General Survey and Mental Status Examination

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General Survey

~A study of the WHOLE person
~Covers GENERAL health state and physical characteristics
~An introduction to the physical exam

Areas to Assess in the General Survey

~Physical Appearance
~Body Structure
~Mobility
~Behavior

Age

Does pt appear stated age (younger, older)

Physical Appearance

Sex

Is pt's development appropriate for their GENDER and age?

Physical Appearance

Level of Consciousness

Is pt ALERT and ORIENTED?

Physical Appearance

Skin Color

Is pt's color tone even, pigmentation consistent with genetic background?
Look for abnormalities:
~Pallor
~Cyanosis
~Jaundice
~Erythema

Physical Appearance

Pallor

Skin is pale, white tone: shock, anemia, decreased circulation

Skin Color Abnormality

Cyanosis

Skin is blueish gray in lips, finger nails, and around the eyes: cardiac or respiratory problems (Decreased circulation)

Skin Color Abnormality

Jaundice

Skin has yellow discoloration: Liver disease

Skin Color Abnormality

Erythema

Skin has red discoloration: fever, blushing, inflammation, polycythemia, carbon monoxide poisoning

Skin Color Abnormality

Facial Features

Symmetric?

Parkinson's Disease

Flat expressionless facial expression

Facial Features

Graves Disease (hyperthyroidism)

Bulging eye balls, very thin (high BMR)

Facial Feature Abnormality

Hypothyroidism

Low BMR, struggle with weight, mixed edema, dry skin and very coarse hair

Facial Feature Abnormality

Stroke (CVA)

Paralysis of facial muscles

Facial Feature Abnormality

Body Structure: Stature

Is pt's height normal for age and heritage?

Achondroplastic Dwarfism

Congenital disorder preventing the convertion of cartilage into the long bones; short arms and legs, prominent forehead

Stature Abnormality

Gigantism

Excessive secretion of growth hormone BEFORE puberty; delays closure of the bones

Stature Abnormality

Acromegaly

Excessive secretion of growth hormone AFTER puberty; overgrowth of bones in face, hands, head and feet (not height)

Stature Abnormality

Short Stature

Decrease in growth hormone in childhood below the 3rd percentile

Stature Abnormality

Body Structure: Nutrition

Is pt's weight within normal range

Cachectic

Emaciated; physical "wasting" with malnutrition, loss of weight and muscle mass due to disease

Nutritional Abnormality

Obesity

Even fat distribution

Nutritional Abnormality

Centripetal Obesity

Obesity concentrated in FACE, NECK and TRUNK with thin legs and arms (Cushing's Disease and long dosage of steroids)

Nutritional Abnormality

Body Structure: Symmetry

Equal?

Atrophy

The wasting away of a body organ or tissue

Symmetry Abnormality

Hypertrophy

Abnormal increase of a body part or organ

Symmetry Abnormality

Body Structure: Posture

Is pt comfortably erect? Check plumb line through EAR, SHOULDER, HIP, PATELLA and ANKLE

Body Structure: Position

Is pt comfortable sitting?

Tripod Position

Client leans forward and uses arms to support weight and lift chest to increase breathing capacity; often seen in COPD

Position Abnormality

Upright Position

Sitting straight up; often seen in CHF (Congestive Heart Failure)

Position Abnormality

Fetal Position

Curled up body position that resembles a fetus in the uterus; often seen in abdominal pain

Position Abnormality

Body Structure: Body Build

Proportionate?
Arm span = Height

Marfan's Syndrome

Arm span > height; (Abraham Lincoln and Rachmaninoff)

Body Build Abnormality

Mobility: Gait

Smooth, even and balanced?

Hemiparesis

Leg is stiff and drags in semicircle (CVA); Partial paralysis of the right or left half of the body

Gait Abnormality

Cerebellar Ataxia

Wide based gait, difficulty with turns and uncoordinated movement (tumors with cerebellum, intoxication)

Gait Abnormality

Parkinsonian Gait

Posture is stooped, wth head and neck forward; Pt is slow in getting started. Steps are short and often shuffled.

Gait Abnormality

Steppage or Foot drop

Hallmark sign of untreated syphilis

Mobility: Range of Motion

Does pt have full mobility of each joint? No involuntary movements?
~Check for paralysis (absent movement)

Tics or Tremors

Seen in pt's with nueromuscular disease, Parkinson's disease, alcohol abuse, multiple sclerosis

Behavior: Facial Expression

Are the pt's expressions appropriate and do they maintain eye contact?

Behavior: Mood and affect

Is the pt's comfortable and cooperative?
~Flat affect, depressed, anxious?
~Hostile, distrustful, suspicious?

Behavior: Speech

Does the pt have good articulation? Is language clear and understandable

Dysarthria

Impairment in ARTICULATION; problem uttering words (disease of the oral cavity, tongue or pharynx muscles)

Speech Abnormality

Dysphasia

Impairment in PRODUCTION and UNDERSTANDING (brain lesion or nuerodevelopmental problem)

Speech Abnormality

Behavior: Dress

Is pt's clothing appropriate to climate? Is the clothing clean?

Behavior: Personal Hygiene

Is the pt clean and groomed? Change in grooming indicates illness, depression, mental illness

Mental Status

Consists of a person's EMOTIONAL and COGNITIVE functioning

Good mental status-> optimal functioning

Mental Disorder

Clinically significant behavior or psychological pattern that is associated with present DISTRESS, DISABILITY and has a significant risk of suffering, death, pain, disability, or loss of freedom
~organic disorder: physical cause (delirium, dementia, intoxication, brain lesions)
~psychiatric mental illness (anxiety disorders)

Distress

Pt will have PAINFUL symptomatology

Disability

Pt will have IMPAIRED functioning

Mental Disorder

In the physical exam, mental status is inferred thru assessment of BEHAVIOR

If an abnormality is noted in mental exam, CLIENT MUST BE REFERRED FOR FURTHER PROFESSIONAL EVALUATION

Dementia

~Onset is GRADUAL
~IRREVERSIBLE
~Course is PROGRESSIVE
~Attention span is normal
~Recent memory is impaired
~Caused by alcoholisms, cerebral anoxia, brain infarcts, many diseases (Alzheimer's)

Delirium

~Onset is ABRUPT
~REVERSIBLE
~WORSE in the PM
~Attention is impaired
~Recent memory is impaired
~ Caused by acute illness, fever, infection, dehydration, electrolyte imbalance, medications and alcoholism

Depression

~Onset can be ABRUPT or GRADUAL
~Prognosis is variable
~WORSE in the AM
~Attention span is variable
~Memory can be impaired
~May coincide with life event

Cerebrum

Responsible for mental status; 2 hemispheres divided into lobes (Cerebral cortex -> higher mental functioning)

Frontal lobe

Responsible for motor cortex, emotions, short term memory, speech formation (Broca's area)

Parietal lobe

Responsible for processing sensory data and long term memory

Temporal lobe

Responsible for perception and interpretation of sounds (Wernicke's area), comprehension of spoken and written language, long term memory

Limbic System

Responsible for survival behaviors (mating, agression, fear, love) and formation of memories

Components of the Mental Status Exam

ABCT
Appearance
Behavior
Cognition
Thought processes

Full mental status exam when: 1

Family member is concerned: pt exhibits memory loss and/or inappropriate behavior

Full mental status exam when: 2

Brain lesions: pt has experienced trauma to the head, lesion, s/p CVA

Full mental status exam when: 3

Aphasia: pt has impaired language due to brain damage

Full mental status exam when: 4

Symptoms of psychiatric illness: especially if acute onset

HPI: Disorientation

Onset: Abrupt or Insidious?
Duration:
Associated Probelms: nuerological problems, brain injury or infection?
Medications: opoids, narcotics, anti-depression agents?

HPI: Depression

Thought or Feellings: hopelessness
Best in AM or PM
Recent cause of grief
Hurting self
Medications

HPI: Anxiety

Describe avoidance of situations or people
Traumatic event
Associated symptoms
Medications

PMH: Nuerological disorders/Psychiatric therapy or hospitalizations

Brain surgery, brain injury, chronic diseases

FH: Psychiatric disorders

Mental illness or susbtance abuse

FH: Mental retardation

Includes autism

FH: Alzheimer's disease

Genetic link

FH: Learning disorders

ADD runs in families

ROS: Emotional Status

Ask about feelings about oneself, coping strategies

ROS: Cognitive changes

Any problems with communication, memory or thought processes

ROS: Sleeping or eating patterns

Any problems with weight loss or weight gain

ROS: Substance abuse

Use of alcohol or street drugs

Examination of Cognitive Abilities

Signs of Possible Impairment
~Significant memory loss
~Confusion
~Impaired communication
~Inappropriate affect
~Personal care difficulties
~Hazardous behavior
~Agitation
~Suspiciousness

Cognitive Impairment Test

~What year is it now?
~What month is it now?
Memory Phase
~What time is it now?
~Count backwards 20 to 1
~Say the months in reverse order
~Repeat the memory phase

High sensitivity in picking up mild forms of dementia

Mini Mental State Examination

Tool for detecting the PROGRESSION of an organic disease
~11 questions
~Score below 24 indicates probable cognitive impairment
~Score below 17 indicates definite cognitive impairment

Examination: State of Consciousness

Should be oriented to:
Person: Full name
Time: day, week, date
Place: Location
Situation: Why pt is there
A+O X 4

Orientation is 1st lost to time -> place-> situatioin and rarely to person

Note Level of Stimulus

Name called in:
~Normal voice
~ Loud voice
~Light touch on person's arm
~Vigorous shake of shoulder
~Pain applied: pinch below clavicle, pressure on chest, press on fingernail, pinch nipple

Alert

Awake or readily aroused, oriented, responds appropriately

Examination: Expected Levels of Consciousness

Lethargy

Drowsy, falls asleep quickly

Examination: Expected Levels of Consciousness

Obtunded

Sleeps most of the time, difficult to arouse, confused when aroused

Examination: Expected Levels of Consciousness

Stupor

Unconscious, responds only to persistent and vigorous shaking or pain, reflex activity persists

Examination: Unexpected Levels of Consciousness

Coma

Completely unconscious, no response to pain, no purposeful movement, some reflex activity to none

Examination: Unexpected Levels of Consciousness

Examination of Cognitive Abilities

~Analogies
~Abstract reasoning (ask pt fable or proverb)
~Arithmetic calculations
~Writing ability (ask pt to write a sentence or draw shape)
~Execution of motor skills (give a simple command)
~Memory (ask pt to repeat a sequence of numbers)
~Attention span (follow a short command)
~Judgement (what would you do if you found a stamped letter)

Examination: Emotional Stability

~Mood and feelings
~Thought process and content (problem with EMOTIONAL disturbances, psychiatric disorders)
~Perceptual distortions and hallucinations (auditory and visual are associated with psychiatric disorders; tactile are associated with alcohol withdrawal)

Examination: Speech and Language Skills

~Voice quality
~Articulation
~Aphasia
~Comprehension
~Coherence

Dysphonia

A disorder of voice VOLUME, quality or pitch due to laryngeal disease

Voice quality abnormality

Dysarthria

A defect in articulation due to a MOTOR defect of the lips, tongue, palate or pharynx

Articulation abnormality

Aphasia

Language comprehension and production secondary to BRAIN DAMAGE

Global Aphasia

Speech and comprehension is absent or reduced (most common and severe aphasia; damage to Broca's and Wernicke's)

Broca's Aphasia

Expressive aphasia; Client can understand language but CANNOT EXPRESS himself well; Speech is mostly nouns and verbs or 'telegraphic'

Wernicke's Aphasia

Can hear sounds but CANNOT INTERPRET them; speech is well articulated but has many neologisms; speech is incomprehensible (they can sing)

Comprehension

Pt should follow one to three step directions

Circumlocution

Roundabout expression substituting a phrase when cannot think of object's name

Flight of Ideas

Words or sentence which proceeds in a disorderly fashion

Echolalia

Repetition of another person's words

Neologism

Inventing a new word that has no meaning

Word Salad

Incoherent mixture of words

Additional Assessment Procedures: Glasgow Coma Scale

Used with altered level of consciousness, brain tumor or hypoxic event
~Objective measurment of neurological functioning
~Assess cerebral cortex and brain stem thru verbal response, motor response, eye opening to specific stimuli

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