Mental Status Exam
Provide feedback on the document according to the rubric and add some information to help it be improved. Name: Date: 11/10/2022
Learning Objectives
At the end of this activity students will be able to:
1. Apply observation and assessment skills essential to mental health nursing.
2. Describe physical, cognitive, and psychosocial changes related to mental illness.
3. Identify risk factors related to mental illness, treatment and rehabilitation.
4. Perform a mental status examination on patients with mental illness.
Activity Instructions
1. Select a patient from assigned unit.
2. Obtain approval from the primary RN and clinical instructor for appropriateness of patient.
3. Complete and submit the Mental Status Examination form as scheduled by your clinical instructor.
4. Review the Mental Status Examination (MSE) grading rubric.
5. Upload completed assignment to BrightSpace.
Oak Point University
NUR4020 Nursing Care of Mental Health Patients
Mental Status Examination Form Guidelines
1
Name: Date: 05/29/2022
| Personal Information/Demographics | ||
| Patient Name:
T. R
|
Admission Date and Unit Admitted to 10/30/22 15 Floor | Age and Gender:
53years and Male |
| Marital Status:
Single |
Religious Preference:
Atheist |
Race:
Caucasian |
| Ethnic Background:
Hispanic |
Employment:
N/A |
Living Arrangements:
At home with my parents and brother |
| Patient’s Reason for Admission/ Chief Complaint:
Suicidal ideation with plan to cut, psychiatric evaluation |
Co-morbid Conditions:
N/A |
|
| Mental Status Examination
|
||
| What You See (list) | Descriptive example (narrative) | |
| 1. Appearance (observed)
· Grooming/Clothing · Level of hygiene · Pupil dilation or constriction · Facial expression · Height, weight, nutritional status · Posture · Gait · Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings · Relationship between appearance and age
|
Well groomed Good hygiene No pupil dilation or constriction No facial expression Well-nourished for height Straight posture Evidence of scratches and cuts |
Presenting presents with well-groomed hair, no body odor, and clean, well-fitting clothes. Patient is wearing a flannel shirt with jeans. Patient has good posture. Looks appropriate for state age. Uninterested facial expression. Scratches visible on face and hands and superficial cuts noted on left arm |
| 2. Behavior (observed)
· Excessive or reduced body movements · Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance and gait) · Abnormal movements: (e.g., tardive dyskinesia, tremor/ tics/ abnormal movements) · Level of eye contact (keep cultural differences in mind) · Possible descriptors: agitated, restless, easily distracted, hyperactive, hypoactive, lethargic, catatonic, wavy flexibility, echopraxia, akathisia |
Normal body movements Maintains eye contact Hypoactive |
No abnormal or peculiar body movements observed. Maintains eye contact during conversation. Appears hypoactive. |
| 3. Attitude (observed)
· Ability to follow commands · Ability to provide reliable information. Possible descriptors: cooperative, hostile, open, secretive, evasive, suspicious, apathetic, focused, defensive, defiant, oppositional, withdrawn, aggressive, reliable reporter/good historian. |
Follows commands Provides reliable information Trustworthy reporter/good historian |
Open to the conversation, answers all questions, cooperative but not interested in talking unless being asked a question |
| 4. Speech
· Rate: slow, rapid, normal · Volume: loud, soft, normal · Disturbances (e.g., articulation problems, slurring, stuttering, mumbling) · Cluttering (e.g., rapid, disorganized, tongue-tied speech) |
Rate: rapid Volume: normal No disturbances No cluttering |
Responsive to cues and provides appropriate responses. Monotonous tone. No speech impairments noted. |
| 5. Mood and Affect (inquired/observed)
Affect · How the client outwardly is expressing emotion · Appropriateness to situation · Congruency with mood · Congruency with thought · Other descriptors include: broad, restricted, constricted, blunted, flat, normal intensity, appropriate, incongruent, anxious, animate Mood · How the patient describes what they are feeling · Possible descriptors include: labile, sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable |
Outward: sad Congruent with mood and thought Blunted affect
“sad, down, anxious”
|
Openly expresses emotions and is appropriate to situation. Blunted Affect.
Client reports to be “a little sad, down, and anxious.” Mood remains constant. States this has been going on for a year. |
| 6. Thought (inquired/observed)
Process · Describes the rate of thoughts, how they flow and are connected · Possible descriptors: Linear, goal-directed, disorganized, circumstantial, tangential, loose associations, flight of ideas, coherent, incoherent, evasive, racing, thought blocking, perseveration, neologisms. Content and/or perceptual disturbances: · Refers to the themes that occupy the patient’s thoughts and perceptual disturbances · Possible descriptors: preoccupations, ideas of reference, delusions, obsessions, suicidal/homicidal ideation, rumination |
Linear thoughts
Suicidal ideation Homicidal ideation |
Thoughts appear linear, coherent, and logical. Responses are relevant.
Reports suicidal and homicidal thoughts with no intent or plan. |
| 7. Perceptual disturbances
· Hallucinations (e.g., auditory, visual) · Illusions |
Auditory hallucinations No illusions |
Reports auditory hallucinations without commands |
| 8. Cognition
· Orientation: time, place, person · Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose) · Memory: remote, recent, immediate · Attention/concentration: performance on serial sevens, spelling a word backwards · Abstract vs concrete thinking: proverbs, involving similarities Judgment · Good, fair, or poor · Impulse control Insight · Good, fair, partial, poor Adaptive Coping Strategies vs Defense Mechanisms Possible defense mechanisms: Denial, projection, rationalization, sublimation, undoing, displacement, intellectualization, avoidance, repression, suppression |
A&O x 3 Alert Intact memory Maintains attention
Fair Judgement
Good insight
Avoidance
|
Oriented to time, place, and person, and is alert. Intact remote and immediate memory. Maintains attention and concentration as evidence by spelling “world” backwards.
Has fair judgment and good insight. Is aware of sickness, and how medications affect self and does express wanted to improve mental health by treating internal factors. Does avoid extensive conversation about illness. |
| 8. Safety of Self/ Others
Risk of Self/Suicidal/Self-Injury · Fully assessed-no indicators of risk · If yes then · Suicidal ideation (current, past) · Suicide attempts (hx of) · Plans to attempt (current, past) · Access to means · Family history · Non-suicidal self-injury (cutting, scratching, or other self-mutilation) present? · Unintentional (when delusions, demented, intoxicated, in manic stages) present? Harm to Others/Aggression · Fully assessed- no indication of risk identified · If yes then · Plan (current, past) to assault Property Destruction · Fully assessed- no indication of risk identified · If yes then · Current admission · Hx of |
Current suicidal ideation No hx of attempts No plans
Non-suicidal self-injury present
No unintentional self-injury present
Yes, no plan
No indication of risk of property destruction identified |
Current suicidal risk present. No history or plans to attempt suicide, but does state having access at home. No family history of mental illness. Presence of non-suicidal self injury to arms and face of scratches and cuts. No unintentional injuries present.
Reports willingness to harm mom and brother when triggered, but no plan to assault. No indication of risk for property destruction. |
image1.png
11/16/22, 7:59 PM Week 3: Mental Status Exam – NUR4020-03:Nursing Care of Mental Health Patients (2022 Fall Term 2)-15650 – Resurrection Un…
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=43590&grpid=0&isprv=0&bp=0&ou=18735 1/5
Mental Status Examination Course: NUR4020-03:Nursing Care of Mental Health Patients (2022 Fall Term 2)-15650
Criteria Level 5 5 points
Level 4 4 points
Level 3 3 points
Level 2 2 points
Level 1 1 point
Level 0 0 points
Criterion Score
Personal
Informatio
n/
Demograp
hics
Section
Requireme
nts
/ 5
Appearanc
e Section
Requireme
nts
/ 5
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
11/16/22, 7:59 PM Week 3: Mental Status Exam – NUR4020-03:Nursing Care of Mental Health Patients (2022 Fall Term 2)-15650 – Resurrection Un…
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=43590&grpid=0&isprv=0&bp=0&ou=18735 2/5
Criteria Level 5 5 points
Level 4 4 points
Level 3 3 points
Level 2 2 points
Level 1 1 point
Level 0 0 points
Criterion Score
Behavior
Section
Requireme
nts
/ 5
Attitude
Section
Requireme
nts
/ 5
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
11/16/22, 7:59 PM Week 3: Mental Status Exam – NUR4020-03:Nursing Care of Mental Health Patients (2022 Fall Term 2)-15650 – Resurrection Un…
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=43590&grpid=0&isprv=0&bp=0&ou=18735 3/5
Criteria Level 5 5 points
Level 4 4 points
Level 3 3 points
Level 2 2 points
Level 1 1 point
Level 0 0 points
Criterion Score
Speech
Section
Requireme
nts
/ 5
Mood &
Affect
Section
Requireme
nts
/ 5
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
11/16/22, 7:59 PM Week 3: Mental Status Exam – NUR4020-03:Nursing Care of Mental Health Patients (2022 Fall Term 2)-15650 – Resurrection Un…
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=43590&grpid=0&isprv=0&bp=0&ou=18735 4/5
Criteria Level 5 5 points
Level 4 4 points
Level 3 3 points
Level 2 2 points
Level 1 1 point
Level 0 0 points
Criterion Score
Thought
Section
Requireme
nts
/ 5
Perceptual
Disturbanc
es Section
Requireme
nts
/ 5
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
11/16/22, 7:59 PM Week 3: Mental Status Exam – NUR4020-03:Nursing Care of Mental Health Patients (2022 Fall Term 2)-15650 – Resurrection Un…
https://oakpoint.brightspace.com/d2l/lms/dropbox/user/folder_submit_files.d2l?db=43590&grpid=0&isprv=0&bp=0&ou=18735 5/5
Total / 50
Overall Score
Criteria Level 5 5 points
Level 4 4 points
Level 3 3 points
Level 2 2 points
Level 1 1 point
Level 0 0 points
Criterion Score
Cognition
Section
Requireme
nts
/ 5
Safety of
Self/Other
s Section
Requireme
nts
/ 5
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
Section is
complete and
contains all of
the accurate
information
needed. There
are no spelling
errors & the
section is
typed.
Section has
no more than
one error in
any of the
following
areas: missing
an area, a
piece of
information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
two errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
three errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section has
no more than
four errors in
any
combination
of the
following:
missing an
area, a piece
of information
that does not
belong in that
section, a
misspelled
word, or is not
typed.
Section is
missing.
Level 4 45 points minimum
Level 3 40 points minimum
Level 2 35 points minimum
Level 1 1 point minimum
For any questions, feedback, or comments, we have an ethical customer support team that is always waiting on the line for your inquiries.
Leave a Reply
Want to join the discussion?Feel free to contribute!