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Mental-health nursing assessment: history, the mental status from the nursing side and risk screening

  • Assessment

The nurse observes and asks about mood, thought, behaviour and risk, takes a psychosocial history and compares each finding with the baseline.

Updated

What it is

A mental-health nursing assessment adds to the physical examination: the mental status examination, a psychosocial history, a review of medicines that treat or cause psychiatric symptoms, screening for suicidal ideation, trauma or violence and substance use, a spiritual assessment, developmental and cultural considerations, and relevant laboratory results. Much of the mental status is gathered while doing the general survey; a focused examination follows when there are cues such as unusual behaviour or difficulty with daily life. New findings are compared with the admission baseline to judge whether the person is better, worse or the same.

Reference values

  • Expected: alert and oriented to person, place and time; calm, no signs of distress.
  • Expected: groomed and dressed for the setting, culturally appropriate eye contact, no threatening behaviour.
  • Expected: spontaneous, clear speech with even rate and rhythm; smooth gait, no tremor or restlessness.
  • Expected: affect congruent with mood and appropriate to the situation; logical, goal-directed thought; no suicidal or homicidal ideation.
  • Expected: understands their situation and looks towards recovery; attention and short-term memory intact.

What you need

  • A private, safe place and enough time.
  • The institution's psychosocial assessment form and the validated screening tools in use.
  • The medicine list and recent laboratory results.
  • Information from the family or companions, with the patient's consent when possible.

How to measure it (and why)

  1. Start with the reason for seeking care in the patient's own words: it shows what matters most to them now.
  2. Observe appearance, behaviour, speech and movement during the general survey: much of the mental status comes from observation.
  3. Ask open questions about mood and thoughts («Tell me how you have been feeling»): it gives subjective data no device can measure.
  4. Ask leading questions about perceptions («Have you seen or heard things others could not?»): patients often hide hallucinations.
  5. Introduce suicide screening as a routine question asked of everyone, then use the validated tool: it normalises the topic.
  6. Take the psychosocial history: past illness, medicines, substances, trauma or violence, family, coping, function and spirituality.
  7. Ask about culture and meaning («What do you think is causing this?»): it adapts the plan to the person's beliefs.
  8. Review medicines and laboratory results relevant to the treatment: some medicines cause psychiatric symptoms or need levels.
  9. Compare with the baseline and record observed behaviour in precise terms: vague labels do not let the team track change.

How to read it

  • Psychomotor agitation is purposeless activity; psychomotor retardation is very slow movement and speech.
  • Flat affect has no emotional expression; blunted affect has reduced range and intensity; labile affect changes quickly.
  • Delusion: fixed false belief not shared by cultural peers. Hallucination: perception without a stimulus. Illusion: misperception of a real stimulus.
  • Flight of ideas jumps topics quickly; loose associations join unrelated ideas; clang associations link words by sound.
  • New thought disorder may announce a psychotic episode: report it.

Next step: when to call for help

  • Call at once, as protocol says: unresponsive patient, breathing difficulty, chest pain or sudden confusion.
  • Notify the nurse in charge or doctor the same moment: positive suicide screen, a plan or intent, or command hallucinations to harm.
  • Report promptly: threats or homicidal ideation, rapid escalation of agitation, or signs of intoxication or withdrawal.
  • Report in the shift handoff and record: new findings compared with the baseline, refusal of meals or medicines, sleep changes.

Test yourself

Think of the answer, then tap the question to see it.

Which components make up the mental status examination?

Level of consciousness and orientation, appearance and behaviour, speech, motor activity, affect and mood, thought and perception, attitude and insight, and cognition, plus the examiner's own reaction.

A patient seems to be listening to something no one else hears. What should the nurse ask?

Gently ask what they hear, and find out whether the voices tell them to harm themselves or others, because that changes the safety plan.

How can suicide screening be introduced so it does not feel intrusive?

As a routine question asked of everyone in the service, explaining that it helps not to miss anything important, then using the validated tool.

What is the difference between a delusion and an illusion?

A delusion is a fixed false belief that persists despite evidence; an illusion is a misperception of a real stimulus, such as seeing a branch as an arm.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing: Mental Health and Community Concepts, 4.5: Assessment (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022); Nursing: Mental Health and Community Concepts, 1.6: Establishing safety (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022); Nursing: Mental Health and Community Concepts, 2.3: Therapeutic communication (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022).

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