Conducting a General Survey

AND
Assessment of Mental Status
N 1 I 0 2 FA L L 2 0 2 3

P R E S E N T E D B Y: A S H L E Y P E T I S , R N , M N , B S C N , M O H A W K C O L L E G E
General Survey: Learning Outcomes
Through research, class discussion and learning activities, students will be able
to:
1.Describe the purpose, components, and normal range of findings when completing the
general survey and their relationship to interpreting and acting in nursing.
2.Gather initial assessment information by performing a general survey on a peer.

Large Group Class:

- Review the 4 parts of the general survey and the various elements to address
- Consider adaptations for growth and developmental stages
- Discuss the importance of the general survey as an initial step in noticing
What is the first step of the Clinical Judgment
Model?

Noticing!
General Survey
Purpose: study the whole person, looking at overall health state and for
any obvious abnormal findings; gives an overall impression of a person.
◦ Objective data collected through noticing
When to perform?: the moment you first encounter the client, and
continue to perform as you move through health history, physical exam,
functional assessment etc.
• Does the patient stand promptly as their name is called, and walk easily to meet you?
• Does the patient make eye contact, and smile?
• Does the patient look ill?
• Is the hospitalized patient conversing with visitors?

Encompasses: Physical Appearance, Body Structure, Mobility/ROM,

Behaviour
General survey
• Think about your encounters with people (family, friends, strangers)
• What was your first impression before you spoke to the person?
What do you notice?
General survey – 4 aspects

1.Physical appearance
2.Body structure
3.Mobility
4.Behavior
1. Physical Appearance
Assess:
◦ Age (appears younger/older than stated age)
◦ Gender/Sex (development appropriate for age)
◦ Signs of Distress (grimacing, hostile, crying, anxious,
distrustful)
◦ Level of Consciousness (alert, drowsy, stupor, unresponsive)
◦ Skin colour (pale, cyanosis, erythema, jaundice)
◦ Facial features (symmetrical, drooping)
Normal Physical Appearance
findings:
•Appears his / her age
•Sexual development appropriate
for gender / age
•Alert
•Oriented (person, self, place and
time)
•Responding appropriately
•Attending to questions
•Intact skin with no obvious
discoloration or lesions (note table
p. 241: Jarvis (2024) that discusses
differences between assessment of
light and dark skin)
•Facial features symmetrical with
movement
•No signs of acute distress
Physical appearance – levels of
consciousness
• Alert: orientated, fully aware of external and internal stimuli and
responds appropriately, conducts meaningful interpersonal
interactions
• Lethargic: Not fully alert, drifts off to sleep when not stimulated,
looks drowsy, responds appropriately to questions or commands,
but thinking seems slow and fuzzy
• Obtunded: sleeps most of the time, difficult to arouse
• Stupor: responds only to persistent and vigorous shake
• Coma: completely unconscious
• Acute confusional state: Delirium

Jarvis, p. 96-97
 What do you notice?

Asymetrical facial features- Cranial

Decreased LOC (obtunded)
nerve paralysis (Bell’s Palsy)

Discolouration- cyanosis

Acute distress– asthma attack

Abnormal Physical Appearance
Findings:
•Appears older than stated age •Lesions
•Delayed or precocious •Bruising
puberty
•Drooping
•Pallor
•Asymmetry
•Cyanosis
•Pain indicated by facial
•Jaundice grimaces
•Erythema •Holding affected body part
2. Body Structure
Assess:
◦ Stature/body type (ht/wt within normal range for stated age and genetic
heritage)
◦ Nutrition (wt within normal range for age, obese, emaciated)
◦ Symmetry (body parts equal bilaterally and in relative proportion)
◦ Posture (standing / sitting / slouched/ tense)
◦ Position (sitting comfortably, arms relaxed)
◦ Body build & Contour (body proportions– arm span: height, crown to
pubis to sole, any obvious physical deformity)
Normal Body Structure Findings:
•Height within normal range for age
and genetic heritage (WHO growth
charts for peds)
•Weight within normal range for age
and genetic heritage (growth
charts)
•Body parts equal bilaterally and
relative proportion to each other
•Sitting or standing comfortably,
erect
• “plumb line” through anterior ear,
shoulder, hip, patella, ankle
•Arms relaxed at sides, head turned
to examiner
•Normal limb proportions ie. arm
span, body / torso proportions
•No obvious physical deformities
 Position (tripod)

Body Structure Assessment

Symmetry, posture
Stature, nutrition
Symmetry, deformity Stature, nutrition, posture, position
Abnormal Body Structure Findings:
•Excessively short or tall •Tripod position
•Obesity – truncal, or even •Fetal position
distribution
•Slumped, stiff, tense, rigid
•Cachectic
•Hypertrophy or Atrophy of
•Emaciated limb/body area (unilateral)
•Elongated limb span
•Missing extremities / digits
3. Mobility and ROM
Assess:
•Gait (base width equal to shoulder •Range of Motion and joint
width; accurate foot placement; mobility (full mobility in each joint;
smooth balanced walk; symmetrical deliberate, accurate smooth,
arm swing) coordinated movements)
• Gait is a coordinated action that
requires the integration of sensory
function, muscle strength,
proprioception, balance and a
properly functioning central
nervous system (vestibular system,
and cerebellum)
(Astle & Duggleby, p. 1259)
Normal Mobility / ROM findings:
•Base width equal to shoulder •Full mobility in each joint
width
•Deliberate, accurate, smooth
•Accurate foot placement coordinated movement
•Smooth, even and well-
balanced walk
•Presence of associated
symmetrical arm swing
Mobility/ROM assessment
https://www.youtube.com/watch?v=wrGkXzL-E5M

https://www.youtube.com/watch?v=yhgUOY2ohUE
Abnormal Mobility/ ROM findings:
•Exceptionally wide base •Paralysis
•Staggering •Absence of movement
•Stumbling •Jerky, Uncoordinated
movement
•Limping with injury
•Tics
•Nonfunctional limb
•Tremors
•Difficulty stopping
•Involuntary movements
•Limited Range of motion
4. Behaviour
Assess:
•Facial expression (Eye contact, appropriate expression)
•Mood and affect (Comfortable, cooperative, flat, sad, angry, anxious,
hostile, suspicious, animated)
•Speech (Clear and understandable, articulation, fluent pace, appropriate
word choice, conveys ideas, ESL, monotone)
•Dress (Appropriate for climate, age, clean, mismatched)
•Personal hygiene/grooming (shaven, combed, clean, groomed, body
odor, halitosis, makeup)
Normal Behavior findings:
Maintaining eye contact (*cultural
considerations*)
Expression appropriate to the
situation
Comfortable and cooperative with
the examiner
Clear and understandable speech
Clear articulation
Fluent pace of speech
Conveys ideas clearly
Word choice is appropriate
Communicating in native language
easily or with interpreter
Clothing appropriate for climate
Clean clothing that fits (*cultural
considerations*)
Clean and groomed appropriately
Behaviour assessment
https://www.youtube.com/watch?v=zA-fqvC02oM
Abnormal Behavior findings:
Flat affect Garbled speech
Depressed Unkempt appearance
Angry Sudden change in appearance/dress
Sad Long sleeves concealing needle marks?
Anxious
Hostile
Distrustful
Suspicious
Crying
Monotone
Extremes in speech
Other relevant observations
Observe for Abuse:

•Abuse of women, children, older adults is a growing

health problem
•Look for obvious physical injury, bruising, or malnutrition
•Assess for fear of guardian or spouse
•If you suspect abuse interview the person in private when
possible
See Astle & Duggleby, 2024, p614
Other relevant observations
•Observe for possible substance abuse:

•Substance abuse affects all socioeconomic groups

•Patients who frequently miss appointments
•Patients who often report lost prescriptions
•Patients who have chief complaints of insomnia, bad
nerves
•Patients who make frequent emergency dept. visits
•Patients with family history of addiction
See Astle & Duggleby, 2024, p614
Refer to performance guidelines
References
Astle, B.J. & Dubbleby, W. (2024). Potter and Perry’s Canadian fundamentals of nursing
(7th ed.). Elsevier.
Browne, A.J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2024). Jarvis physical
examination and health assessment (4th Canadian edition). Elsevier.
Assessment of
Mental Status

N1I02
ASHLEY PETIS MN, BSCN, RN
Learning Outcomes
1. Identify the four components of the mental health assessment and complete a
focused mental status assessment using objective data related to appearance,
behaviour, cognition, and thinking.
2. Notice cues related to mental status and ask appropriate health history questions
related to mental status.
3. Use interpreting and responding skills to assess when supplemental mental status
examination is required and rationalize the purpose for doing so.
4. Examples: Set Test and Clock test, Montreal Cognition Assessment (MoCA), MMSE,
The Rowland Universal Dementia Assessment Scale.
5. Understand the role of the professional nurse and relational practice considering age,
culture, and socioeconomic status.
Let’s get in the right frame of mind

https://www.fraserhealth.ca/health-topics-a-to-z/mental-health-and-substance-
use/mental-wellness#.X3YAHGhKiUk
Assessment of Mental
Status
 Let’s clarify some terminology!
We all have a brain, we all are human = we
all have mental health
The degree of mental health is as variable as
our physical health
Mental illnesses are medical diagnoses with
varying degrees of severity (like
cardiovascular disease can be)
A person can have a mental illness but still
have positive mental health!

Optional: Watch this video for deeper exploration of this idea:

https://youtu.be/KIswi_4yRaE
Click on the link and take the Mental Health Meter.
https://cmha.ca/mental-health-meter

What are your results? What are your strengths? Where can you
enhance your own mental health?
https://startswithme.ca/mental-health-is-not-mental-illness-why-we-need-to-
get-clear-on-the-difference/
What is mental status?
A persons emotional and cognitive functioning
What does it mean to be “well” mentally?
◦ State of well-being; Satisfaction in work, relationships, and within self; Capacity to
feel, think, and behave in ways that are positive to a person; Ability to manage
challenges in life
◦ Can vary over time, depending on life circumstances

What does it mean to be “unwell” mentally?

◦ No exact division between well and unwell
◦ A mental illness is a biological condition of the brain that causes alterations in
thinking, mood, or behaviour; associated with distress and impaired daily functioning
◦ No exact division between normal and abnormal; when symptoms begin to interfere
with a person’s ability to cope with personal relationships, work, environment, sleep,
diet etc.
◦ How do we assess this??
Mental Health Nursing Assessment
Purpose:
To understand the patient’s mental health or wellness, illness
beliefs, and experiences, challenges in daily living, and
strengths and resources in relation to mental health or
wellness.
To assess the full scope of the patient’s mental health or
wellness, patient interactions with heath care providers and
other professionals, the patient’s needs, risk factors, and
needed intervention.
(Browne et al., 2024, p. 81-82)
Difference Between Neurological and
Mental Status
MENTAL STATUS EXAM NEUROLOGICAL EXAM
Emotional State CNS function
Cognitive Function Sensory pathways
Mood and Affect
Motor pathways
Orientation
Cranial Nerves
Attention
Spinal Nerves
Memory
Peripheral Nerves
Abstract Reasoning
Thought Process Autonomic Nervous system

Perception
A comprehensive Mental Health
Assessment includes:
It can often be completed in the context of the health history interview:

◦ Biographical information: name, age, gender identity, relationship status,

employment
◦ History of present illness/Reason for seeking care
◦ Past medical history: childhood illnesses, injuries, birth trauma, prenatal use of
alcohol and drugs, abuse, neglect, trauma, OB history, impact of chronic illness on
mental health
◦ Family history: mental illness may have a genetic component
◦ Psychosocial factors – living situation, supports, recent trauma, education,
employment, financial etc.
◦ Current health: allergies, immunizations, medications
◦ Substance use: alcohol, nicotine, cannabis, opioids, etc.
Mental Health Assessment
Approaches
Includes both objective observations made by the clinician, as well as subjective
descriptions given by the patient

The Mental Status

◦ Observation of client and their interactions Examination should always
◦ Interview be included in the overall
◦ Mental Status Examination physical assessment of all
patients
◦ Physical assessment
◦ Collateral information (collaboration with others)
When to perform a full Mental Health
Assessment?
Mental health can usually be assessed as part of a general health history
Assesses behavior, memory, emotions, cognition, language function
Any abnormality in mood or behavior -- “something not quite right”
Concerned family members report changes in behaviour, memory loss, inappropriate
social interaction
Brain lesions caused by trauma, stroke, tumour
Aphasia (language impairment due to brain damage)
Symptoms of psychiatric illness, especially acute onset
**Mental status examination assesses emotional and cognitive functioning– it is a
subset of the mental health assessment
Before you can begin…
Relational Practice
◦ It is respectful, non-judgmental and reflexive (examining your own beliefs, practices,
thinking deeply)
◦ Requires effort in examining self and social structures that contribute to inequities for
people
How do you do this?
◦ Reflect on how internal and external factors (nudge, nudge…McMaster Model of Nursing) will
impact your nurse-client interaction
◦ What are your own views on mental health, wellness, mental illness, and recovery?
◦ Requires curiosity to learn about the life of your client and how it is impacted by a
mental illness
Why:
A nurse-client relationship aiming for the best interests and health outcomes for the
client
 Assessment of Mental Status
Structured approach to understand
psychological state of patient and
determines if/how affects self-care
in everyday life
*only provides a snap shot at a point
in time*

Assists with diagnosis, choosing

interventions, evaluate progress,
risk assessment
Components: A, B, C, T
Mental status exam describes
person’s current state of mind,
under domains of Appearance,
Behaviour, Cognition and Thought
Processes
 Assessment of Mental Status
Appearance
◦ General presentation to others including age, ht, wt
◦ Body posture and position (lying, sitting, rigid, slouched)
◦ Body movements (voluntary, deliberate, coordinated,
involuntary tremors, repetitive)
◦ Dress (appropriate for setting, season, age, gender,
social groups, appropriate fit and worn properly)
◦ Hygiene and grooming (clean, well groomed, neat and
clean hair, disheveled, appears older/younger than stated
age)

Subjective questions we can ask?

Have you changed the way you dress lately? Are you able to keep up with your personal needs?
Assessment of Mental Status
Behaviour
◦ Level of consciousness (alert, aware, lethargic, response to stimuli)
◦ Activity level, gait
◦ Facial expression (calm, stressed, crying; appropriateness to the situation)
◦ Eye contact, attentiveness to examiner (consider cultural factors; cooperative/not with
exam)
◦ Speech (makes appropriate conversation, clear articulation, quality/tone, pace, word
choice effortless and matches education level)
◦ Mood and Affect- determined by facial expression, body language & asking pt (happy,
sad, ok; stability, appropriateness (in or out of context), intensity; flat, normal, labile)
◦ Affect should be congruent with mood and change appropriately with topics

Subjective questions we can ask?

◦ How do you feel today? How do you usually feel? How long have you felt this way?
Assessment of Mental Status
Cognitive Function
◦ Orientation (time, person, place, self)
◦ Attention span (distractibility, able to follow series of directions)
◦ Can give 3 step command to follow: take this paper, fold it in half, and put it under your chair
◦ Immediate memory (recall statement just made)
◦ your name, words you ask them to repeat, what your last questions was
◦ Recent memory (24hr - verifiable)
◦ what time they arrived today, diet recall (must be able to verify answers)
◦ Remote memory (verifiable past events)
◦ New learning – four unrelated words test

◦ Subjective questions to ask:

◦ Do you know where/who you are? Do you know what you ate in last 24hrs? When is your
birthday? Can you pick this glass of water up with your left hand, take a drink, and put it back
down with your right hand?
Assessment of Mental Status
Thought processes- the way a person thinks (coherence,
logic, stream vs abnormal thought processes)
Thought content – what a person is thinking (consistent and
logical vs ruminations, phobias, paranoia, obsessions, etc.)
Perceptions– awareness of objects through 5 senses (aware
of reality vs hallucinations, illusions)
Other considerations:
◦ Insight- recognize one’s illness, need for treatment and consequences
◦ Judgement- ability to make responsible decisions
◦ Screen for suicidal ideation – be deliberate and straight forward

Subjective questions to ask:

◦ Do you feel the need to do things repeatedly? Do you perform certain
actions to reduce certain thoughts? Do you feel as if you are being
watched, followed, or controlled? Can you see or hear things that no
one else can see?
Functional Assessment
Describe a typical day, steps to promote and maintain health
Assess ADL’s, including finances, coping, relationships
Nutrition: dietary or weight changes, dissatisfaction with body image or
size (eating disorders)
Sleep/Rest: alterations common in many mental disorders
◦ Assess sleep onset, sleep hygiene, duration, awakening, sleep satisfaction
Activity/Mobility: withdrawal from usual activities, excessive exercise
Elimination: can be affected by medication side effects, use of diuretics
& laxatives
Functional Assessment cont…
Interpersonal Relationships: role in the family, social networks,
withdrawal from usual relationships
Self Esteem & Self Concept: rate on scale from 0-10
◦ Ask about values, beliefs, accomplishments that are important to the patient

Coping & Stress: major stressors, usual coping

Smoking, Alcohol, Drug Use: whether seen as a problem by self or
others
Home & Environmental Health: safety related to preparing meals,
bathing, walking at home and in community, lighting
Factors impacting mental status exam
Illness or health problems
Substance use
Medications
Education and developmental level
Stress patterns, social interaction, sleep habits
Mental Status Exam
Watch the first 3 minutes: https://www.youtube.com/watch?v=P7qMfG-yNfA
What do you notice in terms of:
Appearance:
◦ sitting on edge of chair, restless, dress appropriate for season and age, appears clean and well
groomed in video

Behaviour:
◦ alert, makes eye contact, facial expressions match the situation/topic; rapid speech, articulate,
appropriate word choice; anxious and irritable

Cognition:
◦ not assessed for orientation to person, place, time, self, memory or new learning therefore
unable to determine; able to concentrate on interview

Thought processes:
◦ delusions
Self Study: Practice Example
Go to your Elsevier Clinical Skills Essentials Collection
ØAssessing the Neurologic System: Mental Status and Cranial Nerves
ØSelect the “VIDEOs” tab at the top
ØWatch from the beginning to 5:50 for an example a mental status exam as part of a
health history. (you do NOT need to watch the cranial nerve part)
ØFollow along with the performance guideline
Developmental Considerations
Infants and Children: emphasis on developmental milestones (fine motor, gross motor,
cognitive, social-emotional, language, etc.), as well as risk factors (trauma, in-utero
exposure, home life etc.)
◦ Young children and infants often imprecise and only gross deficits detected; once 5-6yrs able to
detect with more precision
◦ Parental involvement and use of play helpful during assessment

Adolescents: follow same guideline, but also consider developmental patterns (weight,
mood regulation, sleep, eating, interpersonal behaviours, high-risk behaviours,
substance use etc.)
◦ Half of diagnosable mental health disorders begin by age 14
◦ Eating disorders on the rise in younger age groups

Assess weight, regulation (anger management, self soothing skills), high risk behaviours and
academic performance
Developmental Considerations
Older adults: need to consider sensory status as well as mental status;
take your time, reduce distractions, minimize sensory impairments

• Age related changes in hearing, vision can impact mental status tests – check
sensory status first
• Knowledge, vocabulary, intelligence, remote memory remain intact
• Brain processes information and reacts a bit more slowly, which may impact new
learning and recent memory
• Potential impact of multiple losses on mental health: job, spouse, home, loved ones,
energy
• 10% of people over 65 and 50% over 85 receive an Alzheimer’s diagnosis
• By age 80, brain has lost 15% of mass – affects fine coordination and response time
 Older adults additional screening
Set test – Screen for dementia, takes less
than 5 minutes
• ask patient to name 10 items in the following
categories: fruit, animals, colours, and towns
(FACT); each correct answer is 1 point.
◦ <15/40 points indicative of dementia
◦ Assesses alertness, motivation, concentration,
short-term memory, and problem-solving

Clock test – patient asked to draw clock

face with specific time
◦ Tests cognitive function, memory, auditory
processing, visual-spatial acuity, concentration,
numerical knowledge, and abstract thinking
Supplemental Mental Status
Examinations
Mini-mental state exam (MMSE) – most widely used cognitive screening
test.
◦ Quick and easy (only 11 questions; 5-10min)
◦ Useful for both initial and serial examinations
◦ Cognitive functioning only (not mood or thought processes)
◦ Orientation, registration, attention and calculation, recall, and language
◦ Screening tool, not diagnostic

What could it diagnose?

- It is not a diagnostic tool, rather a screening tool for cognitive impairment.

https://cgatoolkit.ca/Uploads/ContentDocuments/MMSE.pdf
Relies on verbal
skills, reading
and writing, so Max score = 30
certain patients 23 or less is
may perform indicative of
cognitive
poorly even if impairment
they have no
cognitive
impairments.
Supplemental mental status
examination
Montreal Cognition Assessment (MoCA) –

◦ Screening tool for dementia, not diagnostic

◦ Simple and brief (30 questions, 10-15min to administer)
◦ Useful for both initial and serial examinations
◦ Cognitive functioning only (not mood or thought processes… or intelligence)
◦ Evaluates visuospatial and executive function, naming, memory, attention, language,
abstraction, and orientation.
◦ Scored out of 30. Above 26 indicates no cognitive impairment.
◦ Because tests for executive function, more sensitive than the MMSE for mild
impairment
◦ Takes longer to administer than MMSE

https://www.dementiacarecentral.com/montreal-cognitive-assessment-test/
Rowland universal dementia
assessment scale
Multicultural cognitive assessment scale
Assesses memory, visuospatial orientation, praxis,
visuoconstructional drawing, judgement, memory recall, language
The Rowland Universal Dementia Assessment Scale (RUDAS): A
Multicultural Cognitive Assessment Scale - Scoring Sheet
Minimizes effects of culture and language
Complete in patient’s language

Naqvi et al., 2015

Next week
Prepare for week 10: Assessment of Pain AND Patient
positioning and transfers

Learning Plan assignments due to lab tutor via A2L drop box
by 0830 Wed Nov 23.
References
Browne, A.J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2024). Jarvis physical
examination and health assessment (4th Canadian edition). Elsevier.
Canadian Mental Health Association (CMHA). (2020). Fast facts about mental illness.
https://cmha.ca/fast-facts-about-mental-illness
Clinical Skills: Essentials Collection (1st ed.). Elsevier.
Dementia Care Central. (2022). Montreal cognitive assessment test (MoCA) for dementia
and Alzheimer’s. https://www.dementiacarecentral.com/montreal-cognitive-assessment-test/
Naqvi, R.M., Haider, S., Tomlinson, G., Alibhai, S. (2015). Cognitive assessments in
multicultural populations using the Rowland Universal Dementia Assessment Scale: A
systematic review and meta-analysis. Canadian Medical Association Journal, 187(5), E169-
179. https://www.cmaj.ca/content/cmaj/187/5/E169.full.pdf
Wallace, M. (1999). Best practices in nursing care to older adults.
https://cgatoolkit.ca/Uploads/ContentDocuments/MMSE.pdf