general survey, mental status exam, and

8/4/2019 General Survey, Mental Status Exam, And

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The general survey is the first step in a head-to-toe assessment. The information gathered

during the general survey provides clues

about the overall health of the client.

The general survey includes:a. Overall impression of the client this

impression requires objective observation

skills to assess the clients appearance,

mobility, and body build.

b. Mental Status Exam this exam helps to

determine the clients emotional and

cognitive functional status.


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Vital Signs pulse, respiration, blood

pressure, temperature, and pain are

the bodys indicators of health.

- Pain is considered to be the 5th

vital sign. It is inexpensive to assess

and does not involve the use of fancy

instruments yet it can be an early

predictor of impending disability.


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Forming an overall impression consists of

systematic examination and recording these

general characteristics and impression of the

client. Assess overall wellness or health of the

client.

Observe any significant abnormalities in the

clients skin color, dress, hygiene, posture,gait, and body build, level of consciousness,

level of comfort, behavior, body movements,

affect, facial expression, speech and mental

acuities.


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It includes determining the clients level of

consciousness, noting posture, andmovements; and evaluating dress, grooming

and hygiene, facial expression, speech, mood,

feelings, and expressions, thought process and

perceptions, and cognitive abilities.

Mini-Mental State Examination this tool is

quick, easy to use, and can be repeated to

monitor the clients improving or deteriorating

progress.

- it is important to note that it assesses only

the clients cognitive functions and does not

assess the clients thought processes or moods.


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Non-invasive physical assessmentprocedure that most clients are

accustomed to.

It provides data that reflect the status ofseveral body systems including but not

limited to the cardiovascular,

neurological, peripheral vascular, and

respiratory systems.

Includes: temperature, pulse,

respirations, blood pressure and pain.


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For the body to function on cellular

level, a core body temperature

between 36.5C and 37.7C

Several factors may cause normalvariations in the core temperature like

strenuous activities, stress and

hormones (ovulation).Body temperature is lowest early in the

morning (4-6am) and highest late in the

evening (8pm-midnight).


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A shockwave is produced when the heart

contracts and forcefully pumps blood out of

the ventricles into the aorta. Then it travels

along the fibers of the arteries and is

commonly called arterial or peripheral pulse.

Several characteristic should be assessed

when measuring the pulse rate, rhythm,

amplitude and contour, and elasticity.

Amplitude can be quantified as:1+ Thready or weak (easy to obliterate)

2+ Normal (obliterate to moderate pressure)

3+ Bounding (unable to obliterate or requires

very firm pressure)


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Respiration can easily observed

without alerting the client by

watching the chest movement.

Notable characteristics of

respiration are rate, rhythm, and

depth.


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It reflects the pressure exerted on the wallsof the arteries. This pressure varies with the

cardiac cycle, reaching a high point with

systolic and a low point with diastole.

It is expressed as the ratio of the systolicpressure over the diastolic pressure.

Blood pressure is affected by:

a. Cardiac output

b. Distensibility of the arteries

c. Blood volume

d. Blood velocity

e. Blood viscosity


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Pulse Pressure difference between

systolic and diastolic pressure. it

reflects the stroke volume, the volume

of blood ejected with each heartbeat.


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Pain screening is very important in

developing a comprehensive.

It is important to identify the location,

intensity, quality, duration and anyalleviating or aggravating factors.

Pain intensity measurement tools such as

a 1-10 Likert scale may be used.Pain quality may be described as dull,

sharp, radiating or throbbing.


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Character: Describe the signs or symptoms.

Onset: When did it begin?

Location: Where is it? Does it radiate?

Duration: How long it last? Does it recur?

Severity: How bad is it?

Pattern: What makes it better? Worse?

Associated Factors: what other symptoms

occur with it?


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Assessment

Procedure

Normal Findings Abnormal Findings

GENERAL APPEARANCE

Observe physical and

sexual development.

Compare clients stated

age with her apparent

age and developmental

stage.

Observe skin condition

and color.

Sexual development is

appropriate for gender and

age.

Client appears to be her

stated chronologic age.

Color is even without

obvious lesions: loght to

dark beige-pink in light-

skinned client: light tan-

dark brown or olive in dark-skinned clients.

Include delayed puberty,

male client with female

characteristics, and female

client with male

characteristics.

Client appears older that

actual chronologic age.

Extreme pallor, flushed, or

yellow in light-skinned

client; loss of red tones and

ashen gray cynosis in dark-

skinned client.

Ob d D i i f U di d l hi l li h


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Observe dress.

Observe

hygiene.

Dress is appropriate for

occasion and weather.

Dress varies considerably

from person to person,

depending on individual

preference. There may beseveral normal dress

variations depending on

the clients

developmental level, age,

socioeconomic level,

culture or subculture.

The client is clean and

groomed appropriately foroccasion. Stains on hands

and dirty nails may

reflect certain

occupations such as

mechanic or gardener.

Uncoordinated clothing, extremely light

clothing or warm clothing for the

weather conditions may be seen on

mentally ill, grieving, depressed, or

poor clients. This may also be noted in

clients with heat or cold intolerance.Extremely loose clothing held up by

pins or a belt suggest recent weight

loss. Clients wearing long sleeves in

warm weather may be protecting

themselves from the sun or covering up

needle marks secondary to drug abuse.Soiled clothing may indicate

homelessness, elderly vision deficits, or

mental illness.

A dirty, unshaven, unkempt appearance

with a foul body odor may reflectdepression, drug abuse, or low

socioeconomic level. Poor hygiene may

be seen in dementia or other conditions

that indicate a self-deficit. If the client

is cared for by others, poor hygiene may

reflect neglect by caregiver.

Ob t P i d C f i i di


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Observe posture

and gait.

Observe body

build as well as

muscle mass and

fat distribution

Posture is erect and

comfortable for age.

Gait is rhythmic and

coordinated with arm

swinging at side.

A wide variety of

body types fall within

a normal range: from

small amounts ofboth fat and muscle

to large amount of

muscle/and or/fat. In

general, the normal

body is proportional.

Curvature of spine indicates a

musculoskeletal disorder. Stiff, rigid

movements are common in arthritis or

Parkinsons disease. Slumped shoulders

may signify depression. Client with chronic

pulmonary obstructive disease tend to leanforward, brace themselves with arms.

A lack of subcutaneous fat with prominent

bones is seen in malnourished. Abundant

fatty tissue is noted in obesity.

MENTAL STATUS


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MENTAL STATUS

Observe the clients

level of

consciousness. Ask

the client his/her

name, address, andphone number.

Observe behavior,

body movements,

and affect.

Observe facial

expression.

Client is alert and oriented

to what is happening at the

time of the interview and

physical assessment. Client

responds to your questionsand interacts appropriately.

Client is cooperative and

purposeful in his or her

interactions with others.Mild to moderate anxiety

may be normal in a client

who is having a health

assessment performed.

Facial features aresymmetric with movement.

Client establishes good eye

contact when conversing

with others. Smiles and

frowns appropriately.

If the client does not respond

appropriately. Lethargy,

obtundation, stupor, and coma

are seen in various conditions

such as neurologic disordersand cerebrovascular disease.

Uncooperative, bizarre

behavior may be seen in the

angry, mentally ill or violentclient. Apathy or crying may

be seen with depression.

Incongruent behavior may be

seen in clients who are in

denial of problems or illness.

Poor eye contact is seen in

depressed clients. An

expressionless, masklike face

is common in Parkinsons

disease. Staring, watchfulness

appears in metabolic disordersand anxiet ina ro riate

F i l i M i di t


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Listen to speech.Note style and

pattern.

Observe mood,

feeling, andexpression. Ask

client, how are

you today?

Speech is clear, moderatelypaced, and culturally

appropriate.

Facial expressions. May indicate

mental illness. Drooping or

gross asymmetry occurs with

neurologic disorder or injury.

Disorganized speech, consistentspeech, or long periods of

silence may indicate mental

illness or a neurologic disorder.

Th 18 it b l f t h h f lt d b h d d i th t k F h it


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The 18 items below refer to how you have felt and behaved during the past week. For each item,indicate the extent to which it is true, by checking the appropriate box next to the item.

1. I do things slowly.Not at allJust a little

SomewhatModerately

Quite a lotVery much

2. My future seems hopeless.Not at allJust a littleSomewhatModerately


3. It is hard for me to concentrate on reading.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

4. The pleasure and joy has gone out of my life.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

5 I have difficulty making decisions


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5. I have difficulty making decisions.Not at allJust a littleSomewhatModerately


6. I have lost interest in aspects of life that usedto be important to me.

Not at allJust a littleSomewhatModeratelyQuite a lotVery much

7. I feel sad, blue, and unhappy.Not at allJust a littleSomewhat

ModeratelyQuite a lot

8 I am agitated and keep moving around


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8. I am agitated and keep moving around.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

9. I feel fatigued.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

10. It takes great effort for me to do simple things.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

11. I feel that I am a guilty person who deserves to be punished.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

12. I feel like a failure.


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12. I feel like a failure.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

13. I feel lifeless -- more dead than alive.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

14. My sleep has been disturbed -- too little, too much, or broken sleep.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

15. I spend time thinking about HOW I might kill myself.Not at allJust a littleSomewhatModeratelyQuite a lotVery much

16 I feel trapped or caught


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16. I feel trapped or caught.Not at allJust a littleSomewhatModerately


17. I feel depressed even when good things happen to me.Not at allJust a little

SomewhatModeratelyQuite a lotVery much

18. Without trying to diet, I have lost, or gained, weight.

Not at allJust a littleSomewhatModeratelyQuite a lotVery much


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54 and up Severely Depressed

36 - 53 Moderate - Severe

22 - 35 Mild - Moderate

18 - 21 Borderline depression

10 - 17 Possibly Mildly Depressed

0 - 9 No Depression Likely


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general survey, mental status exam, and

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