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

2. 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

3. 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.

4. 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

5. 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.”

6. 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. “

7. 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

8. 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.

9. 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.”

10. 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

11. Level of Consciousness
Orientation
Time, place and person
Oriented to person, place and time
One Step Command
Able to follow one step command

12. 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”

13. 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

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

15. Mini-Mental Status Examination (MMSE)
Measures orientation and cognitive function
Standard set of 11 questions and requires only 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

16. 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

17. 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”

18. 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 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.

19. 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)

20. 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.

21. Sample Charting

22. Sample Charting (cont.)