Presentation on theme: "NRS103 General Survey: Mental Status"— Presentation transcript:
1NRS103 General Survey: Mental Status Chapter 7Nancy Sanderson MSN, RN
2Be careful about “assumptions” General SurveyGives an overall impression of patients healthProvides information about :Hygiene (body & breath)Body structureMobilityBehaviorBe careful about “assumptions”and stereotyping
3Interviewing 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.
4Mental Status/ Cerebral Function Main components of a mental status examMental StatusAppearanceBehaviorLanguageLevel of ConsciousnessIntellectual FunctionMemoryKnowledgeAbstract Thinking
5Physical Appearance & Behavior Gender and RaceDifferent physical features are related to gender and raceAgeAge influences normal physical characteristics and a person’s ability to participate in some parts of the examinationAssess if appears stated ageSigns of acute distressi.e. pain, difficulty breathing, anxiety“Pt is 34 y/o Hispanic male in no apparent distress.”
6Physical Appearance & Behavior Body build/ContourFit, muscular, well nourished, obese, overweight, excessively thinBody type reflects level of health, age, and lifestylePostureErect, slumped, bentOften reflects mood or pain“Pt is well nourished and sitting comfortably erect. “
7Physical Appearance & Behavior DressClothing appropriate to climate, looks clean & fits the body, & is appropriate to the patient’s culture & age groupAppropriate for setting, season, age, gender & social groupPersonal 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 odorUnpleasant odor may result from exercise, poor hygiene or certain disease statesNo body odor present
8Appearance & Behavior . Mood & Affect Patient abuse Affect is person’s feelings as they appear to othersAssess if affect and facial expressions are appropriate to situationIf depressed assess for suicidal thoughtsPatient is comfortable and cooperative & interacts pleasantlyPatient abuseAssess for obvious physical injury or neglecti.e. Evidence of malnutrition or bruising on trunkAssess for patient’s fear of spouse, partner, caregiver, parent, or adult child.
9Physical Appearance & Behavior GaitBase as wide as shoulders width, smooth, even, well balanced with symmetrical arm swingBody movements/ROMFull mobility for each joint. Deliberate, accurate, smooth & coordinated. No involuntary movements“Gait and body movements aresmooth and coordinated.”
10Level of Consciousness AlertOpens eyes, looks at you, and responds appropriateLethargicDrowsy, but opens the eyes and looks at you, responds to questions then falls asleepObtundedDifficult to arouse-needs loud shout or vigorous shake. Opens eyes and looks at you, responds slowly, confusedStuporArouses from sleep only after painful stimuli.ComaUn-arousable-no response to any stimuli
11Level of Consciousness OrientationTime, place and personOriented to person, place and timeOne Step CommandAble to follow one step command
12Level of Conscious Glasgow Coma Scale Flexion (formerly decorticate) objective tool often used with head injury pt’sFlexion (formerly decorticate)Flexion of arms, adduction ofupper extremities, extension oflower extremitiesExtension (formerly decerebrate)Arcing of back, backward flexion of head, adduction & hyperpronation of arms,extension of feet“GCS= 15”
13Language Speech Assess rate, articulation of words, fluency Speech fluent, understandable & appropriateAphasiaSensory (receptive)Inability to understand written or verbal speechWernicke’s aphasiaMotor (expressive)Understands, but cannot write or speech appropriatelyBroca’s aphasiaMixedCombination of the twoGlobal aphasia
14Intellectual Function More difficult to assess in Elderly with sensory deficits and people from other cultures/languagesMemoryKnowledgeAbstract ThinkingAssociationJudgement
15Mini-Mental Status Examination (MMSE) Measures orientation and cognitive functionStandard set of 11 questions and requires only 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
16Mini-Mental Status Examination (MMSE) MMSE ComponentsTime OrientationPlace OrientationRegistration of 3 wordsSerial 7s as a test of attention and calculationRecall of 3 wordsNamingRepetitionComprehensionReadingWritingDrawing
17Thought Processes & Perceptions Assess for abnormal thought content/ perceptionsie. Phobia, hypochondriasis, obsession, compulsion, delusions, hallucinations, illusionsNever argue with the patient about these…they are real for them, instead point out inconsistenciesScreen 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”
18Problem 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.
19Continued: problemsAssessed 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)
20Continued: ProblemsInterpersonal 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.