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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 FunctionMain 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 & BehaviorGait
Base 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.)