ASSESSING GENERAL APPEARANCE AND MENTAL STATUS

LEGEND:
 5 – Excellent – Able to perform correctly all task at a given time
 4 – Very Satisfactory – Able to perform correctly almost all task at a given time
 3 – Satisfactory – Able to perform correctly some/moderate task at a given time
 2 – Fair – Able to perform correctly few/ very little task at a given time
 1 – Unsatisfactory – Unable to perform correctly all task at a given time.
PROCEDURE 1 2 3 4 5
1. Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client what you are going
to do, why it is necessary, and how he or she can participate. Discuss
how the results will be used in planning further care or treatments.

2. Perform hand hygiene and observe other appropriate infection prevention

procedures.
3. Provide for client privacy.
4. Observe for signs of distress in posture or facial expression.
5. Observe body build, height, and weight in relation to the client’s age,
lifestyle, and health.
6. Observe client’s posture and gait, standing, sitting, and walking.

7. Observe client’s overall hygiene and grooming.

8. Note body and breathe odor.
9. Note obvious signs of health or illness (e.g., in skin color or breathing).

10. Assess the client’s attitude (frame of mind).

11. Note the client’s affect/mood; assess the appropriateness of the client’s
responses.
12. Listen for quantity of speech (amount and pace), quality (loudness,
clarity, inflection).
13. Listen for relevance and organization of thoughts.
14. Document findings in the client record using printed or electronic forms
and checklists supplemented by narrative notes when appropriate.

[ CITATION Ber151 \l 1033 ]

Score
70 – 67 1.0
66 – 63 1.25
62 – 59 1.50
58 – 55 1.75
54 – 51 2.0
51 – 48 2.25
47 – 44 2.5
43 - 41 2.75
40 - 38 3.0

STUDENT:

RATE:

CLINICAL INSTRUCTOR/FACILITATOR:

References
Berman, A., Snyder, S., & Frandsen, G. (2015). Kozier and Erb's Fundamentals of Nursing Tenth Edition.
Pearson.