Assessing with Altered Mental Status

[Blueorchid, ASN, RN]

Alright, so for my very first care plan (in my very first clinicals) I've got a 69 year old male patient with a chronic subdural hematoma developed from a fall his family believe occurred last November. He has a history of Parkinsons disease, BPH, and hyperlipidemia and developed status epilepticus post fall. He has had both a craniectomy and a craniotomy for the hematoma developing complications from the latter. As a result of the status and complications he has also had a trach placed for a little over 4 weeks and has just started on room air Saturday.

Throughout all of this he has had changes in mental status ranging from mild to severe. And as this is my first care plan I know I need to perform a head to toe assessment in order to collect information for his ROS. Since my school starts clinicals for first semester students at the end of the term I also only have one more day to visit the patient before my care plan is due.

My major concern is that having worked with him once before I know we have to take things one at a time and I need to gather a lot of information. One of my diagnoses is definitely going to involve risk for sensory overload but my question for the more experienced nurses is have you found any super condensed assessment tools in order to gather all this info? What I'm worried about is the fact that I'm already a new person with a different routine for morning care and we only have eight hours (I never thought I'd say that). The last thing I want to do is overload the poor man listening to his lung sounds as I'm charting my vitals and doing a bed bath and have him completely shut down.

For those of you that feel the need to answer "welcome to nursing," I'm well aware that I'm getting the hang of this and have a lot to learn. We also have a game plan set out for head to toe assessments that I'm being tested on in my health assessment class so I'm not completely out in the dark. Basically I'm looking for anyone that has dealt with a patient similar to this and might have advice or a few handy links. I know how to combine a few tests to interpret things like multiple cranial nerves but any help would be appreciated.

Thanks!

[Daytonite, BSN, RN]

look at the defining characteristics for the nursing diagnoses of acute and chronic confusion and then at the signs and symptoms on the dementia page of the merck manual (http://www.merck.com/mmpe/sec16/ch213/ch213c.html). when you are working with this man just keep these symptoms in the back of your mind and look for them in this man. observe his orientation to person, place and time. know how to do a neuro assessment. you should check out the assessment weblinks on this sticky thread as well: https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html