Normal Findings of a Mental Status and Level of Consciousness (LOC) Assessment Exam

• Normal appearance and behaviours include awake and alert, relaxed posture, neatly dressed and groomed, clean with no body odours, pleasant manner, and mood and affect are well matched and appropriate for the situation.
• Speech is clear, not slurred, not pressured, overly loud or soft with a rate that is clearly understood with distinct and appropriate wording; the conversation is smooth and rhythmic.
• Mood is labile, not overly happy or sad, and appropriate to the situation.
• Thought processes make sense, are organized and understandable, there is evidence of insight (understanding of what is occurring), and sound judgement and ability to reason are apparent.
• Person knows who they are, where they are and why they are there, can concentrate and understand the conversation and remember recent and past events.

Pathological Signs and Symptoms of Altered Mental Status and LOC

• Appearance may be dishevelled and unclean; behaviours may be anxious, suspicious, agitated, depressed, or avoidant.
• Speech may be incoherent, unorganized, pressured, overly loud or quiet, with long pauses or periods of non-communication
• Mood may be too happy, extremely sad, inappropriate for the situation, or incongruent (affect does not match the mood)
• Thought processes may be illogical, disorganized, and difficult to follow; insight and judgement may be absent, and perceptual abnormalities such as illusions or hallucinations may be present.
• Cognitive disturbances such as unawareness of person, time or place may be present, recent or remote memory may be absent or reduced, ability to concentrate may be impaired, and assessment of ability to learn or follow commands may be absent or reduced.

Video

Examination Checklist

Documenting Mental Status Assessment Findings

The client is alert and orientated to person, time, place, and situation; they are well dressed and groomed, relaxed and pleasant, speech is fluent and organized, mood is labile, affect is congruent with mood, thought processes are logical, with evidence of appropriate insight and judgment.  Recent and remote memory is intact, and the client can understand and focus on conversations and required tasks during the assessment process.