Mental Status Examination

Mr. Malik Manasrah

Expected Findings/Optimal Level Unexpected Findings/Impaired

Assessment
of Functioning Functioning

Unresponsive
Difficulty breathing
Calm and comfortable with no signs Chest pain
Signs of Distress
of distress New onset of confusion
Moaning
Grimacing

Unable to provide name, location, or

day
Level of Alert Clouded consciousness
Consciousness Oriented to person, place, and time Delirium
and Orientation Aware of the situation Obtundation
Stupor
Coma

Appears stated age

Appears older than stated age
Well-groomed
Unkempt
Dressed appropriately for the
Not dressed appropriately for the
weather and situation
Appearance and weather and/or situation
Erect posture
General Behavior Slumped posture
Good oral hygiene
Poor eye contact
Culturally appropriate eye contact
Does not socialize with others
Socializes with others
Demonstrates threatening behavior
No threatening behaviors

Speech Exhibiting spontaneous speech Does not respond to verbal questions

Even speech rate, rhythm, and tone Does not follow instructions
Responds to verbal questions appropriately for development level
Speech is clear and understandable Speech is unclear
Follows instructions appropriately Rapid or pressured speech
 Expected Findings/Optimal Level Unexpected Findings/Impaired
Assessment
of Functioning Functioning

for developmental level Halting speech

Poor balance
Uneven gait
Slow movements
Lack of spontaneous movement
Good balance
Motor restlessness (akathisia)
Motor Activity Moves extremities equally bilaterally
Repetitive movements
Smooth gait
Tremors
Pacing
Uncontrolled, involuntary movement
(dyskinesia)

Inappropriate or incongruent with

the situation
Displays wide range of emotions that
Subdued
are appropriate to situation
Tearful
Congruent with mood
Affect and Mood Labile
Bright
Blunted
Hopeful with goals
Flat
Positive self-worth
Dysphoric
Euphoric

Thought and Realistic Inability to focus or concentrate

Perception Logical Irrational fear
Goal-directed Exaggerated response
Organized Delusions
Ability to focus or concentrate Hallucinations
Absence of suicidal ideation Illusions
Absence of homicidal ideation Obsessions
Absence of violence ideation Racing thoughts
Flight of ideas
Loose associations
Clang associations
Suicidal ideation
 Expected Findings/Optimal Level Unexpected Findings/Impaired
Assessment
of Functioning Functioning

Homicidal ideation

Exhibits hostility, anger,

Looks toward improvement and/or helplessness, pessimism,
Attitude and recovery overdramatization, self-centeredness,
Insight Demonstrates understanding of the or passivity
situation Demonstrates little or no
understanding of the situation

Distractibility
Focused attention
Cognitive Poor immediate recall
Good immediate recall, short-term
Abilities Poor short-term memory
memory, and long-term storage
Poor long-term memory

Noticing and managing examiner’s Lack of awareness of examiner’s

Examiner’s
internal responses to the client such internal responses to the client such
Reaction to
as frustration, boredom, sadness, as frustration, boredom, sadness,
Client
anxiousness, or countertransference anxiousness, countertransference
Cultural Formulation Interview Questions
1. What brings you here today?

2. What troubles you most about this problem?

3. Why do you think this is happening to you? What do you think is the cause of this problem?

4. Are there any kinds of support that make this problem better, such as support from family, friends, or
others?

5. Are there any kinds of stresses that make this problem worse, such as difficulties with money or family
problems?

6. Sometimes aspects of people’s background or identity can make their problem better or worse, such
as the communities they belong to, the languages they speak, where they or their family are from, their
race or ethnic background, their gender or sexual orientation, or their faith or religion. Are there any
aspects of your background or identity that make a difference to this problem?

7. Sometimes people have various ways of dealing with problems. What have you done on your own to
cope with this problem?

8. Often, people look for help from many different sources, including different kinds of doctors, helpers,
or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for this
problem?

9. Has anything prevented you from getting the help you need?

10. What kinds of help do you think would be most useful to you at this time for this problem?

11. Are there other kinds of help that your family, friends, or other people have suggested that would be
helpful for you now?

12. Sometimes health care professionals and patients misunderstand each other because they come
from different backgrounds or have different expectations. Have you been concerned about misaligned
care expectations and is there anything that we can do to provide you with the care you need?

Reason for Seeking Health Care

It is helpful to begin the psychosocial assessment by obtaining the reason why the patient is
seeking health care in their own words. During a visit to a clinic or emergency department or on
admission to a health care agency, the patient’s primary reasons for seeking care are referred to
as the chief complaint. Assessing a client’s chief complaint recognizes that clients are complex
beings, with potentially multiple coexisting health needs, but there is often a pressing issue that
requires most immediate care. Questions used to evaluate a client’s chief complaint are as
follows:
  What brought you in today?
 How long has this been going on?
 How is this affecting you?

 Sample PQRSTU Questions

PQRSTU Sample Questions

What makes your pain worse?

Provocation/Palliation
What makes your pain feel better?

What does the pain feel like?

Quality Note: You can provide suggestions for pain characteristics such as
“aching,” “stabbing,” or “burning.”

Where exactly do you feel the pain? Does it move around or radiate
Region
elsewhere?

How would you rate your pain on a scale of 0 to 10, with “0” being no
Severity
pain and “10” being the worst pain you’ve ever experienced?

When did the pain start?

What were you doing when the pain started?
Is the pain constant or does it come and go?
Timing/Treatment
If the pain is intermittent, when does it occur?
How long does the pain last?
Have you taken anything to help relieve the pain?

Understanding What do you think is causing the pain?

Thoughts of Suicide
As discussed in Chapter 1, all clients aged 12 and older presenting for acute care should be
screened for suicidal ideation. Clients being evaluated or treated for mental health conditions
often have suicidal ideation, and up to 10 percent of emergency department clients presenting
with medical issues have a hidden risk for suicide, such as recent suicidal ideation or previous
suicide attempts. Universal screening allows for the detection of suicide risk and implementation
of early interventions before a person attempts suicide.
It is important to introduce suicide screening in a way that helps the patient understand its
purpose and normalize questions that might otherwise seem intrusive. A nurse might introduce
the topic in the following way: “Now I’m going to ask you some questions that we ask everyone
treated here, no matter what problem they are here for. It is part of the hospital’s policy, and it
helps us to make sure we are not missing anything important.

Spiritual Assessment
Spiritual assessment is included in a psychosocial assessment. It is common for people in the
process of recovery from mental health disorders and substance use to search for spiritual
support.
Spirituality includes a sense of connection to something larger than oneself and typically
involves a search for meaning and purpose in life. Basic questions used to assess spirituality
include the following:
 Who or what provides you with strength or hope?
 How do you express your spirituality?
 What spiritual needs can we advocate for you during this health care experience?
Over the past decade, research has demonstrated the importance of spirituality in health care.
Spiritual distress is very common for clients experiencing serious illness, injury, or the dying
process, and nurses are on the front lines as they assist these individuals to cope with these life
events. Addressing a patient’s spirituality and advocating spiritual care have been shown to
improve patients’ health and quality of life, including how they experience pain, cope with stress
and suffering associated with serious illness, and approach end of life.

The FICA© Spiritual History Tool

F – Faith and Belief: Determine if the patient identifies with a particular belief system or
spirituality.
I – Importance: Ask, “Is this belief important to you? Does it influence how you think about
health and illness? Does it influence your health care decisions?”
C – Community: Determine if the client belongs to a spiritual community (e.g., a church,
temple, mosque, or other group). If not, ask, “Would it be helpful to you to find a spiritual
community?”
A – Address in Care: Evaluate what should be addressed during the client’s care. Ask, “What
should be included in your treatment plan? Are there spiritual practices you want to develop?
Would you like to see a chaplain, spiritual director, or pastoral counselor while you are here?”

Screening Tools
Screening tools are evidence-based methods to assess specific information related to mental
health disorders. These tools may be used on admission to the hospital or treatment facility, as
well as at different times throughout the client’s stay. Findings may be used to compare client
progress during the hospital stay or from a previous admission. The registered nurse often
conducts these screening tools as part of the interprofessional health care treatment team. Read
more about specific screening tools in each “disorder” chapter.

Laboratory and Diagnostic Testing

Nurses review laboratory and diagnostic testing results as part of the assessment process.
Nurses monitor electrolytes and medication levels as they evaluate the need for medication
adjustment. For example, serum sodium levels may be out of range due to conditions such as
polydipsia, and poor nutritional or hydration status related to mental health disorders may require
additional interventions by the nurse.

Life Span Considerations

Life span considerations influence nursing assessments, care planning, and interventions. Mental
health disorders occur across the life span, from the very young to the very old, and
developmental stages must be considered when identifying impairments. Assessments and
interventions must be individualized to the age and developmental level of the
client. Development encompasses physical, social, and cognitive changes that occur
continuously throughout one’s life.

Figure 4.4
Human Life Cycle
There are multiple factors that affect human development with expected milestones along the
way. Cognitive development encompasses several different skills that develop at different rates.
Each human has their own individual experience that influences development of intelligence and
reasoning as they interact with one another. With these unique experiences, everyone has a
memory of feelings and events that is exclusive to them.
There are many theories regarding how infants and children grow and develop into happy,
healthy adults. Three major theories that have historically impacted nursing care are Freud’s
Psychosexual Theory of Development, Erikson’s Psychosocial Stages of Development, and
Piaget’s Cognitive Theory of Development.