(5) Note elevation of blood pressure, especially when it occurs with a
widening pulse pressure.
2-13. MENTAL STATUS
a. Mental status assessment should evaluate the following areas:
State of consciousness.
b. The terms used to describe state of consciousness are often subjective and
ambiguous. For this reason, such terms should not be used in nursing documentation
unless they are qualified with an explanatory statement. When assessing a patient who
is other than "awake and alert," it is best to use a standardized assessment scale. One
such scale is the Glasgow Coma Scale (GCS), described in paragraph 2-16. Terms
used to describe state of consciousness include:
(1) Conscious (alert)--the patient responds immediately, fully, and
appropriately to visual, auditory, and other stimuli.
(2) Somnolent--unnatural drowsiness. The patient can be aroused and will
respond to commands, but will fall asleep again as soon as he is left alone.
(3) Stuporous--partial unconsciousness. The patient can be aroused with
painful stimuli and will attempt to respond with purposeful withdrawal from the stimulus.
The patient may be restless or combative as well.
Comatose--complete unconsciousness, no purposeful response to any
c. Orientation is determined by questioning the patient about person, place, and
(1) Ask the patient to spell his name, name his children, or recite his
address. Does the patient know who he is? Does the patient know who others are?
(2) Ask the patient to tell you where he is. He may be asked to name the
hospital, city, state, and so on.