Psychiatric Nursing History and Mental
Status Assessment
GENERAL ADMISSION INFORMATION
Name: (Please Use Alias) ______________________________________________
Age/Gender: ___________________ Marital Status: ____________________
Racial and Ethnic Data: ___________________________
Number and Ages of Children/Siblings: __________________________________
Living Arrangements: _________________________________________________
Educational Attainment: _______________________________________________
Occupation: _________________________________________________________
Religious Affiliations: _________________________________________________
CONDITIONS OF ADMISSION
Voluntary: __________ Involuntary: ________________
Accompanied to Facility by (Family Friend Police Other): ___________________
Route of Admission (ambulatory, wheelchair, stretcher) _____________________
Admitted from: (home, other facility, street, place of destination) ______________
PRESENTING PROBLEM (Chief Complaint)
_________________________________________________________________________
________________________
● Statement in the client’s own words of why he or she is hospitalized or seeking
help
____________________________________________________________________
____________________________
____________________________________________________________________
____________________________
● Onset / precipitating factors
____________________________________________________________________
_____________________________
____________________________________________________________________
_____________________________
PSYCHIATRIC NURSING HISTORY AND MENTAL HEALTH STATUS ASSESSMENT
DAY _ DAY _
GENERAL APPEARANCE
Present Absent Analysis Present Absent Analysis
Facial Expression
Animated
1 | Page
Fixed or Immobile
Sad or Depressed
Angry
Pale
Reddened
Posture
Slouched
Stooped
Upright (erect)
Stiff
2 | Page
Gait
Smooth Rhythmic
Shuffling
Staggering
Dress
Appropriately Dressed
Inappropriately Dressed
Pressed
Wrinkled
Grooming
Well Groomed
Unkempt
3 | Page
Hygiene
Clean
Untidy
Odor (Body/Breath)
None
Alcohol
Acetone Pungent
Cigarette Smoke
Foul Smelling
Physical Deformity
4 | Page
Specify: ______________
5 | Page
Eye Contact
Maintains Good Eye Contact
Poor Eye Contact (Lacks Eye
Contact)
Eye Cast (Client squints his
eyes, pupils dilated)
MOTOR BEHAVIOR (Gestures, stereotyped behavior, pacing, any purposeless activity should be
described.)
Purposeful and Coordinated
Movement
Catatonia
Echopraxia
Tics
6 | Page
Spasm
Compulsive
Waxy Flexibility
Parkinson-like symptoms
Akathisia
Dyskinesia
Apraxia
Catatonic Stupor
7 | Page
Catatonic Excitement
Hyperkinesia
Catalepsy
Cataplexy
SPEECH (How the client is communicating, rather than what the client is telling you. Rate, volume,
modulation and flow.)
Rate
Rapid
Slow
Volume
Loud
8 | Page
Soft/mumbled
Quantity
Paucity
Muteness
Voluminous
Quality
Articulate
Congruent
Spontaneous
Monotonous
9 | Page
Talkative
Repetitious
Pressured Speech
EMOTIONAL STATE (Mood/Affect) (Expression of emotion as seen by others;what examiner infers
from patient’s facial expression/behavior)
Appropriate
Inappropriate
Flat
Pleasurable Affect
Euphoria
Exaltation
10 | P a g e
Ecstacy
Unpleasurable
Depression
Anxiety
Fear
Agitation
Ambivalence
Aggression
Mood Swings
11 | P a g e
Lability
Panic
Anger
12 | P a g e
Perceptions (Process by which physical stimuli are brought to mental awareness )
Hallucinations
Auditory
Visual
Tactile
Gustatory
Olfactory
Illusions
Depersonalization
Derealization
Thinking (The way the person functions intellectually; the process or way of thinking or analysis of
the world: the wayof connecting or associating thoughts; the overall organization of thoughts.)
(1) Thought Content-What a client is thinking
13 | P a g e
1.1 Delusions
a. Delusions of
Grandeur
b. Delusions of
Reference
c. Delusions of
Persecution
d. Religious Delusion
e. Somatic Delusion
f. Paranoid Delusion
1.2 Phobia: Specify
(2) Thought Process - How a person thinks
a. Blocking
14 | P a g e
b. Flight of Ideas
c. Word Salad
d. Perseverance
e. Neologism
f. Circumstantialism
g. Echolalia
h. Obsession
i. Verbigeration
15 | P a g e
j. Rhyming
k. Punning
l. Mutism
ATTITUDES (The learned tendency to respond to people, concepts, and events in an evaluative
way.)
a. Cooperative
b. Outgoing
c. Withdrawal
d. Evasive
e. Sarcastic
16 | P a g e
f. Aggressive
g. Perplexed
h. Apprehension
i. Arrogant
j. Dramatic
k. Submissive
l. Fearful
m. Seductive
17 | P a g e
n. Uncooperative
o. Impatient
p. Resistant
q. Impulsive
18 | P a g e
DEFENSE MECHANISMS (Automatic psychological process that protects the individual against
anxiety and from awareness of internal or external stressors or dangers.)
a. Denial
b. Repression
c. Rationalization
d. Reaction Formation
e. Sublimation
f. Compensation
g. Projection
19 | P a g e
h. Displacement
i. Identification
j. Conversion
k. Regression
l. Introjections
m. Undoing
n. Substitution
o. Intellectualization
20 | P a g e
p. suppression
21 | P a g e
GENERAL ADMISSION INFORMATION
Name: (Please Use Alias) ______________________________________________
Age/Gender: ___________________ Marital Status: ____________________
Racial and Ethnic Data: ___________________________
Number and Ages of Children/Siblings: __________________________________
Living Arrangements: _________________________________________________
Educational Attainment: _______________________________________________
Occupation: _________________________________________________________
Religious Affiliations: _________________________________________________
DIAGNOSIS:
_________________________________________________________________________
________________________
22 | P a g e
THERAPEUTIC
COMMUNICATIO DAY _
N TECHNIQUE
NURSE PATIENT
Use Not Rationale/ Respons Interpretation/
d Used Justification e Analysis
Accepting
Broad openings
Consensual
validation
Encouraging
comparison
Encouraging
description of
perceptions
Encouraging
expression
Exploring
23 | P a g e
Focusing
Formulation a
plan of action
General leads
Giving
information
Giving
recognition
Making
observations
Offering self
Placing event in
time or sequence
24 | P a g e
Presenting
reality
Reflecting
Restating
Seeking
information
Silence
Suggesting
collaboration
Summarizing
Translating into
feelings
25 | P a g e
Verbalizing
implied
Voicing doubt
SUBMITTED BY: SUBMITTED TO:
_____________________
______________________
26 | P a g e