NUR 2092 Exam 2 Study Guide: Health Assessment
1. Delirium: (Acute Confusional State) potentially preventable in hospitalized persons. Characterized by
disorientation, disordered thinking and perceptions (illusions and hallucinations), defective memory,
agitation, inattention
• Sudden, over hours to days
• Causes: hypoglycemia, fever, dehydration, hypotension, infection, adverse drug reaction, head
injury, change in environment, pain, emotional distress, substance abuse
• Cognition: impaired memory, judgment, calculations, attention span, can fluctuate day to day
• Level of Consciousness: Altered
• Activity Level: Can be increased or reduced; restlessness; behaviors may worsen in evening
(sundowners); sleep/wake cycle may be reversed
• Emotional State: Rapid swings, can be fearful, anxious, suspicious, aggressive, have
hallucinations and/or delusions
• Speech and Language: Rapid; inappropriate, incoherent, rambling
• Prognosis: Reversible with proper and timely treatment
2. Dementia: a chronic progressive loss of cognitive and intellectual functions, although perception and
consciousness are intact. Characterized by disorientation, impaired judgment, memory loss.
• Onset: Slowly, over months
• Causes: Alzheimer disease, vascular disease, HIV, neurological disease, chronic alcoholism,
head trauma
• Cognition: Impaired memory, judgment, calculations, attention span, abstract thinking, agnosia
• Level of Consciousness: Not altered
• Activity Level: Not altered; behaviors may worsen in evening (sundowners)
• Emotional State: Flat; agitation
• Speech and Language: Incoherent, slow (sometimes due to effort to find the right words),
rambling, repetitious
• Prognosis: Not reversible; progressive
3. Suicide:
4. Mini-Mental State Exam (MMSE): used with caution with people with low education; Requires paper
and pencil; person must be able to write and have no vision impairment. It is quick and easy with 11
questions and takes 5-10 min to administer. It will demonstrate worsening or improvement. It
concentrates only on cognitive functioning, not mood or thought process. It is detector of organic
disease; dementia and delirium and to differentiate these from psychiatric mental illness. Max score is
30, normal will score average 27; 24-30 indicates no cognitive impairment. Available only by copyright.
5. Denver II Screening: gives chance to interact with child to assess mental status; designed to detect
developmental delays
6. Mini-Cog: reliable, quick and easily available to screen for cognitive impairment in older adults. Takes
3-5 min. Consists of a 3-item recall test and a clock-drawing test.
7. 4 Unrelated Words Test: tests the person’s ability to lay down new memories. It is a highly sensitive
and valid memory test. It avoids the danger of unverifiable material. Pick words with semantic and
phonetic diversity. Ask to repeat in 5 min, 10 min and at 30 min. Normal response for people younger
than 60 is accurate 3-4 recall. People with Alzheimer will score 0-1 words. Score can be low with
anxiety and depression due to inattention and distractibility.
8. Appearance, Behavior, Cognition, and Thought Processes (A, B,C,T): four main headings of mental
status assessment.
9. Physical Changes in Elderly:
, • Vision and Hearing changes may alter alertness and leave a person looking confused. Always
check sensory status before assessing any aspect of mental status.
• There is no decrease in knowledge; response time is slower because it takes brain longer to
process information and to react.
• Recent memory is decreased
• Hearing Problems: Consonants are high frequency sounds; older people have difficulty hearing
them. This produces frustration, suspicion, and social isolation, and makes the person look
confused.
• Losses (loved ones, income…): can lead to despair and grief; can result in disorientation,
disability, or depression.
• Orientation: many elderly persons experience social isolation, loss of structure, a change in
residence, or some short-term memory loss. You can consider them oriented if they know
generally where they are and the present period.
• People in their 70’s will average 2-4 words in 5 min. They will improve at 10 and 30 min after
being reminded by verbal ques.
10. Assessment Techniques:
• Inspection: concentrated watching; it is close scrutiny first of whole and then each body
system.
Begins moment first meet and develop a general survey
Train yourself not to rush by holding hands behind back
Use person as his/her own control and compare right and left sides of the body. Should
be nearly symmetric
Requires good lighting, adequate exposure, and use of tools (penlight…)
• Palpation: uses sense of touch to assess texture, temperature, moisture; organ location and
size; swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses, and presence of tenderness or pain.
Different parts of hand:
➢ Fingertips: best for fine tactile discrimination, as of skin texture, swelling,
pulsation and determining presence of lumps
➢ A Grasping Action of fingers and thumb: to detect the position, shape and
consistency of an organ or mass
➢ Dorsa (back) of Hands and Fingers: Best for determining temperature because
skin is thinner than on palms
➢ Base of fingers (Metacarpophalangeal) or Ulnar surface of hand: best for
vibrations.
Technique should be slow and systematic, calm and gentle.
➢ Warm hands first
➢ Note any tender areas and do them last.
Start with light palpation to detect surface characteristics and to allow patient to get
used to being touched
Use Deep palpation next: intermittent pressure is better than one long, continuous one.
Bimanual Palpation: requires use of both hands to envelop or capture certain body
parts such as kidney, uterus.
• Percussion: is tapping the skin with short, sharp strokes to assess underlying structures.
Mapping out location and size by where the percussion note changes between borders
Signaling density of a structure by a characteristic note
Detecting abnormal mass if it’s superficial; percussion penetrates about 5cm deep
1. Delirium: (Acute Confusional State) potentially preventable in hospitalized persons. Characterized by
disorientation, disordered thinking and perceptions (illusions and hallucinations), defective memory,
agitation, inattention
• Sudden, over hours to days
• Causes: hypoglycemia, fever, dehydration, hypotension, infection, adverse drug reaction, head
injury, change in environment, pain, emotional distress, substance abuse
• Cognition: impaired memory, judgment, calculations, attention span, can fluctuate day to day
• Level of Consciousness: Altered
• Activity Level: Can be increased or reduced; restlessness; behaviors may worsen in evening
(sundowners); sleep/wake cycle may be reversed
• Emotional State: Rapid swings, can be fearful, anxious, suspicious, aggressive, have
hallucinations and/or delusions
• Speech and Language: Rapid; inappropriate, incoherent, rambling
• Prognosis: Reversible with proper and timely treatment
2. Dementia: a chronic progressive loss of cognitive and intellectual functions, although perception and
consciousness are intact. Characterized by disorientation, impaired judgment, memory loss.
• Onset: Slowly, over months
• Causes: Alzheimer disease, vascular disease, HIV, neurological disease, chronic alcoholism,
head trauma
• Cognition: Impaired memory, judgment, calculations, attention span, abstract thinking, agnosia
• Level of Consciousness: Not altered
• Activity Level: Not altered; behaviors may worsen in evening (sundowners)
• Emotional State: Flat; agitation
• Speech and Language: Incoherent, slow (sometimes due to effort to find the right words),
rambling, repetitious
• Prognosis: Not reversible; progressive
3. Suicide:
4. Mini-Mental State Exam (MMSE): used with caution with people with low education; Requires paper
and pencil; person must be able to write and have no vision impairment. It is quick and easy with 11
questions and takes 5-10 min to administer. It will demonstrate worsening or improvement. It
concentrates only on cognitive functioning, not mood or thought process. It is detector of organic
disease; dementia and delirium and to differentiate these from psychiatric mental illness. Max score is
30, normal will score average 27; 24-30 indicates no cognitive impairment. Available only by copyright.
5. Denver II Screening: gives chance to interact with child to assess mental status; designed to detect
developmental delays
6. Mini-Cog: reliable, quick and easily available to screen for cognitive impairment in older adults. Takes
3-5 min. Consists of a 3-item recall test and a clock-drawing test.
7. 4 Unrelated Words Test: tests the person’s ability to lay down new memories. It is a highly sensitive
and valid memory test. It avoids the danger of unverifiable material. Pick words with semantic and
phonetic diversity. Ask to repeat in 5 min, 10 min and at 30 min. Normal response for people younger
than 60 is accurate 3-4 recall. People with Alzheimer will score 0-1 words. Score can be low with
anxiety and depression due to inattention and distractibility.
8. Appearance, Behavior, Cognition, and Thought Processes (A, B,C,T): four main headings of mental
status assessment.
9. Physical Changes in Elderly:
, • Vision and Hearing changes may alter alertness and leave a person looking confused. Always
check sensory status before assessing any aspect of mental status.
• There is no decrease in knowledge; response time is slower because it takes brain longer to
process information and to react.
• Recent memory is decreased
• Hearing Problems: Consonants are high frequency sounds; older people have difficulty hearing
them. This produces frustration, suspicion, and social isolation, and makes the person look
confused.
• Losses (loved ones, income…): can lead to despair and grief; can result in disorientation,
disability, or depression.
• Orientation: many elderly persons experience social isolation, loss of structure, a change in
residence, or some short-term memory loss. You can consider them oriented if they know
generally where they are and the present period.
• People in their 70’s will average 2-4 words in 5 min. They will improve at 10 and 30 min after
being reminded by verbal ques.
10. Assessment Techniques:
• Inspection: concentrated watching; it is close scrutiny first of whole and then each body
system.
Begins moment first meet and develop a general survey
Train yourself not to rush by holding hands behind back
Use person as his/her own control and compare right and left sides of the body. Should
be nearly symmetric
Requires good lighting, adequate exposure, and use of tools (penlight…)
• Palpation: uses sense of touch to assess texture, temperature, moisture; organ location and
size; swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses, and presence of tenderness or pain.
Different parts of hand:
➢ Fingertips: best for fine tactile discrimination, as of skin texture, swelling,
pulsation and determining presence of lumps
➢ A Grasping Action of fingers and thumb: to detect the position, shape and
consistency of an organ or mass
➢ Dorsa (back) of Hands and Fingers: Best for determining temperature because
skin is thinner than on palms
➢ Base of fingers (Metacarpophalangeal) or Ulnar surface of hand: best for
vibrations.
Technique should be slow and systematic, calm and gentle.
➢ Warm hands first
➢ Note any tender areas and do them last.
Start with light palpation to detect surface characteristics and to allow patient to get
used to being touched
Use Deep palpation next: intermittent pressure is better than one long, continuous one.
Bimanual Palpation: requires use of both hands to envelop or capture certain body
parts such as kidney, uterus.
• Percussion: is tapping the skin with short, sharp strokes to assess underlying structures.
Mapping out location and size by where the percussion note changes between borders
Signaling density of a structure by a characteristic note
Detecting abnormal mass if it’s superficial; percussion penetrates about 5cm deep
