6.4 Assessing Mental Status
Open Resources for Nursing (Open RN)
Routine assessment of a patient’s mental status by registered nurses includes evaluating their level of consciousness, as well as their overall appearance, general behavior, affect and mood, general speech, and cognitive performance.[1],[2] See the “General Survey Assessment” chapter for more information about an overall mental status assessment.
Level of Consciousness
Level of consciousness refers to a patient’s level of arousal and alertness.[3] Assessing a patient’s orientation to time, place, and person is a quick indicator of cognitive functioning. Level of consciousness is typically evaluated on admission to a facility to establish a patient’s baseline status and then frequently monitored every shift for changes in condition.[4] To assess a patient’s orientation status, ask, “What is your name? Where are you? What day is it?” If the patient is unable to recall a specific date, it may be helpful to ask them the day of the week, the month, or the season to establish a baseline of their awareness level.
A normal level of orientation is typically documented as, “Patient is alert and oriented to person, place, and time,” or by the shortened phrase, “Alert and oriented x 3.”[5] If a patient is confused, an example of documentation is, “Patient is alert and oriented to self, but disoriented to time and place.”
There are many screening tools that can be used to further objectively assess a patient’s mental status and cognitive impairment. Common screening tools used frequently by registered nurses to assess mental status include the Glasgow Coma Scale, the National Institutes of Health Stroke Scale (NIHSS), and the Mini-Mental State Exam (MMSE).
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess and continually monitor a patient’s level of consciousness when damage has occurred, such as after a head injury or a cerebrovascular accident (stroke). See Figure 6.9[6] for an image of the Glasgow Coma Scale. Three primary areas assessed in the GCS include eye opening, verbal response, and motor response. Scores are added from these three categories to assign a patient’s level of responsiveness. Scores ranging from 15 or higher are classified as the best response, less than 8 is classified as comatose, and 3 or less is classified as unresponsive.
National Institutes of Health Stroke Scale
The National Institutes of Health Stroke Scale (NIHSS) is a standardized tool that is commonly used to assess patients suspected of experiencing an acute cerebrovascular accident (i.e., stroke).[7] The three most predictive findings that occur during an acute stroke are facial drooping, arm drift/weakness, and abnormal speech. Use the box below to view the stroke scale.
A commonly used mnemonic regarding assessment of individuals suspected of experiencing a stroke is “BEFAST.” BEFAST stands for Balance, Eyes, Face, Arm, and Speech Test.
- B: Does the person have a sudden loss of balance?
- E: Has the person lost vision in one or both eyes?
- F: Does the person’s face look uneven?
- A: Is one arm weak or numb?
- S: Is the person’s speech slurred? Are they having trouble speaking or seem confused?
- T: Time to call for assistance immediately
View the NIH Stroke Scale at the National Institutes of Health.
Mini-Mental Status Exam
The Mini-Mental Status Exam (MMSE) is commonly used to assess a patient’s cognitive status when there is a concern of cognitive impairment. The MMSE is sensitive and specific in detecting delirium and dementia in patients at a general hospital and in residents of long-term care facilities.[8] Delirium is acute, reversible confusion that can be caused by several medical conditions such as fever, infection, and lack of oxygenation. Dementia is chronic, irreversible confusion and memory loss that impacts functioning in everyday life.
Prior to administering the MMSE, ensure the patient is wearing their glasses and/or hearing aids, if needed.[9] A patient can score up to 30 points by accurately responding and following directions given by the examiner. A score of 24-30 indicates no cognitive impairment, 18-23 indicates mild cognitive impairment, and a score less than 18 indicates severe cognitive impairment. See Figure 6.10[10] for an image of one of the questions on the MMSE regarding interlocking pentagons.
Visit the Oxford Medical Education website for more information about the Mini-Mental Status Exam.
- Martin, D. C. The mental status examination. In Walker, H. K., Hall, W. D., Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed.). Butterworths. https://www.ncbi.nlm.nih.gov/books/NBK320/ ↵
- Giddens, J. F. (2007). A survey of physical examination techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education, 46(2), 83-87. https://doi.org/10.3928/01484834-20070201-09 ↵
- Huntley, A. (2008). Documenting level of consciousness. Nursing, 38(8), 63-64. https://doi.org/10.1097/01.nurse.0000327505.69608.35 ↵
- McDougall, G. J. (1990). A review of screening instruments for assessing cognition and mental status in older adults. The Nurse Practitioner, 15(11), 18–28. ↵
- Huntley, A. (2008). Documenting level of consciousness. Nursing, 38(8), 63-64. https://doi.org/10.1097/01.nurse.0000327505.69608.35 ↵
- “glasgow-coma-scale-gcs-600w-309293585.jpg” by joshya on Shutterstock. All rights reserved. Imaged used with purchased permission. ↵
- National Institutes of Health. (n.d.). NIH stroke scale. https://www.stroke.nih.gov/resources/scale.htm ↵
- McDougall, G. J. (1990). A review of screening instruments for assessing cognition and mental status in older adults. The Nurse Practitioner, 15(11), 18–28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6751405/ ↵
- Koder-Anne, D., & Klahr, A. (2010). Training nurses in cognitive assessment: Uses and misuses of the mini-mental state examination. Educational Gerontology, 36(10/11), 827–833. https://doi.org/10.1080/03601277.2010.485027 ↵
- “InterlockingPentagons.svg” by Jfdwolff[2] is licensed under CC BY-SA 3.0 ↵
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
You are a nurse working in a long-term care facility. You have been assigned to care for Mr. Johns, a 74-year-old client recently diagnosed with a urinary tract infection, resulting in frequent incontinence. Mr. Johns suffered a cerebrovascular accident (stroke) six months ago and has difficulties ambulating and attending to his own needs because of weakness on his right side. Mr. Johns is alert and oriented to person, place, and time, but has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a wheelchair due to his difficulty with ambulation. He eats about 50% of his meals. While assessing Mr. Johns, you note that he is thin for his height, incontinent of foul-smelling urine, and has a red area of skin on his sacrum.
- What additional information, including lab work, would you like to gather to further assess Mr. Johns' potential for pressure injury development?
- What factors make him particularly vulnerable to the development of pressure injuries?
Test your knowledge using this NCLEX Next Generation-style bowtie question. You may reset and resubmit your answers to this question an unlimited number of times.[1]
