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General Survey Components

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1.) Physical Appearance 2.) Body Structure 3.) Mobility 4.) Behavior

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Physical Appearance:

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- Age - Sex - Level of Consciousness (LOC) - Skin Color - Facial Features - Overall appearance

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PA: Age

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do they actually look the age they stated

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PA: Sex

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sexual development is appropriate for age (note state of transgender)

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PA: LOC

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alert & oriented, place, time & situation; attend to questions & responds appropriately

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PA: Skin color

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tone is even, skin is intact; note tattoos & piercings

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PA: Facial Features

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symmetric with movement

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PA: overall appearance

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no signs of acute distress are present

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Body Structure:

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- Stature - Nutrition - Symmetry - Posture - Position - Body Build/Contour - Obvious deformities

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Body Structure: Stature

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Height appears normal for age and genetic heritage

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Body Structure: Nutrition

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Weight appears normal for height and body build; fat distribution is even

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Body Structure: Symmetry

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Body parts look equal bilaterally and are in relative proportion

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Body Structure: Posture

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Stands comfortably erect & appropriate for age; Note normal 'plumb' line

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Body Structure: Position

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Sits comfortably, arms relaxed, head turned towards examiner

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Body Structure: Body Build/Contour

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Arm span (fingertip to fingertip) = height; Body length from crown to pubis = length from pubis to sole

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Body Structure: Obvious deformities

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Note any congenital or acquired defects

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Mobility:

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- Gait - Range of Motion (ROM)

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Gait:

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- Base is as wide as the shoulder width - Walk is smooth, even, and well-balanced without assistance - Associated movements (symmetric arm swing) are present

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ROM:

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- Full mobility for each joint - Movement is deliberate, accurate, smooth, and coordinated - No involuntary movement

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General Survey: Behavior

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- Facial expression - Mood and affect - Speech - Speech pattern - Dress - Personal hygiene

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Behavior: Facial expression

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- Maintains eye contact - Expressions are appropriate to situation

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Behavior: Mood and affect

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- Person is comfortable and cooperative - Interacts pleasantly

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Behavior: Speech

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- Articulation is clear & understandable

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Behavior: Speech pattern

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- Stream of talking is fluent - Conveys ideas clearly - Communicates easily

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Behavior: Dress

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- Clothing is appropriate to climate, culture, and age group - Clothing looks clean & fits appropriately

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Behavior: Personal hygiene

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- Appears clean and well-groomed for age, occupation, and socio- economic group - Hair is groomed

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Mental Status:

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person's emotional and cognitive functioning

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Mental Status aims

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Optimum functioning aims toward simultaneous life satisfaction in work, in caring relationships, and within self

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Mental Health is

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Mental health is relative & ongoing

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Assessment focus:

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Focuses on the effect that illness has on the patient and family

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Assessment emphasis:

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Emphasizes assessment of individuals/families that are having difficulty coping with the emotional aspects of illness

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Assessment influences:

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Influences the diagnosis and treatment of the illness

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Mental Disorder

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Defined as a significant behavioral or psychological pattern that is associated with distress

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Mental Disorder apparent

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Apparent when a person's response is much greater than the expected reaction

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Mental Disorder types:

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1.) Organic Disorders 2.) Psychiatric Mental Illness

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Psychiatric Mental Illness cause

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an organic etiology has not been established

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Organic Disorders cause

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aused by brain disease of known specific organic cause

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Organic Disorders

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- Delirium - Dementia - Alcohol & drug intoxication

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Psychiatric Mental Illness

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- Anxiety disorder - Schizophrenia

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Behaviors in Mental Disorder:

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- Consciousness - Language - Mood & Affect - Orientation - Attention - Memory - Abstract Reasoning - Thought Process - Thought Content - Perceptions

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Mental Disorder behaviors are not

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objective; very subjective

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Components of Mental Status Examination:

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Systematic check of emotional and cognitive functioning

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Mental Status Exam Steps

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1.) Four main headings (ABCT) 2.) Perform a full mental status exam when you discover any abnormality in affect or behavior and in the following situations

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Four main headings (ABCT)

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Appearance Behavior Cognition Thought Processes

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Complete a Mental Status Exam when:

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- Initial brief screening suggest an anxiety disorder or depression - Family member's are concerned about a person's behavioral changes - Brain lesions - Aphasia - Symptoms of Psychiatric illness, especially with acute onset

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Aphasia

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Loss of speech; could be a stroke

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Mental Status Examination Health History Note:

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- Known illnesses or health problems (alcohol use or renal disease) - Current medications which side effects include confusion & depression - Usual educational and behavioral level - Responses to personal history questions

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Personal history question topics:

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- Stress - Social interaction patterns - Sleep habits - Drug & alcohol use

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Mental Status Examination Health History completed by:

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Asking personal history questions

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Asking personal history questions

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- Who do you have for social support? - How do you sleep? - Do you fall asleep quickly, slowly; do you stay asleep? How long do you sleep? - Who do you talk to for support?

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Objective Data

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Appearance Body Movements Dress Grooming & hygiene

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Appearance:

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- Posture & position - erect & relaxed

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Body Movements:

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- Voluntary, deliberate, coordinated, smooth, even

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Dress

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- Appropriate for setting, season, age, gender, & social group - Fits & worn properly

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Grooming & hygiene

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- Clean, well-groomed - Hair neat & clean (You are looking for a CHANGE in appearance)

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Behavior

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- LOC - Facial Expression - Speech - Mood & affect

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Behavior: LOC

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- Awake, alert, & aware of stimuli from the environment - Responds appropriately

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Behavior: Facial Expression

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- Look is appropriate to the situation - Comfortable eye contact unless precluded by cultural norm

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Behavior: Speech

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- Speech is effortless - Pace is moderate, stream is fluent - Articulation is clear - Word choice is effortless and appropriate to educational level

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Behavior: Mood & affect

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- Appropriate to person's place & condition - Ask "how do you feel today?" or "how do you usually feel?"

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Cognitive Functions

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- Orientation - Attention span - Recent memory - Remote memory - New learning

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Orientation

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Person, place & time

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Attention span

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- Checking ability to complete a thought without wondering - Give a series of instructions to follow

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Recent memory

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Ask recent memory question like 24-hour diet recall

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Remote memory

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Ask to verify past events

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New learning

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Four unrelated words test - Give 4 unrelated words (have semantic & phonetic diversity) - After 5 minutes, ask to recall - After 10 minutes, ask to recall - After 30 minutes, ask to recall

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Thought processes & perceptions:

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- Thought Processes - Thought content - Perceptions

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Thought Processes:

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- Ask yourself "does this person make sense?" & "can I follow what they are saying?"

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Thought content:

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- What the person says should be consistent & logical

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Perceptions:

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- The person should be consistently aware of reality - Are they carrying on a conversation that verbally makes sense, but are they saying something crazy like putting tin foil over windows so someone doesn't steal their identity

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Mental Health Examinations:

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1.) Mini Mental Exam (MMSE) 2.) Denver II Screening 3.) Older Adults 4.) Supplemental Mental Status

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Mini Mental Exam (MMSE)

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- Simplified scored form of the cognitive functions of the mental status examination - Quick & easy - Contains 11 questions - Requires 5-10 minutes to administer - Used for initial and serial measurement - Maximum score is 30 - Normal mental status = 27 - No cognitive impairment = 24-30 - Under 24 = cognitive impairment

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Denver II Screening

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- Designed to detect developmental delays in infants and preschoolers - Gives the opportunity to interact directly with the child to assess mental status

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Older Adult Mental Health Examination:

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a) Behavior b) Cognitive Functions c) New Learning

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Supplemental Mental Status Examinations:

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- Mini-cog - Screens for cognitive impairment - 3-5 minutes to administer - Screens cognitive impairment in otherwise healthy older adults - Consists of 3 item recall test & a clock-drawing test

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Clock-drawing test

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drawing a clock: the circle, the hands, but #s are backward

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Older Adult Mental Health Examination: Behavior

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- LOC - Glascow coma scale

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Older Adult Mental Health Examination: Cognitive Functions

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- Orientation - Do they generally know where they are and the present time period

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Older Adult Mental Health Examination: New Learning

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- In people of normal cognitive function, an age related decline occurs in performance on the Four Unrelated Words Test

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Glascow coma test useful:

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testing consciousness in aging people that may be confused

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Glascow coma test:

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if someone is comatose or coming out of anesthesia

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Intimate Partner Violence (IPV) Types:

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1.) Physical 2.) Sexual violence 3.) Threat of physical or sexual violence 4.) Psychological/emotional abuse and/or coercive tactics when there has been prior physical and/or sexual violence between persons who are spouses, nonmarital partners, or former spouses or partners

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Sexual violence

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(use of physical force to compel one to engage a sex act against one's will)

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Physical violence

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intentional use of physical force

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Child Abuse & Neglect defined by:

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federal & state levels

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Neglect

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Failure to provide for the child's basic needs - Food, shelter, clothing, etc.

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Physical abuse

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A nonaccidental physical injury due to beating, punching, biting, burning, shaking, etc

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Sexual abuse

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Fondling, incest, penetration, rape, etc

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Emotional abuse

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Any pattern of behavior that harms a patient's emotional development or sense of self worth

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Adolescent relationship violence

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Defined as "physical, sexual, or psychological/emotional violence within a dating relationship, and includes stalking"

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Adolescent relationship violence referred to as:

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Referred to as: teen or "tween" dating violence, dating abuse, or relationship abuse

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Adolescent relationship violence occurrence:

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Abuse can occur in person, or electronically: - May occur between a current or former dating partner - With the advance in technology, relationship violence can be perpetrated 24/7 from a distance

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Elder Abuse & Neglect:

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1.) Physical abuse 2.) Sexual abuse or abusive sexual contact 3.) Psychological or emotional abuse 4.) Financial abuse or exploitation

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Elder Abuse & Neglect: Physical abuse

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When an elder is injured, assaulted, threatened with a weapon, or inappropriately restrained

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Elder Abuse & Neglect: Sexual abuse or abusive sexual contact

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Sexual contact against the elder's will

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Elder Abuse & Neglect: Psychological or emotional abuse

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When the elder experiences trauma after exposure to threats or coercive tactics

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Elder Abuse & Neglect: Financial abuse or exploitation

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Unauthorized or improper use of the elder's resources for monetary or personal benefit, profit, or gain

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Health Effects of Violence:

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- Approximately 1 million women report being physically and/or sexually assaulted by an intimate partner annually - In 2011, 677,000 children were deemed by CPS to be maltreated Intimate partner violence against women is 31% - Intimate partner violence against men is 26%

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Maltreated children

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- 79% were neglected - 18% were physically abused - 9% were sexually abused - 10% were victims of some other parental maltreatment - Some of the children were in more than 1 category

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IPV against women:

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More likely to be physically or sexually assaulted by a current or former intimate partner than by an acquaintance, family member, friend, or stranger

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Assessment of Violence:

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Universal assessment done by asking every women at every health care encounter if they have been abused

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Universal assessment

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This universal assessment for IPV has been called for by most nursing professional organizations and the U.S. Preventive Services task Force (USPSTF)

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How to Assess IPV:

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1.) Abuse Assessment Screen (AAS) 2.) Elder Abuse Suspicion Index (EASI) 3.) Child Abuse & Neglect

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Elder Abuse Suspicion Index (EASI)

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- Short, five question, yes/no clinical tool - Used to identify elders at risk for abuse - Has a sixth questions designed for the medical provider to answer about assessing whether the patient had poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, etc.

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Abuse Assessment Screen (AAS)

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- Strong reliability & validity - Translated into at least 7 languages - Has never been copyrighted so nurses can revise and reformat its content to their own health care setting - If your patients answers "yes" to any of the questions... - Ask specific follow up questions to determine how recent and - how serious the abuse was - Show concern about the degree of violence - Explain that help is available - Be nonjudgmental

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Child Abuse & Neglect Assessment

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- American Academy of Pediatrics recommends screening for IPV as a means to prevent child maltreatment - It is very important to determine the child's age and developmental level

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Child Abuse & Neglect Assessment Tips:

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- Verbal history should be obtained away from the caregiver through open ended statements - Medical history is also important - Get answers while playing, drawing, etc. - Get parents away by asking them to fill out paperwork - Children might be hesitant or afraid if they see abuser

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Physical Examination of IPV:

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Most important

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PE of IPV tips:

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- Complete head to toe visual physical examination - Document physical findings using forensic terminology - Pediatric differences

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Pediatric differences:

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- Trauma is defined as any injury beyond temporary redness of the skin - Bruising is one of the most common physical finding in child abuse

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Trauma to a child:

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Example: parent spanking child & the area stays red for more than a short period of time that is trauma

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Documentation:

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- Court cases have been won/lost based on documentation - Includes detailed, non-biased notes (Written documentation of histories should be verbatim) - Use of injury maps - Digital photographic documentation

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Digital photographic documentation

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- Invaluable - Prior written consent must be obtained

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Common Women in Homicide:

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- Women in this country are more often killed by a husband,, boyfriend, or ex-husband

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Assessing the risk of homicide:

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- Danger Assessment (DA)

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Danger Assessment (DA)

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- 19 item - Yes/no instrument use by nurses - The more Yes answers, the more serious the danger of the woman's situation

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When examining a patient, the nurse can assess mental status by: a.)examining the patient's electroencephalogram. b.) observing the patient as he or she performs an IQ test. c.) observing the patient and inferring health or dysfunction. d.) examining the patient's response to a specific set of questions.

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c.) observing the patient and inferring health or dysfunction.

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The nurse is assessing mental status in children. Which of the following statements is true? a.) All aspects of mental status in children are interrelated. b.) Children are highly labile and unstable until the age of 2 years. c.) Children's mental status is largely a function of their parents' level of functioning until the age of 7 years. d.) Children's mental status is impossible to assess until the child develops the ability to concentrate.

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a.) All aspects of mental status in children are interrelated.

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When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: a.)the presence of phobias. b.)their general intelligence. c.) the presence of irrational thinking patterns. d.) their sensory-perceptive abilities.

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d.) their sensory-perceptive abilities.

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he nurse is assessing a 75-year-old man. As the nurse beings the mental status portion of the assessment, the nurse expects that this patient: a.) will have no decrease in any of his abilities, including response time. b.) will have difficulty on tests of remote memory because this typically decreases with age. c.) may take a little longer to respond, but his general knowledge and abilities should not have declined. d.) will have had a decrease in his response time because of language loss and a decrease in general knowledge.

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c.) may take a little longer to respond, but his general knowledge and abilities should not have declined.

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