Phys Assess #1 Flashcards
Learn to develop a trusting relationship with the patients, they will be in a vulnerable state if they are __
ill
Important to be self aware and knowledgeable of our own ___
differences
It is important to be self-aware and knowledgeable about one’s own culture-
it shows how we care for people
Awareness is an interactive and ongoing process-
it could change
is an integral part of becoming culturally competent
Cultural self assessment
US Demographics: Total population passed 321 million in
2015
US Demographics: 61.6% of the population identified as
non-Hispanic and whites
US Demographics: Largest and fastest growing group
Hispanics
US Demographics: Remember the US has a lot of
immigrants
US Demographics: Minority is
increasing
Emerging Minority Group Trends: Differences noted in
age, poverty level, and household composition
Emerging Minority Group Trends: All ethnic and racial minority groups exceed the national poverty level
they are living in poverty, related to lower levels of education, income, and correlated with higher levels of disability
Emerging Minority Group Trends: Low educational attainment and lower income are correlated with __
likelihood of disability.
Emerging Minority Group Trends: Family size and multigenerational families are more evident in ___
minority groups
They have little to no understanding to the US health care system-
immigrants
HC addresses the needs to this specific population if they ___
do not understand
Immigration and Health Care Concerns: Status of immigrants entering the health care system:
In 2014, 13.2% of population were foreign born individuals.
Expected population to double by the year 2065
Immigration and Health Care Concerns: Minimal understanding of the following:
US health care system
Medical practice interventions
Immigration and Health Care Concerns: Communication is an essential component:
Need for an interpreter
Provide materials that are based on health literacy principles
Immigration and Health Care Concerns: Limited understanding of the HC system, medical practice interventions, may stay away from __
health care and become sicker
Determinants of Health and Health care Disparities: Social Determinants of Health (SDOH)-
helps identify vulnerable patients that need the most help. They face social, economic and environmental disadvantages.
Constellation of related factors
Affect a person from preconception to death
EBP indicates that poverty has greatest influence on health status.
Social Determinants of Health (SDOH)-
Patients may have lower
ability to read and write or not at all
Require the greatest assistance or interventions for
racial minorities, people with disabilities, or members of the LGBTQ population
Neighborhood and built environment, Health and health care, Social and community context, Education, Economic stability
Social Determinants of Health (SDOH)-
Healthcare Disparities: Our goal to Identify, define, and recognize vulnerable populations.
“A particular type of health difference that is closely linked with social, economic, or environmental disadvantage.”
Healthcare Disparities: Work toward eliminating by utilizing available resources.
Us dept of health and human services: Goal of Healthy People- program of nation wide health promotion and disease.
Healthcare Disparities: Promotion of health care frameworks-
providing Accessible, culturally and linguistically competent delivery of health care to promote quality of life for all patients
The goal for healthy people is to eliminate ___
health disparity
Can see increased disparities in specific populations, greater obstacles in obtaining HC due to ___
racial or ethnic characteristics
Even though we want to decrease disparities, There has not been any change to ____
access of care or health care disparities
National Standards for Culturally and Linguistically Appropriate Services in Health Care
Set of 15 standards
They provide a blueprint to improve quality of care for diverse populations to eliminate health disparities
Civil Rights Act 1964- support individuals with LEP
LEP- limited English proficiency
Assisting with communication utilizing resources such as interpreters to make sure the pts are understanding the care they receive
Language barriers can decrease quality of care if they __
do not understand
Culture-Related Concepts
4 Basic Characteristics of culture
Terminology
4 Basic Characteristics of culture
Learned, Shared, Adapted, Dynamic
Learned –
Culture is learned from birth through a process of language acquisition and socialization.
Shared-
Shared by all members of the same cultural group.
Adapted-
Adapted to specific conditions that related to environmental and technical factors in the context of available resources.
Dynamic-
Culture Is dynamic. Very hard to define.
Not biologically or genetically determined and subcultures are going to occur when groups function within a larger culture but they break off into smaller cultures based on gender differences, age, occupation, or ethnicity
Ethnicity:
Social group with shared traits
Ethnic identity:
Self-identification with a particular ethnic group
Assimilation:
Process of adopting culture and behaviors of a major culture. Includes pt adopting practices such as dress and diet.
Biculturalism and integration:
Allow for reciprocating and maintaining ethnic identity. Allows patient to be apart of both cultures
Acculturative stress:
Based on the input from the environment include social, interpersonal, and societal factors
Spirituality:
broad encompasses something larger than one’s own existence with a belief in transcendence. Helps individuals to find a purpose and a meaning to life.
Religion:
organized system of beliefs as a shared experience that can assist in meeting one’s individual spiritual needs
Two concepts that can be interrelated but do not have to exist simultaneously
Spirituality and Religion
They help individuals define their feelings and beliefs.
Spirituality and Religion
Cultural interview-
it is very important gathering info about health related beliefs
If a patient is wearing a charm or amulet. Ask __
what is it and what is represents
Disease Causation Theories:
Biomedical or scientific- basis of western medicine
Naturalistic or holistic
Magico religious
Biomedical or scientific- basis of western medicine
Cause and effect that can provide physical and psychological illnesses—e.g., germ theory.
Does state that microorganisms such as bacteria or viruses are responsible for disease
Naturalistic or holistic-
Belief in the forces of nature that there is balance in the universe—e.g., yin/yang theory
yin/yang theory- Yin
Female or negative forces- emptiness darkness and cold.
Cold foods are going to be eaten during hot illness.
yin/yang theory- Yang
Male forces or positive forces that emit warmth and fullness, hot foods are going to be eaten during a cold illness.
Example of Cold diseases:
ear ache, chest cramps, paralysis or GI discomfort, rheumatoid arthritis, or TB.
Example of Hot illness:
abscess, sore throat, rash, and kidney disorders
Magicoreligious-
Supernatural forces dominate resulting in good versus evil—e.g., voodoo or faith healing
Each culture has its own healers- speak in their __
native tongue
Use of alternative, complementary, or traditional therapies based on __
belief system
Hispanic Tongue:
curandero, espiritualista, yerbo, or sabedor
Black Tongue:
Ougan, spiritualist, old lady
American Indian Tongue:
shaman, medicine woman, medicine man
____ states that the healing is not complete unless the body and mind are both healed
The Medicine man
Asian Tongue:
herbalists, acupuncturists, bone setters
Amish Tongue:
braucher
Always maintain cultural sensitivity, offer to call priest of spiritual specialist
If unsure ask
Ask if they had attempted other remedies at home, ask if they ___
have been seen
OTC meds are readily available for patients they might try it before ___
coming to see the doctor
Awareness of beliefs across the life cycle can impact perception of health care delivery and treatments
Developmental Competence
Parenteral and childs perceptions of illness
Consider the patients beliefs
Cultural taboos
Cultural taboos-
Avoided by both children and adults from the religion.
Specific to cultures not consuming pork or caffeine.
Jehovah witness: blood refusal
Providing care to an older adult, assess the role of the family, may not know about health promotion or programs available
Values held by dominant culture influence perception of older adults
Independence, self-reliance, and productivity
Care-dependent versus caregivers- role switch
Culture shock- coming from a different country
Older generation- the ability to care for themselves has ___
changed
Transcultural expression of pain: Remember that Expectations, manifestations, and management of pain are all embedded in a ___
cultural context.
Transcultural expression of pain: Pain is highly personal, depending on cultural learning, the meaning of the situation, and other factors unique to ___
the person.
Transcultural expression of pain: Considers the situation, what is causing the pain which effects how they express the paint, and ___
other unique factors related to pt
Transcultural expression of pain: Culture affects perceives, responds, and ___
manages the pain
Providing care- will see different variations of expression of pain. May turn to their social environment for ___
validation and comparison
Becoming a Culturally Competent Practitioner
Culturally sensitive, appropriate, competent, and cultural care
Culturally sensitive
Caregivers possess basic knowledge and understanding.
Culturally appropriate
Caregivers apply knowledge to improve health outcomes.
Culturally competent
Caregivers apply a universal concept of understanding to all contextual aspects of care.
Cultural care
Provision of health care across cultural boundaries in consideration of context
Care may not always align, ask questions that are not ___
too complex
When touching patient’s, use touch within _____
cultural boundaries
Pace questions through out the ____
assessment
Treat personal items with ____
care and respect
Cultural Self-Assessment: Explore your own personal history to develop cultural sensibility.
Use thoughtful reasoning.
Responsiveness
Discrete interactions
Cultural Self-Assessment: Think about the components of culture that you experience in your own daily life.
Purposely action to gain better understanding to help others
Only when we acknowledge our own values and beliefs are we able to fully help others.
Helps us greater understand and help our patients
When acknowledging values and beliefs we can fully take care of them
Ask about their influences, family traditions, where they are from to ___
gain info
Cultural Assessment: There is no one universally accepted tool that addresses ___
all variables.
Cultural Assessment: Do not apply stereotypes-
listen and learn.
Cultural Assessment: Recommended list of domains of interest that may be included:
Heritage, health practices and communication
Family roles and social orientation, nutrition and pregnancy, birth/childrearing
Spirituality/religion, death, and health providers
To gain a better understanding of our patient
After a pt recognizes a symptom they will seek self treatment- OTC
Cultural Assessment
Spiritual Assessment: Use open-ended questions to start the conversation
“Do you have any religious or spiritual preferences that we can support”?- answers spiritual portion
Spiritual Assessment: Variety of tools available
FICA—Faith, importance/influence, community and address/action
Brief R-COPE—examines patient’s coping mechanisms
Unmet spiritual needs lead to ___
decreased outcomes
Important in gather info regarding our ____
patient
Best chance what the patient perceives their ___
health state to be
First opportunity to gather information about patient’s beliefs, concerns, and perception of their individual health state
Interview Purpose
Allows for compilation of subjective data and awareness of objective data
Interview Purpose
Gather subjective data in the interview
What the patient says includes chest pain, heart burn, itching
Objective data- what we observe through our ___
Physical assessment
Successful Interview Characteristics
Gather, Establish, Teach, Build, Discuss
Gather ___
complete and accurate data about person’s health state including description and chronology of any symptoms.
Establish ___
trust to foster acceptance and allow for data sharing.
Teach ___
the person about their individual health state. Ways the manage health or promote
Build ___
rapport to continue therapeutic relationship.
Discuss ___
health promotion and disease prevention.
Gather info about ___
current health state, when the symptoms start, what are they, when did it change
Contract between you and the client
Interview
The mutual goal of the interview is
optimal health
Process of Communication: Sending
Verbal communication
Nonverbal communication
Verbal communication
Words you speak—vocalization
Tone used in conversation
Nonverbal communication
Body language helps to provide cues which may be correlated with truer feelings.
Recognize importance of unconscious messages that body language portrays
Change in demeanor or posture-
note It
Can be related to be forced to make difficult decision, make sure to educate them
Internal Factors:
Liking others, Empathy, Ability to listen, Self-awareness
Liking others—
using a “genuine” approach
Empathy—
develop an understanding and sensitivity for others feeling’s
Ability to listen—
make sure to use an “active” process
Self-awareness—
be aware of “implicit bias”, own belief systems. Different things as the HC team member to maximize skills
Process of Communication: External Factors
Ensure privacy, Avoid interruptions, Physical environment, Dress, Note-taking, Electronic Health Record (EHR)
Ensure privacy—
aim for “geographic” privacy but ensure “psychological” privacy
Avoid interruptions—
minimize and/or refuse
Physical environment—
“equal status” seating- same level, 4-5 ft apart for comfort and communication
Dress—
appearance and comfort
Note-taking—
keep to a minimum, offer “focused” attention so that it is not a barrier
Electronic Health Record (EHR)-
make sure the computer screen is not in between you and the client
If interviewing the team, can ask parents to leave for a moment
Turn off the TV to
minimize distractions
Techniques of Communication
Introducing the interview, Working phase,
Introducing the interview-
What it is for
Working phase-
Data-gathering phase
Verbal skills include questions to patient and your responses to what is said.
Two types of questions: Open-ended-
Broad range, narrative information. States the topic discussed in general terms. To begin the interview. “How has your health been since the last visit”- allows pt to elaborate
Two types of questions: Closed-
ask for specific information that leads to a forced choice. Yes or No.
Each has a different place and function in interview.
Open and closed ended questions
Verbal Responses: Assisting the Narrative
Facilitation, Silence, Reflection, Empathy, Clarification, Confrontation, Interpretation, Explanation, Summary
Facilitation—
Encourage to share more info
Silence—
Providing directed attentiveness, Paying attention
Reflection—
Echo or help express meaning
Empathy—
Name a feeling and allow for its expression
Clarification—
Wanting to conform info. Can be used if the patient’s word choice is confusing. Can be used to summarize the patients words or to better understand them
Confrontation—
Clarifying inconsistent information
Interpretation—
Making associations in order to identify a cause of conclusion
Explanation—
Inform the person by sharing factual and objective information
Summary—
Provide the conclusion based on verifying the info receives and verified that the interview process is ending.
Ten Traps of Interviewing to avoid
Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using why questions
Gives patients a false sense of provided comfort-
false assurance or reassurance
Nonverbal Skills—Congruency
When verbal and nonverbal messages are congruent, the verbal message is reinforced.
Nonverbal Skills— Incongruent
When they are incongruent, nonverbal message is viewed as the truer one as it is under unconscious control.
Make sure the nonverbal and verbal skills are __
matched
Nonverbal Modes of Communication
Physical appearance, Posture, Gestures, Facial expression, Eye contact, Voice, Touch
Physical appearance-
Take note of the image as an initial perception (First impression)
Posture-
Interpretation of body language and how it effects engagement
Gestures-
Can send messages
Facial expression-
Can reflect emotion and culture
Eye contact-
Differ from culture to culture, if able and culturally appropriate maintain eye contact. Be mindful of cultural diversity
Voice-
Aware of the tone, intensity, and rate
Touch-
Use caution when talking about eye contact and touch
Be cautious, interpreting by
age, gender, cultural background, pt past experiences, specific cultural setting,
Ending should be gradual thereby allowing for adequate closure to allow for final expression.
Closing the Interview
No new topics introduced
Closing the Interview
Summary provided as final statement- understand what the patient said
Closing the Interview
Not abrupt or awkward
Closing the Interview
Make sure to give patient the opportunity to include any last input
Closing the Interview
Communicating with Different Ages: Use “Stages of cognitive development” as a guideline to ___
facilitate communication.
Communicating with Different Ages: Consider the ___ and ___ level of the child.
maturity and developmental
Communicating with Different Ages: Consider that a health care crisis can lead to ___ as a common response.
regression
Communicating with Different Ages: Be aware of ___ to maintain engagement.
nonverbal behaviors
Communicating with Different Ages: Primary method of communication with infants
Nonverbal
Communicating with Different Ages: One direction at a time, keep simple, and give warnings before transitions.
Make sure they know what’s going on, mentally prepared.
May need to stoop down to their level and connect with an inanimate object
Toddlers
Communicating with Different Ages: Interviewing parent of child or children- include __
child and parent
Communicating with Different Ages: Address child by name to build ___
rapport with the child
Stages of Cognitive Development
Infants- Birth to 12 months
Toddlers- 12 to 36 months
Preschoolers- 3 to 6 years
School-age- 7 to 12 years
Adolescents- Starts with puberty
Infants- Birth to 12 months
Gentle handling with quiet calm voice
Toddlers- 12 to 36 months
Give one direction at a time and provide simple explanations
Preschoolers- 3 to 6 years
Short directions with concrete explanation
School-age- 7 to 12 years
Ask questions to gather data and be nonjudgmental
Adolescents- Starts with puberty
Respectful, honest attitude with focused on the individual
May speak 1 to 2 words-
toddlers
World revolves around them –
preschoolers
Objective and realistic-
School age
Drastic change to their self concept, communicate so they are aware-
adolescents
Developmental task of finding purpose and evaluating existence
The Older Adult
Address respectfully
The Older Adult
Typically, the interview process will take longer.
The Older Adult
Use therapeutic touch to provide empathy.
The Older Adult
May need increased response time- time to interpret, process and answer the questions
The Older Adult
May have a lot more information to provide, may take longer
The Older Adult
Hard of hearing- facing patient and make sure they can see our mouth
The Older Adult
Include questions that are related to aging
The Older Adult
Consider appropriate pacing
Physical limitations
Typically, the interview process will take longer.
Interviewing People with Special Needs: Consider key elements that will address vulnerable populations.
Acutely ill, drug/alcohol abuse, sexually aggressive, emotionally distraught (crying), angry and/or threatening violence and anxious
Interviewing People with Special Needs: Use appropriate resources as they relate to the context of the situation.
Social worker, aid
Interviewing People with Special Needs: Be alert to “personal question” queries as they may indicate ulterior motives:
Provide appropriate response based on personal ethics.
Interviewing People with Special Needs: Alcoholism and drug abuse-
educating the drug interactions
Interviewing People with Special Needs: Disease processes worse, can interact with all medications-
alcohol
Interviewing People with Special Needs: Common admitted to the hospital-
Alcohol and drugs
Being aware of maintaining cultural
Maintaining privacy and modesty
Being aware of maintaining cultural
Maintaining privacy and modesty
Be mindful of your communication patterns
Being aware of your own personal bias and baggage
Sexual orientation
Interpreter services may be necessary
Communication
Use appropriate language
Consider verbal and nonverbal ques
Culture and Genetics Considerations
Involves understanding and following directionsA patient may be literate (read) but not have health literacy (Educational level).
that lead to effective communication between the patient and the health care provider.
Health Literacy
A patient may be literate (read) but not have health literacy (Educational level).
Health Literacy
Provide simple and easy to use directions, use layman’s terms
Health Literacy
Written materal make sure its based on standard education levels
Health Literacy
Provide education in different method, videos, if they cannot read or write
Health Literacy
Use 12 pt font, don’t use all capitalizations
Health Literacy
Teach back for verification and clarification
Health Literacy
Standardized Communication—SBAR
Situation, Background, Assessment, Recommendation or Request
Situation
Provide a brief description of pertinent patient variables, demographics, clinical diagnosis, and location
Backgrounds
Provide pertinent history as it directly relates to patient’s current health status
Assessment
State pertinent assessment findings obtained with interpretation of data
Recommendation or Request
State what you need or want for the patient in terms of medical treatment and/or assistance
Communicate with other professions
Standardized Communication—SBAR
Maintain standard of communication, promote effective interpersonal communication
Standardized Communication—SBAR
Creates environment of respect and enhance collaboration
Standardized Communication—SBAR
Maintain open lines of communication providing timely updates in an organized manner
Standardized Communication—SBAR
Decrease or get rid of communication within the healthcare setting- main goal
Standardized Communication—SBAR
Collect subjective data to combine with objective data from physical exam and labs to form the database for our patient
Purpose of Health History
Provides a complete picture of patient’s past and present health status
Purpose of Health History
Can be used as a screening tool for detection of abnormalities or find trends
Purpose of Health History
Depending on what the pt is seen for the focus may differ in terms of clinical practice setting and/or nature of complaint.
Purpose of Health History
Describes the individual as a whole and how they interact with the environment
Purpose of Health History
Dealing w a pt who is ill, gather symptoms in chronological order,
Purpose of Health History
Objective data, labs and health history=
database
The Health History Sequence
Biographic data, Source of history, Reason for seeking care, Present health or history of present illness, Past health, Family history, Review of systems, Functional assessment including activities of daily living (ADLs)
When performing the health history do it in an
orderly fashion
The Health History Areas of focus may differ slightly in terms of
individual patient concerns.- issued reported
developmental considerations- delays in development
presence of health problem
no detection of health problems.
concerns r/t aging.
identification of vulnerable population.
identified barriers to communication.
Subjective data
Determine if they have access to care or needs resources
The Health History
Name, address, and phone number
Biographic Data
Age, birth date, and birthplace
Biographic Data
Gender (identification) and relationship status
Biographic Data
Race and ethnic origin
Biographic Data
Occupation: usual and present, changed occupations due to health or illness
Biographic Data
Primary language- Language-concordant provider or medical interpreter
Biographic Data
Includes patients information
Basic info that makes up the patient
Biographic Data
If they had lost a job due to illness, know
what kind of job they lost and why they had to change the profession
Record who furnishes information, usually the person, although source may be relative or friend.
Source of History
Judge reliability of informant and how willing he or she is to communicate.
Source of History
Reliability leads to consistency of information.
Source of History
Note any special circumstances, such as use of interpreter.
Source of History
Think critically about who is reliable
Source of History
This info goes into the patient medical record
Source of History
Drug reconciliation
Source of History
Ill patient, sleepy, under the influence- not reliable info to gather
Source of History
Brief spontaneous statement in (pts) person’s own words describing reason for visit
Reason for Seeking Care
Document reported findings
Reason for Seeking Care
Subjective sensation person feels from disorder documented in quotes
Symptom:
Objective abnormality that can be detected on physical examination or in laboratory reports
Sign:
Reason for care is not a diagnostic statement.- document exactly what the patient says they are there
Reason for Seeking Care
Focus on patient’s prioritized reasons for seeking care.- ask the patient why they came to seek help.
Reason for Seeking Care
Present Health or History of Present Illness (HPI): Collect all provided data and identify eight critical characteristics (Pain or injury, discomfort)
Location, character(quality), quantity(severity), timing, setting, aggravating or relieving factors, associated factors and patient’s perception
Present Health or History of Present Illness (HPI): Make sure that collected data are precise and accurate.
Use measurable standards and/or patient’s own words as qualifiers.
Present Health or History of Present Illness (HPI): Use standardized indicators to document findings
Reliability and validity of reported results (Pain scale)
Go over pts past health and present illness
Present Health or History of Present Illness (HPI):
Gather pts perception to try to identify what they feel is going on
Present Health or History of Present Illness (HPI):
Each of the identified areas can have residual impact on present (as well as future) health status. (ex: Stroke)
Past Medical History
Focus on obtaining specific pertinent information relative to each of the identified categories.
Past Medical History
More accurate and detailed information obtained will lead to better clinical decision making.
Past Medical History
Will provide cues as to how patient’s cope with illness and/or health concerns. Identify how they cope, what they use, how much they use.
Past Medical History
Patients can become emotional when talking about the past, stop and comfort them
Past Medical History
Ask them if they had any changes within the past year
Past Medical History
Past Medical History: Childhood illnesses
Experienced or exposed to presence or absence of complications. Document actual diagnoses
Past Medical History: Accidents or injuries
Type and nature of event, acute and/or residual deficit noted. (serious injuries)
Past Medical History: Serious or chronic illnesses
Presence of comorbidities has pronounced effect. (Ex: COPD)
Past Medical History: Hospitalizations
Types based on clinical indications, interventions used as therapy, and length of stay along with dates of occurrences
Past Medical History: Operations
Facility, procedure, date
Past Medical History: Obstetric History
Relevant data r/t childbearing inclusive of GPAL, labor/delivery experience, condition of infant, and postpartum course.
Past Medical History: Immunizations
Correlate with CDC Guidelines. If they are up to date or if they have them.
Past Medical History: Last Examination Date
Obtain last data set for commonly occurring labs/diagnostics (blood work, ECG, chest x-ray, occult blood and gender-specific testing—PAP/PSA).
Past Medical History: Allergies
Note allergen and reaction. Sometimes people list the symptoms of the medication instead of the reaction. When it occurred.
Past Medical History: Current Medications
Perform medication reconciliation to determine the right meds and dose
Include prescribed and OTC medication and/or herbal therapy.
Highlights diseases or conditions that an individual may be at risk for as a result of genetics
Family History
Provides age and health or cause of death of relatives (immediate)
Family History
Ability based on results to seek early screening, make possible lifestyle adjustments, and/or undergo periodic surveillance
Family History
Pedigree or genogram used as standardized tool to organize data
Family History
Biographic data
Cross-Cultural Care Implications: Additional questions for new immigrants
Spiritual resource and religion: assess if certain procedures cannot be done
Cross-Cultural Care Implications: Additional questions for new immigrants
Past health: what immunizations, if any
Cross-Cultural Care Implications: Additional questions for new immigrants
Health perception- to begin relationship
Cross-Cultural Care Implications: Additional questions for new immigrants
How does person describe health and illness?
Cross-Cultural Care Implications: Additional questions for new immigrants
How does person see problems he or she is now experiencing?
Cross-Cultural Care Implications: Additional questions for new immigrants
Nutrition: taboo foods or food combinations that is important in their culture
Cross-Cultural Care Implications: Additional questions for new immigrants
Evaluate past and present state of each body system (surgeries that effects them)
Purpose of ROS
Assess that all pertinent data relative to each body system have been noted
Purpose of ROS
Evaluate health promotion practices- Vaccinations, breast exams, testicular exams
Purpose of ROS
Organized manner proceeding in a logical sequence
Cephalocaudal approach
If information obtained in HPI, then it doesn’t have to be re-assessed again.
Items within different systems may not be inclusive
Double check
Patients review of their own body
Make sure including questions that reflects normal process of aging
Review of Systems
Functional Assessment: ADLs- Determines ability that related to their functional status
Self-care activities of daily living as they relate to general health status
Functional Assessment: Objectively measure functional status
Monitor and assess for changes over time.
Functional Assessment: Relevant data related to lifestyle and type of living environment
May include “sensitive” topics r/t lifestyle behaviors and as such may require attention to privacy concerns
Different types of “screening tools” may provide more objective validation of information with regard to substance and/or alcohol abuse. (severity)
Maintain privacy when talking about ___
incontinence
Measure pts ability to provide self care in regard to ADLs, IADLs nutrition, social relationships, self concept, and coping. Healthy living environment
Functional Assessment
Learns how the pt handles day to day activities
Functional Assessment
Questions are asked at the end of the interview
Functional Assessment
Alcohol abuse or misuse- Cage assessment, older population may be more dependent and can drink more.
Cutting down?
Annoyed about criticism?
Guilty about drinking?
Drink in the morning as an eye opener?
If any says yes to 2 or more of the questions, suspect alcohol abuse. Perform more complete substance abuse questionnaire with this patient
Perception of Health- Ask questions such as the following:
How do you define health? Barriers? Focus on a subject?
How do you view your situation now?
What are your concerns?
What do you think will happen in the future?
What are your health goals?
What do you expect from us as nurses, physicians, or other health care providers? To work towards
Use open ended questions to gather as much info as possible
Ask how their health is after last visit
Perception of Health
Informant will not be the PT.
Developmental competence- child
Immunizations, Medications
Developmental competence- child
Past health history can have a residual impact on present (and future) health status
Developmental competence- child
Prenatal delivery and Postnatal period
Developmental competence- child
Most info may come from the parent
Always document the source of the information and the relationship to the child, and if used an interpreter
Determining if the child met their developmental growth or milestone
Development changes or issues
Developmental competence- child
Nutritional changes or issues (bottle or breastfed, nutritional supplements, special formula)
Developmental competence- child
Family History
Developmental competence- child
Review of Systems: CHILD: Same method of inquiry used with the adult patient can now be used with the child.
Use an organized approach.
Include at least “two” individuals—parent and/or child.
Review of Systems: CHILD: Tailor questions to the child’s ___
age and level of development.
Review of Systems: Functional assessment-
focus on child’s position within the family unit. Respect the relationship of the child and caregiver
Not ignoring the child- use inanimate objects
Review of Systems: CHILD
Know about past hospitalizations, allergies and reactions
Review of Systems: CHILD
IADL-
paying bills, laundry, shopping for groceries, effects the patients independence
Pts emotional functioning and cognitive functioning
Relative and dynamic (changes)
Mental status assessment
Mental status is a person’s
emotional and cognitive functioning.
Mental status cannot be scrutinized directly like the characteristics of
skin or heart sounds.
Its functioning is inferred through assessment of an individual’s behaviors:
LOC, Use of language, Mood/affect, Orientation, Ability to pay attention, Memory and abstract reasoning and Perception
When asking questions the pt may take longer to answer questions
Older Adults
The ability to answer questions not effected
Older Adults
As the patients age it will leave the patients mind mostly intact and their general knowledge may not decrease
Older Adults
Should not have any loss of vocabulary
Older Adults
Recent memory allow the thought process to take place
Older Adults
Remote memory should not be effected in older adults
Older Adults
Clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities
Mental disorder
Due to brain disease of known specific organic cause
Organic disorders
Delirium or dementia or alcohol and drug use and use or abuse=
organic disorders
Organic etiology has not yet been established
Psychiatric mental illnesses
Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.
Psychiatric mental illnesses
Anxiety disorder and schizophrenia
Psychiatric mental illnesses
Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are interdependent.
Developmental Competence Infants and Children
Addressing concerns that parents or teachers have as developmental process associated with aging continues
Developmental Competence Infants and Children
Critical issues may be seen r/t substance abuse, suicide, and impact of mental health issues being diagnosed and/or individuals receiving treatment
Developmental Competence Infants and Children
Age-related changes in sensory perception can affect mental status along with chronicity of disease process (presence of comorbidity). (ex: COPD)
Developmental Competence Aging adults
Experienced more Grief and despair surrounding these losses can affect mental status and can result in disability, disorientation, or depression or sadness)
Developmental Competence Aging adults
Older adulthood contains more potential for losses.
Developmental Competence Aging adults
Aging alone should not impact their
mental health
Full mental status examination is a systematic check of emotional and cognitive functioning.
Components of the Mental Status Examination
Usually, mental status can be integrated within the context of the health history interview.
Components of the Mental Status Examination
Four main headings of mental status assessment: A-B-C-T
Appearance/Presentation
Behavior/not normal
Cognition
Thought processes/communication
Document and note
abnormalities
When a Full Mental Status Examination Is Necessary
Initial screenings, sudden behavioral changes, brain lesions, sudden aphasia, symptoms of psychiatric mental illness
Suggests an anxiety disorder or depression
Initial screening
Memory loss, inappropriate social interaction. May have family members reporting changes.
Sudden Behavioral changes
Trauma, tumor, cerebrovascular accident, or stroke
Brain lesions
Impairment of language ability secondary to brain damage. Determine the type. Expressive (cannot speak) or receptive(cannot understand)
Sudden Aphasia
Especially with acute onset
Symptoms of psychiatric mental illness
Enough info to identify any problems-coping skills-
full health history
Known illnesses or health problems
Factors That Could Affect Interpretation of Findings
Medications: Side effects, confusion, depression
Factors That Could Affect Interpretation of Findings
Educational and behavioral level: Level of understanding
Factors That Could Affect Interpretation of Findings
Stress responses observed in: social interactions, changes in sleep habits, stress responses, under the influence or withdrawing
Factors That Could Affect Interpretation of Findings
If any of these factors are present, note them
Factors That Could Affect Interpretation of Findings
Appearance, behavior, cognitive functions, and thought processes
Additional screenings as needed based on observations
Objective Data: Collection Addressing key areas:
Additional screenings as needed based on observations
Objective Data: Collection Addressing key areas:
Documentation of findings and what has changed since the last time seeing this pt
Objective Data: Collection Determination of normal versus abnormal findings
Obtaining baseline and then trending results upon ongoing assessment
Objective Data: Collection Determination of normal versus abnormal findings
Make sure to start with the basic functions first (Conscious) then
language barriers
Objective Data: Appearance
Posture, Body movements, Dress, Grooming and hygiene
Erect and position relaxed, comfortable
Posture
Voluntary, deliberate, coordinated, and smooth and even
Body movements
Appropriate for setting, season, age, gender, and social group
Dress
Congruence between grooming and age
Grooming and hygiene
Objective Data: Behavior
LOC, Facial expression, Speech, Mood and affect
Awake, Alert, Aware, respond appropriately and reasonably to stimuli
Level of consciousness
appropriate to the situation and that is changes appropriate with the topic
Facial expression
Quality of speech is appropriate, note slurring and effortlessly communicate
Speech
Assess body language and facial expressions
Mood and affect
Objective Data: Cognitive Functions
Orientation, Attention span, Recent memory, Remote memory
Discern orientation through course of interview, or use direct questioning to verify
Time:
Place:
Person:
Orientation
Appropriately pay attention
Attention span
Recent memory- 24 diet recall, when did you arrive at the agency. Dementia patients may make up responses
Recent memory
Birthday, Anniversaries, historical events relevant to the person.
Remote memory
____ is going to be lost when the cortical storage area for that memory is damaged.
Occurs in Alzheimer’s disease and dementia or other diseases when the cerebral cortex is damages
Remote memory
Highly sensitive and valid memory test
The Four Unrelated Words Test
Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall
The Four Unrelated Words Test
Pick four words with semantic and phonetic diversity; ask person to remember the four words. Sound different and completely unrelated.
The Four Unrelated Words Test Assessment Process
To be sure person understood, have him or her repeat the words.
Ask for the recall of four words at 5, 10, and 30 minutes.
The Four Unrelated Words Test Assessment Process
Normal response for persons younger than 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes.
The Four Unrelated Words Test Assessment Process
Memory recall test
Tests patients ability to make new memories
Ball, pillow, dog, letter
The Four Unrelated Words Test
____ are the two most common mental health disorders seen in individuals seeking health care.
Anxiety and depression
Generalized anxiety disorder scale (GAD-7)
Consists of 7 itemized scale
Higher the score, greater the likelihood.
First 2 questions relate to core anxiety.
Greater or equal than 3 indicates diagnosis.
Sudden onset of anxiety- lasting less than 10 mins-
panic attack
Irrational fear of a specific object-
Phobia
Generalized anxiety disorder, Social anxiety disorder, OCD and PTSD
most common
Series of tools that can be used in
clinical setting
Patient Health Questionnaire-2 (PHQ-2) complete assessment if positive
Asks 2 questions about depressed mood and anhedonia (lack of interest).
Little interest of pleasure of doing things, feelings of hopelessness. How bad are the symptoms. The higher the score the higher the diagnoses.
Serves as a screening tool to use full PHQ-9 tool
PHQ-9- Series of 9 questions requiring adding column totals that relate to frequency of occurrence of symptoms
Higher the score, the greater the likelihood of functional impairment or clinical diagnosis.
Assess for possible risk for harm if the person expresses feelings of sadness, hopelessness, despair, or grief.
Screening for Suicidal Thoughts
Begin 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
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.
Screening for Suicidal Thoughts
Share with mental health professional to get more help
Screening for Suicidal Thoughts
Is the ability to compare and evaluate alternatives and reach an appropriate course of action
Judgment
____ about daily or long-term goals, likelihood of acting in response to hallucinations (sensory perception for which no external stimuli exists, can strike any sense) or delusions, and capacity for violent or suicidal behavior.
Test judgment
These plans should be realistic and rational.
Judgment
Determined patients family obligations, plans for the future and make sure health plans are appropriate considering their
health condition
Supplemental Mental Status Examination
Mini-Mental State Exam (MMSE) & Montreal Cognitive Assessment (MoCA)
Concentrates only on cognitive functioning
Mini-Mental State Exam (MMSE)
Standard set of 11 questions requires only 5 to 10 minutes to administer.
Mini-Mental State Exam (MMSE)
Useful for both initial and serial (follow up) measurement
Mini-Mental State Exam (MMSE)
Detect dementia and delirium and to differentiate these from psychiatric mental illness.
Mini-Mental State Exam (MMSE)
Normal mental status average 27; scores between 24 and 30 (highest score) indicate no cognitive impairment
Mini-Mental State Exam (MMSE)
Anything greater than or equal to 26 is considered normal
Mini-Mental State Exam (MMSE)
Looks at orientation, ability to pay attention, language
Mini-Mental State Exam (MMSE)
Patient must be able to read and write and able to see the examination
Mini-Mental State Exam (MMSE)
Low education levels or decreased intellectual abilities- be careful
Mini-Mental State Exam (MMSE)
Examines more cognitive domains, more sensitive to mild cognitive impairment
Montreal Cognitive Assessment (MoCA)
Make sure what they are saying is logical
Assess for dementia or delirium
Supplemental Mental Status Examination
Denver II screening test gives a chance to interact directly with child to assess mental status.
Infants and children Screening Tests
“Behavioral Checklist” for school-age children, ages 7 to 11, is tool given to parent along with the history.
Covers five major areas: mood, play, school, friends, and family relations
It is easy to administer and lasts about 5 minutes.
For child from birth to 6 years of age, Denver II helps identify those who may be slow to develop in behavioral, language, cognitive, and psychosocial areas.
An additional language test is the Denver Articulation Screening Examination.
Denver II screening test
Adolescents
Follow same A-B-C-T guidelines as for adults.
Appearance
Behavior
Cognition
Thought
Confusion is common and is easily misdiagnosed.
Presence of delirium can have serious affects.
Developmental Care of Aging Adults
Check sensory status, vision, and hearing before any aspect of mental status.
Developmental Care of Aging Adults
Delirium-
Acute confused state, potentially preventable especially dealing with hospitalized patients. Sudden onset of symptoms related to uti, infection, and impaired sleep. Can be paired with memory deficit
Dementia-
chronic and progressive loss of cognitive abilities. Lose intellectual functions and develop slowly and over time. Impaired judgement and memory
Depression-
long term depressed mood. Lack of pleasure, disturbed sleep, major depressive disorder- one or more major depressive episodes at least 2 weeks of the depressed state. At least 4 additional symptoms of depression
dysrhythmic disorder-
accompanied by 2 years of depressed mood for more days than not. Ask how long they have been depressed
Testing Aging Adults
Follow same A-B-C-T guidelines for the younger adult with these additional considerations.
Appearance
Behavior
Cognition
Though Process
LOC assessment especially if they are dealing with
confusion
If pt has been hospitalized for a significant amount of time they may not be able to tell specifically the
amount of time they have been there
Dementia pts- if asking again it does not
effect the ability to learn
