2012
Psychiatric–Mental Health Nursing
‫أستاذ زياد طارق‬
Mental Status Assessment
Gathering the correct information about the client’s mental status is
essential to the development of an appropriate plan of care. The mental
status examination is a description of all the areas of the client’s mental
functioning. The following are the components that are considered critical
in the assessment of a client’s mental status.
Identifying Data
1. Name
2. Sex
3. Age
4. Race/culture
5. Occupational/financial status
6. Educational level
7. Significant other
8. Living arrangements
9. Religious preference
10. Allergies
11. Special diet considerations
12. Chief complaint
13. Medical diagnosis
General Description
Appearance
1. Grooming and dress
2. Hygiene
3. Posture
4. Height and weight
5. Level of eye contact
6. Hair color and texture
7. Evidence of scars, tattoos, or other distinguishing skin marks
8. Evaluation of client’s appearance compared with chronological age
Motor Activity
1.Tremors
2. Tics or other stereotypical movements
3. Mannerisms and gestures
4. Hyperactivity
5. Restlessness or agitation
6. Aggressiveness
7. Rigidity
8. Gait patterns
9. Echopraxia
10. Psychomotor retardation
11. Freedom of movement (range of motion)
Speech Patterns
1. Slowness or rapidity of speech
2. Pressure of speech
3. Intonation
4. Volume
5. Stuttering or other speech impairments
6. Aphasia
General Attitude
1. Cooperative/uncooperative
2. Friendly/hostile/defensive
3. Uninterested/apathetic
4. Attentive/interested
5. Guarded/suspicious
Emotions
Mood
1. Sad
2. Depressed
3. Despairing
4. Irritable
5. Anxious
6. Elated
7. Euphoric
8. Fearful
9. Guilty
10. Labile
Affect
1.Congruence with mood
2.Constricted or blunted (diminished amount/range and intensity of
emotional expression.
3. Flat absence of emotional expression.
4. Appropriate or inappropriate (defines congruence of affect with the
situation or with the client’s behavior.
Thought Processes
Form of Thought
1 .Flight of ideas
2 .Associative looseness
3 .Circumstantiality
4 .Tangentiality
5. Neologisms
6.Concrete thinking
7.Clang associations
8.Word salad
9.Perseveration
10 .Echolalia
11. Mutism
12.Poverty of speech (restriction in the amount of speech)
13. Ability to concentrate
14. Attention span
Content of Thought
1 .Delusions
a. Persecutory
b. Grandiose
c. Reference
d. Control or influence
e. Somatic
f. Nihilistic
2 .Suicidal or homicidal ideas
3. Obsessions
4 .Paranoia/suspiciousness
5.Magical thinking
6 Religiosity
7.Phobias
8. Poverty of content (vague, meaningless responses)
Perceptual Disturbances
1.Hallucinations
a. Auditory
b. Visual
c. Tactile
d. Olfactory
e. Gustatory
2 .Illusions
3.Depersonalization (altered perception of the self)
4 .Derealization (altered perception of the environment)
Sensorium and Cognitive Ability
1 .Level of alertness/consciousness
2 .Orientation
a. Time
b. Place
c. Person
d. Circumstances
3 .Memory
a. Recent
b. Remote
c. Confabulation
4 .Capacity for abstract thought
Impulse Control
1 .Ability to control impulses related to the following:
a. Aggression
b. Hostility
c. Fear
d. Guilt
e. Affection
f. Sexual feelings
Judgment and Insight
1 .Ability to solve problems
2.Ability to make decisions
3.Knowledge about self
a. Awareness of limitations
b. Awareness of consequences of actions
c. Awareness of illness
4.Adaptive/maladaptive use of coping strategies and
ego defense mechanisms