Module 3 General Inspection & Measurement Culture Competency Pain Assessment Mental Health Assessment

General Inspection

Initial observations and measurement of baseline data

Observe

• Physical appearance and hygiene

• body structure

• body movement/Mobility

• Emotional Status

• Disposition

• Behavior

Measure

• Height

• Weight

• Vital signs

Appearance

Overall health state

Age

Level of consciousness

Signs of distress

Skin

Hygiene

Level of consciousness (LOC)

A patients level of arousal and awareness

• Alert: responsive and able to open their eyes and answer questions spontaneously
  and appropriately

• Lethargic: able to open eyes and respond but is drowsy and falls asleep readily

• Obtunded: response to light shaking but can be confused and slow to respond

• Stuporous: requires painful stimuli (pinching a tendon or rubbing the sternum)
  to achieve a brief response. Might not be able to respond verbally

• Comatose: response to repeated painful stimuli. Abnormal posturing. Glasgow coma scale (GCS) measures LOC

Orientation

Orientation to person, place, time, and situation

• What is your name?

• Where are you?

• What is the date today?/ What year is it?

• Who is the current president?

• What brought you to the hospital

Normal LOC and orientation documentation

Order of orientation loss

• Time: Loss first

• Place: lost second

• Person: Lost last

Skin color

Will cover extensively in skin assessment

Examples of abnormal include:

• Pallor- pale

• Cyanosis- blue

• jaundice- yellow/green

• Rashes

• Ecchymosis- purple/blue bruising

Signs of Physical abuse or neglect

unexplained injuries, such as bruises, fractures or burns

Injuries that don’t match the given explanation

Untreated medical or dental problems

Poor growth or weight gain

Poor hygiene

Lack of clotting or supplies to meet physical needs

Dehydration

Insect infestations

Signs of substance abuse

Smell alcohol and/or marijuana

Bloodshot or glazed eyes

Dilated or constricted pupils

Abrupt weight changes

Bruises, infections, or other physical signs at drug’s entrance site on body

Tattoos

CAGE assessment: Cut down, Annoyed by criticism, Guilty, and eye opener

Body structure and position

Inspect the stature, build, height, weight, and symmetry

Provides a general impression of nutritional status

Gross abnormalities

• Skin lesions

• Amputations

Position or posture

• slumped posture: spinal deformities or back pain

• Tripod position: difficulty breathing

• Fetal position/guarding: severe pain

• Sitting upright: left-sided heart failure

• Leaning forward with arms propped up

Mobility

Range of motion

• immobile or stiff joint

Motor activity

• apparent involuntary motor activity

Gait

• Smooth halting

Body movements

• voluntary or involuntary

• Purposeful or tremulous

Assistance device

• cane

• walker

• crutches

Emotional Status, Disposition, Behavior

Facial expression

Mood and affect

Speech

Dress, hygiene, grooming, and odors (Body, breath)

Mood and affect

Mood: a temporary state of mind or feeling

Affect: an observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor

Speech

Articulate

Garbled

Rapid

Slow

Tone of voice

Aphasia, dysphasia

Dress, Grooming, and Personal Hygiene

Clothing appropriate for weather

Clean, properly buttoned

Clothing appropriate for age and/or social group

Tattoos, piercings

Hygiene and grooming appropriate for age, lifestyle, occupation

The Nose Knows

Odors of the body

• Alcohol- substance abuse issues

• Acetone- diabetes/elevated ketones

• Pulmonary infections- odor based on the pathogen

• Uremia- ammonia smell with kidney failure

• Liver failure- sweet fecal smell

• Fruity- diabetes/ketoacidosis

Height

Influenced by age, genetics, and dietary intake

One of the primary measures of growth

Use a platform scale with height attachment to measure

Weight

Affected by genetics, age, dietary intake, exercise, health
conditions, and fluid volume
• Important in nutritional assessment
– Compare to the previous weight and calculate the changes
– Unintentional weight loss may indicate a disease process
– Unintentional weight gain may indicate fluid retention
• 1000ml (1 quart) fluid retain = 2.23lb weight increase

Common or Concerning symptoms

Fatigue or weak

fever, chills, night sweats

Weight changes

Pain

Fatigue verses weakness

Fatigue

• nonspecific symptom with many causes

• Refers to sense of weariness or loss of engergy

• Can be normal response to hard work

Weakness

• denotes demonstrable loss of muscle power

• Suggest possible neuropathy or myopathy

Fever, chills, and night sweats

Fever: acute or chronic illness, did you use a thermometer

Chills: did you feel cold or shivered throughout the body and teeth were chattering

Night sweats: worry about cancer or tuberculosis

Culture

Knowledge, belief, art, morals, customs, and any other capabilities and habits acquired by a person as a member of society

Nurses must be culturally competent

Cultural Competence

Steps to perform a culturally competent assessment
– Develop a sensitivity to differences between own culture
and that of the patient
– Avoid stereotyping and assuming the meaning of the
behavior of others
– Incorporate questions in the history to learn about the
patient’s health beliefs, health practices, spiritual/religious
beliefs, and gender identity

Pain

Subjective

An unpleasant sensory and emotional experience associated with actual or
potential tissue damage

Pain is whatever the experiencing person says it is, existing wherever he
says it does

Types of Pain

Acute pain

• Recent onset, less than 6 months
  • Result from tissue damage and is self–limiting
  • Ends when the tissue heals
  • Stress response may cause physiologic signs associated with pain, such as an
  increase in blood pressure, pulse rate, and respiration

Chronic Pain

• Intermittent or continuous
• Lasting longer than 6 months
• No physiologic stress demonstrated
• Result in symptoms of irritability, depression, and insomnia

Memory

• Immediate recall
– Ask the patient to repeat the names of three unrelated objects that are spoken
slowly, such as “dog,” “cloud,” and “apple.”
• Recent memory
– Give the patient a short time to view four or five objects and explain that you will
ask about these objects in a few minutes. After about 10 minutes, ask the patient
to name the objects. All objects should be remembered.
• Remote memory
– Ask the patient about his or her mother’s maiden name, high school attended, or
a subject of common knowledge.