Mental Health Assessment Flashcards
Appearance
Posture - erect and position
Body Movements
Dress
Grooming and Hygiene
Mental Status
Appearance
Behaviour
Cognition
Thinking
Behaviour
Level of conscious
Mood and affect
Speech - smooth, clear, not choppy or muffled. Easily makes laryngeal sounds
Facial expression
Cognition
Orientation - to time, to place, to person and to self
Memory - immediate, recent, remote
Attention
New learning - four unrelated word test
Insight - into ones own illness/need for treatment
Judgement - plans for future
Thinking
Thought Processes
Thought Content
Perceptions
Thought Processes
Does this person make sense?
Can I follow what they are saying?
Do they deviate from topic more than once?
Is the way they think logical, coherent, goal direct, relevant and consistent with reality?
Thought Content
Should be consistent and logical
Ask questions to uncover compulsions - do you count things over and over or perform specific actions to reduce stress
Fears: do you have any fears that cause you to avoid certain situations?
Delusions: do you have any thoughts other people think are strange
Do you have any special powers or abilities?
Perceptions
Should be consistently aware of reality and perceptions should be congruent with yours
How do people treat you?
Do you feel as if you are being watched, followed, or controlled?
Is your imagination very active?
Have you heard your name when you are alone?
Posture
Is erect and position is relaxed
Body Movements
Are voluntary, deliberate, coordinated, smooth and even
Dress
Is appropriate for setting, season, age, gender, and social group. Clothes fit and are put on correctly
Grooming and Hygiene
Clean and well groomed.
Women have moderate or no make-up
Men are shaven or have well-groomed facial hair
Nail are clean
Level of consciousness
Awake, left, aware of stimuli and responds
Facial Expression
Appropriate to situation and changes appropriately with topic.
Comfortable eye contact
Speech
Makes laryngeal sounds effortlessly
Makes appropriate conversation
Is voice raised or muffled
One word or elaborating answers
How fast or slow they speak
Do they articulate?
Expect moderate pace and fluent stream of speech
Word choice is effortless and appropriate to educational level
Completes sentences occasionally pausing to think
Orientation
To time // day of week
To place // where you are
To person // who you are and why you are there
To self // who they are, how old they are
Attention Span
Ability to concentrate
Completes thoughts without wandering
Not easily distracted
Immediate Memory
Ability to recall something just said
Recent Memory
24 hour diet recall or how they arrived
Remote Memory
Ask about verifiable past events
New Learning
Four unrelated words
Carrot, ankle, fun, loyalty
Recalled immediately, at 5, 10, 30 minutes
Insight and Judgement
recognition of own illness, need for treatment and consequences of behaviour as stemming from illness
Judgement is shown when patient shows their plans with regards to alternatives of treatment and going forward …plan for when they leave
