Appearance and general behavior
Body habitus, grooming habits, interpersonal style, degree of eye contact, how the patient looks compared with his or her age
Disheveled appearance may suggest schizophrenia
—
Provocative dress may suggest bipolar disorder
Appearance: well-groomed, immaculate, attention to detail, unkempt, distinguishing features (e.g., scars, tattoos), ill- or well-appearing
Unkempt appearance may suggest depression, psychosis
Eye contact: good, fleeting, sporadic, avoided, none
Poor eye contact may occur with psychotic disorders
General behavior: congenial, cooperative, open, candid, engaging, relaxed, withdrawn, guarded, hostile, irritable, resistant, shy, defensive
Paranoid, psychotic patients may be guarded
Irritability may occur in patients with anxiety
Motor activity
Body posture and movement, facial expressions
Parkinsonism, schizophrenia, severe major depressive disorder, posttraumatic stress disorder, anxiety, medication effect (e.g., depression), drug overdose or withdrawal, anxiety
—
Akathisia (restlessness), psychomotor agitation: excessive motor activity may include pacing, wringing of hands, inability to sit still
Bradykinesia, psychomotor retardation: generalized slowing of physical and emotional reactions
Symptoms may develop within weeks of starting or increasing dosages of antipsychotic agents
Catatonia: neurologic condition leading to psychomotor retardation; immobility with muscular rigidity or inflexibility; may present in excited forms, including excessive motor activity
Tendency toward exaggerated movements occurs in the manic phase of bipolar disorder and with anxiety
Speech
Quantity: talkative, expansive, paucity, poverty (alogia)
Schizophrenia; substance abuse; depression; bipolar disorder; anxiety; medical conditions affecting speech, such as cerebrovascular accident, Bell palsy, poorly fitting dentures, laryngeal disorders, multiple sclerosis, amyotrophic lateral sclerosis
—
Rate: fast, pressured, slow, normal
Volume and tone: loud, soft, monotone, weak, strong, mumbled
Fluency and rhythm: slurred, clear, hesitant, aphasic
Coherent/incoherent
Mood and affect
Affect: physician's objective observation of patient's expressed emotional state
Mood: patient's subjective report of emotional state
Depression, bipolar disorder, anxiety, schizophrenia
How are your spirits?
How would you describe your mood?
Have you felt discouraged/low/blue lately?
Have you felt angry/irritable/on edge lately?
Have you felt energized/high/out of control lately?
Thought process
Form of thinking, flow of thought
Anxiety, depression, schizophrenia, dementia, delirium, substance abuse
—
Thought content
What the patient is thinking about
Obsessions, phobias, delusions (e.g., schizophrenia, alcohol or drug intoxication), suicidal or homicidal thoughts
Obsessions: Do you have intrusive thoughts or images that you can't get out of your head?
Phobias: Do you have an irrational or excessive fear of something?
Delusions: Do you think people are stealing from you? Are people talking behind your back? Do you think you have special powers? Do you feel guilty, as if you committed a crime? Do you feel like you are a bad person? (Positive responses to last two questions may also suggest a psychotic depression)
Suicidality: Do you ever feel that life is not worth living? Have you ever thought about cutting yourself? Have you ever thought about killing yourself? If so, how would you do it?
Homicidality: Have you ever thought about killing others or getting even with those who have wronged you?
Perceptual disturbances
Hallucinations
Schizophrenia, severe unipolar depression, bipolar disorder, dementia, delirium, acute intoxication and withdrawal
Do you see things that upset you? Do you ever see/feel/hear/smell/taste things that are not really there? If so, when does it occur? Have you had any strange sensations in your body that others do not seem to have?
Sensorium and cognition
Sensorium: level and stability of consciousness
Underlying medical conditions, dementia, delirium
See Tables 2 and 3
Cognition: attention, concentration, memory
Insight
Patient's awareness and understanding of illness and need for treatment
Bipolar disorder, schizophrenia, dementia, depression
What brings you here today? What is your understanding of your problems? Do you think your thoughts and moods are abnormal?
Judgment
Patient's recognition of consequences of actions
Bipolar disorder, schizophrenia, dementia
What would you do if you found a stamped envelope on the sidewalk?
Physician should adapt questions to clinical circumstances and patient's education level
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Department: … & more: CHART SMART Huntley, Ann RN, APRN, BC, CCRN, MSN Ann Huntley is a clinical nurse specialist at Emory Healthcare in Atlanta, Ga. Nursing: August 2008 - Volume 38 - Issue 8 - p 63-64 doi: 10.1097/01.NURSE.0000327505.69608.35Documenting level of consciousness
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