nurs 129: mental health assessment descriptors

physical appearance

neat/clean, sloppy, disheveled, appropriate for climate, poor hygiene

facial expression

grimacing-contorted, exhibiting pain; decreased expression

posture

upright, slouching, rigid, waxy flexibility, abnormal

waxy flexibility

patient’s limbs retain position to which they were placed in

body movements

restless, impulsive, compulsive, psychomotor agitation, bizarre, psychomotor retardation (impairment), shuffling, EPS movements (dystonia, akathisia, pseudoparkinsonian effects, tardive dyskinesia)

compulsive

repetitive acts (OCD)

psychomotor agitation

rapidity of activity (pacing, talking)

psychomotor retardation (impairment)

slowed down body movements accompanied by slowed thoughts

extrapyramidal symptoms

EPS movements

EPS movements

drug induced movements

dystonia

continuous spasms and muscle contractions

akathisia

motor restlessness

pseudoparkinsonian effects

muscle rigidity caused by decreased dopamine

tardive dyskinesia

jerky muscle movements

behavior

cooperative, uncooperative, restless, agitated, mistrustful, hostile/aggressive, repetitive movements, mannerisms or gestures slowed

mood

euthymic, happy, sad, anxious, tense, alert, tearful, calm

euthymic

normal

affect

objective expression of mood

affect

flat, blunted, labile

labile

mood swings

flat

absence of expression

blunted

severe reduction in intensity of feelings

flat

absence of expression

speech and language skills

clear, slow, stutters, slurring, echolalia, slurred, rambling, hesitant, mumbling, fast, garbled, inaudible, slang, loud, rapid, soft, language spoken

echolalia

repetition of words spoken by another

perception

hallucinations, auditory, visual, olfactory, tactile, illusions

illusions

misinterpretation of environment

hallucinations

false sensory perception in the absence of external stimulus

cognition

school years completed

memory

immediated intact, recent intact, remote intact

immediate memory

3-5 minutes

recent memory

within 24 hours

remote memory

1 year

thoughts

goal directed/linear, delusional, tangential, circumstantial, suicidal, blocking, looseness of association, ideas of reference, word salad, flight of ideas, phobias, preservation, neologisms, obsessions, compulsions, coherent, somatizations, confabulations, grandiose, maginal thinking, thought blocking, thought insertion

goal directed/linear

put thoughts in order of how it happened

delusional

persistent belief or thoughts of something that isn’t true despite evidence of the contrary

tangential

train of thought wanders, lack of focus, never returning to initial thought

circumstantial

conversation drifts then comes back to the point

blocking

speech suddenly interrupted by silences lasting few seconds or longer

looseness of association

sequence of unrelated or remotely related ideas

ideas of reference

misinterpretation of incidents and events in outside world

word salad

attempted communication but words appear random and unrelated in incoherent sequence; unaware that didn’t make sense

flight of ideas

fast speech with frequent shifting of ideas

perseveration

repetition of word, phrases, ideas

neologisms

newly created word whose meaning is unknown to others/made up word

obsessions

intrusive irrational thoughts and fears

compulsions

repetitive behavior one feels they must do

coherent

expressed thoughts in clear and calm way

somatizations

psychological concerns convert to physical symptoms

confabulations

fabricated or distorted without the intention to deceive

grandiose

unrealistic sense of superiority

magical thinking

one’s thoughts can influence the world

thought insertion

someone else has put thoughts into their mind

abstract ability

concrete, abstract

concrete

thinking on the surface, no depth

abstract

think about things not actually present, away from here and now, more depth

attention

spell “world” backwards and forwards

concentration

serial sevens, serial threes, follows three step commands

serial sevens

test brain activity

serial sevens, serial threes

measures attention and mental concentration

analogies

able/not able

insight, judgment

good, fair, poor, justify

orientation

person, place, time, situation