Chapter 5

Mental Status Assessment

 Defining Mental Status (1 of 2)
 Mental status is a person’s emotional and cognitive functioning.
 Optimal functioning aims toward simultaneous life satisfaction in
work, caring relationships, and within the self.
 Influenced by biological, environmental and sociodemographic
factors.
 Mental health determines an individual’s coping mechanisms used
to handle stress
 Stress can be triggered by traumatic life events causing transient
dysfunction which can be an expected response
 Assessment during a traumatic life event can help identify strengths, mobilize
resources and help the individual cope
 Defining Mental Status (2 of 2)
 Mental health determines coping mechanisms
used to handle stress
 Its functioning is inferred through assessment of
an individual’s behaviors:
 Consciousness, language, mood, and affect
 Orientation and attention
 Memory and abstract reasoning
 Thought process, thought content, and perceptions
Mental Status Structure and Function
 Mental disorder
 Clinically significant behavioral emotional or cognitive syndrome
that is associated with significant distress or disability involving
social, occupational, or key activities
 Organic disorders
 Due to brain disease of known specific organic cause (e.g.,
delirium, dementia, alcohol and drug intoxication, and withdrawal)
 Psychiatric mental illnesses
 Organic etiology has not yet been established (e.g., anxiety
disorder or schizophrenia)
 Mental status assessment documents a dysfunction and
determines how that dysfunction affects self-care in everyday life.
 Developmental Competence
 Infants and children
 Difficult to separate and trace development of just one aspect of
mental status in children, because all aspects are interdependent.
 Addressing concerns as developmental process associated with
aging continues
 Critical issues r/t substance abuse, suicide, and impact of mental
health issues being diagnosed and/or individuals receiving treatment
– increasing prevalence seen in adolescents
 Aging adults
 Age-related changes in sensory perception can affect mental status
along with chronicity of disease process (presence of comorbidity).
 Grief and despair surrounding these losses can affect mental status
and can result in disability, disorientation, or depression.
 Older adulthood contains more potential for losses.
 Genetics and Environment
 Can play a role in mental illness and dementia
 Family history of mental health diagnoses
 Genetic component of disease - Alzheimer
 Contributing environmental factors
 Food insecurity
 Explore the impact of social risk factors
 Sexual and Gender Minority
Considerations
 Impact on SGM community
 Stigma and rejection
 Higher risk for mental health issues
 Need social acceptance
 Appropriate referrals and support
 Create a friendly culture environment
 Components of the Mental Status
Examination
 Full mental status examination is a systematic
check of emotional and cognitive functioning.
 Usually, mental status can be integrated within
the context of the health history interview.
 Four main headings of mental status
assessment: A-B-C-T
 Appearance
 Behavior
 Cognition
 Thought processes
 Mental Status Examination
 It is necessary to perform a full mental status
examination when any abnormality in affect or
behavior is discovered and in certain
situations.
 You will collect ample data to be able to
assess mental health strengths and coping
skills and to screen for any dysfunction.
 When a Full Mental Status
Examination Is Necessary
 Initial screening
 Suggests an anxiety disorder or depression
 Behavioral changes
 Memory loss, inappropriate social interaction
 Brain lesions
 Trauma, tumor, cerebrovascular accident, or
stroke
 Aphasia
 Impairment of language ability secondary to brain
damage
 Symptoms of psychiatric mental illness
 Especially with acute onset
 Factors That Could Affect
Interpretation of Findings
 Known illnesses or health problems:
 Such as alcoholism or chronic renal disease
 Medications:
 Side effects of confusion or depression
 Educational and behavioral level:
 Note factor as normal baseline
 Stress responses observed in
 social interactions, sleep habits, drug and alcohol
use
 Examination Sequence of Steps
Data Collection

Assess accurately and assure validity

Basic function (consciousness and language)

Sequence of steps forms a hierarchy in which the most basic functions are assessed
first
 Objective Data: Collection
 Addressing key areas:
 Appearance, behavior, cognitive functions, and
thought processes and perceptions and judgment
 Additional screenings as needed based on
observations - anxiety, depression or suicidal
thoughts
 Determination of normal versus abnormal findings
 Documentation of findings
 Obtaining baseline and then trending results upon
ongoing assessment
 Objective Data: Appearance
 Posture
 Erect and position relaxed
 Body movements
 Body movements voluntary, deliberate, coordinated, and
smooth and even
 Dress
 Appropriate for setting, season, age, gender, and social
group
 Grooming and hygiene
 Congruence between grooming and age
 Pupils
 Note pupil size and reaction to light
Objective Data: Behavior (1of 2)
 Level of consciousness
 Person is awake, alert, aware of stimuli from
environment and within self, and responds
appropriately and reasonably soon to stimuli.
 Facial expression
 Appropriate to situation and changes appropriately
with topic; comfortable eye contact unless
precluded by cultural norm
Objective Data: Behavior (2 of 2)
 Speech
 Judge the quality of speech, noting that person
makes sounds effortlessly and shares
conversation appropriately.
 Pacing, articulation, and word choice
 Mood and affect
 Judge by body language and facial expression
and by direct questioning.
 Mood should be appropriate to person’s place and
condition and should change appropriately with
topics; person is willing to cooperate.
 Objective Data:
Cognitive Functions (1 of 2)
 Orientation
 Discern orientation through course of interview, or use direct
questioning to verify
• Time: day of week, date, year, season
• Place: where person lives, address, phone number, present location,
type of building, name of city and state
• Person: own name, age, who examiner is, type of worker
 Many hospitalized people normally have trouble with exact date
but are fully oriented on remaining items.
 Attention span
 Check person’s ability to concentrate
• by noting whether he or she completes a thought without wandering.
 Attention span commonly is impaired in people who are anxious,
fatigued, or intoxicated.
 Objective Data:
Cognitive Functions (2 of 2)
 Recent memory
 Assess in context of interview by 24-hour diet recall or by
asking time person arrived at agency.
 Ask questions you can corroborate to screen for occasional
person who confabulates or makes up answers to fill in gaps
of memory loss.
 Remote memory
 In the context of the interview, ask the person verifiable past
events; for example, ask to describe past health, the first job,
birthday and anniversary dates, and historical events that
are relevant for that person.
 Remote memory is lost when cortical storage area for that
memory is damaged, such as in Alzheimer disease,
dementia, or any disease that damages cerebral cortex.
 New Learning:
The Four Unrelated Words Test
 Highly sensitive and valid memory test
 Requires more effort than recall of personal or
historic events, and avoids danger of unverifiable
recall
 Assessment Process
 Pick four words with semantic and phonetic diversity; ask
person to remember the four words.
 To be sure person understood, have him or her repeat the
words.
 Ask for the recall of four words at 5, 10, and 30 minutes.
 Normal response for persons younger than 60 is an accurate
3- or 4-word recall after 5, 10, and 30 minutes.
 Additional Testing for Persons with
Aphasia
 Aphasia: loss of ability to speak or write
coherently or to understand speech or writing
due to a cerebrovascular accident
 Word comprehension: point to articles in the room
or articles from pockets and ask person to name
them
 Reading: ask person to read available print; be
aware that reading is r/t educational level
 Writing: ask person to make up and write a
sentence; note coherence, spelling, and parts of
speech
Thought Processes and Perceptions
 Thought processes
 Way person thinks should be logical, goal directed,
coherent, and relevant; should complete thoughts
 Thought content
 What person says should be consistent and
logical.
 Perceptions
 Person should be consistently aware of reality;
perceptions should be congruent with yours.
 Screen for Anxiety Disorders
 Anxiety and depression are the two most
common mental health disorders seen in
individuals seeking health care.
 Generalized anxiety disorder scale (GAD-7)
• Consists of 7 itemized scale
• Higher the score, greater the likelihood.
• First 2 questions relate to core anxiety.
• Greater or equal than 3 indicates diagnosis.
 Screen for Depression Disorders
 Series of tools that can be used in clinical setting
 Patient Health Questionnaire-2 (PHQ-2)
• Asks 2 questions about depressed mood and anhedonia
(lack of interest).
• Serves as a screening tool to use full PHQ-9 tool
 PHQ-9
• Series of 9 questions requiring adding column totals that
relate to frequency of occurrence of symptoms
• Higher the score, the greater the likelihood of functional
impairment or clinical diagnosis.
 Screening for Suicidal Thoughts
 Assess for possible risk for harm if the person expresses
feelings of sadness, hopelessness, despair, or grief.
 Begin with more general questions and proceed if you
hear affirmative answers.
 It is very difficult to question people about possible suicidal
wishes for fear of invading privacy.
 Risk is far greater skipping these questions if you have the
slightest clue that they are appropriate; you may be the only
health professional to pick up clues of suicide risk.
 For people who are ambivalent, you can buy time so the
person can be helped to find an alternate remedy.
 Share any concerns you have about a person’s suicide
ideation with a mental health professional.
 Judgment
 Is the ability to compare and evaluate alternatives
and reach an appropriate course of action
 Test judgment about daily or long-term goals, likelihood
of acting in response to hallucinations or delusions, and
capacity for violent or suicidal behavior.
 In the context of the interaction
 Note what person says about job plans, social or family
obligations, and plans for the future; job and future plans
should be realistic, considering person’s health situation.
 Ask for rationale for his or her health care, and how he or
she decided about compliance with prescribed health
regimens; actions and decisions should be realistic.
 Supplemental Mental Status
Examination
 Mini-Mental State Exam (MMSE)
 Concentrates only on cognitive functioning
 Standard set of 11 questions requires only 5 to 10 minutes to
administer.
• Useful for both initial and serial measurement
• Detect dementia and delirium and to differentiate these
from psychiatric mental illness.
• Normal mental status average 27; scores between 24
and 30 indicate no cognitive impairment
 Montreal Cognitive Assessment (MoCA)
 Examines more cognitive domains, more sensitive to mild
cognitive impairment
 Ten minutes to administer
• Total score of 30 with a score of greater to or equal than 26
considered normal
 Developmental Competence
 Infants and children
 Covers behavioral, cognitive, and psychosocial
development and examines how child is coping
with his or her environment
 Follow A-B-C-T guidelines as for adults, with
consideration for developmental milestones
 Abnormalities often problems of omission; child
does not achieve expected milestone
 Parent’s health history, especially sections on
developmental history and personal history, yields
most of mental status data.
 Screening Tests
 Infants and children
 Denver II screening test gives a chance to interact directly
with child to assess mental status.
• For child from birth to 6 years of age, Denver II helps identify
those who may be slow to develop in behavioral, language,
cognitive, and psychosocial areas.
• An additional language test is the Denver Articulation Screening
Examination.
 “Behavioral Checklist” for school-age children, ages 7 to 11,
is tool given to parent along with the history.
• Covers five major areas: mood, play, school, friends, and family
relations
• It is easy to administer and lasts about 5 minutes.
 Adolescents
 Follow same A-B-C-T guidelines as for adults.
 Developmental Care of
Aging Adults
 Check sensory status, vision, and hearing
before any aspect of mental status.
 Confusion is common and is easily misdiagnosed.
 Presence of delirium can have serious affects.
 Overall presence of dementia has decreased.
determination of delirium versus dementia must be
evaluated when cognitive impairment is present
upon examination of the older adult.
 Testing Aging Adults
 Follow same A-B-C-T guidelines for the younger
adult with these additional considerations.
 Behavior: level of consciousness
 Glasgow Coma Scale is useful in testing consciousness in
aging persons in whom confusion is common.
 Gives numerical value to person’s response in eye-opening,
best verbal response, and best motor response
 Avoids ambiguity when numerous examiners care for same
person
Aging Adults: Cognitive Functions
 Orientation
 Many aging persons experience social isolation, loss
of structure without a job, change in residence, or
some short-term memory loss.
 Aging persons may be considered oriented if they
know generally where they are and the present
period.
 Consider them oriented to time if year and month
are correctly stated.
 Orientation to place is accepted with correct
identification of the type of setting (e.g., the hospital
and name of town).
 Aging Adults: New Learning
 Cognitive functions: new learning
 In people of normal cognitive function, age-related
decline occurs in performance in the Four
Unrelated Words Test.
 Persons in the eighth decade average two of four
words recalled over 5 minutes and will improve
performance at 10 and 30 minutes after being
reminded by verbal cues.
 The performance of those with Alzheimer disease
does not improve on subsequent trials.
 Aging Adults: Supplemental Mental
Status Testing
 Mini-Cog
 Reliable and quick instrument to
screen for cognitive impairment in
healthy adults
 Consists of three-item recall test
and clock-drawing test
 Tests person’s executive function,
including ability to plan, manage
time, and organize activities, and
working memory
 Those with no cognitive
impairment or dementia can recall
the three words and draw a
complete, round, closed clock
circle with all face numbers in
correct position and sequence and
hour and minute hands indicating
time you requested.
 Case Study Question 1
A nursing student is learning about the importance
of performing a mental status assessment on
patients to provide an adequate indicator of
cognitive status.

1. What information would be included in a mental

status assessment for an adult patient?
Answer to Case Study Question 1
 See Chapter 5: Defining mental status
 From Textbook:
 Mental status cannot be scrutinized directly like
the characteristics of skin or heart sounds. Its
functioning is inferred through assessment of an
individual’s behaviors:
• Review definition of concepts
• Consciousness, language, mood, and affect
• Orientation, attention, memory, and abstract reasoning
• Thought process, thought content, and perceptions
 Case Study Question 2

2. How would the nursing student assess abstract

reasoning in an adult patient?
Answer to Case Study Question 2
 To test abstract reasoning in an adult patient,
the nursing student would use a situation in
which the patient would have to apply or
interpret a statement. Abstract reasoning
involves problem solving and interpretation of
analogies. The concept can be applied both
verbally and graphically, allowing the adult
patient to provide an interpretation and
understanding of a process or sequence.
 Case Study Question 3

3. How would the nursing student differentiate

between recent and remote memory in an
adult patient?
Answer to Case Study Question 3
 To differentiate between recent and remote
memory in an adult patient, the nursing student
could use probing questions r/t recent/current
events versus past family/childhood
experiences. The context of how the adult
patient frames the information would provide the
distinction between the assessment of recent
and remote memory.
 Case Study Question 4
4. The nursing student is reviewing the
components of a Mini-Mental Status Exam
(MMSE) to be used during the assessment
process. How would the nursing student
interpret the results of an MMSE if the score
was noted as 15?
 Answer to Case Study Question 4
 See Cognitive Function in Chapter 5: Mental Status
Assessment.
 MMSE exam is based on a numeric scale of 1 to 30 with
the higher score indicating full cognitive function.
 From Textbook:
 The maximum score on the test is 30; people with normal mental
status average 27. Scores between 24 and 30 indicate no
cognitive impairment.
 Scores that occur with dementia and delirium are classified as
follows: 18 to 23 = mild cognitive impairment; 0 to 7 = severe
cognitive impairment.
 As the score noted is 15, this would indicate that the patient had more than just
mild cognitive impairment.
 Question 5

5. The student nurse is reviewing comparative

differences between delirium and dementia. Based
on these observations, how would the student nurse
characterize the following presentations?
 A 78-year-old male presents with new onset confusion in the
physician’s office.
 A 65-year-old female has been having continued difficulty
remembering phone numbers for several months’ duration
and comes to the physician’s office out of concern.
 An 89-year-old male has a urinary tract infection and is
confused on admission to the hospital.
 Answer to Case Study Question 5
 See section The Aging Adult in Chapter 5: Mental Status
Assessment.
 From Textbook:
 Delirium is an acute confusional change or loss of
consciousness and perceptual disturbance, may accompany
acute illness (e.g., pneumonia, alcohol/drug intoxication), and is
usually resolved when the underlying cause is treated.
 In contrast, dementia is a gradual progressive process—causing
decreased cognitive function even though the person is fully
conscious and awake—and is not reversible.
• The 78-year-old patient should be evaluated for delirium, as this is a
“new onset” confusion.
• The 65-year-old patient should be evaluated for dementia, as this is
an ongoing problem.
• The 89-year-old patient should be evaluated for delirium due to the
comorbid condition of a urinary tract infection.