PART II MENTAL STATUS ASSESSMENT
The mental status examination should always be included in the overall physical assessment of all patients. The assessment you perform may be either an initial admission assessment or it may be the daily, on-going assessment. In either case, the mental status assessment is an essential part of the examination. As you perform your medical assessment of the patient you will perform parts of the mental status assessment, almost without being aware of it.
In general terms, mental status could be described as an individual’s state of awareness and responsiveness to the environment. It also includes the more complex areas of a person’s mental functioning, such as intelligence, orientation, thought process and judgment. As you see, mental status is very dependent upon other body systems. Physical illness may certainly impair mental status.
In describing the techniques of assessing mental status, you should remember to incorporate parts of this examination into the patient’s general physical exam. If the mental status exam is presented in one separate group to the patient, the patient will usually become very anxious over the types of questions being asked. You can assess mental status as you perform the medial exam. For example, memory is assessed while taking the history. Mood can be assessed when you meet the patient. Mental status findings are important. Patient care plans may have to be altered in order to properly care for patients with impaired mental status.
The following guidelines should be used for the assessment:
First impressions
Record your first impressions of the patient. Some very subtle thought disorders may be detected. As an example, the patient acts just a little peculiarly, but you don’t see anything grossly wrong.
Medical survey
Incorporate the mental status exam into your medical survey (general physical assessment). There are parts of the mental status assessment that may indicate an organic process as well as a mental illness.
Explain procedures
Always explain to the patient what you are about to do. Most patients are very anxious just to be in the hospital, not to mention the sensitive questions you are going to ask them.
Take notes
Take notes during the assessment. Always explain to the patient what you are doing. You are taking notes so that you will not forget anything important.
Use common sense
If they say they are depressed, and might want to die, finish the remainder of your interview and have someone stay with the patient; report your findings, but make sure someone constantly stays with the patient; safety first.
The following outline is the basic mental status exam. As each section is presented, techniques will be discussed.
PART I Overall Assessment
PART II Intellectual Functioning
PART III Mood and Affect
PART IV Thought Cohesiveness
Again, use common sense; the examination does not have to be performed in this exact order. The exam is presented in this order only to give the nurse a guide to follow. It is a way to organize your own thinking before you begin to assess patient’s thoughts. Now proceed through steps of the exam in the following pages.
PHYSICAL ASSESSMENT:
The following topics are part of the routine daily assessment of most patients. As you read and review each system, be aware of the possible abnormalities of the mental status examination.
Neurological Assessment
Changes in level of consciousness; restlessness, listlessness, confusion, disorientation, others. Any of these changes may or may not accompany functional disorders, or can be only temporary symptom of a medical problem.
Respiratory System
Dyspnea, hyperventilation, others. Persons with certain disorders of the nervous system will manifest signs of respiratory distress; therefore, the mental status may also be affected.
Cardiovascular System
Rapid or irregular pulse or even the opposite may occur, a slowed pulse rate; many other changes may be obvious, such as the depressed patient who may have a slowing of all body systems.
Gastrointestinal System
These changes may include the minor complaints such as chronic indigestion, nausea, cramps, vague stomach pains, can also include symptoms such as vomiting or diarrhea or constipation.
Genital-Urinary System
Urinary symptoms may include the following: frequency or retention, scant urine which is concentrated may be present in the person who is depressed and not taking adequate fluids.
There may be other symptoms in addition to these. This is not to say that if a person has any of these symptoms, they also have a change in their mental status. All we can conclude is that if there has been no diagnosed reason for the particular symptoms, the nurse should always consider that a possibility can be an altered mental status with physical symptoms. Now we will discuss the next step which is mental status assessment with each step listed for clarity.
Overall Assessment
History
This is usually obtained during the medical history. Items to be included are drugs taken, trauma surgery, etc.
General Appearance
This part of the exam is often overlooked. Be sure to note the manner of dressing, grooming, and hygiene: abnormal: sloppy clothes, body odor, dirty clothes, all could mean OBS or depression. Very tidy or meticulous grooming may mean obsessive-compulsive personality.
Facial Appearance
Note facial expressions and appearance. Abnormal: depression and some other diseases can cause an inappropriate facial expression.
Posture
A normal reaction to hospitalization can make a person tense and unable to relax. Do note if they are too tense or too relaxed.
Motor Assessment
Includes patient’s gait, speech, and general motor activity. Speech and motor activity are the most pertinent to our mental status examination. Abnormal: altered speech and motor activity can indicate depression, organic disease or other functional disease.
General Behavior
This is the: “First Impressions” category. Is patient open to your questions? Is the patient cooperative? Is the patient relaxed? Abnormal: belligerence, hostility, combativeness, would be considered a sign of some type of disease process.
Intellectual Functioning
Intellectual here means the higher brain functions of cognition which were mentioned earlier. By the higher brain functions, we mean that there must be some thought used, the brain must be used to its fullest capacity; i.e. thought, integration of memory and the conscious mind, Presented now, are those higher brain functions which will be assessed in our exam.
Orientation
Most nurses are familiar with this phase of brain function. Orientation is measured in time, person, and place. During your interview, it should become apparent the person is confused. Be precise with questions; time of day, day of week, date, month and the year. Start questions from the general to more precise questions. The patient may not know it is August 24, but they may know it is the month of August. Use this method for person and place as well.
Communications Skills
This category includes vocabulary used, information facts, spelling and reading.
Assess these qualities only if needed. To perform a detailed examination in these areas, it might be necessary to consult another reference which lists vocabulary words, spelling word exams, reading tests, etc. Most nurses would not ordinarily need this much detail, unless they work in a specialty area such as neurology. Abnormal: Vocabulary is an excellent method of assessing intelligence, as well as information facts.
Some examples are:
- How many days are there is a week?
- What is a major city in Italy?
- How many ounces in a pound?
- Abstract Reasoning
This area includes the ability of the person to be able to interpret abstract concepts. To test the person, ask proverbs and their meaning:
What do these mean?:
- A stitch in time, saves nine.
- A rolling stone gathers no moss.
- The proof of the pudding is in the eating.
Abnormal
The disorder of not being able to think abstractly is called concrete thinking. The person takes the words by their literal and actual meaning. If you were to direct the patient to: “take a seat, please” the person would pick up the chair and ask you where to “take” it. Test them by using proverbs. Always remember that there are other factors which can influence this test. Persons who are from a different country and are not proficient in the English language, will also test poorly in this area unless they are tested in their own language.
Attention Span
Clinically speaking, this category includes the ability to pay attention to the interviewer and to concentrate on the subject of the interview. There are some methods of testing for this ability. Use of the digit span and the serial numbers sequence is the method of choice. For our purposes, however, these methods are also too time-consuming, and the information gained would have to be evaluated by an expert. In most instances, the physician performs this test and the others like it.
Memory
Most memory deficits will be apparent during the history-taking process. First, test the patient for long-term (remote) memory by asking birthdays, anniversary children’s birthdays, etc. Test short-term memory by asking recent events. Also to test the recent memory, you can tell the patient a fact that he did not know previously, then ask them to recall the fact at a later time. Start at five minute intervals and then make the time longer or shorter, depending upon how the patient performs.
Abnormal: Of course, lack of memory is abnormal. If the patient exhibits partial loss or transient loss of memory, that is significant, and needs to be assessed carefully. Also of great significance, is if the patient makes up answers to your questions (confabulation). When testing memory it is best to ask questions which can be easily verified. Recent memory can be assessed by asking the name of an object or address. If the patient answers wrongly, then ask the question again, very clearly, as he may not have heard you and answer the question wrong.
Another way to test memory is to ask information questions such as:
- How many days are there in a week?
- What is the capital of Italy?
- What must you do to water to make it boil?
- When is Memorial Day?
- What are the four seasons of the year?
- What is a prime number?
- Where does the sun set?
- Who wrote Moby Dick?
Persons of average ability should be able to answer up to 75% of the questions correctly. There are cultural differences to consider. There are intellectual considerations. However, the average person will answer eight out of ten such questions posed. If you are unsure of the patient’s intelligence when answering the above questions, use the test below in order to determine if they are of at least average intelligence.
Vocabulary Test: Ask the meaning of the following:
| apple | donkey | diamond | join | fur |
| shilling | bacon | seclude | spangle | flout |
| recede | amanuensis | dilatory | microscope |
Using this test, and some of your own words, you can determine if the person is of average intelligence. Again, cultural and educational backgrounds may prevent a person from performing well on this test, so use your judgment when interpreting the results. Above 50% would be considered normal (using increasingly difficult words in a list of at least 14 words).
Judgment
This area can also be assessed during the medical survey. Note if the patient has acted with good judgment prior to admission to the hospital. Do they continue to use good judgment while in the hospital? For example, do they keep trying to get out of bed even though they have been instructed not to?
Abnormal: Judgment is one of the higher brain functions. It is usually the first quality of the patient to deteriorate in the event of disease. Even the administration of hypnotics or narcotics can “cloud” the patient’s thoughts enough that they can show poor judgment, so take drugs into consideration. Trust your judgment in assessing the patient’s judgment, and their behavior.
MOOD AND AFFECTS
Assessment of mood is usually a simple task for most nurses. There are physical signs that the patient exhibits, that will give a clue to their mood. Also do not forget that mood changes can be subtle and can happen quite unexpectedly. It is usually easy to detect the depressed patient; but what about the patient who has just the opposite symptoms? There is also great difficulty in assessing the patient who is just slightly “high” or “manic” as we usually do not know what they were like before they entered the hospital. In these cases, you should consult the family of the patient. Ask questions such as, “Is he more manic than usual?” or “Is he more restless than usual?” If a patient seems depressed or “down” to you, do not be afraid to ask them, “Are you depressed?” If they answer “yes,” “Do you feel that you might hurt yourself?”
If a person is depressed, they should be assessed for any suicidal tendencies. Always take into consideration the physical evidence as well as the mood of the patient when planning your nursing care. If your patient is depressed, or very upset, they should be evaluated for a psychiatric condition.
Now, to deal with the term, “affect.” This term goes one step beyond the definition of mood. Affect means assessing the patient’s mood and their behavior. Affect means the “appropriateness” of their mood and behavior. As an example, a patient’s spouse has just died in a car accident.
The person acts and speaks “normally” without emotion. This is not a normal affect, they should be showing grief. The person’s outward mood may be “normal” for anyone else, but considering that there was JUST a death in the family, their affect is not normal.
Therefore, “affect” is a combination of mood and behavior of the person. A slightly depressed affect might be normal in the above situation. I would worry more about a person who seemed normal, than the person who was crying over the death of a spouse. At least their affect is normal for the situation. When you assess mood and affect, take into consideration all of the above facts; this is why a good history is important.
THOUGHT COHESIVENESS
The previous section describing Mood and Affect, will now lead us into discussing this section on the thought process. If a person’s affect is inappropriate or grossly pathological, there is probably a thought process disturbance. Listed in this section, are most of the major thought disorders and their definitions. Always remember that these disorders are functional; but in any case, psychiatric attention and treatment may be necessary.
NEUROTIC DISORDERS
These are associated with neurosis … the patient is probably functioning at an adequate level, outside the hospital, but still does need some type of medical attention. In neurosis, the person is still in touch with reality; meaning that there is no major thought disorder, however, the conditions may become worse and can interfere greatly with the person’s life.
- Obsessive-Compulsive Behavior: The obsession is the recurrent thought that the patient has that they should perform some type of behavior that most other people would consider abnormal. The compulsion is the actual performing of the act, or in other words, acting upon the obsession. A very common example of this is that of compulsive cleaning. The person who is so absorbed with cleaning, that they take clean clothes out of the closet and wash then again. This behavior will not actually hurt anyone but it will tend to limit the life of the person who is afflicted with this obsession and compulsion.
- Ruminations: This term refers to repetitive thoughts or ideas that the patient expresses. These thoughts are usually centered around abstract ideas or concepts.
- Phobias: These are irrational fears expressed by the patient. They can be extremely anxiety-producing for those persons. Most of us are familiar with the common phobias. Normally, these phobias do not interfere with the person’s life, The person will usually just avoid contacting the situation which makes them anxious.
- Anxiety: (Free-floating anxiety) the person expresses a sense of dread. They are usually unable to define exactly what they are not afraid of, but it can become very strong and the patient has feelings of impending doom.
PSYCHOTIC DISORDERS
These are usually associated with the more severe thought disorders and usually with schizophrenia. The person with a psychotic disorder is usually gravely ill. This disorder can interrupt and limit the quality of the person’s life.
- Feelings of depersonalization: The patient has feelings that he/she is not real. He/she exhibits feelings of changes in him/herself and in his/her personality.
- Feelings of unreality: The patient has feelings that everything in his/her environment is unreal. This is different from the above, where the patient feels that he/she, him/herself, is unreal. In this case, he/she feels everything around him/her is unreal, or changed in some way.
- Feelings of persecution: The patient has vague feelings that all people are plotting against him/her or that they do not like him/her. This disorder obviously borders on paranoia.
- Feelings of Influence: The patient feels that others are controlling him/her and his/her life.
- Feelings of reference: The patient has feelings that everything is about him/her. The radio is talking to him/her alone so does the television, so do all other events take place due to him/her.
- Delusions: Delusions are false beliefs which the patient holds. These beliefs are usually well fixed in his/her mind. The delusions may be very simple, such as he/she believes him/herself to be the president. They may also be very elaborate, such as the patient acts out his/her entire life as if he/she were Jesus; on a day-to-day basis he/she acts like he/she were Jesus and believes that he/she is.
- Illusions: The patient misinterprets outside stimuli. In other words, the patient may look at a pencil, but he/she sees a snake. This disorder is not usually as elaborate as a hallucination, and there is a stimulus. The patient just misinterprets the object(s).
- Hallucinations: A completely unreal sensory experience by the person. A hallucination has no basis in reality as did an illusion. Hallucinations can be visual, auditory, olfactory, or by any other of the senses, such as touch.
The last several disorders may, in part, be caused by a perceptual disorder. They can all be caused by a physical or emotional disorder as well.
Abnormal Findings:
Drugs, OBS, fever, dehydration, and other organic stimulants may be the cause of the preceding psychotic disorders, as well as being functional in origin. The nurse can be very important to the proper diagnosis of these conditions. Many times these disorders may be classified as a psychiatric disorder, when actually the patient was just extremely dehydrated and started to hallucinate. Be careful to document these following items when you are assessing your patients:
- Symptoms get better or worse at different times of the day.
- Drug history of the patient
- Changes in vital signs coincide with changes in the symptoms
- Psychiatric history (if any)
- Venereal disease history of the patient
- Any historical information
These and any other factors you might notice can be very important. Many nurses have developed that “sixth sense.” You know that something is wrong, but you just cannot put your finger on it. Sometimes a patient may say something just a slightly odd. Don’t dismiss it! Investigate everything! Those remarks that the patient may make might be significant. So look for any other signs of a thought disturbance.
Performing the Examination
Those nurses who work in a psychiatric setting will have some very specific guidelines for performing the mental status examination. Therefore, we will not spend much time going over those settings. However, a word of caution to even the most “seasoned” psychiatric nurses; do not become so “routine” with your exams that you overlook some obvious signs and symptoms. If you do use a form for taking your interview, stop first and take a critical look at the patient. No patient can fit your form exactly. No matter how comprehensive your outline is, each patient will have some sign or peculiarity that needs further documentation. In summary, look at your patient first, and not the form that you may be using.
For medical-surgical nurses reading this; do not be afraid to ask your patient any of these questions. Those nurses who are not accustomed to asking these questions, will feel uncomfortable asking the patient certain questions.
For example:
1. Do you feel like hurting yourself?
2. Do you feel people are against you?
3. Do you see disturbing sights that other people do not see?
Ask these questions tactfully, and if the patient acts or feels uncomfortable with these questions, it could be that there is a problem; it could be a significant finding. Chart: “The patient denies having hallucinations, but becomes very anxious when questioned about it.” This will alert the doctor that maybe the patient does have a problem that needs looking into.
Charting will be discussed later. The following outline should be followed by complete mental status examination:
- These will be obtained in your medical history:
- General appearance
- General behavior
- Orientation (general)
- Motor activity
- Level of consciousness
- Mood and affect
Assess abnormalities in any of the above:
- Dirty clothing
- Depression
- Hallucinations
- Anxiety
- Disorientation
- Others mentioned
Intellectual functioning:
- Assess orientation
- Judgment
- Abstract reasoning
- Others mentioned in text
Mood and Affect:
- Is their mood normal
- Others mentioned in the text
- Is affect appropriate for the situation
Thought Cohesiveness:
- Thought content – are responses appropriate
- Nursing measures – are any emergency measures necessary.
Summary:
The main point to remember when performing this assessment is that many of the areas mentioned will be assessed during the general medical assessment. Always, however treat the mental status exam as a separate examination. It is an important step, and it should be handled separately in order to fully be able to assess the patient’s level of mental health and adjustment to their hospitalization. In a real-life situation most nurses do not have time to perform a detailed and separate mental status assessment. Therefore, one purpose of this course is to force you to think of each part of the exam, and to be more observant while performing the general physical assessment. The observant nurse can perform the complete mental status exam in a very brief time. So even to those nurses who say, “I do not have time to ask all of those questions.” Even for those nurses, we say that you do have time, if you are able to sharpen your skills as an observer.
Charting
As we have seen in the previous section, all of your observations are worthless unless you chart them accurately and completely. In this section, we will not try to change your method of charting but rather we will try to help you organize your thoughts better and to chart more completely. Most nurses have their own method of organizing their charting. On a more practical note, we will instead try to present guidelines to increase your awareness of what is important to chart, and to draw valid conclusions.
Chart general findings first: (even if normal)
Does the patient appears stated age, dressed casually, is cooperative, follows instructions well is alert, responds appropriately to questions. Also report history pertinent to the medical exam.
Intellectual:
Patient is oriented in three spheres, shows no impaired judgment, nor impaired memory.
Mood:
If mood is very depressed or very inappropriate, this category will be mentioned first in our charting, (that goes without saying). However, if the mood is normal, you might just chart that the patient is in good humor or in good spirits; Affect is appropriate or not.
Thought Cohesiveness
If this is normal, there is no need to mention it except to say, “Responds appropriately.” If abnormalities present, describe them.
General Impressions:
All nurses should allow themselves a space for narrative description of the patient. Perhaps your patient will not nearly fit into any of the above descriptions perfectly. Perhaps you are not sure what is wrong with him/her, and need to describe it. Also remember that many facilities now use checklists for charting must of the “routine” assessments. Be careful to check each item carefully, and to write any abnormal findings that do not fit into the categories of the checklist type of charting.
Acute and Chronic OBS
The following is a comparison of two major types of organic brain disorders. The two will first be discussed, followed by a comparison of signs/symptoms. The two types of disorders are acute OBS (delirium), and chronic OBS (dementia). With the acute disorder many of the same symptoms may be present as with the chronic disorder. Delirium, however, seems to have a more fluctuating level of consciousness than does dementia. Cognitive functions for both disorders are the same. Both patients will be disoriented (usually), attention and memory will become worse. Judgment and perceptions are usually poor.
This is a comparison of the two (Chronic vs. Acute OBS):
| Acute OBS (delirium) | Chronic OBS (dementia) |
| cognitive functions deteriorate | cognitive functions deteriorate |
| mood—anxious, fearful, labile | irritable, labile |
| behavior – restless with fluctuating level of consciousness | deterioration of personal habits |
| thought content – delusions,illusions, hallucinations, might be confused | if any of these three are present (delusions, illusions, hallucinations) they will be transient and mild’; patients are confused |
As you see, one of the most distinguishable factors of chronic OBS, is confused. However, if the patient has delusions or hallucinations, they are transient (come and go quickly). Causes for the acute type are numerous, Chemical toxicity can cause the acute type. Drugs, whether prescribed or non-prescribed, can cause acute OBS (organic brain syndrome). If the body cannot tolerate high doses of any drug, toxic symptoms will be seen. Other causes for the acute type are: fluid and electrolyte imbalance (severe ones), heavy metal poisoning, chemical poisoning (other than drugs already mentioned), and others.
When the nurse performs the mental status examination keep in mind the above factors about OBS. Also remember the safety of the patient. Whether the patient is young or old, they can hurt themselves when they are in this state of agitation or confusion. Make sure you pad the bed side rails if necessary, restrain if necessary. However, many is the time the unsuspecting nurse was injured by that “frail little old lady” in room 210. So think safety! Restrain the patient if needed; for the safety of all!