Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Assessment Tool Reference Guide
Tool Description of Tool Refer to…
Extensive Nursing Assessment/Mental Status Questions
  • Sample questions to be used for nurse-client interview.
Appendix D

Mini-Mental Status Exam (MMSE)

View here.

  • Most widely used mental status assessment; a good tool to substantiate clinical observations in nursing.
  • Measures: memory, orientation, language, attention, visuospatial and constructional skills.
Appendix E
Clock Drawing Test
  • May assist in supporting a diagnosis of dementia or in indicating to a clinician areas of difficulty experienced by a client.
  • Complements other tests which focus on memory/language.
Appendix F
Neecham Confusion Scale
  • Measures level of confusion in processing, behaviour and physiologic control.
Appendix G

Confusion Assessment Method (CAM) Instrument

View here.

  • To help identify individuals who may be suffering from delirium or an acute confusional state.
  • Useful for differentiating delirium and dementia.
Appendix H

Screening for Depression in the Older Adult

SIG E Caps

  • Clinical tool used at bedside if there are concerns regarding depressed mood.
  • Use the acronym SIG E CAPS to describe.
Appendix I
Cornell Scale for Depression
  • Provides a quantitative rating of depression in individuals with or without dementia.
  • Utilizes information from the caregiver as well as the client.
Appendix J
Geriatric Depression Scale and Geriatric Depression Scale (GDS – 4 Short Form)
  • May assist in supporting a diagnosis of depression (an adjunct to clinical assessment).
  • Provides a quantitative rating of depression.
Appendix K & L
Suicide Risk in the Older Adult
  • Helps identify suicidal risk in individuals with a depressed mood.
Appendix M
Mini Cog
  • An alternative to the MMSE; used to assess a person's registration, recall and executive function.
  • Appropriate to be used with older adults at various heterogenous language, culture and literacy levels.

Website:

www.nursingcenter.com

Montreal Cognitive Assessment (MoCA)
  • A cognitive screening test designed to assist health professionals in the detection of mild cognitive impairment,
  • Preferred for assessment of executive dysfunction.

Website:

www.mocatest.org

[back to top]

Please refer to “Screening for Delirium, Dementia, and Depression” Best Practice Guideline for more details.