Disclaimer Show
Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always … More Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. You do not currently have access to this chapter. 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 consciousnessrefers 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, “Can you tell me 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 ScaleThe 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 \(\PageIndex{1}\)[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 ScaleThe 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 following hyperlink 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.
Mini-Mental Status ExamThe 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 \(\PageIndex{2}\)[10] for an image of one of the questions on the MMSE regarding interlocking pentagons. Which parameters are assessed when using the Glasgow Coma Scale?The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. Reporting each of these separately provides a clear, communicable picture of a patient's state.
Which criteria would the nurse use to assess the mental status of a patient?The mental status exam should include the general awareness and responsiveness of the patient. Additionally, one may also include the orientation, intelligence, memory, judgment, and thought process of the patient. At the same time, the patient's behavior and mood should undergo assessment.
Which question would the nurse ask when using the Patient Health Questionnaire 2?The PHQ-2 screen asks, “Over the past 2 weeks, how often have you been bothered by: (1) a lack of interest; or (2) feeling sad or depressed?” These questions are rated on a scale of 0 to 3 (range from 0 to 6) with a positive score being 3 or greater.
Which finding would be seen in a patient with aphasia?Patients with thalamic aphasia usually present with fluent language disorders, often without hemiparesis. Associated findings include anomia, jargon speech, semantic paraphasic errors, intact repetition, and relatively preserved comprehension.
|
Which parameter is the nurse assessing when the patient is asked about date and time?
zusammenhängende Posts
Urheberrechte © © 2024 decemle Inc.
