Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Components of a Mental Status Assessment

Appearance

  • Age (chronological age and whether person looks this age)
  • Sex, Race
  • Body build (thin, obese, athletic, medium)
  • Position (lying, sitting, standing, kneeling)
  • Posture (rigid, slumped, slouched, comfortable, threatening)
  • Eye contact (eyes closed, good contact, avoids contact, stares)
  • Dress (what individual is wearing, cleanliness, condition of clothes, neatness, appropriateness of garments)
  • Grooming (malodorous, unkempt, dirty, unshaven, overly meticulous, hairstyle, disheveled, makeup)
  • Manner (cooperative, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating, evasive, friendly, hostile)
  • Attentiveness to examiner (disinterested, bored, internally preoccupied, distractible, attentive)
  • Distinguishing features (scars, tattoos, bandages, bloodstains, missing teeth, tobacco-stained fingers)
  • Prominent physical irregularity (missing limb, jaundice, profuse sweating, goiter, wheezing, coughing)
  • Emotional facial expression (crying, calm, perplexed, stressed, tense, screaming, tremulous, furrowed brow)
  • Alertness (alert, drowsy, stupor, confused)

Motor/Behaviour

  • Retardation (slowed movements)
  • Agitation (unable to sit still, wringing hands, rocking, picking at skin or clothing, pacing, excessive movement, compulsive)
  • Unusual movements (tremor, lip smacking, tongue thrust, mannerisms, grimaces, tics)
  • Gait (shuffling, broad-based, limping, stumbling, hesitation)
  • Catatonia (stupor, excitement)

Speech

  • Rate (slowed, long pauses before answering questions, hesitant, rapid, pressured)
  • Rhythm (monotonous, stuttering)
  • Volume (loud, soft, whispered)
  • Amount (monosyllabic, hyper-talkative, mute)
  • Articulation (clear, mumbled, slurred)
  • Spontaneity

Mood/Affect

  • Stability (stable, fixed, labile)
  • Range (constricted, full)
  • Appropriateness (to content of speech and circumstance)
  • Intensity (flat, blunted, exaggerated)
  • Affect (depressed, sad, happy, euphoric, irritable, anxious, neutral, fearful, angry, pleasant)
  • Mood (reported by patient/client)

Thought Content

  • Suicidal or homicidal ideations (intent, plan, access to means, time-frame)
  • Depressive cognition (guilt, worthlessness, hopelessness)
  • Obsessions (persistent, unwanted, recurring thought)
  • Ruminations
  • Phobias (strong, persistent, fear of object or situation)
  • Ideas of reference
  • Paranoid ideation
  • Magical ideation
  • Delusions (false belief kept despite no supportive evidence)
  • Overvalued ideas
  • Thought broadcasting, insertion or withdrawal
  • Other major themes discussed by patient/client

Thought Process

  • Coherence (coherent, incoherent)
  • Logic (logical, illogical)
  • Stream (goal-directed, circumstantial, tangential [diverges suddenly from a train of thought], looseness of associations, flight of ideas, rambling, word salad)
  • Perseveration (pathological repetition of a sentence or word)
  • Neologism (use of new expressions, phrases, words)
  • Blocking (sudden cessation of flow of thinking and speech related to strong emotions)
  • Attention (distractibility, concentration)

Perception

  • Hallucinations (auditory [including command, running commentary], visual, olfactory [smelling], gustatory [taste], tactile)
  • Illusions (misinterpretation of actual external stimuli)
  • Depersonalization
  • Déjà vu, Jamais vu

Cognition

  • Orientation (time, person, place)
  • Memory (short-term, long-term)
  • Intellect
  • Abstract thought
  • Capacity to read and write
  • Level of consciousness

Insight/Judgement

  • Awareness of illness (insight)
  • Ability to make a decision wisely considering pros and cons for a course of action