Mental Status, Physical and Cognitive Examination and Findings

Mental status should be completed as part of a comprehensive assessment, or as part of a focused exam if a client is experiencing issues like confusion or memory loss. The mental status assessment provides the nurse with information about cognitive and emotional functioning. Let's review the process of completing a mental status assessment.

Okay, so generally, you'll need paper, pencil, and a copy of the mental status test you plan to administer. Then, prepare for the exam by ensuring your client is in a comfortable position, and that the temperature in the room is comfortable. Provide privacy by closing the door and curtains. Before getting started, explain the procedure to your client and be sure to answer any questions they might have before obtaining verbal consent. Then, perform hand hygiene and collect your supplies.

The method of assessment for a mental status exam is inspection.

First, let's begin with appearance, which can be observed when your client moves into the exam room. When evaluating appearance, expect their posture to be erect and relaxed; and their movement should be smooth and purposeful. If your client appears restless or fidgety, this could be a sign of anxiety. Other unexpected findings include tics, which are sudden, repetitive movements like eye blinking or throat clearing; and tremors, which are rhythmic shaking movements.

Then, observe your client's grooming. Expected findings include good hygiene, appropriate dress for the client's age, season, and weather; and there should be no obvious hygiene issues such as body or breath odor. Inappropriate dress or evidence of poor hygiene might indicate conditions like depression or cognitive disturbances like dementia.

Next, assess your client's behavior, beginning with their level of consciousness. Your client should be awake, alert, oriented, and responsive to both internal to environmental stimuli. Unexpected findings include lethargy or drowsiness; or being obtunded, meaning your client has a diminished response to environmental stimuli.

Also observe your client's facial expressions, which can tell you a lot about their emotional state. Their expressions should vary throughout the conversation and be appropriate to the context. A client who does not show much emotion through facial expressions exhibits a flat affect, which is a characteristic sometimes seen in clients with Parkinson disease or schizophrenia. On the other hand, your client is labile if they exhibit a rapid shift in facial expressions and emotions, a common finding in bipolar disorder.

Then, assess your client's speech, paying attention to their tone, pace, word choice, and articulation. Their speech should be effortless with appropriate variations in tone. If your client has difficulty articulating words, this is known as dysarthria, and can be caused by conditions related to dysfunction of the central nervous system. Other unexpected findings include dysphonia, or an abnormal pitch or volume, which can be related to laryngeal disease; and aphasia, meaning there's a problem with either the production or understanding of language.

Moving on to cognition, first, evaluate your client's orientation, meaning their familiarity with person, place, and time. To assess your client's orientation to person, ask them to tell you their first and last name or how old they are. For orientation to place, ask them where they are, or the city or state they are in. Lastly for time, ask them to tell you the day, month, or year. If your client is disoriented, meaning they are unable to correctly identify person, place, or time, it can mean they have symptoms of delirium or dementia.

Then, assess your client's memory. To evaluate immediate recall, ask your client to listen to and then repeat a short sentence or series of numbers. For recent memory, ask about the recent past, like what the client ate for breakfast. You can also show your client a few objects, and let them know that you will ask about them in a few minutes. After ten minutes, ask them to list the objects. Lastly, to assess long term memory, ask them about verifiable events in the past, like their health history.

Finally, assess your client's thought process. To start, assess if your client's thoughts make sense and are rational, or if they are illogical or unrealistic. You'll want to observe for signs of perceptual disturbances such as hallucinations, which can be visual, auditory, or tactile; or illusions, which are misperceptions of reality. If present, these can be an indication of mental illness or dementia.

Now, there are some special tests you can administer to further test your client's mental status. The Mini-Mental State Examination, or MMSE, includes a series of 11 questions that measure areas like orientation, language, recall, attention, calculation, and the ability to follow commands. An alternative to the MMSE is the Montreal Cognition Assessment, or MOCA. Lastly, in the elderly population, another test to help evaluate cognition and function is the Mini-Cog, which focuses on word recall and visuospatial processing using the clock drawing test.

As the nurse, it's your responsibility to correctly assess, interpret, report, and document findings. If your assessment reveals something that's potentially abnormal or emergent, like an acute change in mental status, you should report this immediately to the healthcare provider, while monitoring client progress and changes from baseline.

Alright, as a quick recap… A mental status assessment should be completed as part of a comprehensive assessment, like during a routine physical exam, or as part of a focused exam if a client is experiencing issues like confusion or memory loss. The method of assessment for a mental status exam is inspection and includes the administration of special tests like the MMSE, MOCA, or Mini-Cog. As the nurse, it's your responsibility to correctly assess, interpret, report, and document your assessment findings.