20.1: Mental Health Assessment

Learning Objectives

By the end of this section, you will be able to:

• Analyze the components of a health history specific to mental health
• Recognize factors that could influence a mental health assessment
• Describe different components of a mental status examination
• Identify the nurse’s role in conducting a mental health assessment

When assessing a patient’s overall mental health, begin by evaluating their current mental status. As a nurse performing a mental health assessment, you will collect data that is subjective and objective. The nurse observes the patient’s behavior, mood, speech, and thought processes as objective assessment components. Objective data about a patient are measurable and collected through direct observation. Subjective data are not directly measured or observed. Instead, they are gathered during the nursing interview with the patient as the primary source. Other people in the patient’s life, such as family and other members of the healthcare team, can be secondary sources of subjective data.

Components of Health History Specific to a Mental Health Assessment

A mental health assessment is a part of the patient assessment. The information gathered during the interview helps the nurse understand how the medical and psychosocial components of a patient’s health fit together. Among these components are the patient’s personal mental health history, their family mental health history, and any current or past treatment for mental illness. The nurse would also assess the patient for any current signs or symptoms of mental health conditions, such as depression, anxiety, and suicidal idereal rnation.

The nurse collects objective data through direct observation and measurement. Common examples of objective data would be physical exam findings, vital signs, and laboratory test results. Subjective data are not directly measured. Instead, they are actively shared by the patient. For example, the nurse may ask the patient to talk about the symptoms they’ve been having. The patient’s response, which may include their thoughts, feelings, and perceptions, would be considered subjective data.

Previous Mental Health Illnesses

When the nurse is assessing a patient’s current mental status, verifying the patient’s history of mental illness is essential. This step assists the nurse in discovering factors that contribute to the patient’s mental state.

However, the nurse cannot rely only on the patient’s report to confirm that the information is accurate and current. For example, it would be easy for a patient to misremember the name of a prescribed medication or confuse the names of a diagnosed condition. The nurse uses medical records and clinical documentation in the electronic health record (EHR) to confirm the patient’s medication, diagnosis, treatment, and providers.

The patient’s past mental health also does not replace a current assessment. While establishing a patient’s history is a necessary step in the process, the nurse must consider it in the context of the patient’s current state of health. The nurse assesses the patient’s presentation and symptoms but can use any relevant history to inform management approaches.

Patients with a diagnosed mental illness could be more susceptible to triggers that could cause them to relapse or their symptoms to worsen. For example, patients previously diagnosed with bipolar disorder may experience episodes of mania or depression triggered by stress, hunger, fear, confusion, or a lack of sleep. During a mental health assessment, the nurse could find this patient in a manic episode or a depressive state. A mental health assessment could be compromised by a patient’s current symptoms, making it challenging to get a clear picture of their day-to-day symptoms. For example, an inability to obtain information could be due to poor communication from the patient. Understanding a patient’s past experiences with mental illness, including any psychiatric and/or anxiolytic medications or other treatment they have tried, can help the nurse determine the interventions that have worked well previously and those that have not had the desired effect.

It is also important to note that some people experiencing mental illness have difficulty adhering to a medication or treatment regimen. Weight gain, abnormal body movements, and feeling like they are always sleepy are just some of the reasons patients stop taking their medications. They might even cease psychiatric therapy all together. This interruption in the treatment regimen will cause their mental health symptoms to return and possibly spiral the patient into a severe mental health episode. Nurses play an important part in working to improve medication compliance and adherence to the treatment plan as a whole. Nurses can encourage patients to speak about any difficulties adhering to both the medication and treatment plans. Nurses work closely with all members of the interdisciplinary team and can provide interventions or suggestions to address the patients’ concerns and provide support.

When a patient has been hospitalized previously for mental illness, they are at high risk for future readmissions. These patients experience more barriers to accessing care due to cost, stigma, or noncompliance. The nurse should carefully assess these patients for their current level of functioning, overall physical and mental well-being, and identification of any risk factors for self-harm or thoughts of harming others.

Alcohol and Substance Abuse History

A thorough assessment for substance abuse includes detailed notes, including the type, amount, frequency, and consequences of the patient’s current or previous drug use. Their use of prescription medications and readiness to change their behavior are also critical components of the nurse’s assessment. The nurse may begin by asking the patient broad questions, such as, “Tell me your story and what brings you here today.” This gives the patient an opportunity to share openly in an environment of mutual respect and safety. If the nurse needs further information, the questions can become more focused, such as, “Tell me about your history with alcohol and drugs.” This allows the patient to open up about their habits and their history. A complete investigation of drug and alcohol abuse will be covered later in this chapter.

Link to Learning

The nurse should be able to distinguish between symptoms of a drug overdose and other mental health symptoms. The National Institute on Drug Abuse provides a wealth of information about illicit drugs and their effects including drug and addiction facts.

Family History of Mental Illness

During the mental health assessment, the nurse should determine if the patient has a family history of mental illness, which provides insight into the patient’s risk factors for developing mental health conditions. Depression, anxiety, bipolar disorder, and schizophrenia each have a genetic component, meaning that people in the family are at a higher risk of developing the same disorder. Including this information in a nursing assessment assists in creating a personalized plan of care.

Developmental History Related to Mental Illness

From childhood to adolescence, young adulthood, middle age, and beyond, a patient’s age and developmental stage are also relevant to their mental health. For example, the nurse needs to understand how mental health conditions may present differently in children versus adults, or the criteria for assessing a younger patient versus an older one.

Considering the patient’s stage of life is also necessary because aspects of the aging process may influence their mental health. As people get older, they will experience bodily changes as well as brain changes. For some people, this may include cognitive disorders such as dementia, or mood disorders such as depression and anxiety.

Experiences at certain stages of development also influence a patient’s mental health later in life. For example, people who were diagnosed with mental illness in their youth are at increased risk of accelerated aging, worsening health in later adulthood, and early death (Richmond-Rakerd et al., 2021; Wertz et al., 2021). Understanding the effects of a patient’s past and current mental health on their future well-being helps the nurse develop an effective, long-term management strategy.

Social History Contributing to Mental Illness

Social history is not only important for assessing current challenges and barriers that a patient may be facing, but also gives the nurse valuable insight into how a patient’s life experiences may have affected their mental health.

A patient’s background, living conditions, employment status, education level, and family dynamics all shape and contribute to their mental health. Collecting these data gives the nurse information about the patient’s life outside the medical setting and highlights factors that may increase or mitigate risks for developing mental health conditions.

Poverty, unemployment, and lack of access to health care or education are just a few social history factors that can negatively affect an individual’s mental health. For example, a patient who has lost their job and is under a great deal of stress could be at risk for increased anxiety and depression, and that risk may be higher if they have a history of mental illness. A patient who does not have the means to access health care and social support may struggle to manage their symptoms effectively, which may lead to worsening mental health over time.

Factors Influencing Mental Health Assessments

While the nurse’s goal is to create a complete picture of a patient’s mental well-being, there are factors that can make it more difficult to obtain a thorough assessment. The nurse should be aware of patient factors that can negatively affect the assessment:

• Biological, such as genetics, physical illnesses or injuries, and hormonal imbalances
• Psychological, such as past trauma, personality disorders, and substance abuse
• Social, such as poverty and lack of access to healthcare services, healthy food, and water

The nurse will not always know which factors they will encounter before they begin assessing a patient. Being aware of the potential factors and understanding how they can interfere with the assessment helps the nurse learn to recognize them. It also gives the nurse time to come up with solutions and strategies for dealing with the factors when they do emerge.

Patient Willingness to Participate

Nurses may encounter patients who are unwilling to participate in their mental health assessment. They may have experienced trauma in a previous mental healthcare setting, they could be experiencing barriers to health care, or they could be concerned about the stigma associated with mental illness. The nurse should approach the patient with empathy and sensitivity, especially in these cases, by establishing trust and a rapport with the patient. Listening attentively and showing concern demonstrates that the nurse is interested in the patient’s thoughts. Establishing trust with the patient is paramount.

Current Health Status

A patient’s physical health can contribute significantly to their mental health, and the effects of this interplay can affect the mental health assessment. The nurse evaluates the patient’s current health status for physical health factors, such as conditions and the medications used to treat them, that could be contributing to the patient’s mental health symptoms.

It is common for a patient to report symptoms that seem to be related to their mental health but are actually manifestations of physical illness. For example, older adults often experience delirium when they have a urinary tract infection (UTI). During the assessment, they may appear confused or combative and have difficulty expressing themselves. However, in this case, the patient’s cognitive symptoms are related to an underlying physical health condition, not a mental health condition. Once the UTI is treated, the delirium often resolves as well.

Older adults are also more likely to be prescribed multiple medications to treat physical health conditions. In some cases, cognitive or mental health symptoms are medication side effects or the result of interactions between drugs. In this case, the patient’s symptoms may improve if the drug is stopped or the dose adjusted.

Culture

Patients each bring their own cultural beliefs, values, and expectations to the clinical encounter. A patient’s cultural background also influences how they feel about their health and how they approach specific aspects of their care.

During the patient assessment, the nurse must be able to recognize factors such as language and communication practices that could affect their encounter with the patient. For example, while direct eye contact during a conversation is an expectation in many Western cultures, it is not the norm in many Asian cultures where it is viewed as disrespectful (Uono & Heitanen, 2015).

Cultural Context: Cultural Formulation Interview (CFI)

The American Psychiatric Association developed the evidence-based Cultural Formulation Interview (CFI) questions to incorporate cultural assessment into all patients’ care, which enhances clinical understanding and decision-making (Aggarwal & Lewis-Fernandez, 2020). The CFI questions are used to clarify key aspects of the presenting clinical problem from the point of view of the individual and other members of the individual’s social network (e.g., family, friends, or others involved in the current problem). This includes the problem’s meaning, potential sources of help, and expectations for healthcare services. For example, the nurse may ask the patient if any aspects of their life are making it harder for them to address their current problem, such as a lack of social support from family and friends or financial constraints.

Some examples of how a person’s culture may affect their mental health exam include the following:

• Every culture approaches mental health care differently. Some cultures attach a stigma to mental health challenges, and people who seek mental healthcare services may be considered weak.
• If a patient requires the assistance of a translator during their evaluation, their perception of the questions and the nurse’s perception of the answers may be skewed by the translation process.
• Patients who are new to this country’s healthcare system may become easily overwhelmed as they attempt to navigate a new culture and a new healthcare system. Many times, mental health symptoms can be exacerbated by stressful situations.

Nurses must have cultural competence, which is the ability to provide care to patients with a diverse set of values and beliefs, meeting the patients’ social, cultural, and linguistic needs. The need to demonstrate cultural competence begins with the nurse’s first interaction with the patient, which will often include the assessment. The nurse must be aware that a patient’s culture affects many aspects of their life, from their lifestyle and diet to social support and beliefs about illness. The nurse needs to be able to consider these factors within the context of the patient’s cultural background. By directly asking the patient to share their cultural beliefs during the assessment, the nurse can gather these key details.

Cultural competence is necessary to ensure the accuracy of the assessment but also serves another important function: helping the nurse establish rapport. The nurse can build trust by showing awareness and understanding of the patient’s culture. The nurse may not share the patient’s beliefs, but they can reinforce trust by showing respect for the patient throughout their interactions.

Cultural Context: Cultural Manifestations of Common Mental Illnesses

Cultures and communities exhibit and explain symptoms of mental illness and manifest stress in various ways. Nurses should be aware of relevant contextual information stemming from a patient’s culture, race, ethnicity, religion, or geographical origin. Maintaining cultural awareness is critical for the nurse to recognize cues during the initial assessment from culturally diverse groups. Culture-specific reactions to stress are known as culture-bound syndromes. For example, ataques de nervios is a syndrome reported among Latinx in response to stressful situations and includes symptoms of uncontrollable shouting and trembling, or even fainting spells. Other examples include uncontrollable crying and headaches which are symptoms of panic attacks in some cultures, whereas difficulty breathing may be the primary symptom in other cultures. Understanding such distinctions will help nurses effectively treat patients.

At the center of patient-centered care is practicing cultural humility and inclusiveness. In the 2021 edition of Nursing: Scope and Standards of Practice, the American Nurses Association (ANA) established a Standard of Professional Performance called Respectful and Equitable Practice. This standard is defined as “The registered nurse practices with cultural humility and inclusiveness.” Cultural humility is “a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.” Inclusiveness is “the practice of providing equal access to opportunities and resources for people who might otherwise be excluded or marginalized, such as those having physical or mental disabilities or belonging to other minority groups.”

Marginalized people, including minorities, immigrants, refugees, and people from the LGBTQIA+ community, are often exposed to more stress and are therefore at higher risk for mental illness. These people are also more susceptible to socioeconomic disparities, and they are more susceptible to conditions of poverty. These stressors can worsen existing mental illness and should be considered when completing a mental health assessment.

Health Literacy

Health literacy refers to a patient’s ability to access and understand basic health information. A patient’s health literacy can affect the outcome of a mental health assessment if the patient is not able to fully understand and use the information being shared. If the patient does not have the knowledge and understanding, they cannot make informed decisions about their health (Centers for Disease Control and Prevention (CDC), 2022). Once the nurse has assessed the patient’s health literacy, they can adapt their delivery of the assessment to accommodate any gaps in the patient’s knowledge.

Link to Learning

The Agency for Healthcare Research and Quality has done extensive research on health literacy and developed Health Literacy Measurement Tools to measure aspects of personal health literacy. The Rapid Estimate of Adult Literacy in Medicine Short Form may be used in clinical settings to identify patients with limited literacy.

Low health literacy can be a barrier to getting an accurate patient assessment, as the patient may not understand what the nurse is asking or may provide answers that are incorrect because they lack sufficient knowledge. By breaking down the conversation into simpler parts and guiding the patient through the process of thinking about and describing their current medications, the nurse can get a more accurate assessment.

Patient Conversations: Obtaining a Medication List from a Patient with a Low Health Literacy

Scenario: Nurse walks into the room preparing to ask the patient about what medications they are taking, as part of their admission patient assessment.

Nurse: I’d like to go over your list of medications. Here in your medical record, it says that you take three medications. I’ll list them off and I’d like you to tell me if you are still taking them, okay?

Patient: Sure.

Nurse: Great . . . are you still taking the lisinopril for your blood pressure?

Patient: Um, I’m not sure. Is that the little blue one?

Nurse: No, it’s not a blue pill.

Patient: Oh, sorry. I’m not sure what the names of them are. I just put them in my pill organizer and make sure I take them.

Scenario update: The patient expresses confusion and uncertainty about the names of their medications, so the nurse adapts their assessment to the patient’s lower level of health literacy.

Nurse: That’s okay. Your medical record says you take three different medications every day. Does that match up with your pill organizer?

Patient: Yeah. I put three pills in for each day.

Nurse: Great. I know you said one of them is a little blue one. Can you tell me what shape it is?

Patient: Round. Like a circle.

Nurse: Alright. What time do you take it?

Patient: In the morning.

Nurse: Does it come in an orange bottle you have to pick up from the pharmacy?

Patient: No, it’s one I buy myself at the store.

Nurse: Okay, so it’s not a prescription for your doctor?

Patient: They told me to take it but said I can buy it. I think the box is blue and white.

Nurse: Do you take it for your arthritis?

Patient: Yeah, in my hands.

Nurse: Okay, that matches up with the medication I see on your list called Aleve.

Patient: Yeah, that’s it! Sounds like “relieve.”

Communication Barriers

Communication barriers are any factors that interrupt, complicate, or otherwise negatively affect the exchange of information between the nurse and a patient. Communication is integral to providing patient-centered care. In cases where the patient can communicate for themselves, the nurse must ensure that they understand the message that is being conveyed.

Communication barriers can make assessing a patient’s mental status difficult. Patients can struggle with communication barriers, including difficulty verbalizing distress, shame over their symptoms, concerns they are “untreatable,” difficulty processing information, worries about stigma, physiological barriers, language barriers, cultural barriers, and other psychological barriers.

When a patient has a diminished ability to communicate for any reason, a nurse will find it more difficult to glean pertinent data during an assessment. For example, a patient who is hard of hearing may struggle to hear the questions the nurse is asking or may mishear what is being asked. In this situation, the nurse would need to recognize the barrier and come up with a solution. For example, the nurse may need to speak louder and more slowly, write questions down for the patient to read, or use visual aids (like pointing to a body part on an office chart) to communicate more effectively with the patient.

When a nurse notices that a patient is either having difficulty communicating or comprehending questions, they will need to re-evaluate their assessment method and determine what alternative methods of communication would be appropriate. Involving the patient in the process ensures that they are able to express themselves and fully understand questions.

Current Stressors

When beginning a mental health assessment, the nurse should find ways to minimize stressors on the patient, allowing them to participate fully in the assessment. Patients who are hospitalized often complain of sleep deprivation. The nurse should complete their assessment when the patient is well rested. Hunger is another barrier to a low-stress assessment. Assessing the patient after a meal may improve their outlook and increase compliance.

Other potential stressors can also affect the assessment, many of which are beyond the nurse’s control. For example, the patient could be dealing with financial worries if they are out of work and hospitalized. They may be confronting mental health stigma from people in their life and feel confused, ashamed, or frightened—especially if they have an untreated mental illness.

Sex

Research shows that a patient’s sex can influence how they perceive their symptoms and communicate them to healthcare providers (Cabral & Dillender, 2021). Studies have found that females report more physical symptoms when discussing depression and anxiety, while males tend to externalize their symptoms with aggression, risky behavior, or substance abuse (Smith et al., 2018).

Sex is also correlated with various mental health diagnoses. Females are much more likely to report suffering from depression and anxiety, and males have a higher prevalence of substance use disorder (SUD) and dangerous behavior (Pattyn et al., 2015). Overall, females and males are equally likely to seek help for emotional problems, but females tend to seek help sooner. Numerous studies reveal that males tend to wait until symptoms are heavily affecting their lives before seeking treatment (Kwon et al., 2023).

Previous Negative Experiences

When a patient has a history of negative experiences in health care, it can be difficult to assure them that they are safe to share and participate in the nurse’s assessment. The nurse should give each patient enough time to express their fears and concerns. For example, if a patient has a history of bipolar disorder and in childhood received frightening treatment that did not seem to improve their symptoms, they may be less trusting of revealing information to the nurse and less inclined to seek help or participate in improving their mental health. This is when the nurse’s reassurance and encouragement come in.

A patient may also be facing stigma and shame surrounding a mental health diagnosis, either from outside the healthcare system (e.g., family) or through their interactions and experiences with other providers. The nurse needs to be aware of the broader societal stigma around mental illness and ensure they are not intentionally or unintentionally promoting it. This means paying attention to not only the language they use to talk about mental health, but also their responses (both verbal and nonverbal reactions) that communicate sentiment to the patient when they are confiding in the nurse.

Nurse’s Attitude or Approach

The way a nurse approaches the patient lays the foundation for how their assessment will unfold. This is especially true for patients experiencing a disturbance in their mental well-being. For this reason, the nurse should take extra care to approach the patient with empathy, understanding, and kindness. If the patient is reassured that the nurse is not there to judge them but to help, they will likely be more cooperative in their assessment.

Real RN Stories: It’s All in the Approach

Nurse: Barb, RN
Clinical setting: Medical/surgical floor in a level 1 trauma center
Years in practice: 16
Facility location: Kansas City, Missouri

I was a nurse on a busy medical/surgical floor with six patients to care for this particular day. In report, I was informed that Mrs. Baker in room five had been treated for kidney stones, and her symptoms have resolved, but she is displaying some additional behaviors that could be related to either a side effect of some of her new medications or a mental health disorder. Mrs. Baker is an 84-year-old female who lives alone and has no family. She had been experiencing visual and auditory hallucinations since her admission three days earlier with kidney stones. Her husband Robert passed away more than ten years ago, and the rest of her family lives out of state. After finishing report, I go into the room and introduce myself to Mrs. Baker. I’m surprised to find her having a pleasant conversation with an empty chair.

“Oh, Robert,” Mrs. Baker laughed, “I love it when you read poetry to me.”

I approach her quickly because I’m in a hurry, telling her, “Honey, there’s no one there. You’re talking to an empty chair. Do you talk to furniture at home?”

Dejected and embarrassed, Mrs. Baker became confused and tearful, getting back into bed and pulling the blankets over her face. She refuses to talk to me at all. I mumbled under my breath that I don’t have time for this, and with frustration I tell Mrs. Baker, “I’ll be back to check on you later.” Within the next hour, a new admission arrives on the floor, so Mrs. Baker is reassigned to a different nurse named Terry. Terry had experience working with older adults and had also worked in a behavioral health hospital before transitioning to this hospital. When she took report from me, she knew exactly what Mrs. Baker needed. Terry gathered a bouquet of flowers that a departing patient had left and walked toward Mrs. Baker’s room. Terry asked her permission to enter the room to sit and talk with her. She seemed touched that a nice man had brought her flowers. Terry explained to Mrs. Baker that at the hospital, the staff are concerned with every level of their patients’ health. Terry also told her that while her physical symptoms have gotten better, she wanted to ask her some questions to see if there is anything else we might be able to do to help her.

When met with Terry’s easygoing, honest approach, Mrs. Baker was happy to comply. I learned from Terry that nurses must remember to meet patients where they are. Nurses should take a moment to get to know their patients and proceed only when they have established trust.

Conducting a Mental Status Examination

Registered nurses must use effective clinical interviewing skills to assess a patient’s mental status and develop a therapeutic nurse-patient relationship. Assessing a patient with a suspected or previously diagnosed mental health disorder focuses on both verbal and nonverbal assessments. The subjective data are data a patient actively shares with the nurse, including data about signs and symptoms. The objective data are data the nurse collects through direct observation. Compare new assessment findings to the baseline admission findings to determine if the patient’s condition is improving, worsening, or remaining the same.

The mental status examination is a priority component of a comprehensive patient evaluation. Many successful nurses perform the bulk of the mental status examination through unstructured observations made during the routine physical examination. A mental status examination assesses a patient’s level of consciousness and orientation, appearance and general behavior, speech, motor activity, affect and mood, thought and perception, attitude and insight, and cognitive abilities, some of which will be covered here in more detail.

Link to Learning

Learning how to master mental health examinations takes time and determination. Many nursing students may not get the opportunity to spend a lot of time observing and practicing mental health assessments. These free virtual games help nursing students learn specific ways to assess many mental health disparities.

Generalized Behavior and Motor Assessment

A mental health assessment has some elements of a complete assessment. During a complete physical assessment, the nurse observes that the patient is awake, alert, and oriented to person place, time, and situation. The patient’s general appearance and behavior is also noted. A mental health assessment is a more in-depth assessment of the patient’s’ appearance, behavior, and demeanor (Table 20.1). While the patient may report some symptoms (subjective data), the nurse also needs to pay attention to objective data that can be observed by listening and watching carefully.

Table 20.1: General Assessment of Behavior (Source: Finney et al., 2016.)

Element	Objective Assessment
Hygiene	Is the patient clean, or are there signs of not bathing or washing their hair? Are their teeth brushed, or do they seem to set aside oral care? Are nails clean and clipped, or are they long, ragged, or dirty?
Grooming	Is the patient’s hair combed, or is it disheveled? Do they have body odor?
Dress	Do the patient’s clothes match, and are they clean and well-fitting? Do their shoes match, and are the laces tied, or are they dragging on the floor?
Eye contact	When you speak to the patient, do they make eye contact, or is it difficult for them to look you in the eye?
Mannerisms	Does the patient’s body posture seem unusual (rigid or slumped)? Do they rock back and forth rhythmically? Do they move in jerky movements? Do they have a tremor?
Interpersonal behaviors	Is the patient able to have a conversation with you? Do they acknowledge your presence? Are they talking to anyone who is not present? Are they talking to inanimate objects?

Clinical Safety and Procedures (QSEN): QSEN Competency: Performing a Situational Assessment

See the competency checklist for Performing a Situational Assessment. You can find the checklists on the Student resources tab of your book page on openstax.org.

Mood and Affect

A short-lived emotional state that can change based on emotion is known as mood. Mood can be described using terms such as neutral or elevated. It can also be described as anxious; angry; sad; irritable; dysphoric, exhibiting depression; or euphoric, a pathologically elevated sense of well-being. Sustained emotions influence a person’s behavior, personality, and perceptions.

The term affect refers to the patient’s expression of emotion. People may express feelings of emptiness, impaired self-esteem, or indecisiveness, or they may have crying spells. Normal affect and mood are described as euthymic, which means that an individual displays a wide range of emotions that are appropriate for the situation. Abnormal findings related to affect include inappropriateness for the situation, like laughing at the recent death of a loved one, or incongruence. Consistency between verbal and nonverbal communication is known as congruence. A patient’s expression of emotion may also be described as follows:

• broad affect: emotions are expressed in a healthy, appropriate manner
• inappropriate affect: emotional responses that are not appropriate for the situation
• subdued affect: minimal emotion, lack of spontaneity, withdrawn, unmotivated
• tearful affect: quick to cry, vulnerable, easily overwhelmed
• labile affect: varying and suddenly shifting emotions
• blunted affect: diminished range and intensity
• restricted affect: reduced emotional expression and intensity, which can be expressed in depression, inhibited personalities, and schizophrenia
• flat affect: no emotional expression

Emotions and Attitude

The patient’s attitude is the emotional tone displayed toward the examiner, other individuals, or their illness. It may convey a sense of hostility, anger, helplessness, pessimism, overdramatization, self-centeredness, or passivity. Determining the patient’s attitude toward emotional problems or diagnosed mental health disorders is essential. Does the patient look forward to improvement and recovery or are they resigned to suffering?

Expressions

Emotions and facial expressions are congruent in most individuals. When a person feels joyful, they generally wear a smile and have a pleasant countenance. When a person is sad, their facial expression often conveys their sadness to others. When a person is experiencing mental illness, however, they may be experiencing one emotion while their affect and body language tell another story. The term mood congruence is the consistency between the patient’s emotional state and their affect. When assessing a patient’s mental health, the nurse should note any mood incongruence between their facial expressions and current emotions.

Depression

Depression differs from the usual mood fluctuations and short-lived emotional responses to everyday stressors. When it is recurrent with moderate or severe intensity, depression can become a serious health condition that causes the affected person to suffer greatly and function poorly at work and school. Depression can also adversely affect relationships with family and friends. At its worst, depression can lead to suicide.

Anxiety

Anxiety presents as a general nonspecific discomfort with feelings of vulnerability and, often, impending doom. Individuals experiencing anxiety feel extreme worry and threat about scenarios that might happen. Symptoms of anxiety can include the following:

• increased blood pressure
• sweating
• trembling
• increased respiratory rate
• tachycardia
• nausea and vomiting
• muscle tension
• diarrhea
• flushing
• dry mouth
• pupil dilation
• clammy skin
• impaired normal function
• urinary frequency

Thought Process and Content

The way a patient perceives and responds to stimuli is a critical part of a mental health examination. For example, does the patient harbor real concerns or have their concerns escalated to become irrational fear? Are the patient’s responses exaggerated compared to actual events? Is there no discernible basis in reality for the patient’s beliefs or behavior? Patients with mental health disorders may experience intrusive thoughts, delusions, and obsessions.

A patient’s thought processes may also affect the outcome of a mental health assessment. If the patient utilizes abstract thinking—the ability to think about objects, principles, or ideas that are not physically present—the assessment will yield more helpful information, as the patient can discuss occurrences beyond the here and now. If the patient only displays concrete thinking, a literal form of thought, they will take in all the information they can see, hear, or touch at face value and have difficulty applying it beyond the present. In each of these scenarios, the outcome of the assessment may be affected by the patient’s cognitive process. Nurses should keep this in mind when assessing patients.

Clarity of Ideas

Clarity of ideas, or mental clarity, allows people to process thoughts and abstract ideas. Clarity allows them to work through problems and remain productive. Mental clarity allows people to make decisions confidently and engage in meaningful conversations with others. Those who do not have mental clarity experience confusion, forgetfulness, and difficulty focusing their thoughts. Lack of sleep, stress, and multiple mental disorders can lead to poor mental clarity.

Patient Conversations: Unregulated Thought Process: Word Salad

Scenario: The nurse walks into patient’s room to complete a nursing assessment. The patient grows anxious, eyes wide. She is sitting in the chair by the window, and she turns her head to face the corner.

Nurse: Hello, Ms. Williams, my name is Gabriella, and I’ll be your nurse today. I’m going to sit over here [several feet from the patient so she feels less threatened] and ask you some questions, okay?

Patient: Umph. I upstairs by the wanted toaster rhyme with down water noggin tasty rough pack.

Nurse: Okay, Ms. Williams, here’s some water. Just relax. No one here is going to hurt you. Are you understanding what I’m saying to you?

[Patient slowly nods head.]

Nurse: Would you please tell me your name and date of birth?

Patient: After I wanted down to pickles and objects fast cars with pudding, nightmares, funny little friends. Can’t get there from walnut pickers.

Nurse: One more thing, Ms. Williams, can you hold up three fingers for me?

[Patient slowly holds up three fingers.]

Scenario follow-up: The nurse needs to evaluate the patient’s communication and comprehension, as well as overall demeanor. When the nurse enters the room, the patient is anxious and hesitant. As the nurse questions the patient, it becomes clear that the patient is struggling to communicate; her words are nonsensical. When asked if she understands, the patient’s nonverbal communication (nodding her head) conveys that she does. However, her verbal communication to the nurse continues to be a string of random words. The nurse adjusts the assessment by asking the patient to demonstrate her understanding nonverbally (holding up three fingers), which the patient is able to do. Through observation, the nurse has determined that although the patient is struggling to communicate and produce coherent speech, she appears to be able to comprehend what is being said to her.

Impulse Control

Nurses can evaluate a patient’s impulse control by asking the patient if they ever become involved in activities without first planning them. An example of this would be a patient buying a last-minute airline ticket overseas without first considering their job, family responsibilities, or the financial expenditure of such a trip. Patients with poor control of impulses may have a weakened ability to control temptations or urges. Poor impulse control is seen in various disorders, including substance abuse, disordered eating, risky sexual behavior, pathological gambling, antisocial personality disorder, bipolar disorder, schizophrenia, and impulse control disorder.

Thoughts of Self-Harm

While any patient may experience thoughts of self-harm or engage in self-harming behaviors, those who have mental illness such as severe depression or who are experiencing stress and trauma are at especially high risk. Patients with altered perceptions, particularly if they are experiencing hallucinations and delusions, may also have violent thoughts that are directed at themselves or others. If a patient has auditory hallucinations, the nurse must determine if the voices encourage them to hurt themselves or others. A person experiencing suicidal ideation has been thinking about suicide but does not necessarily have the intention to act on that idea. A person who has attempted suicide harms themselves with the intent to end their life but does not die. A person with a suicide plan has a plan to die by suicide, the means to injure themselves, and intends to die. Everyone can help prevent suicide by recognizing warning signs and intervening appropriately. In addition to encouraging these general action steps (Figure 20.2) to prevent suicide, nurses can further prevent suicide by establishing a safe care environment. Establishing a safe care environment is a priority nursing intervention.

Figure 20.2: These suicide prevention action steps help start a conversation that could save a life. (credit: National Institute of Mental Health, Public Domain)

Clinical Safety and Procedures (QSEN): Competency: Clinical Safety and Procedures

Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance. The nurse will:

• Identify risk factors and protective factors.
• Discuss a suicide assessment.
• Determine risk levels and interventions.
• Document a treatment plan.

Every year, more than 700,000 people die by suicide (World Health Organization, 2023). The nurse needs to be aware of the risk factors and protective factors that can affect a patient’s risk for suicide.

Examples of risk factors that may make suicide more likely include mental health conditions, trauma, previous suicide attempts, lack of social support, social isolation, substance abuse, and access to the means to die by suicide (such as having weapons in the home).

Patients with the following symptoms are more likely to be at a risk for suicide (CDC, 2024):

• feeling like a burden
• being isolated
• increasing levels of anxiety
• feeling trapped
• being in unbearable pain
• increasing substance use
• seeking access to lethal means
• increasing anger or rage
• exhibiting hopelessness
• sleeping too little or too much
• talking about wanting to die
• making plans for suicide
• exhibiting extreme mood swings

The nurse needs to understand the barriers to effective care for depression, which include a lack of resources, a shortage of trained healthcare providers, and social stigma associated with mental health disorders.

Protective factors, which make suicide less likely, include having access to health care and mental health treatment, social support, effective coping skills, close relationships, and limited access to means to attempt or die by suicide. Protective factors help reduce the risk of suicide, but do not eliminate it. A patient may appear to have several protective factors and few risk factors if they are trying to conceal their distress or suicidal intent. While the nurse needs to be able to recognize the warning signs of suicide, they also need to be aware that some patients who are having suicidal thoughts may not show these signs.

Link to Learning

Visit the Suicide Prevention Resource Center’s webpage to read more about the Patient Safety Screener: A Brief Tool to Detect Suicide Risk to help assess suicide risk. The tool is appropriate for youth and adults. Most people who die by suicide have visited a healthcare provider within months before taking their lives. This presents an opportunity to screen and identify patients at risk and get them connected with the appropriate resources.

Thoughts of Harming Others

Threats or acts of life-threatening harm toward another person is known as homicidal ideation. When a patient states that they are experiencing homicidal thoughts, it merits thorough exploration. The nurse’s goal in assessing them should be as follows: recognize and detect risk factors, then perform a thorough screening focused on the patient’s current homicidal ideation. Determine whether they have a plan in place and the means to carry out the plan. Do they intend to carry out their plan? Also, look into the patient’s history to find out if they have a history of injuring or killing others. Determine the current risk, then develop and fully document an intervention plan that is collaborative and appropriate for the level of risk.

Unusual or Bizarre Beliefs

Patients experiencing mental illness often exhibit alterations in cognitive functioning. Many times, patients do not realize that their thought processes are altered. A thorough mental health assessment will assist in zeroing in on these symptoms to determine the best treatment. Unusual or bizarre beliefs can develop as coping mechanisms to deal with mental illness, or they can appear on their own as a result of mental illness. Some examples of unusual or bizarre beliefs may include a patient’s belief that the government is reading their mind or the belief that world events have something to do with them personally (Table 20.2).

Table 20.2: Unusual or Bizarre Beliefs (Source: Mental Health Coordinating Council, 2015.)

Cognitive Function	Alteration or Bizarre Beliefs
Lack of insight	A person is unaware of their mental health diagnosis and/or is not able to understand the need for treatment (anosognosia).
Thought content	A person’s thoughts are distorted, disorganized, and/or irrational (e.g., delusions, magical thinking).
Thought broadcasting	A person believes their thoughts are broadcast to the public through the radio or television.
Thought insertion	A person believes their thoughts are being forced into their mind from external sources.
Thought withdrawal	A person believes their thoughts are being removed from their mind by another person or entity.
Thought blocking	A person’s flow of thought or speech is suddenly interrupted and they are aware that they cannot complete a mental activity (for example, they are unable to find the right words when having a conversation).
Neologism	A person uses new, unrecognizable words with unknown origins; often seen in schizophrenia.
Ideas of reference	A person falsely believes that world events and innocuous occurrences could have vital personal significance.
Flight of ideas	A person has erratic thoughts and rapid speech that could be a symptom of a manic episode in bipolar disorder.
Loose associations	There is a lack of connection between ideas.
Word salad	A person has severely disorganized and virtually incomprehensible speech or writing marked by a severe loosening of associations.

Delusions or Hallucinations

Patients may also experience altered perceptions, such as hallucinations and delusions. False sensory perceptions, or hallucinations, not associated with actual external stimuli and can include any of the five senses (auditory, visual, gustatory, olfactory, and tactile). For example, patients may see spiders climbing on the wall or hear voices telling them to do things. These are “visual hallucinations” or “auditory hallucinations.” A delusion is a fixed, false belief not held by cultural peers that persists despite objective contradictory evidence. For example, a patient may have a delusion that the CIA is listening to their conversations via satellites.

Nurses must remember that delusions and hallucinations feel real to patients and cause internal emotional reactions, even when a caregiver reassures patients that the delusions are not based in reality. Because patients often conceal these experiences, it is helpful to ask leading questions, such as, “Have you ever seen or heard things that other people could not see or hear? Have you ever seen or heard something that later turned out not to be there?”

Psychomotor Activity

Take note of overall motor activity, including any tics or unusual mannerisms. Normal motor activity refers to the patient having good balance, moving all extremities equally bilaterally, and walking smoothly. Slow movements or lack of spontaneity in movement can occur due to a physical condition affecting movement, side effects of medications, as well as mental health and cognitive disorders such as depression or dementia. Uncontrolled, involuntary movement, or dyskinesia and akathisia (motor restlessness) may occur if the patient is experiencing extrapyramidal syndrome related to psychotropic medication use. Nurses may note psychomotor agitation, which is a condition of purposeless, non-goal-directed activity; or psychomotor retardation, a condition of extremely slow physical movements, slumped posture, or slow speech patterns. In some cases, patients will present in a catatonic or near-catatonic state. Waxy flexibility, or catalepsy, or , is a state of continued unresponsiveness where the patient may remain in a fixed body posture for extended periods.

Cognition

Cognition is the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses. It includes thinking, knowing, remembering, judging, and problem-solving. When performing mental examination on cognition, the examiner assesses several functions, including orientation, attention, language, and memory. The nurse may also assess the patient’s thought content, executive function, motor function, and spatial awareness.

A term related to assessing attention is distractibility, referring to the patient’s attention being quickly drawn to unimportant or irrelevant external stimuli. A patient with normal cognition can generally exercise appropriate judgment, which refers to one’s ability to recognize relationships, draw conclusions from collected evidence, and evaluate people and situations. Another valuable insight that may come out during the assessment of cognition is the patient’s self-concept, or their evaluation of themselves, which includes physical and psychological attributes.

Orientation

The first step in the cognition status part of the exam is to assess the patient’s orientation. Is the patient alert and oriented? Nurses evaluate patients’ orientation to person, place, time, and event. If the patient is alert and oriented to person, place, time, and event, the chart will often note, “Patient is A&Ox4.”

Orientation, or the lack thereof, is sometimes evident in regular conversation with patients, but to obtain a proper evaluation, ask patients the four following questions:

• “Would you please tell me your full name?”
• “Where are we today?”
• “Can you tell me the date? Or the day of the week?”
• “Who is the President of the United States?” or “Why are we here today?”

Attention Span

Patients who are easily distracted will often lose their train of thought and forget what they say when speaking. This is noteworthy in your assessment. A disorganized thought process and a reduced ability to focus attention on the subject at hand is known as tangential thinking. People experiencing this type of thought disturbance include excessive or irrelevant details in conversations and have difficulty reaching the main point in their conversations. Another type of distracted thinking is circumstantial thinking, or when a person’s speaking and thought process strays from the original topic before returning to the initial subject.

Memory

Patients who present with poor attention spans will often experience memory problems as well. Memory disturbance is a common complaint and is often a presenting symptom in older adults. Memory can be grouped into immediate recall, short-term memory, and long-term memory. Short-term memory is the most clinically pertinent, so evaluating is essential. Short-term retention requires that the patient process and store information to move on to a second intellectual task and then call up the remembrance after completing the second task. For example, short-term memory may be tested by having the patient repeat the names of four unrelated objects and then asking the patient to recall the information three to five minutes after performing a second unrelated mental task.

The term remote memory refers to memories in the patient’s distant past. Many people who are experiencing short-term memory problems are still able to recall remote memories, such as the names of childhood playmates and teachers, old commercial jingles, and song lyrics. These memories are stored in a different area of the brain than recent memories and may be easier to access. To evaluate long-term or remote memory, the nurse should ask the patient about personal life events or ask them to recite a poem or sing a song they know.

Patients experiencing a remote memory deficit may be able to learn new information but have difficulty remembering things that happened in the past. When remote memory is impaired, it can be a challenge to determine the root cause. A patient experiencing remote memory dysfunction may be experiencing dementia or Alzheimer disease, brain tumors, blood clots, a brain infection, thyroid, liver or kidney disease, overconsumption of alcohol, a head injury, or medication side effects.

New Learning: The Four Unrelated Words Test

The Four Unrelated Words Test is a way the nurse can assess the patient’s ability to form new memories by testing their immediate and delayed recall. The findings from the unrelated word test can help the nurse assess the severity of the patient’s cognitive impairment and determine whether they may benefit from interventions such as memory aids.

Patient Conversations: Performing the Four Unrelated Words Test

Scenario: The nurse enters the room to perform the Four Unrelated Words Test on a 76-year-old patient, Mr. Conrad, who has shown signs of mild cognitive impairment.

Nurse: Mr. Conrad, I’m going to tell you four words and I want you to repeat them back to me, okay?

Patient: Okay.

Nurse: Apple, pillow, fox, yellow.

Patient: Apple, pillow, fox, yellow.

Scenario follow-up: By asking the patient to repeat the words right away, the nurse has assessed their immediate recall. Mr. Conrad has successfully remembered all four words correctly. Now, the nurse needs to test the patient’s delayed recall.

Nurse: Great. Now, we’re going to do a different task, but I want you remember those words, okay?

Patient: Okay.

Scenario follow-up: The nurse engages the patient in an unrelated task, like counting, for approximately five minutes. Afterward, the nurse asks the patient to recall the four words.

Nurse: Mr. Conrad, can you tell me those four words?

Patient: Um . . . apple . . . fox . . .

Nurse: Can you remember the other two?

Patient: One was a color, I think?

Nurse: Yes, one was a color.

Patient: … was it yellow?

Nurse: Yes, that’s correct. Do you remember the fourth word?

Patient: No, I don’t. I don’t know what it was.

Scenario follow-up: Here, the patient was able to recall two of the four words, and a third word with a hint. They were not able to come up with the fourth word. The nurse records the patient’s performance on the memory task and may retest them again at ten and thirty minutes.

The Nurse’s Role in Conducting a Mental Health Assessment

The nurse plays an important role in the mental health assessment by collecting, organizing, and analyzing data. They will use the information gathered to develop a nursing diagnosis and present their findings to the patient’s interdisciplinary team to discuss treatment. Based on the findings from the full mental health assessment, the nurse may consider other options for psychological testing (Table 20.3).

Table 20.3: Common Psychological Tests

Test Name	Description
Mini-Mental State Exam (MMSE)	An easily performed test that is the precursor to more advanced testing and provides insight into the patient’s current mental status
Beck’s Depression Inventory	A twenty-one-question test for evaluating a patient’s current level of depression
The Cornell Depression Scale	A geriatric version of Beck’s Depression Inventory that can be used in people with dementia
Beck’s Scale for Suicide Ideation	Used to screen for suicide risk in children and adolescents
Harkavy-Asnis Suicide Scale	Used to screen for suicide risk in children and adolescents
Suicidal Behaviors Questionnaire for Children	Used to screen for suicide risk in children and adolescents
Geriatric Depression Scale	Used to screen older adults for depression

Collecting Data

Collecting data during psychological testing consists of conducting patient interviews as well as administering a psychosocial assessment, a mini-mental exam, or other appropriate tests. The nurse also reviews the patient’s medication list and screen for suicidal or homicidal ideation. The patient will be assessed for exposure to trauma, violence, and substance abuse (Lengel & Tortorice, 2022).

Gathering these data helps the nurse establish a baseline that will inform the remainder of the assessment. The information collected helps the nurse begin to create an accurate picture of the patient’s current state as well as any past factors that might be influencing their mental health.

During the data collection phase, the nurse also supports the patient by evaluating their ability to participate in the assessment and adjusting their questions accordingly to ensure that the patient is able to communicate and be heard.

Organizing Data

A nurse will likely have a framework, such as an electronic health record, to organize their data. Once the nurse has collected all the pertinent data, they should be entered into the patient’s chart so the interdisciplinary team can access the most recent, relevant information. All material should be organized and validated before putting it in the patient’s chart.

Analyzing Data

Data analysis is the stage where the nurse views all collected data and draws conclusions based on them. During this phase, the nurse should assemble the data, develop findings, develop conclusions based on the findings, and develop recommendations for patient care. Validation is the processing of all data by the nurse to be sure it is factual and accurate.

Developing Nursing Diagnosis and Planning

Nursing diagnoses are customized to each patient and drive the development of the nursing care plan. Some examples of nursing diagnoses related to mental health may include (1) disturbed thought process related to psychological barriers as evidenced by inappropriate social behavior or (2) ineffective coping related to inadequate resources as evidenced by inability to ask for help.

Once the diagnosis component is complete, the next step in the nursing process is planning for the patient’s treatment. The data that the nurse have gathered and analyzed, along with their knowledge of current practice, are used to develop evidence-based strategies that address the patient’s needs. The nursing interventions are documented in the patient’s record so that they are accessible to other members of the care team.

Implementing

Implementation begins after the patient receives a medical diagnosis and a treatment plan. Usually, an interdisciplinary team assists in putting together a therapeutic care plan for the patient, which various team members will then carry out.

The nurse is involved in several aspects of the patient’s care, as opportunities exist for nursing interventions at every step of the treatment plan. While coordinating care, the nurse may provide the patient with referrals to community support groups, advocate for dignified care with the interprofessional team, and communicate patient trends with the staff. Health teaching and health promotion are important steps in the treatment process where the nurse delivers teaching about self-care, stress-management techniques, and coping strategies. The nurse also provides teaching about medications and their mechanisms of action, intended effects, potential adverse effects, and ways to cope with side effects. In group therapy, the nurse should encourage patient participation. Throughout treatment, the nurse advocates for the least restrictive interventions and environments necessary to maintain patient safety. Nurses in the mental health setting should observe patients for changes in behavior and document changes in patient behavior. By demonstrating caring behaviors and utilizing therapeutic communication techniques, nurses can help a patient feel at ease, allowing them to participate in treatment.

Evaluating Interventions

Evaluation focuses on reviewing the effectiveness of the nursing interventions by comparing the patient’s condition with the expected outcomes. Evaluation includes data analysis from assessments, screening tools, laboratory results, pharmacologic interventions, and the effectiveness of nursing interventions.

During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a patient’s expected outcomes have been met, partially met, or not met by the established time frames. The nurse should revise the care plan if outcomes are not met or only partially met.

For example, if a patient’s care plan includes cognitive behavioral therapy (CBT) for panic disorder, the nurse will have established goals for the patient during the planning phase and will need to measure the patient’s progress toward those goals throughout treatment. The nurse assesses the patient’s participation in the intervention and reviews any provider notes. They will also talk to the patient about the treatment and assess for any changes in symptoms or behaviors. For example, the patient may report that since starting CBT, they have experienced fewer panic attacks. Conversely, they may report no change in their symptoms. In either case, the subjective information from the patient about their perception of the intervention’s efficacy will need to be documented and considered along with the provider’s evaluation of the patient’s progress. Together, these data help the nurse determine whether the patient’s care plan needs to be adjusted to help them meet their treatment goals.

If a revision is necessary, the nurse should consider which nursing process step requires modification. Have additional assessment data been obtained, or have assessment data changed? Has a different nursing diagnosis become a priority? Were the identified goals or expected outcomes unrealistic? Were any interventions not effective?

Reassessment should occur every time the nurse interacts with a patient, discusses the care plan with others on the interprofessional team, or reviews updated laboratory or diagnostic test results. Nursing care plans should be updated as higher-priority goals emerge. The evaluation results must be documented in the patient’s medical record.