Assessment Exam 1 : Module 2: Chapters 3, and 6

• Dullness:

Thud‐like sound over organ (normal), pleural effusion (abnormal)

Cognitive Abilities Concentration and Memory Concentration:

(ability to stay focused and attentive, follow directions) ◦ Abn. Distraction and inability to focus could be anxiety, fatigue, attention deficit disorders & impairment Recent memory: Ask about weather or what time arrived at the clinic (verifiable) Remote memory: Ask about past events (verifiable) - what happened 9/11/2001? ◦ Abn. Inability to recall recent events—delirium, dementia, depression and anxiety ◦ Abn. Inability to recall past events is seen with cerebral cortex disorders

Differentiate aging v. dementia

+Poor judgment and decisionmaking +Inability to manage a budget +Losing track of the date or season + Difficulty having a conversation + Misplacing things and being unable to retrace steps to find them AGE: - Making a bad decision once in awhile - Missing a monthly payment -Forgetting which day it is and remembering later -Sometimes forgetting which word to use -Losing things from time to time

Sims' position (semi-prone side position)

A left side-lying position in which the upper leg (right leg) is sharply flexed so it is not on the lower leg (left leg) and the lower arm (left arm) is behind the person

Cognitive Abilities: New Learning & Abstract Reasoning New Learning:

Ask client to report 4 unrelated words ◦ Have them repeat the words ◦ Ask them to repeat again in 5, 10, and 30 min. ◦ Abn. Inability to recall is seen in anxiety, depression or Alzheimer's disease Abstract reasoning: Ask client to compare objects (how are an apple and orange the same?) or explain a proverb (less often used) ◦ Abn. Inability to compare/contrast is seen with schizophrenia, mental retardation, delirium & dementia

CAGE Self Assessment Tool

C Have you ever tried to cut back on your use? A Have you ever been annoyed/angered when questioned about your use? G Have you ever felt guilt about your use? E Have you ever had an eye-opener to get started in the morning? Scoring: One "yes" answer suggests a possible alcohol problem. More than one "yes" answer means it is highly likely that a problem exists.

Mental Status

Client's level of cognitive functioning and emotional functioning Mental health is an essential part of one's total health "Health is a state of complete physical, mental, and social well-being, not merely the absence of disease" (WHO, 2010) Healthy mental status is needed to think clearly and respond for optimal life function You cannot DIRECTLY measure mental status - observe behaviors

Evidence Base: Dementia/Alzheimer's Disease

Dementia is a set of symptoms associated with loss of cognitive function General symptoms ◦ Memory loss ◦ Challenges in problem solving ◦ Difficulty completing tasks ◦ Confusion with time or place ◦ Trouble understanding visual images or spatial relationship ◦ New problems with words ◦ Decreased or poor judgment ◦ Misplacing things or losing ability to retrace steps ◦ Withdrawal from work or social activities ◦ Changes in mood or personality Aging has common forms of decline that are often MISTAKEN for dementia ◦ Slower thinking, problem solving, learning, and recall; decreased attention or concentration; distraction

Cognitive Abilities Assess visual, perceptual, construction ability

Draw the face of a clock well Copy simple figures ◦ Abn. Inability to draw the clock face or the simple figures is seen with mental retardation, dementia, or parietal lobe dysfunction

Factors Affecting Mental Health

Economic and social factors Unhealthy lifestyle choices Exposure to violence Personality factors Spiritual factors Cultural factors Changes or impairments in the structure and function of the neurologic system Psychosocial developmental level and issues

Glasgow Coma Scale

Eye opening response Most appropriate verbal response Most integral motor response (arm) Score 3-15 Score of 7 or lower is considered coma **Not used in intubated or aphasic patients.

Quick Inventory of Depressive Symptomatology (Self-Report)

Falling asleep Sleep during the night Waking up too early Sleeping too much Feeling sad Decreased or increased appetite Decreased or increased weight (within last 2 weeks) Concentration/decision making Perception of oneself Thoughts of death or suicide General interest Energy level Feeling sluggish Feeling restless

Flatness:

Flat sound heard over bone or muscle

Evidence Base: Substance Abuse

Healthy People 2020 is addressing substance abuse in adolescents and military personnel serving overseas Goal: to reduce substance abuse to protect the health, safety and quality of life for all Screening: Use simple tools to identify risk ◦ CAGE ◦ AUDIT Teach clients and family

Mental Status and substance abuse Subjective Data assessing:

History Be alert to verbal & nonverbal cues; determine validity (reliability) of client responses Explain the purpose of Qs Other body systems may affect mental status (metabolic, neurologic) In-depth history is required ◦ May include sensitive issues ◦ Sexuality, dying, spirituality

Mental Status and substance abuse Subjective Data

History Note questions and rationale for asking each Biographical data History of present health concern ◦ What is most urgent health concern now? ◦ COLDSPA Personal health history ◦ Past tx or hospitalization for mental health issue? ◦ Head injury, neurologic problems Family history Lifestyle and health practices ◦ Diet, exercise, elimination, sleep, caffeine, alcohol and substance use, exposure to environmental toxins, relationships, support systems, current stressors, feeling about the future

• Resonance:

Hollow sound heard over normal lung

Abnormal Levels of Consciousness

Lethargy: opens eyes, answers questions, and falls back asleep Obtunded: opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment. Stupor: awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. Coma: remains unresponsive to all stimuli; eyes stay closed.

Complete Mental Status

Mental status exam is incorporated with the health history Much of objective data also involves questioning, performing various verbal tests Perform MSE early in head to toe exam to determine validity of client's information Perform full MSE if: ◦ Screening suggests anxiety, depression, cognitive impairment ◦ Family member concern RT behavioral changes ◦ Memory loss ◦ Inappropriate social interaction ◦ Brain lesions, aphasia or other symptoms

Evidence Base: Dementia/Alzheimer's Disease

Nonmodifiable Risks: ◦ Increasing age ◦ Genetic predisposition and family history ◦ Latino or African American descent due to higher vascular disease rates Modifiable Risk: ◦ Hypertension/ cholesterol ◦ Head trauma ◦ Smoking ◦ Dysrhythmias, depression ◦ HRT Client Education: ◦ Engage in mentally challenging activities ◦ Maintain healthy aging behaviors ◦ Healthy weight ◦ Avoid tobacco use and excessive alcohol intake ◦ Stay socially connected ◦ Exercise body and mind ◦ Avoid activities that increase head trauma risk ◦ Ask about HRT ◦ Heart healthy diet/exercise

Sitting position

Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

standing position

Position used to examine male genitalia and to assess gait, posture, and balance

Physical Examination:

Preparing the Physical Setting • Provide for comfort, warm temperature • Private area free of interruption • Quiet area with adequate lighting • Firm examination table or bed • Bed should be at a height that prevents stooping or bending over (protect your back) • Beside table/tray to hold equipment

Speech Normal/abnormal

Speech: moderate tone, clear with moderate pace, and culturally appropriate. ◦ Abn. Slow, repetitive speech is characteristic of depression or Parkinson's disease. Loud, rapid speech is seen with manic phases of bipolar disorder. ◦ Abn. Dysarthria, difficulty forming words may be seen with neurologic disorder.

Assessing LOC: Painful stimuli decorticate posture

The body is rigid, the arms are stiff and bent, the fists are tight, and the legs are straight out.

Cognitive Abilities: Judgment Ask client a question that involves problem solving: "

What would you do if driving and a police officer behind you turned on the lights and siren? ◦ Should be able to demonstrate sound rationale ◦ Abn. Impaired judgment may be seen in organic brain syndrome, emotional disturbances, mental retardation or schizophrenia.

Tympany: Drum‐

like sound over gastric bubble (normal sound)

prone position

lying on abdomen, facing downward

lithotomy position

lying on back with legs raised and feet in stirrups, hips and knees flexed, thighs abducted and externally rotated

Supine position

lying on back, facing upward

knee-chest position

patient is lying face down with the hips bent so that the knees and chest rest on the table

dorsal recumbent position

patient is lying on the back, face up, with the knees bent

Client Preparation

• Begin exam with less‐intrusive procedures. • Approach client from right‐side of exam table because most exam techniques are performed with examiner's right hand (even if examiner is left‐handed). • Explain procedure being performed. • Explain to client why position changes are necessary; HOWEVER be organized to minimize unnecessary position changes.

Physical Examination: Percussion

• Direct, blunt & indirect. Tapping body parts to produce sound waves/vibrations - Most common is with deep tendon reflexes • Purpose: - Eliciting pain - Determining location, size, and shape - Determining density (air, fluid, solid) - Detecting abnormal masses - Eliciting reflexes (use percussion hammer)

Client Approach :

• Establish nurse‐client relationship . • Explain the procedure and the physical assessment that will follow, describing the steps of the examination. • Respect client's requests and desires; sequence may vary with age or patient acuity. • Explain the importance of the examination. • Reassure client as new examiner: "I always listen in a number of places; that doesn't mean there is a problem." • Leave room while client changes clothes. • Provide necessary container in case of need for sample.

Prepare Yourself

• Examine your thoughts, anxieties - Anxiety can be transmitted to the client • Project self‐confidence (practice competence confidence) • Prevent transmission of infectious agents - CDC (Centers for Disease Control) and HICPAC (Hospital Infection Control Practices Advisory Committee) updated Standard Precautions in 2007

Equipment Table 3‐1

• Gloves, Gowns, Mask • Stethoscope, watch with 2nd hand, pain scale, thermometer • Tape measure, platform scale • Exam light, penlight • Mirror, Wood's light • Braden Scale/Fall tool • Ophthalmoscope, Snellen chart, pocket screener, otoscope, tuning fork • Tongue blade • Doppler device and gel • Cotton‐tip applicators, cotton balls • Reflex hammer

Physical Examination: Inspection

• Good lighting (sunlight best) - At times will use penlight, or tangential lighting - May use otoscope or ophthalmoscope • Look and observe before touching • Completely expose part being examined, while keeping other areas draped • Note color, patterns, size, location, consistency, symmetry, movement, behavior, odors, sounds - Shape of chest, abdomen; color of skin • Compare appearance of symmetric body parts - Compare left & right sides of body

Childbearing Women: Common Findings

• Identify common complaints and findings of pregnancy; explain the cause - Skin: chloasma, striae, linea nigra, spider nevi - (Fundoscopic exam not addressed in this course) - BP lower 2nd trimester - Possible enlarged thyroid - Gingival hypertrophy - Nasal stuffiness - Breast changes - Increased AP diameter, slight hyperventilation - Possible systolic heart murmurs - Varicose veins, dependent edema - Lordosis of spine

Physical Examination: Palpation

• Palpate for texture, temperature, moisture, mobility, consistency, strength of pulses, size, shape, degree of tenderness, swelling, crepitus, lumps or masses • Table 3‐2 • Fingerpads: fine discrimination (pulses, texture, size, consistency, shape, crepitus) • Ulnar/palmar surface: vibrations, thrills • Dorsal (back surface): temperature • Keep nails short; Light palpation deep, if used • ***ASSESS TENDER AREAS LAST*** • Light palpation: - Dominant hand (1 hand only), less than 1 cm. Little or no depression. - Feel surface structure using circular motion (pulses, tenderness, texture, temperature and moisture • Moderate: 1‐2 cm. (easily palpable organs and masses) • Deep: (2 hands‐‐dominant hand on skin surface; nondominant hand on top of dominant hand (not performed routinely by nurses).

Cultivating Your Senses

• Sight, Smell, Touch, Hearing • Inspection, Palpation, Percussion, Auscultation -One at a Time -IN THIS ORDER -One exception = Abdomen

Physical Examination: Auscultation

• Using a stethoscope to listen to sounds not audible to the human ear. (SCOPE TO SKIN) - Heart sounds, lung sounds, bowel sounds - Diaphragm: high‐pitched sounds, FIRM pressure • Lung sounds, bowel sounds, normal heart sounds - Bell: low‐pitched sounds, LIGHT pressure • Abnormal heart sounds (murmurs, bruits) • Eliminate distracting noise. • Expose the body part being auscultated. • Place earpieces into outer ear canal. • Angle binaurals (metal tubing) down toward nose.

Correct Use of a Stethoscope

• Warm diaphragm and bell before use. • Explain what you are listening to and answer any questions. • Avoid listening through clothes. NEVER LISTEN OVER A GOWN OR CLOTHES. • Closing your eyes may help (concentration)

Mental Status Facial expression: maintains eye contact appropriate to culture.

◦ Abnormal Findings: ◦ Reduced eye contact is seen in depression or apathy; extremes of emotions (happiness, anger, fright may be seen in anxious clients ◦ With Parkinson's disease may have a mask-like, face. ◦ Inappropriate facial expressions (smiling when expressing sad thoughts) may indicate mental illness. ◦ Drooping or marked facial asymmetry may occur with Bell's palsy or stroke.

Speech: If the client has difficulty with speech, perform this:

◦ Ask client to name familiar objects, read age-appropriate written print and write a coherent sentence with correct spelling & grammar. ◦ Abn. If client cannot name objects, read or write sentences, they should be referred for neurologic assessment for cortex problems.

Cognitive Abilities Assess orientation:

◦ Ask client's name and names of family (person) ◦ Place (where the client lives or is now) ◦ Time (hour, day, date or season) ◦ With a change in orientation, time is lost first and person is lost last. ◦ Older adults in a new setting may seem confused but should know who and where they are and the current month/year

Mental Status Observe behavior and affect: Observe dress and grooming: Hygiene: Normal-

◦ Client is cooperative and purposeful in interactions with others; affect is appropriate for the client's situation ◦ Dress is appropriate for occasion and weather; varies with age, SES, developmental and culture Hygiene: ◦ Client is clean and groomed appropriately for occasion (based on developmental, socioeconomic level and culture). (Review abnormal findings)

Assess Suicide Risk Identify suicidal tendencies or thought processes.

◦ Client should verbalize positive, healthy thoughts about the future and self ◦ Abn. Clients who are suicidal may share past attempts of suicide, give plan for suicide, verbalize worthlessness about self, joke about death frequently. ◦ Abn. Clients who are depressed or feel hopeless are at higher risk for suicide. HIGHEST risk is person with a realistic plan and means to carry out the plan. ◦ Abn. depression early in life have a twofold risk for dementia.

Mental Status and substance abuse Objective Data: Physical Assessment Level of consciousness and mental status

◦ Level of consciousness ◦ Posture, gait, body movements ◦ Behavior and affect ◦ Dress and grooming ◦ Hygiene ◦ Facial expressions and speech ◦ Mood, feelings and expressions ◦ Thought processes and perceptions

Mental Status Observe the client's Level of consciousness

◦ Normal- client is alert and oriented to person (name of self/family), place time and date ◦ If no response, try to wake patient up verbally. They should be awake and alert with eyes open and respond. ◦ If no response to calling name or shaking, may use tactile or painful stimulus. Begin with least invasive ◦ Reduced orientation may be organic brain disorders or psychiatric illness

Mental Status and substance abuse Objective Data: Physical Assessment Cognitive abilities

◦ Orientation ◦ Concentration ◦ Recent and remote memory ◦ Use of memory to learn new information ◦ Abstract reasoning ◦ Judgment ◦ Visual, perceptual, and constructional ability ◦ Confusion Assessment Model

Modified SAD PERSONS Suicide Tool Risk Factors

◦ S - Sex ◦ A - Age ◦ D - Depression ◦ P - Previous attempt ◦ E - Ethanol abuse ◦ R - Rational thinking Loss ◦ S - Social supports lacking ◦ O - Organized plan ◦ N - No Spouse ◦ S - Sickness (Some tools include another A for availability of means)

Mental Status Observe posture, gait & body movements

◦ Should appear relaxed, with shoulders & back erect when standing or sitting. Gait is rhythmic and coordinated, symmetric arm swing ◦ Abn. Slumped posture may indicate powerlessness, depression or organic brain disease ◦ Abn. Bizarre movements may be seen in schizophrenia or a side effect of meds

Mood, Feelings, Expressions Ask the client "How are you feeling today?" and "What are your plans for the future?"

◦ Should express feelings appropriate to situation, verbalize positive feelings re: future and positive coping mechanisms ◦ Abn. Flat affect, euphoria, anxiety, fear, ambivalence, irritability, depression, and/or rage are examples of altered mood (depression, manic episodes, anxiety, obsessive-compulsive disorders). Screen the client for depression and suicide thoughts

Mental Status observe thought processes for clarity, content, and perception.

◦ Use statements such as "Tell me more about what you just said" or ask client to elaborate on health ◦ Client should express full, free-flowing thoughts, follow directions accurately, express realistic perceptions, makes sense; denies suicide thoughts. ◦ Abnormal processes include persistent repetition of thoughts, invention of words, flight of ideas, rhymes, delusions, compulsions and obsessions, confabulation.O