Rural and Remote Mental Health Service

Mental Health Nursing Assessment Guide

To be completed within one hour of arrival on the ward

It is vital that the Mental Health Nursing Assessment is completed for every client within one hour of their arrival onto the ward, this includes transfers from other wards and closed units

This assessment is necessary to ensure the safety of the Client the staff of the unit and other clients
Personal Details
This section requires little explanation however please ensure that inquiries are made regarding the main language spoken and if an interpreter may be required and any religious beliefs or cultural requirements that may be necessary for us to consider
Presenting Information and Social Structure

A statement is required of the actual reason for presenting for admission the nature of the presentingproblem and the history of the presenting problem including precipitating factors and recent stressors

If possible note history of compliance with current treatment regimen’s

Please also include the Clients expectations for this admission

A brief comment about the financial and or employment status of the Client ie source of income

Please note their present accommodation status adequacy and satisfaction of housing

Please identify if there are any social issues that may require intervention by the Multi Disciplinary Team

A brief outline of the support structures available for the Client is also required

Other agencies involved including Community Mental Health Teams please note key worker

Status

Please circle either Voluntary or Detained and note any existing Guardianship Board Orders
Family Structure
Please complete the basic Genogram and adjust as necessary It is not intended to complete a family or Social Work assessment
Medications
Identify any drugs prescribed reason for prescription date commenced highest dose taken current dose and any side effects noted also note current level of compliance

Sensitivities Allergies
Please not any drug sensitivities or allergies and record on the appropriate CR forms

Alcohol / Illicit Drugs
Identify type of drug taken frequency and amount of use

Summarise effects and adverse reactions

 

MENTAL STATE NURSING ASSESSMENT

APPEARANCE AND BEHAVIOUR

General Appearance
Note the physical characteristics of the Client their apparent age

Any distinguishing marks or tattoos

Peculiarities of dress use of cosmetics and jewellery

Any vocation indicators
Level of Consciousness
Note the Clients state of consciousness in terms of alertness lethargy stuporous or comatose
Motor Activity and Behaviour
Please record your observations about the following;

Status Posture Gait Gestures Tics Grimaces Tremors Mannerisms

Activity Overactive Underactive Purposeful or Disorganised Stereotypical Graceful Echopraxia Apraxia

Any signs of psychomotor retardation

Facial expression Alert Tense Worried Happy Sad Happy Dreamy Frightened Pained Angry Sneering

Ecstatic Laughing Smiling or Suspicious

Please record your observations about the following;

Indifferent Frank Friendly Dramatic Evasive Resentful Sullen Irritable Afraid

Seductive Exhibitionistic Impulsive Embarrassed

 

CONVERSATION COMMUNICATION AND SPEECH

Description
Is the Clients conversation Soft Loud Stuttering or Hesitant

Is there evidence of an Accent Enunciation or is the Client Mute

Is there any indication that the conversation speech is Pressured

What is the flow like Even or Uneven

Does the Clients conversation contain references to Disordered Thought or Psychotic thinking

Is there any evidence of Thought Blocking or Ideas of Reference


AFFECT AND MOOD

Affect
The feeling state inferred by the assessor on the basis of the patients statements appearance and behaviour Is there indication of Shallowness or Flattening of Affect Is there an indication of Inappropriate

Affect or Dissociation between Affect and thought content Note Lability or Fluctuating Affect

Other descriptors include Aloof Apathetic Complacent Composed Dull Elated Grandiose Recalcitrant Sarcastic Tense Worried Restricted Blunted Euthymic

Mood
This is the patients subjective statement about their feeling state

Biological Signs (Vegitative Symptoms)
Please record any Appetite or Weight change

Note changes in Sleep patterns

Note any Diurnal Mood shift

Psychomotor Agitation / Retardation

Record any general loss of Interest or Pleasure

Changes in Energy or Fatigue or increase or loss of usual levels of Energy

Feelings of Worthlessness

Note any difficulty os changes in Concentrating

Record any Ruminating Thoughts

Note thoughts of Death or Suicide and record any suicide plans made or pacts past attempts etc

 

PERCEPTIONS

Illusions
Please note any misperceptions of External Stimuli

Hallucinations
False sensory impression without any external basis

Please note any Visual Auditory Olfactory Gustatory or Tactile hallucinations

Note any apparent distractibility or possible responses to hallucinations


THOUGHT

Content
Delusions are uncompromising beliefs held in the face of incontrovertible evidence to the contrary

Examples of Delusions can be Religious Persecutory being alien control Grandiose in nature and can also

include Somatic Conditions and Thought Insertion or Withdrawal

Are associations Loose or Illogical Circumstantial or contain unnecessary detail

Is their any Blocking or Flight of Ideas


ORIENTATION

Time
Hour Day Month Year Note if they can identify the Prime Minister

Place
Which Hospital are they in What city What country

Person
To self or other

 

MEMORY

Remote past recall
Ability to present a coherent life story with dates and places for example birth occupations relationships

Recent past recall
Ability to recall the history and events leading to their hospitalisation

Immediate past recall
Can the Client recall a persons name and three unrelated facts 5 minutes after they have been given

Mini - Mental Assessment Yes / No Score
If you believe it is warranted please conduct a Mini-Mental Assessment

It is not intended to conduct a Psychological assessment rather to identify if such an assessment may be warranted or if the client might be at risk of wandering etc

 

INSIGHT AND JUDGEMENT

Insight
The degree to which the patient realises the significance of their symptoms and their current situation

Is there an appreciation of how their illness may effect their life Do they think they have an illness

Are they able to explain why they are in hospital

Judgement
The ability to make correct estimations and form opinions concerning external objective matters

Are they able to manage their own finances

PHYSICAL NURSING ASSESSMENT

Admission Observations
This section requires little explanation
Activities of Daily Living
A statement of the patients general level of physical fitness

Taking note of any regular exercise type amount and frequency

Note any special diet requirements and nutritional status of the Client

Record any mental health relaxation or meditation efforts

Note attendance or membership of self help or support groups
Previous Health Status
A brief statement recording any childhood illnesses any serious or chronic illness

Note especially any head injuries / trauma occurrences of fits or epilepsy or blackouts

Record any occurrences of general hospitalisations Noting occasions of surgery and reasons

Record obstetric history if appropriate

SUMMARY OF NURSING ASSESSMENT

Summary Statement
A brief succinct statement or formulation of what the central issues are and the reasons for admission

Include a brief Problem List
Risk Assessment
Outline any existence of thoughts or evidence of self harm or suicidal or homicidal thoughts

Record any history of violence or fire risk

Current drug or alcohol intoxication

Risk Category
The Risk Category is based on the whole Nursing Assessment and the above risk assessment information

Please circle the number you believe that best describes the Clients Risk Status and ensure appropriate nursing action as required

1 = Voluntary with little evidence of risk

2 = Voluntary or Detained with some evidence of risk

3 = Detained with evidence of increased risk

4 = Requires Special 1:1 Nursing Care

5 = Requires Closed Ward Management
Verbal Safety Contract
The Client is able to and has given an undertaking to ensure their safety and has indicated a willingness to seek staff out if they are feeling unsafe
Registered Nurse Completing Assessment
The Registered Nurse completing the Mental Health Nursing Assessment must record the date and time the assessment was completed and then sign the record print their name and document their designation


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