Registered Mental Health Nursing (RMN)
ASSESSEMENT OF MENTAL HEALTH STATUS OF A PSYCHIATRIC PATIENT
This is a clinical assessment process that is used to observe and describe a patient’s psychological functioning at a given point in time. It involves the systematic gathering of the patient’s subjective and objective information.
Purpose
- Gather baseline data
- Obtain useful information in formulating a diagnosis
- Plan effective nursing and medical care
- Monitor and evaluate the progress of patient’s response to treatment
Equipment
- Table
- Chair
- Pen and paper
- Patient’s folder (Electronic/ Manual)
Procedure steps
- Welcome patient and offer a comfortable seat
- Use simple clear language the patient understands
- Establish rapport (refer procedure) and explain the reason for the interaction
- Ensure privacy and assure patient of confidentiality
- Obtain information from the following areas:
- Appearance - grooming, facial expression, deformity, etc.
- General Attitude - cooperative, hostile, overly anxious etc.
- Motor Activity - hyperactivity, retardation, gait, etc.
- Thought Process
- Thought form - word salad, thought block, flight of ideas etc.
- Thought content - delusions, suicidal ideation, magical ideation, etc.
- Speech - rate, coherent, stuttering, etc.
- Emotions
- Mood – irritable, euphoria, depression, etc.
- Affect – congruence, blunt, flat, etc.
- Perceptual disturbances - hallucinations, illusion, depersonalization, etc.
- Sensorium and Cognitive ability - orientation, memory, consciousness, etc.
- Impulse control – aggression, affection, sexual feeling, etc.
- Judgment and Insight - arithmetic ability, awareness of illness, decision making, etc.
- Express appreciation to patient
- Document assessment findings in the nurse’s note/ patient folder
References and further reading
Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.
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