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.

Maria, 76-year-old female client visits the clinic and tells the nurse about not feeling well for the last 2

weeks. The nurse observes that the client’s speech is slow; she has an unkempt appearance, and

maintains poor eye contact with the nurse. The nurse asks her to clarify what she means by not feeling

well. The client states “I feel like I am losing my mind. Since my husband died a year ago, I can’t seem to

remember anything. I lose my keys and wallet all the time. The other day, I even forgot how to get home

from the supermarket. My neighbor saw me walking around aimlessly and came over to me. I was a

block from home. I am getting worried that something may be wrong.” The nurse questions her further

regarding her daily activities and learns that she lives alone and hardly goes out. Her son and daughter

live out of state, and she doesn’t see them often, although they talk on the phone every week. The

client’s medical and surgical history is negative for medical conditions or surgeries. She appears thin and

frail. Her last visit for a medical exam was 3 years ago.

Questions:
 a. Based on the information provided by the client and the nurse’s assessment, what further
assessment should the nurse conduct?

b. Based on the data from the interview and the physical and mental assessment, formulate a plan
of care for this client.

NURSING INTERVIEW GUIDE TO COLLECT SUBJECTIVE DATA

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

Gender

Address, Phone Number

Date and Place of Birth

Nationality or Ethnicity

Marital Status

Religious or Spiritual Practices

Primary and Secondary Languages spoken,

written, and read; Birth Language
Educational Level

Occupation and Working Status

Who lives with the client? Identify significant

others
Caregivers and support people for the client

Present History (Reasons for Seeking Health Care)

What is your major health care or concern?

Are you comfortable with seeking care from this

organization? Past Experiences good or not?
History of Present Health Concern (use COLDSPA when appropriate)
Character of symptom or condition?

Onset (when it begin; better? Worse? Same?

Location (where and does it radiate?)

Severity (on scale of 1-10?)

Pattern (what makes it better? Worse?

Associated factors (other associated symptoms?

Effect on leisure or exercise?)

Past Health History

Head injuries, meningitis, encephalitis, stroke?
Effects on health?

Past medical diagnoses, surgeries

Past counselling services received? Results?

Headaches? Describe
Served in active duty in armed forces?

Breathing Difficulties?

Heart Palpitations?

Exposure to environmental toxins?

Family History
Family history of mental health problems?

Family history of psychiatric disorders, dementia,

brain tumors?

Lifestyle and Health Practices

Describe typical activities in a day

Energy level with ADLs?

Typical eating habits?

Alcohol consumption? Type? Amount?

Frequency?

Use the CAGE self-assessment tool to detect at

risk clients. ( Box 6-1 p.79)
Use the AUDIT questionnaire to assess alcohol
related disorders. Calculate score. ( Assessment
Tool 6-1 pp 93-94 in the textbook).

Any use of recreational drugs (i.e. marijuana,

tranquilizers, barbiturates, cocaine,
methamphetamines)?

Sleep patterns

Typical bowel elimination patterns

Exercise patterns

Use of prescribed or OTC drugs

Religious practices and activities?

Role in family and community?

Relationship with others (family members,

coworkers, neighbors)

Perception of self and relationship with others?

View of one’s future? Life goals?

PHYSICAL ASSESSMENT GUIDE TO COLLECT OBJECTIVE DATA

*When time is limited, use the St. Louis
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, address
and phone number as 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.

Observe behaviour and the clients affect.

Note dress, grooming and hygiene.

Observe facial expression.

Observe speech
Note mood, feelings and expressions. Use
depression questionnaire (Box 6-2 p. 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.

Observe for any destructive or suicidal

tendencies.

Observe the following cognitive abilities:

 Orientation to person, time and place
 Concentration and alternatives
 Recent memory
 Remote memory
 Memory to learn new information
 Abstract reasoning
 Judgment
 Visual and constructional ability

Use the Alcohol Use Disorders 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 (CAM) to
assess for confusion (see Assessment Tool 6-4 p.
96 in the textbook)
Use the modified SAD Persons Suicide Risk tool to
assess for suicide risk (see Assessment Guide 6-1
p. 83 in the textbook).

Analysis
Formulate nursing diagnoses

Formulate collaborative problems