HA-RLE Worksheet # 3

ASSESSING MENTAL STATUS AND SUBSTANCE ABUSE

Case Study:

Read the following case study. Then work through the steps of analysing the case study
data.

1. First identify abnormal data and strengths in subjective and objective findings;
2. Assemble cue clusters;
3. Draw inferences;
4. Make possible nursing diagnoses;
5. Identify defining characteristics;
6. Confirm or rule out the diagnoses; and
7. Document your conclusions.

Use the table below to collect subjective and objective data provided to guide you.
Propose nursing diagnoses that are specific to the client in the case study. Identify
collaborative problems, if any, for this client. Finally identify data, if any, which point
toward a medical problem requiring a referral.
 Mrs. Susan Dy, a 54-year-old, 6th grade Mathematics teacher, comes to wellness
screening and expresses concern that she has had difficulty recalling her students’
names over the past semester. She also misplaces objects more frequently than in the
past. Both her memory and misplacing things are getting worse. She has no history of
stroke, meningitis, or head injury and no family history of Alzheimer’s. Her brother had
bipolar disorder. She is able to perform activities of daily living but it is getting more
difficult to grade math papers at night. She tries more easily than in the past. She
awakens two times a night but is able to return to sleep within 30 minutes. She reports
having good appetite and a daily well-formed bowel movement. She is active in her
church community and walks 3 miles, four times a week. She enjoys quilting. Mrs.
Susan has positive relationships with her husband and two daughters.

Mental status – alert and oriented to person, place, day, and time. Clean and
neat appearance. Has direct eye contact with pleasant cooperative disposition. Speech
clear with moderate tone. Somewhat anxious over forgetting names and location of
objects. Looking forward to retirement in 8 years. Able to name familiar objects in room.
Expressed clear, realistic and logical thought processes about the past and future.
Recalls breakfast and past dates of family member’s birthdays. Repeated four unrelated
words after 5 minutes, one word after 10 minutes, unable to repeat any words after 12
minutes. Explained the meaning of common proverbs, explained what she would do in
an emergency situation in her classroom. Correctly drew the face of a clock. Scored 28
in the Saint Louis University Mental Status (SLUMS) Examination.
Note: Please secure consent before starting the interview to actual client….

NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA

QUESTIONS FINDINGS
Biographical Data
Name (use Code Name or Alyas) Cassie

Gender Female

Address, Phone Number General Santos City

Date and Place of Birth n/a

Nationality or Ethnicity Filipino

Marital Status Married

Religious or Spiritual Practices Roman Catholic

Primary and Secondary Languages English and Filipino

spoken, written, and read; Birth Language
Educational Level College graduate

Occupation and Working Status Mathematics Teacher

Who lives with the client? Identify Husband, two daughters

significant others
Caregivers and support people for the n/a
client

Present History (Reasons for Seeking Health Care)

What is your major health care or The client has a problem in retaining her
concern? memory.

Are you comfortable with seeking care n/a

from this organization? Past Experiences
good or not?

History of Present Health Concern (use COLDSPA when appropriate)

Character of symptom or condition? Memory loss

Onset (when it begin; better? Worse? Estimated fifteen weeks ago

Same?
Location (where and does it radiate?) n/a

Severity (on scale of 1-10?) n/a

Pattern (what makes it better? Worse? n/a

Associated factors (other associated n/a

symptoms? Effect on leisure or
exercise?)

Past Health History

Head injuries, meningitis, encephalitis, none
stroke? Effects on health?
Past medical diagnoses, surgeries none

Past counselling services received? n/a

Results?

Headaches? Describe n/a

Served in active duty in armed forces? n/a

Breathing Difficulties? n/a

Heart Palpitations? n/a

Exposure to environmental toxins? n/a

Family History
Family history of mental health problems? Brother-Bipolar disorder

Family history of psychiatric disorders, none

dementia, brain tumors?

Lifestyle and Health Practices

Describe typical activities in a day  active in church community
 enjoys quilting.

Energy level with ADLs? high

Typical eating habits? Healthy eating habits

Alcohol consumption? Type? Amount? none

Frequency?

Use the CAGE self-assessment tool to n/a

detect at risk clients. ( Box 6-1 p.79)

Use the AUDIT questionnaire to assess n/a

alcohol related disorders. Calculate
score. ( Assessment Tool 6-1 pp 93-94 in
the textbook).

Any use of recreational drugs (i.e. none

marijuana, tranquilizers, barbiturates,
cocaine, methamphetamines)?

Sleep patterns Disrupted sleep

Typical bowel elimination patterns Well-formed bowel movement

Exercise patterns walks 3 miles, four times a week.

Use of prescribed or OTC drugs n/a

Religious practices and activities? Active in church community

Role in family and community? teacher

Relationship with others (family members, n/a

coworkers, neighbors)

Perception of self and relationship with n/a

others?

View of one’s future? Life goals? Looking forward for retirement in 8 years

PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA

*When time is limited, use the St. Louis Score: 28 (normal); high school education
University Mental Status (SLUMS)
examination (Assessment Tool 6-3 p. 95
in the textbook). Report client’s SLUMS
score and clients level of education.
Otherwise complete observation below.
Level of consciousness. Ask for name, The client is responsive and is able to
address and phone number as answer the questions.
appropriate. If no response:

Call name louder

Next shake gently

If still no response, apply painful stimulus.

Use the Glasgow Coma Scale (GCS)
(see Assessment Tool 6-2 p. 93 in the
textbook) for clients who are at high risk
for rapid deterioration of consciousness.
Note posture, gait and body movements. Has direct eye contact during the
interview

Observe behaviour and the clients affect. Alert, oriented to person, time, place and
day

Note dress, grooming and hygiene. Clean and neat appearance

Observe facial expression. Anxious

Observe speech Speech clear with moderate tone

Note mood, feelings and expressions. The client shows a pleasant cooperative
Use depression questionnaire (Box 6-2 p. disposition.
81 in the textbook) if depression is
suspected. Use the Geriatric Depression
Scale (Box 32-2 p 797 in the textbook) for
older adults.
Note thought processes and perceptions. Expressed clear, realistic and logical
thought processes about the past and
future.

Observe for any destructive or suicidal none

tendencies.

Observe the following cognitive abilities:

 ● Orientation to person, time and ● Orientation to person, time and
place place ☑

● Concentration and alternatives ● Concentration and alternatives ☑

● Recent memory ● Recent memory ☑

● Remote memory ● Remote memory ☒

● Memory to learn new information ● Memory to learn new information

● Abstract reasoning ☑

● Judgment ● Abstract reasoning ☑

● Visual and constructional ability ● Judgment ☑

● Visual and constructional ability ☑

Use the Alcohol Use Disorders n/a

identification Test (AUDIT): Interview
Version to interview a client for risk of
alcohol abuse (Assessment Tool 6-1 p.
93 in the textbook).
Use the Confusion Assessment Method During the assessment, the client recalls
(CAM) to assess for confusion (see breakfast and past dates of family
Assessment Tool 6-4 p. 96 in the member’s birthdays. Repeated four
textbook) unrelated words after 5 minutes,

one word after 10 minutes, unable to

repeat any words after 12 minutes.
Use the modified SAD Persons Suicide n/a
Risk tool to assess for suicide risk (see
Assessment Guide 6-1 p. 83 in the
textbook).
Analysis
Formulate nursing diagnoses
Formulate collaborative problems
1. Risk for Acute confusion in related to
fluctuation in sleep-wake cycle and
metabolic abnormalities
2. Deficient knowledge r/t lack of
exposure and recall
3. Impaired memory r/t neurological
disturbances as evidenced by
impaired problem solving/ decision-
making and inability to recall or learn
new information
4. Disturbed sensory perception,
specifically gustatory r/t psychological
stress as evidenced by disturbed
sleeping pattern
5. Mild anxiety r/t stress as evidenced
by restlessness, sleep disturbance