approach when assessing these patients. ( examples described in text pg.71 & 72 to questions a patients substance abuse) (Table 7-3 pg. 72 & box 7-1 pg.75, review on own)

Continued: Problems

• Interpersonal violence- if a patient should answer yes to any interpersonal violence screening questions the nurse then needs to ask additional questions in private only the patient and nurse present. Be calm matter of fact, nonjudgmental, listen carefully and let the patient define the problem.

• Major depression, bipolar, schizophrenia, anxiety disorders obsessive compulsive disorder, delirium and dementia the text book discusses theses disorders and offers an understanding on clinical findings you will learn more about these disorders in the future.

Sample Charting

Sample Charting (cont.)