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

Be careful about “assumptions” General Survey Gives an overall impression of patients health Provides 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. As the nurse you are asking the patient medications that they are taking, what health problems they may have that would contribute to mood and behavior problems. You are also asking if they have any past mental health problems. Asking about family history of mental health problems, violence in a home during childhood can at times perpetrate or experience violent behaviors in adulthood.

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 Race Different physical features are related to gender and race Age Age influences normal physical characteristics and a person’s ability to participate in some parts of the examination Assess if appears stated age Signs 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. “

Physical Appearance & Behavior Dress Clothing 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 & Grooming Patient 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 states No body odor present

Appearance & Behavior . Mood & Affect Patient abuse Affect is person’s feelings as they appear to others Assess if affect and facial expressions are appropriate to situation If depressed assess for suicidal thoughts Patient is comfortable and cooperative & interacts pleasantly Patient abuse Assess for obvious physical injury or neglect i.e. Evidence of malnutrition or bruising on trunk Assess for patient’s fear of spouse, partner, caregiver, parent, or adult child.

Physical Appearance & Behavior Gait Base as wide as shoulders width, smooth, even, well balanced with symmetrical arm swing Body movements/ROM Full 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 appropriate Lethargic Drowsy, but opens the eyes and looks at you, responds to questions then falls asleep Obtunded Difficult to arouse-needs loud shout or vigorous shake. Opens eyes and looks at you, responds slowly, confused Stupor 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 Scale Flexion (formerly decorticate) objective tool often used with head injury pt’s Flexion (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”

Language Speech Assess rate, articulation of words, fluency Speech fluent, understandable & appropriate Aphasia Sensory (receptive) Inability to understand written or verbal speech Wernicke’s aphasia Motor (expressive) Understands, but cannot write or speech appropriately Broca’s aphasia Mixed Combination of the two Global aphasia

Intellectual Function More difficult to assess in Elderly with sensory deficits and people from other cultures/languages Memory Knowledge Abstract Thinking Association Judgement

Mini-Mental Status Examination (MMSE) Measures orientation and cognitive function Standard set of 11 questions and requires only 5-10 minutes to administer Used 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) Scores 24-30, no cognitive impairment 18-23, mild cognitive impairment 0-7, severe cognitive impairment

Mini-Mental Status Examination (MMSE) MMSE Components Time Orientation Place Orientation Registration of 3 words Serial 7s as a test of attention and calculation Recall of 3 words Naming Repetition Comprehension Reading Writing Drawing

Thought Processes & Perceptions Assess 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 thoughts Risk 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.)