Psychosocial & mental status

examination

Mental status examination

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.

Appearance (observed)
Apparent age
Manner of dress
Cleanliness
Posture
Facial expressions
Eye contact

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.

Speech (observed)
Rate Volume
Amount:

paucity, muteness, pressured speech

Characteristics:

Irrelevant / incoherent
stuttering, slurring of words
echolalia

Motor activity (observed)

Level of activity:
lethargic, tense, restless, agitated
Violent

Type of activities:
Tics, grimaces

Unusual pattern:
Excessive movement
Repeated movement
compulsive behavior, stereotypy,
Little movement:
motor retardation, Waxy Flexibility

Interaction during interview

(observed)
Hostile
uncooperative
Irritable
Guarded
Apathetic
Defensive
Suspicious

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.

Mood (observed + inquired)

Rate with scale 0-10

Suicidality

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.

Affect (observed)
Apparent emotional tone
Affect: flat, lability, exaggerated, incongruent

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.

Perception (observed + inquired)

Hallucination

Auditory
Visual
Tactile
Gustatory (taste)
Olfactory

Illusion

Thinking (observed + inquired)

Thought

content
Thought process

Thought content: What of the patient thinking

Delusion
Somatic delusion
Grandiose delusion
Paranoid delusion: persecute
Thought broadcasting
Thought withdrawal
Thought insertion
Ideas of reference
Nihilistic ideas
Obsession
phobia

Thought process

Circumstantial
Flight of ideas
Loose association
Word salad
Thought blocking: halt suddenly during conversation
Neologisms
Perseveration

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.

Level of conscious (observed)

Time
Place
Person

Note oriented to TPP (X oriented times

three)

Memory (inquired)
Remote memory
Recent memory
Immediate memory

Special features: Amnesia, confabulation

Level of concentration and

calculation (observed + inquired)

Ability to pay attention (inattentive)

Calculate simple math

Information and intelligence

(observed + inquired)
Compare intellectual strengths, skills, ability
and general knowledge with previous

Previous education level

Judgment (observed + inquired)

Ability to understand relationship

between facts and conclusion

Insight (observed + inquired)

Understanding of ones illness

Rate or specify:
Full, complete,
partial,
limited, poor,
nil

12 Activity of living
Maintaining a safe environment
Communicating
Breathing
Eating and drinking
Eliminating
Personal cleansing and dressing
Controlling body temperature
Mobilizing
Working and playing
Expressing sexuality
Sleeping
Dying

Factors influencing activities of living

Biological
Psychological
Sociocultural
Environmental
Politicoeconomic

Stuart, G. W. (2013). Principles & practice of

psychiatric nursing (10th ed.). St Louis: Elsvier
Mosby.
Mental status examination P. 88-96
Risk factors and protective factors p. 100-104