MENTAL HEALTH ASSESSMENT CHECKLIST Watching for changes in Mental Health Status APPEARANCE ACTUAL ASSESSMENT Dress Is it appropriate

e to the occasion? To the clients age? Are the clothes in reasonable repair? Does the client show care for his/her hair? (sign of apathy, possible depression) Is make up overdone or splashy? (sign of manic behaviour) Usually straightforward and easy to observe. Twitching, stiffness, shakes or psychomotor retardation of all actions due to depression. ACTUAL ASSESSMENT Speed Volume Relevance Flow Do words come tumbling out? Do sentences trail off? Is the client shouting? Whispering? Is what he/she is saying relevant to the conversation? Is there a logical sequence to the flow of the clients conversation? Is the client jumping from subject to subject?

Grooming

Posture, bizarre mannerisms, facial features Psycho-motor disorders (side effects of medication)

SPEECH

SOCIALIZATION AND INTERPERSONAL RELATIONSHIPS ACTUAL ASSESSMENT Visitors Family Friendships/support systems How does the client deal with a visitor to the home? How does the client relate to family members? What other friendships and support systems does the client have? ACTUAL ASSESSMENT Ideas of Reference Does the client talk about plots? Does he/she seem concerned about them? Is the client repeatedly talking about one subject? Or using one term repeatedly? Is the client performing repeated actions, such as shutting windows or thread picking? ACTUAL ASSESSMENT Judgment Can the client compare and evaluate facts, ideas, and choices? Can he/she understand their relationship and draw appropriate conclusions? Is the client aware of his/her limitations? Is the client aware of the consequences of his/her actions?

PATHOLOGICAL CONTENT OF THOUGHT

Obsessions and compulsions

INTELLECTUAL AREAS OF FUNCTIONING

Insight

MOOD AND AFFECT ACTUAL ASSESSMENT Mood What does your client say his/her spirits are like? What kind of mood does your client say that he/she is in now? Depressive (sad, helpless) Flat (unresponsive, constricted) Inappropriate (mood not corresponding to what is happening) Labile (volatile, chargeable)

Affect

Example Mental Status Assessment Mental Status Assessment 1. Identifying Data a. Sex: F b. Age: 38 Y c. Race/Culture: Hispanic, Argentina d. Occupational/financial status: housewife e. Education Level: equivalent high school in Argentina f. Significant other: husband g. Living arrangements: lives with husband and two daughters, 4Y and 14Y. h. Religious preference: no preference i. Allergies: No allergies j. Special diet considerations: No 2. General Description a. Appearance: Wears clinic gown with unlaced sneakers. Face is expressionless and shows no sign of interest. Sits with head bent and arms crossed. Height is appropriate. Weight is appropriate to height. Eye contact is avoidant and stares at the floor. Hair is tied back but uncombed. Hair is coarse and thick. Appearance correlates with chronological age. Hygiene is well maintained. No makeup. b. Motor Activity: Slow body motions. Walks slowly. Keeps arms crossed when walking.

3. 4.

5. 6. 7. 8.

c. Speech Patterns: Speech is monosyllabic and slow. Speech is accented in English, but fluent in Spanish. Falling intonation. d. General Attitude: Passive, guarded, and withdrawn. When spoken to she is friendly. Emotions a. Mood: Depressed and fearful. Preoccupied. b. Affect: Blunted affect that is congruent and appropriate. Thought Process a. Form of thought: Circumstantial. Flight of ideas and disorganized. b. Content of thought: Delusional; mixed persecutory and jealous type. Suspiciousness. Denies suicidal or homicidal ideation. Perceptual Disturbance: Visual hallucinations. I often find my daughter dead and she cannot wake up. My daughter acts and talks like a 20 year old. Sensorium & Cognitive Ability: Is alert and oriented to person, place, circumstance and time. Appears fatigued. Short and long term memory intact. Unable to think abstractly. Impulse Control: Able to control impulses of fear. Judgment and Insight: patient denies problem and has no insight into need for treatment. Lack of coping strategies.

Actual Assessment Mental Status Assessment Mental Status Assessment 1. Identifying Data a. Sex: b. Age: c. Race/Culture: d. Occupational/financial status: e. Education Level: f. Significant other: g. Living arrangements: h. Religious preference: i. Allergies: j. Special diet considerations: 2. General Description a. Appearance: b. Motor Activity: c. Speech Patterns: d. General Attitude: 3. Emotions a. Mood: b. Affect:

4. Thought Process a. Form of thought: b. Content of thought: 5. Perceptual Disturbance: 6. Sensorium & Cognitive Ability: 7. Impulse Control: 8. Judgment and Insight: Psychiatric Nursing; Contemporary Practice by Mary Ann Boyd Fourth Edition p. 156 Unit III Chapter 10 I. Major reason for seeking help_________________________________________ II. Initial Information Name:________________________________________ Age___________ Gender______________ Marital Status________________ Ethnic Identification_____________________ III. Present and Past Health status_________________________________________________
Physical Functions: System review Elimination Activity/Exercise Sleep Appetite and nutrition Hydration Sexuality Self-care Existing Physical Illnesses Normal Treated Untreated

IV. Responses to Mental Health Problems Major concerns regarding mental health problems______________________________________ Major loss/ change in past year: No___________________________ Yes______________________ Fear of violence: No______________________________ Yes_________________________________ Strategies for managing problems/disorder_____________________________________________ V. Mental Status Examination General Observations (appearance, psychomotor activity, attitude)_______________________________________________________________________________ Orientation (time, place, person) ______________________________________________________ Mood, affect, emotions________________________________________________________________ Speech (verbal ability, speed, use of words correctly)____________________________________ Thought processes (tangential, logic, repetition, rhyming words, loose connections, disorganized) ___________________________________________________________________________ Cognition and Intellectual performance_______________________________________________ Attention and concentration __________________________________________________________ Abstract reasoning and comprehension________________________________________________ Memory (recall, short-term, recent, and remote)________________________________________ Judgment and insight_________________________________________________________________

VI. Significant behaviors (psychomotor, agitation, aggression, withdrawn)_____________________________________________________________________________ VII. Self-concept (body image, self-esteem, personal identity) _________________________________________________________________________________________ VIII. Stress and coping patterns ____________________________________________________________ IX. Risk Assessment_______________________________________________________________________ Suicide: High____________ Low:____________ Assault/homicide: High_______ Low:__________ Suicide thoughts or ideation: No_________________________ Yes___________________________ Current thoughts of harming self_______________________________________________________ Plan__________________________________________________________________________________ Means________________________________________________________________________________ Means Available______________________________________________________________________ Assault/homicide thoughts: No___________________________ Yes___________________________ What do you do when angry with a stranger? What do you do when angry with family or partner? Have you ever pushed or hit anyone? No_____________________ Yes_______________________ Have you ever been arrested for assault? No__________________ Yes______________________ Current thoughts of harming others_____________________________________________________ X. Functional status (Not Needed) XI. Social systems Cultural Assessment Cultural Group _______________________________________________________________ Cultural groups view of health and mental illness_______________________________________ What cultural rules do you try to live by?_______________________________________ Important cultural foods______________________________________________________ Family Assessment Family members______________________________________________________________ Members important to patient_________________________________________________ Decision makers, family roles, supportive members______________________________ Community resources__________________________________________________________________ XII. Spiritual assessment XIII. Economic status XIV. Legal status XV. Quality of life