Assessing Mental Status and Vital Signs PDF

Chapter 6 Assessing Mental Status Including Risk for Substance Abuse Factors Affecting Mental Health ❖ Economic and social factors ❖ Unhealthy lifestyle choices ❖ Exposure to violence ❖ Personality factors ❖ Spiritual factors ❖ Cultural factors ❖ Changes...

Chapter 6 Assessing Mental Status Including Risk for Substance Abuse 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 Proposed DSM-5 Definition of Mental Disorder ❖ A behavioral or psychological syndrome or pattern that occurs in an individual ❖ That reflects an underlying psychobiologic dysfunction ❖ The consequences of which are clinically significant distress or disability ❖ Must not be merely an expectable response to common stressors and losses or a culturally sanctioned response to a particular event ❖ That is not primarily a result of social deviance or conflicts with society Risk Factors for Mental Health Disorders and Substance Abuse ❖ A history of early aggressive behavior ❖ Lack of parental supervision ❖ A history of substance abuse ❖ Drug availability ❖ Poverty Goal of Prevention ❖ Change the balance between risk and protective factors so that protective factors outweigh risk factors. History ❖ Biographical data ❖ History of present health concern ❖ Personal health history ❖ Family history ❖ Lifestyle and health practices Mental Health and Risk for Substance Abuse Assessment ❖ Prepare the client ❖ Equipment o Pencil and paper o Glasgow Coma Scale o Depression Questionnaire o SAD PERSONNA Suicide Risk Assessment Tool o Saint Louis University Mental Status (SLUMS) Assessment Tool  o Confusion Assessment Method (CAM) Physical Assessment ❖ Level of consciousness and mental status o Level of consciousness o Posture, gait, body movements o Behavior and affect o Dress and grooming o Hygiene o Facial expressions o Speech o Mood, feelings, and expressions o Thought processes and perceptions ❖ Cognitive abilities o Orientation o Concentration o Recent memory o Remote memory o Abstract reasoning o Judgment o Visual, perceptual, and constructional ability o SLUMS Dementia/Alzheimer’s test exam Question #1 Is the following statement true or false? Evaluating level of consciousness is part of a mental status exam. Answer to Question #1 True. Evaluating level of consciousness is part of a mental status exam. SLUMS (St. Louis University Mental Status) ❖ A score between 27 and 30 for clients with a high school education and a score of 20–30 for clients with less than a high school education is considered normal. ❖ For clients with a high school education, a score of 20–27 indicates mild cognitive impairment (MCI); for clients with less than a high school education, a score of 14–19 indicates MCI. ❖ For clients with a high school education, a score of 1–19 indicates dementia; for clients with less than a high school education, a score of 1–14 indicates dementia. Glasgow Coma Scale ❖ Eye opening response ❖ Most appropriate verbal response ❖ Most integral motor response (arm) Question #2 Which describes a client who is stuporous? A. Awakes to vigorous shake or painful stimulus but returns to unresponsive sleep. B. Remains unresponsive to all stimuli; eyes stay closed. C. Opens eyes to loud voice, responds slowly with confusion, seems unaware of environment. D. Opens eyes, answers questions, and falls back to sleep. Answer to Question #2 A. Awakes to vigorous shake or painful stimulus but returns to unresponsive sleep. *Stuporous is awakening to vigorous shake or painful stimulus but returning to unresponsive sleep. Coma is remaining unresponsive to all stimuli; eyes stay closed. Obtunded is opening eyes to loud voice, responding slowly with confusion, seeming unaware of environment. Lethargy is opening eyes, answering questions, and falling back to sleep. 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. Alcohol Use Disorders Identification Test (AUDIT) How often do you have a drink containing alcohol? ❖ How many drinks containing alcohol do you have on a typical day when you are drinking? ❖ How often do you have six or more drinks on one occasion? ❖ How often during the last year have you found that you were not able to stop drinking once you had started? ❖ How often during the last year have you failed to do what was normally expected from you because of drinking? ❖ How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? ❖ How often during the last year have you had a feeling of guilt or remorse after drinking? ❖ How often during the last year have you been unable to remember what happened the night before because you had been drinking? ❖ Have you or someone else been injured as a result of your drinking? ❖ Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? Confusion Assessment Method ❖ Level of orientation ❖ Memory ❖ Speech ❖ Cognitive functions Depression Questionnaire ❖ 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 ❖ View of oneself ❖ Thoughts of death or suicide  ❖ General interest ❖ Energy level ❖ Feeling slowed down ❖ Feeling restless Alzheimer Disease ❖ Asking the same question over and over again ❖ Repeating the same story, word for word, again and again ❖ Forgetting how to cook, or how to make repairs, or how to play cards—activities that were previously done with ease and regularity ❖ Losing one’s ability to pay bills or balance one’s checkbook ❖ Getting lost in familiar surroundings, or misplacing household objects ❖ Neglecting to bathe, or wearing the same clothes over and over again, while insisting on having taken a bath or that one’s clothes are still clean. ❖ Relying on someone else, such as a spouse, to make decisions or answer questions that one previously would have handled one’s self. SAD Persons Suicide Risk Tool ❖ Sex ❖ Age ❖ Depression ❖ Previous attempt ❖ Ethanol abuse ❖ Rational thinking loss ❖ Social supports lacking ❖ Organized plan ❖ No spouse ❖ Availability of lethal means ❖ Sickness Normal and Abnormal Findings ❖ Share outcomes of assessment with peers. Validating and Documenting Findings ❖ Wellness and health promotion diagnoses ❖ Risk diagnoses ❖ Actual diagnoses ❖ Collaborative problems ❖ Medical problems Chapter 7 Assessing Psychosocial, Cognitive, and Moral Development Freud’s Stages of Psychosexual Development ❖ Oral: 0–1.5 years ❖ Anal: 1.5–3 years ❖ Phallic: 3–6 years ❖ Latency: 6–11 years ❖ Genital: Adolescence Erikson’s Stages of Psychosocial Development ❖ Infant: Basic trust versus basic mistrust ❖ Toddler: Autonomy versus shame and doubt ❖ Preschooler: Initiative versus guilt ❖ School ager: Industry versus inferiority ❖ Adolescent: Identity versus role confusion ❖ Young adult: Intimacy versus isolation ❖ Middle adult: Generativity versus stagnation ❖ Older adult: Ego integrity versus despair Question #1 Is the following statement true or false? Erikson’s developmental task for young adults is intimacy versus isolation. Answer to Question #1 True. *Erikson’s developmental task for young adults is intimacy versus isolation. Piaget’s Stages of Cognitive Development ❖ Sensorimotor o Substages 1, 2, 3, 4, 5, and 6 ❖ Preoperational o Two substages (preconceptual and intuitive) ❖ Concrete operational ❖ Formal operational Kohlberg’s Stages of Moral Development ❖ Preconventional (premoral) ❖ Conventional (maintain external expectations of others) ❖ Postconventional (maintain internal principles of self—Piaget’s concept of formal operations) Nursing History: Subjective Data ❖ Biographical data ❖ History of present health concerns ❖ Personal health history ❖ Family history ❖ Life and health practices Assessing Development with Subjective and Objective Data ❖ Assessment of Freud’s Stages of Psychosexual Development ❖ Assessment of Erikson’s Psychosocial Development ❖ Assessment of Piaget’s Cognitive Development ❖ Assessment of Kohlberg’s Moral Development Question #2  ❖ Which assessment tool is used to identify cognitive development? A. Freud B. Erikson C. Piaget D. Kohlberg Answer to Question #2 C. Piaget. *Piaget assesses cognitive development. Freud assesses stages of psychosexual development. Erikson assesses psychosocial development. Kohlberg assesses moral development. Differentiating Normal and Abnormal Findings ❖ Validation ❖ Documentation ❖ Diagnostic reasoning Assessing Development of Older Adults ❖ Eriksonian tasks for older adults embrace realistically reviewing and viewing life, recognizing errors and poor choices, learning from past experiences what strengths one has, acknowledging accomplishments and developing new wisdom. ❖ Freud extolled the importance of adults meeting the role expectations of maturity in order to avoid neuroses. ❖ Piaget described the use of formal operations as helpful in anticipating and negotiating the declining of physical and possible cognitive abilities. Older adults suffer multiple losses and must problem solve about possible increased dependency, decreased choices, and impending death. Death is seen by the formal operational thinker as universal, inevitable, and irreversible. ❖ Kohlberg professed that those who had attained his sixth stage of personal principles make use of self-evaluation, self-motivation, and self-regulation, meeting expectations of his ego ideal. He believed that the person operating at the universal principle stage is aware of his “reason for existence.” Data Analysis ❖ Validate nursing diagnoses ❖ Collaborative problems ❖ Referrals Chapter 8 Assessing General Health Status and Vital Signs Preparation for Survey of General Health Status ❖ Perform systematic examination and recording general characteristics and impressions of the client. ❖ Observe any significant abnormalities. Observe Significant Abnormalities ❖ Skin color ❖ Dress ❖ Hygiene ❖ Posture and gait  ❖ Physical development ❖ Body build ❖ Apparent age ❖ Gender General Survey #1 ❖ Physical development and body build ❖ Gender and sexual development ❖ Apparent age as compared to reported age ❖ Skin condition and color ❖ Dress and hygiene ❖ Posture and gait ❖ Level of consciousness ❖ Behaviors, body movements, and affect ❖ Facial expression ❖ Speech ❖ Vital signs Interview ❖ General survey questions ❖ History of present health concern ❖ Personal history ❖ Family history ❖ Lifestyle and health practices Accurate General Survey ❖ Preparing the client ❖ Equipment o Thermometer o Protective, disposable covers for type of thermometer o Aneroid or mercury sphygmomanometer or electronic blood pressure measuring equipment o Stethoscope o Watch with second hand ❖ General impression o Observe physical development, body build, and fat distribution. o Compare client’s stated age with apparent age and developmental stage. o Observe skin condition and color. o Observe posture and gait. Vital Signs ❖ Hands-on physical examination begins with vital signs ❖ Provide data that reflect body systems status o Cardiovascular o Neurologic o Peripheral vascular o Respiratory Order of Vital Signs ❖ Temperature  ❖ Pulse ❖ Respirations ❖ Blood pressure Pulse Amplitude ❖ 0: Absent ❖ 1+: Weak, diminished (easy to obliterate) ❖ 2+: Normal (obliterate with moderate pressure) ❖ 3+: Bounding (unable to obliterate or requires firm pressure) Blood Pressure ❖ Systolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are contracted. ❖ Diastolic blood pressure is a measurement of the pressure of the blood in the arteries when the ventricles are relaxed. Pain ❖ Fifth vital sign ❖ Observe comfort level Older Client Considerations ❖ Temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F. ❖ Osteoporotic thinning and collapse of the vertebrae secondary to bone loss may result in kyphosis. ❖ In older men, gait may be wider based, with arms held outward. Older women tend to have a narrow base and may waddle to compensate for a decreased sense of balance. Steps shorten, with decreased speed and arm swing. Mobility may be decreased, and gait may be rigid. ❖ The older client’s artery may feel more rigid, hard, and bent. ❖ In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging. ❖ More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Systolic pressure over 140 with diastolic pressure under 90 is called isolated systolic hypertension. ❖ Widening of the pulse pressure is seen with aging due to less elastic peripheral arteries. Rise in Temperature ❖ Strenuous exercise ❖ Stress ❖ Ovulation ❖ Hyperthermia o Viral or bacterial infections o Malignancies o Trauma o Various blood, endocrine, immune disorders Question #1 Is the following statement true or false? The rectal temperature is lower than the normal oral temperature. Answer to Question #1 False. *The rectal temperature is between 0.4°C and 0.5°C (0.7°F and 1°F) higher than the normal oral temperature. Factors Affecting Blood Pressure ❖ Cardiac output ❖ Elasticity of arteries ❖ Blood volume ❖ Blood velocity (heart rate) ❖ Blood viscosity (thickness) Characteristics of Radial Pulse ❖ Rate ❖ Rhythm ❖ Amplitude and contour ❖ Elasticity Question #2 Is the following statement true or false? Normally, pulsation is slightly stronger in the left wrist. Answer to Question #2 False. *Normally, pulsation is equally strong in both wrists. Normal and Abnormal Findings ❖ Share outcomes of assessment with peers. Validating and Documenting Findings ❖ Health promotion diagnosis ❖ Risk diagnoses ❖ Actual diagnoses ❖ Collaborative problems ❖ Medical problems Chapter 9 Assessing Pain: The Fifth Vital Sign Definitions  ❖ International Association for the Study of Pain (IASP): Unpleasant sensory and emotional experience which we primarily associate with tissue damage or describe in terms of such damage, or both. ❖ McCaffery and Pasero: Pain is whatever the person says it is. Question #1 Is the following statement true or false? An unpleasant sensory and emotional experience, which we primarily associate with tissue damage, is termed pain. Answer to Question #1 True. *An unpleasant sensory and emotional experience, which we primarily associate with tissue damage, is termed pain. Pathophysiology ❖ Transduction ❖ A-delta primary afferent fibers ❖ Transmission ❖ Perception ❖ Modulation Definition: Acute Pain ❖ Usually associated with a recent injury. Definition: Chronic Nonmalignant ❖ Usually associated with a specific cause or injury and described as a constant pain that persists for more than 6 months. Definition: Cancer Pain ❖ Often due to the compression of peripheral nerves or meninges, or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration. Pain Descriptors ❖ Cutaneous pain: skin or subcutaneous ❖ Visceral pain: abdominal cavity, thorax, cranium ❖ Deep somatic pain: ligaments, tendons, bones, blood vessels, nerves ❖ Radiating: perceived both at the source and extending to other tissues ❖ Referred: perceived in body areas away from the pain source ❖ Phantom pain: perceived in nerves left by a missing, amputated, or paralyzed body part ❖ Neuropathic pain: causes an abnormal processing of pain messages and results from past damage to peripheral or central nerves due to sustained neurochemical levels ❖ Nociceptive: response to noxious insult or injury of tissues such as skin, muscles, visceral organs, joints, tendons, or bones ❖ Inflammatory: a result of activation and sensitization of the nociceptive pain pathway by a variety of mediators released at a site of tissue inflammation Physiologic Responses to Pain  ❖ Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide ❖ Focus on pain, reports of pain, cries and moans, frowns and facial grimaces ❖ Decrease in cognitive function, mental confusion, altered temperament, high somatization, and dilated pupils ❖ Increased heart rate; peripheral, systemic, and coronary vascular resistance; and blood pressure ❖ Increased respiratory rate and sputum retention, resulting in infection and atelectasis ❖ Decreased gastric and intestinal motility ❖ Decreased urinary output, resulting in urinary retention, fluid overload, and depression of all immune responses ❖ Increased antidiuretic hormone, epinephrine, norepinephrine, aldosterone, glucagons, decreased insulin, testosterone ❖ Hyperglycemia, glucose intolerance, insulin resistance, protein catabolism ❖ Muscle spasm resulting in impaired muscle function and immobility, perspiration Seven Dimensions of Pain ❖ Physical ❖ Sensory ❖ Behavioral ❖ Sociocultural ❖ Cognitive ❖ Affective ❖ Spiritual Subjective Data ❖ Review past and family histories in terms of pain. ❖ Review lifestyle and health habits to determine how the pain interferes with the client’s life. Tips for Collecting Subjective Data ❖ Maintain a quiet and calm environment that is comfortable for the client being interviewed. ❖ Maintain the client’s privacy and ensure confidentiality. ❖ Ask the questions in an open-ended format. ❖ Listen carefully to the client’s verbal descriptions and quote the terms used. ❖ Watch for the client’s facial expressions and grimaces during the interview. ❖ DO NOT put words in the client’s mouth. ❖ Ask the client about past experiences with pain. ❖ Believe the client’s expression of pain. Objective Data ▪ Visual Analog Scale (VAS) ▪ Numeric Rating Scale (NRS) ▪ Numeric Pain Intensity Scale (NPI) ▪ Verbal Descriptor Scale ▪ Simple Descriptive Pain Intensity Scale  ▪ Graphic Rating Scale ▪ Verbal Rating Scale ▪ Faces Pain Scale Hierarchy of Pain Assessment Techniques ❖ Self-report ❖ Search for potential causes of pain ❖ Observe client behaviors ❖ Surrogate reporting ❖ Attempt an analgesic trial QUESTT Principles for Pain in Children ❖ Question the child. ❖ Use pain-rating scales. ❖ Evaluate behavior and physiologic changes. ❖ Secure parents’ involvement. ❖ Take cause of pain into account. ❖ Take action and evaluate results. Question #2 Which is an appropriate pain assessment tool for pediatric clients? A. Verbal Descriptor Scale B. Numeric Rating Scale C. Visual Analog Scale D. Faces Pain Scale Answer to Question #2 D. Faces Pain Scale. *An appropriate pain assessment tool for pediatric clients is the Faces Pain Scale. The Verbal Descriptor Scale, Numeric Rating Scale, and Visual Analog Scale are other pain assessment tools for collecting objective data, more appropriate for adult clients. Validating and Documenting Findings ❖ Health promotion diagnoses ❖ Risk diagnoses ❖ Actual diagnoses ❖ Collaborative problems ❖ Medical problems Goodluck on your Prelim Exam. Pls Study and analyze your Prelim Exam questions… more on situational and don’t forget chapter 9. Read about pain in your book for a detailed understanding, ok? GOD bless you all and bring home the bacon!