MENTAL STATUS ASSESSMENT
I. GENERAL ATTITUDE AND BEHAVIOR Behavior: Cooperative ڤ Passive ڤ Domineering ڤ Withdrawn ڤ Restless ڤ Dramatic ڤ Hostile ڤ Intimidating ڤ Suspicious ڤ Uncooperative ڤ Other:________________________
Appearance: Unkempt ڤ Disheveled ڤ Clean ڤ Neat ڤ Unusual ڤ
Attire: Appropriate ڤ Seductive ڤ Loud ڤ Meticulous ڤ Untidy ڤ Atypical ڤ Facial Expression: Unremarkable ڤ Sad ڤ Angry ڤ Perplexed ڤ Fearful ڤ Elated ڤ Immobile ڤ Grimacing ڤ Atypical ڤ
Gait: Normal ڤ Parkinsonian ڤ Ataxic ڤ Shuffling ڤ Unusual ڤ
Motor Activity: Unremarkable ڤ Agitated ڤ Hypoactive ڤ Tremor ڤ Tic ڤ Hyperactive ڤ Pacing ڤ Handwringing ڤ Mannerisms ڤ
II. STREAM OF MENTAL ACTIVITY
Productivity: Spontaneous ڤ Verbose ڤ Pressured ڤ Slow ڤ Soft ڤ Mute ڤ Atypical ڤ Progression: Logical ڤ Association ڤ Loose Association ڤ Circumstantiality ڤ Perseveration ڤ Halting ڤ Incoherent ڤ Fragmented ڤ Tangential ڤ Flight of Ideas ڤ Ruminations ڤ Confabulation ڤ Neologism ڤ
Language: Normal ڤ Childlike ڤ Peculiar ڤ Stilted ڤ
III. Emotional State/Reaction
Affect: Unremarkable ڤ Indifferent ڤ Fearful ڤ Angry ڤ Euphoric ڤ Anxious ڤ Sad ڤ Range: Normal ڤ Labile ڤ Constricted ڤ
Depth: Normal ڤ Shallow ڤ Increased ڤ
Vegetative Sx of Depression:
Depressed mood ڤ Loss of interest or pleasure ڤ Appetitie Disturbance ڤ Sleep Disturbance
ڤ Psychomotor Agitation or Retardation ڤ Fatigue or Loss of energy ڤ Decreased concentration ڤ Feelings of worthlessness or guilt ڤ Diurnal mood variation ڤ Suicidal/Homicidal: Denies ڤ Ideation ڤ Plan ڤ Attempt ڤ
IV. MENTAL TREND AND THOUGHT CONTENT Perception: Unremarkable ڤ Depersonalization ڤ Derealization ڤ Dissociation ڤ Hallucinations: Auditory ڤ Visual ڤ Tactile ڤ Olfactory ڤ Gustatory ڤ
Cognitive Style: Obsessive ڤ Self Deprecatory ڤ Intellectualized ڤ Autistic ڤ Global (Histrionic) ڤ Other: ______________________________ Cognitive Content: Obsessions ڤ Phobias ڤ Compulsive Rituals ڤ Religiosity ڤ Ideas of Reference ڤ Bizarre Ideas ڤ Self Depreciations ڤ Delusions ڤ Nihilistic ڤ Somatic ڤ Grandiose ڤ Paranoid ڤ Guilt ڤ
V. SENSORIUM, MENTAL GRASP AND CAPACITY Consciousness: Alert ڤ Clouded ڤ Fluctuating ڤ Stuporous ڤ
Orientation: Normal ڤ Mild ڤ Moderate ڤ Severe ڤ Disorientation to: Time ڤ Place ڤ Person ڤ Situation ڤ
Memory: Intact ڤ Mild ڤ Moderate ڤ Severe ڤ Memory Deficits ڤ Immediate ڤ Recent ڤ Remote ڤ
Digit span: Forward: Good ڤ Poor ڤ Backward: Good ڤ Poor ڤ
Disorders of: Counting ڤ Calculation ڤ Reading ڤ Writing ڤ Attention ڤ Concentration ڤ Comprehension ڤ
General Knowledge: Good ڤ Poor ڤ Consistent with education ڤ Inconsistent with education
ڤ Personalized ڤ Superficial ڤ Pseudoabstraction ڤ
Intelligence: Normal ڤ Below ڤ Above Normal ڤ
Insight: Good ڤ Fair ڤ Poor ڤ None ڤ
Judgment: Good ڤ Fair ڤ Poor ڤ None ڤ
NORFOLK STATE UNIVERSITY
DEPARTMENT OF NURSING
NORFOLK, VIRGINIA 23504
BS NURSING HISTORY AND HEALTH ASSESSMENT GUIDE: GUIDELINES FOR COMPLETION
This guide is a basic outline of areas to consider when assessing a client. It is not meant to be inclusive of each area needing consideration. Items will need to be added to each category as assessment skills and theoretical base is expanded. When assessing a client, add or delete areas as appropriate for age, growth and developmental stages, presenting conditions, and nursing situation (points for grading are listed in parentheses).
I. BIOGRAPHICAL DATA (2 points)
Date of Interview ___________________
Name of Client ____________________ Age ____ Gender____
Place of Birth _____________________ Culture _____________ Race _________
City of Residence __________________ Marital Status: S M W D Family______
Occupation _______________________ Education
Transportation ________________________ Religion
Information obtained from: Client ________ Other
II. CHIEF COMPLAINT (CC): (3 points)
S: Client’s statement about why he/she is seeking health care at this time; should
III. HISTORY OF PRESENT ILLNESS (PI): (10 points)
A. Usual Health:
S: Client’s summary
B. Chronological Story of Symptoms:
S: Date of onset; manner (gradual or sudden); duration; precipitating factors.
Course since onset: location; quality; quantity; setting; associated
phenomena; alleviating or aggravating factors; family history related to
C. Negative Information:
S: Any negative information regarding the chief complaint that is as significant
as the positive information.
D. Relevant Family History:
S: Any problem similar to chief complaint in blood relatives.
E. Disability Assessment:
S: Effect on activities of daily living (ADL); physical, psychological, sociological
and financial impacts of problems(s).
IV. PAST HISTORY: (14 points)
A. Health Perception:
S: Client’s perception.
B. Childhood Illnesses:
S: (i.e., measles, rubella, mumps, whooping cough, chicken pox,
rheumatic fever, scarlet fever, polio, diphtheria).
C. Adult Illnesses:
S: (Tuberculosis, hepatitis, diabetes, hypertension, myocardial
infarction, tropical or parasitic diseases, other infections).
D. Psychiatric Illnesses:
S: (Mood disorders, psychiatric intervention with dates(s);
hospitalizations and date(s).
E. Accidents and Injuries:
S: (Dates; disability limitation; blood transfusion).
S: (Dates; hospital or outpatient and name of facility; diagnosis and
complications; blood transfusions including reactions, date and number
S: (If not previously noted).
V. CURRENT HEALTH STATUS: (10 points)
S: (Medications; environmental; foods; other).
S: (Smallpox, polio, diphtheria, pertussis and tetanus toxoid, influenza,
choler, typhus, typhoid, Bacille Calmette-Guerin (BCG), hepatitis,
pneumonia; unusual reactions to immunizations; tetanus or other
antitoxin made with horse serum).
C. Screening Tests:
S: (Hematocrit, urinalysis, tuberculin tests, Pap smears, mammogram,
stools for occult blood, and cholesterol tests; list dates and results).
D. Environmental Hazards:
S: (Home, school, work).
E. Use of Safety Measures:
S: (Seat belts, work related measures, safety measures in the home,
F. Exercise and Leisure Activities:
S: (Type and frequency).
G. Sleep Patterns:
S: (Time goes to bed; awakens during night; daytime naps; difficulties in
falling asleep or staying asleep).
H. Diet/Nutritional Data:
S: (Dietary intake for 24-hour period; dietary restrictions or
I. Current Medications:
S: (Home remedies; prescription and nonprescription drugs;
vitamin/mineral supplements and borrowed medications).
J. Tobacco, Alcohol, Drugs, and Related substances:
S: (Type of cigarettes and frequency of use, chewing tobacco/snuff;
street drugs; type of alcohol and frequency; other).
VI. FAMILY HISTORY: (10 points)
S: (Covers three (3) generations and includes age and health, or age and
cause of death, of each immediate family member. Use a
genogram/pedigree diagram/family tree to illustrate family status.
Determine if any of the following conditions have occurred within the
family: diabetes, tuberculosis, heart disease, high blood pressure,
stroke, kidney disease, cancer, arthritis, anemia, thyroid disease,
asthma, sexually transmitted disease, headaches, epilepsy, mental
illness, alcoholism, drug addiction, hematologic disorders (hemophilia,
sickle cell anemia, thalassemia, hemolytic jaundice), Huntington’s
chorea, arteriosclerosis, gout, obesity, and symptoms like those of the
IV. SOCIOLOGICAL SYSTEM: (8 points)
A. Home Situation and Significant Others:
S: Persons with whom client lives; client’s position within the family;
recent family crisis, or changes; significant others.
B. Daily Life:
S: Rest-Sleep-Activity (RSA) patterns, social activities, recent
changes in daily activities; special weekend activities.
C. Life Cycle Events:
S: Marriage, divorce, recent move or job change, marriage of
children—any event which might significantly impact on client’s health
or health seeking behavior.
S: Home, community, work, and recent changes in those
environments; foreign travel.
E. Occupational History:
S: Jobs held, job satisfaction, current place of employment. Exposure
to health hazars.
F. Economic Status and Resources:
S: Source of income, perception of adequacy of income, effect of
illness on economic status.
G. Educational Level:
S: Highest degree or grade attained.
H. Patterns of Health Care:
S: Private and public primary care agencies, dental care, preventive
care, emergency care.
VIII. PSYCHOLOGICAL SYSTEM: (5 points)
A. Cognitive Abilities:
S: Level of education learning patterns, and memory.
B. Responses to Illness and Health:
S: Reaction to illness, coping patterns, value of health.
C. Response to Care:
S: Client’s perceptions, compliance in past.
D. Cultural Implications for Care:
S: Client’s religious beliefs related to health care.
IX. REVIEW OF SYSTEMS (ROS): (40 points)
S: Usual state of health, chills, fever, sweats, weakness, malaise,
fatigue, recent and significant gain or loss of weight.
O: Height and weight, vital signs (TPR; B/P in both arms in at least 2
positions); appearance relative to age; apparent state of health,
awareness, personal appearance, emotional status, nutritional
status, affect, response, cooperation.
INFANTS: Head and chest circumference.
B. Skin, Hair, and Nails:
S: Skin: Color, temperature or texture changes, pruritus, care habits.
Hair: Alopecia, texture changes, care habits (dye hair,
permanents, frequency of shampooing).
Nails: Changes in appearance or texture, care habits.
O: Skin: Color, turgor, texture, pigmentation, eruptions, lesions,
rashes, edema, scars, nevi, petechiae, ecchymoses,
Hair & Scalp: Quality, distribution, color, texture, presence of lesions or
Nails: Color of beds, capillary refill, texture, clubbing, adherence to
nail bed, splinter hemorrhages.
C. Head and Face:
S: Dizziness, injuries, pain, syncope, headaches, masses.
O: Cranium: Contour, tenderness, masses.
INFANTS: Fontanels and type of hair.
Face: Symmetry, movements, sinuses, Cranial Nerve V
S: Visual acuity, with and without corrective lenses; cataracts,
changes in visual fields or vision, diplopia, excessive tearing,
glaucoma; date of last ophthalmologic exam; visual disturbances,
infections, pain, photophobia, pruritus, unusual discharge or
O: Visual acuity (Snellen chart or hand held card), fields (draw
defect if present), alignment of eyes, extra ocular movements
(EOM’s), alignment of eyelids, movement of eyelids (ptosis),
conjunctiva, sclera, cornea, anterior chamber, iris, pupils equally
round, react to light and accommodation (PERRLA), lens,
lacrimal apparatus, ophthalmological apparatus. Test
appropriate cranial nerve(s) and state tests used.
S: Use of prosthetic devices, hearing ability, tinnitus, discharge,
epistaxis, frequency of colds, sinus infections, sneezing,
O: Auricle, canal, otoscopic, exam (tympanic membrane description),
Rinne’ and Weber, discharge, mastoid tenderness. Test
appropriate cranial nerve(s).
F. Nose and Sinuses:
S: Olfactory ability, pain in infraorbital or sinus areas, discharge,
epistaxis, frequency of colds, sinus infections, sneezing,
O: Patency of each nostril, olfaction, turbinates and mucous
membranes, transillumination of sinuses. Test appropriate
G. Mouth and Throat:
S: Pattern of dental care; dental problems, bleeding or swelling of
gums, change in taste, dryness, excessive salivation, lesions,
sore throats, hoarseness, voice changes.
O: Buccal mucosa, gums, teeth/dentures, floor of mouth, hard and
soft palate, tonsilar areas, posterior pharyngeal wall, tongue,
breath, lesions, parotid duct.
CHILDREN: Note teeth pattern.
S: Pain with movement or palpation, swelling.
O: Symmetry, tracheal position, thyroid gland, masses, bruits.
S: Self-examination pattern, masses, discharge, tenderness.
O: Symmetry, axillary nodes, supraclavicular nodes, infraclavicular
nodes, nipples, discharge, masses, dimpling, tenderness to
NEWBORN: size of breast nodule.
J. Respiration System and Chest:
S: Smoking hx., cough, dyspnea, orthopnea, hemoptysis, sputnum,
stridor, wheezing, paroxysmal nocturnal dyspnea (PND); date of
O: Shape and symmetry of thorax, respiratory rate and rhythm,
respiratory movements and use of accessory muscles of
respiration, intercostals retractions, Palpation: tactile fremitus,
tenderness, masses, thoracic expansion, costovertebral ans
spine tenderness. Percussion: diaphragmatic excursion.
Auscultation: breath sounds, adventitious sounds, egophony,
bronchophony, whispered pectoriloquy.
K. Cardiovascular System:
S: Hypertension (HTN), edema, pain, unusual sensations; exercise
history, exercise tolerance; date of last ECG.
O: Position in which heart was examined: Lying, sitting, left lateral,
recumbent. Inspection: bulging, depressions, pulsations.
Palpation: thrusts, heaves, thrills, friction rubs, Point of Maximum
Intensity (PMI). Auscultation: S, S, murmurs and extra sounds. 12
Pulses: temporal, temporal, carotid-rate, rhythm, equality,
amplitude, thrills, bruits, JVP. Palpate peripheral pulses:
brachial, radial, femoral, popliteal, dorsalis pedis and posterior
tibialis; Hct. and Hbg.
L. Abdomen/Gastrointestinal System:
S: Appetite, dysphagia, thirst; nausea, vomiting, diarrhea (NVD);
indigestion, abdominal pain; bowel habits; change in stool color;
dyschezia; flatulence; rectal discomfort; rectal bleeding;
hemorrhoids; nutrition-typical day’s diet.
O: Inspection: Scars, size, shape, symmetry, muscular
development, diastasis, distention, movements.
Auscultation: Peristaltic sounds, bruits.
Palpation: Masses, tenderness, tone of muscalature;
liver size, tenderness; CVA tenderness, palpable
spleen, palpable kidney, distention of urinary
Percussion: Liver-size at MCL, spleen, masses, shifting
INFANT: Movement of umbilicus.
PREGNANT CLIENT: Changes in
abdomen/fundal height measurement.
S: Anuria, change in stream, dysuria, incontinence, nocturia,
oliguria, polyuria, hematuria, pyuria, frequency, flank pain,
Female: Menstrual hx., age at menarche; regularity, frequency,
and duration of periods; amount of bleeding, bleeding between
periods or after intercourse, last menstrual period; dysmenorrhea,
premenstrual tension, age at menopause, menopausal
symptoms, postmenopausal bleeding. (If born prior to 1971,
exposure to DES diethylstilbestrol) from maternal use during
pregnancy). Vaginal discharge, itching, sores, lumps, sexually
transmitted diseases and treatments; obstetrical hx., number of
pregnancies, deliveries, abortions (abortions and induced),
complications; contraceptive hx., birth control methods; sexual
activity, preference, satisfaction or problems; date of last pap
O: Female: External hair distribution, labia, bartholin’s, urethral
meatus, Skene’s glands (BUS); hymen, introitus; vaginal
observation-rectocele, urethrocele, cystocele, tissue, discharge,
Bimanual exam: cervix, uterus, adnexa.
Rectovaginal exam: hemorrhoids, sphincter tone, lesions,
fissures, uterus, cul-de-sac, septum.
Male: Penis: circumcised, lesions;
Scrotum: size, skin, testes, epididymis, spermatic cords, masses;
Prostate gland: size, shape, consistency, tenderness;
Inguinal area: hernia, inguinal and femoral nodes; rectal exam.
CHILDREN: hygiene, secondary sex characteristics (Tanner
PREGNANT CLIENT: Changes related to pregnancy.
N. Extremities and Musculoskeletal:
S: Extremities: Coldness, discoloration;
Muscles: Cramping, weakness;
Bones and Joints: Stiffness, erythema, edema.
O: General assessment: size, shape, masses, symmetry, hair
distribution, color, temperature, edema, varicosities, tenderness,
lesions, Homan’s sign, contractures, epitrochlear lymph nodes.
Muscles: Cramping, weakness;
Back: posture, tenderness, movement-extension, lateral bending,
Pulses: amplitude and character of peripheral pulses, including
radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsal
Infants: measure; inspect sole creases, webbing, and number of
toes and fingers.
Bones and Joints: Range of motion of fingers, wrists, elbows,
shoulders, spine, toes, ankles, knees, hips; swelling, warmth,
tenderness, redness, deformity.
S: General behavior change, mood change, anxiety, nervousness,
seizures, speech, changes in cognitive ability, motor difficulty,
i.e., ataxia, imbalance, tremors, spasm, tic, paresis, paralysis;
O: Mental status, appearance, behavior, speech, mood, thought
processes, cognitive function (insight, vocabulary, abstract
reasoning, serial sevens, judgment), sensorium (orientation,
recent and remote memory), coping behaviors, cranial nerves,
coordination, sensory-touch, pain position, vibration, two-point
discrimination; Babinski’s sign, Romberg’s sign, deep tendon
S: Bleeding, bruising, past hx., of blood transfusion, exposure to
radiation or toxic agents, joint pain.
O: Bleeding, petechiae, bruising.
S: Lymph nodes: Enlarged, tender, suppuration.
O: Lymph nodes: Location, size, shape, consistency, mobility.
S: Intolerance to heat or cold; thyroid gland enlargement or
tenderness, unexplained weight change, diabetes, polydipsia,
polyuria, changes in facial or body hair, increased hat and glove
size, skin striae.
O: (State theorists used in this part of the assessment, e.g., Erikson
for individuals; Duvall for families).
thBates, B., (1991). A guide to physical examination and history taking. (5 ed.). Philadelphia: J.B.
thMalasanos, L., Barkaukas, V., & Stoltenberg-Allen, K. (1990). Health assessment. (4 ed.). St. Louis:
ndSeidel, H., Ball, J., Dains, J., & Benedict, G. (1991). Mosby’s guide to physical examination. (2 ed.). St.
Louis: C.V. Mosby.