Mental Status
client's level of cognitive and emotional functioning and stability
Mental Status is reflected in:
speech, appearance, and thought patterns
Mental Health
state of emotional and psychological well-being in which an individual is able to use his cognitive and emotional capabilities, function in society, and meet ordinary demands of everyday life
Psychosocial Development
frequently used in nursing; refers to client's mental and emotional health as well as one's self-concept, role development, relationships, coping stress patterns, and spiritual beliefs
Neurological System
can affect mental and psychosocial status
Cerebral Abnormalities
disturb client's intellectual ability, communications ability, or emotional behaviors
Done Before Asking Questions to Determine Client's Mental and Psychosocial Status
explain purpose of this part of examination
Required Due to Subjective Nature of Mental Status and Psychosocial Development Level
in-depth nursing history to detect problems affecting activities of daily living (ADLs)
Can Affect Mental Status
problems w/ other body systems
(i.e. client w/ low blood sugar may report anxiety and other mental status changes)
Included in Complete Neurological Assessment
assessment of cranial nerves, motor and cerebellar function, sensory function, and reflexes
Advantage of Assessing Mental Status at Very Beginning of Head-to-toe Exam
provides clues re: validity of subjective information provided by client throughout exam
Done if Nurse Finds Client's Thought Processes are Impaired
another means of obtaining necessary subjective data must be identified
Cognitive Abilities
orientation, concentration, recent and remote memory, abstract reasoning, judgment, visual perception, and constructional ability
Dementia
loss of cognitive skills that occur because of brain diseases or trauma
Vascular Demential (Multi-infarct Dementia)
results from small strokes or brain blood supply changes usually caused by blood clots in small vessels
Done After Collecting Subjective and Objective Data Pertaining to General Survey
identify abnormals and cluster data to reveal significant patterns or abnormalities for use in clinical judgments (nursing diagnoses: wellness, risk, or actual)
Wellness Diagnoses
- health-seeking behaviors related to desire and request to learn more about health promotion
- readiness for enhanced communication
Risk Diagnoses
- risk for self-directed violence related to depression, suicidal tendencies, developmental crisis, lack of support systems, loss of significant others, poor coping mechanisms and behaviors
- risk for developmental delay related to lack of healthy environ
Actual Diagnoses
- impaired verbal communication related to international language barrier (inability to speak English of accepted dominant language)
- impaired verbal communication related to hearing loss
- impaired verbal communication related to inability to clearly ex
Lethargy
client opens eyes, answers questions, and falls back asleep
Obtunded
client opens eyes to loud voice, responds slowly w/ confusion, seems unaware of environment
Stupor
client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
Coma
- client remains unresponsive to all stimuli; eyes stay closed
- client w/ lesions of corticospinal tract draws hands up to chest (decorticate - abnormal flexor posture) when stimulated
- client w/ lesions of diencephalon, midbrain, or pons extends arms a
Middle-aged Adult / Assessment Findings
normal = generativity
abnormal = stagnation
Older Adult / Assessment Findings
normal = integrity
abnormal = despair
Glasgow Coma Scale
provides score in range 3-15;
scores of 3-8 indicate coma;
total score is sum of scores in three categories:
best eye response
best verbal response
best motor response
Eye Opening Response
Spontaneous - open w blinking at baseline 4 points
Opens to verbal command, speech, or shout 3 points
Opens to pain, not applied to face 2 points
None 1 point
Verbal Response
Oriented 5 points
Confused, but able to answer questions 4 points
Inappropriate responses, words discernible 3 points
Incomprehensible speech 2 points
None 1 point
Motor Response
Obeys commands for movement 6 points
Purposeful movement to painful stimulus 5 points
Withdraws from pain 4 points
Abnormal (spastic) flexion, decorticated 3 points
Extensor (rigid) response, decerebrated 2 points
None 1 point