NURSING CARE RELATED TO THE SENSORY AND
NEUROLOGICAL SYSTEMS
2-13
2-13. MENTAL STATUS
a. Mental status assessment should evaluate the following areas:
(1) State of consciousness.
(2) Orientation.
(3) Affect. (Mood)
(4) Memory.
(5) Cognition.
b. The terms used to describe state of consciousness are often subjective and ambiguous. For this reason, such terms should not be used in nursing documentation unless they are qualified with an explanatory statement. When assessing a patient who is other than "awake and alert," it is best to use a standardized assessment scale. One such scale is the Glasgow Coma Scale (GCS), described in paragraph 2-16. Terms used to describe state of consciousness include:
(1) Conscious (alert)--the patient responds immediately, fully, and appropriately to visual, auditory, and other stimuli.
(2) Somnolent--unnatural drowsiness. The patient can be aroused and will respond to commands, but will fall asleep again as soon as he is left alone.
(3) Stuporous--partial unconsciousness. The patient can be aroused with painful stimuli and will attempt to respond with purposeful withdrawal from the stimulus. The patient may be restless or combative as well.
(4) Comatose--complete unconsciousness, no purposeful response to any stimulus.
c. Orientation is determined by questioning the patient about person, place, and time.
(1) Ask the patient to spell his name, name his children, or recite his address. Does the patient know who he is? Does the patient know who others are?
(2) Ask the patient to tell you where he is. He may be asked to name the hospital, city, state, and so on.
(3) Ask the patient to tell you the year, month, and time-of-day (mid-morning, late afternoon, and so forth). Do not ask for the date. This is a poor indication of orientation. Most people cannot tell you the exact date when questioned.
d. Affect, or mood, is evaluated by observing the patient's verbal and nonverbal behavioral responses for appropriateness. For example:
(1) Does the patient laugh when talking about serious or sad subjects?
(2) Is the patient easily startled by loud noises?
(3) Does the patient respond to stimuli in a normal manner?
(4) Does the patient display excessive anger, fear, confusion, and so forth?
e. Long and short term memory should be evaluated by asking questions.
(1) Discussing past events or questioning the patient about his medical history will test his ability for remote recall (long-term memory).
(2) Questions about daily events will test recent recall (short- term memory). For example, ask the patient what he ate for breakfast that morning.
f. Cognition is tested by asking the patient to perform calculations. For example, ask the patient to count backward from 100 by 7s.
