Studied by 24 people
(these are the notes embedded in the powerpoint when u download it)
Without touching a patient, what can you learn?
The study of the whole person:
~covers general health state and any obvious physical characteristics
~provides an overall impression
~includes objective parameters that apply to the whole body
~includes areas of physical appearance, body structure, mobility, and behavior
What would be some immediate concerns when giving a general survey assessment?
ABMM stands for?
Appearance, Body structure, Mobility, Measurement
The appearance part of the general survey assessment includes?
Age (appears stated age)
Sex (sexual development r/t age & sex)
LOC (awake, sleep, coma)
Skin color (even tone, color, consistent)
Facial features (symmetrical)
Overall appearance and Facial expression (good eye contact, happy, smiling)
Mood/affect (comfortable and cooperative)
Speech (clear and purposeful, fluent, even stream)
Dress (appropriate for season, looks clean)
Personal hygiene (cleaned, groomed, age/sex, make-up)
The body structure part of the general survey assessment includes?
Stature (normal for age)
Nutrition (wgt. normal for hgt & body build)
Symmetry (parts bilateral equal)
Posture (erect, slouched over)
Position (sits comfortably-not leaning, standing, lying down)
Body build (proportional)
The mobility part of the general survey assessment includes?
Gait (steady, limping, smooth, purposeful, foot placement, mobility of joint)
ROM (range of motion) (full mobility of joints)
Involuntary movement
The measurement part of the general survey assessment includes?
Height
Weight
Vital Signs (temperature, pulse, blood pressure, respirations, and oxygen saturation)
Optimal functioning aims toward what?
simultaneous life satisfaction in work, caring relationships, and within the self
Mental status strikes a balance between:
good and bad days, allowing person to function socially and occupationally.
A full mental status examination is a systematic check of?
emotional and cognitive functioning
Mental status can be integrated within the context of the?
health history interview
It is necessary to perform a full mental status examination when?
any abnormality in affect or behavior is discovered and in certain situations
Initial screening:
suggests an anxiety disorder or depression
Behavioral changes:
memory loss, inappropriate social interaction
Brain lesions:
trauma, tumor, cerebrovascular accident
Aphasia is?
the impairment of language ability secondary to brain damage
Symptoms of psychiatric mental illness are more concerning when?
they are acute onset
ABCT stands for?
Appearance, Behavior, Cognition, Thought process
The appearance part of the mental status assessment includes?
Posture (erect)
Body movements (voluntary, deliberate, smooth)
Dress (appropriate for setting, season)
Grooming/hygiene (clean and groomed)
The behavior part of the mental status assessment includes?
Level of consciousness(awake, alert, stimulated)
Facial expression (appropriate for situation)
Speech (clear, even paced, articulate)
Mood and effect (How do you feel?) Judge facial/body language
The cognition part of the mental status assessment includes?
Orientation (know where they are, who you are)
Attention span (follows conversation, simple direction)
Recent memory (24 hours diet, medications teaching, names of people)
Remote memory (birthdays, past events, medical history)
New learning (4 unrelated words-recall at 5, 10, 30 min)
Higher intellectual function (used to distinguish between organic brain dx and psyche)
Judgment (ask about life goals, job plans, family plans)
The thought process part of the mental status assessment includes?
Thought processes (do they make sense?)
Thought content (logical and consistent)
Perceptions (hallucinations and illusions)
When would you assess a patient for suicidal thoughts?
if there is a possible risk for harm if the person expresses feelings of sadness, hopelessness, despair, or grief.
Screening for suicidal thoughts includes:
Beginning with more general questions and proceed if you hear affirmative answers.
It is very difficult to question people about possible suicidal wishes for fear of invading privacy.
Risk is far greater skipping these questions if you have the slightest clue that they are appropriate; you may be the only health professional to pick up clues of suicide risk.
For people who are ambivalent, you can buy time so the person can be helped to find an alternate remedy.
Share any concerns you have about a person’s suicide ideation with a mental health professional.
what should you check before any aspect of mental status?
sensory status, vision, and hearing
misdiagnosis with aging key points:
~Confusion is common and is easily misdiagnosed.
~Presence of delirium can have serious affects.
~Overall presence of dementia has decreased. Determination of delirium versus dementia must be evaluated when cognitive impairment is present upon examination of the older adult.
delirium is?
a fast-developing type of confusion that affects your ability to focus your attention and awareness
orientation with aging key points:
~Many aging persons experience social isolation, loss of structure without a job, change in residence, or some short-term memory loss.
~Aging persons may be considered oriented if they know generally where they are and the present period.
~Consider them oriented to time if year and month are correctly stated.
~Orientation to place is accepted with correct identification of the type of setting (e.g., the hospital and name of town).
what is polypharmacy is the elderly?
the regular use of at least five medications, which increases the risk of adverse medical outcomes
alcohol use and abuse key points:
~Many patients will have significant history of drinking that has impact on their health status
~Alcohol consumption has dose-related effects: the more you drink, the higher the risk
~A high number of medications are classified as alcohol interactive.
~Alcohol dependence increases the risk for ED visits, ICU admissions, and sepsis
~Binge drinking associated with increasing health risks
~No amount of alcohol has been determined safe for pregnant women
what are the seven categories of illicit drug use?
Marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type drugs used nonmedically
what can illicit drug use result in?
serious consequences for health, relationships, and future jobs, school, and career
what are the contributing factors to Rx abuse and Opioid crisis?
~Increase in Rx for pain medication
~Marketing strategies to promote medications
~Misrepresentation of “addictive” nature
~Combination addictions—drinking and taking alcohol-interactive medications
in adolescents there is an associated risk between alcohol use and other high-risk behaviors which can lead to:
sexual high-risk, academic problems in school, injuries from trauma, and continuation of alcohol disease in later life
what are the characteristics that increase risks associated with alcohol use?
~Decrease in body’s metabolic functions (liver, water, and renal) leading to increased bioavailability
~Muscle mass decline leads to increased concentration in the body
~Effects of polypharmacy may interact with alcohol
~Increases risk for cognitive decline
~Drinking alcohol increases risk for falls, depression, and gastrointestinal problems
subjection data collection with patients with substance abuse:
-If patient is currently intoxicated or going through substance withdrawal, collecting any history data is difficult and unreliable
*However, when sober, most people are willing and able to give reliable data, provided that the setting is private, confidential, and nonconfrontational
THEN ASK:
Do you sometimes drink beer, wine, or other alcoholic beverages?
-If the answer is yes, then ask screening question about heavy drinking days, such as “How many times in the past year have you had five or more drinks a day (for men) or four or more drinks a day (for women)?
Intimate Partner violence includes?
Physical violence: force resulting in injury or death
Sexual violence: attempted or completed acts without permission
Stalking: repeated unwanted attention through various methods
Psychological aggression: emotional abuse of an aggressive nature
Child Abuse and Neglect includes?
Neglect: failure to provide for children’s basic needs
Physical abuse: nonaccidental injury that leads to harm of a child
Sexual abuse: fondling, sexual acts, exploitation, and trafficking
Emotional abuse: pattern of behavior that harms a child’s sense of self-worth or development
Older Adult Abuse and Neglect includes?
Physical abuse: intentionally assaulted, injured, threatened, or restrained
Sexual abuse or abusive sexual contact: any sexual contact against one’s will
Psychological or emotional abuse: includes verbal and nonverbal behaviors intended to humiliate, isolate, or affirm control
Neglect: failure of caregiver to meet basic older adult needs
Financial abuse or exploitation: unauthorized use and/or improper use of older adult’s funds/resources
*elder abuse is underreported with 60% being performed by a family member
what are the health effects of violence?
Immediate effects as well as residual effects of acts of violence leading to complications and more chronic health problems
Gynecologic and obstetrical conditions with impact on fetus
-Preterm, low birth weight, and perinatal death
More likely to suffer from mental health problems
Depression, suicide, PTTS, and substance abuse
Children who are abused are more likely to experience ongoing poor health as they age.
-Impact on brain development, behavioral learning delays, and higher risk for chronic disease
what are the barriers to treatment?
poverty, discrimination, legal status, lack of access to culturally appropriate care
how do you properly document?
Provide detail, transcribe verbatim, be interdisciplinary, and have non-biased progress notes, injury maps, and photographic evidence
Note 
Flashcard (33)