7/7/14

Suicide: Assessment and Interventions

General Guidelines
■ If, at any time, Pt is threatening suicide, get help, call 911.
■ Provide safe environment.
■ Always take overt or covert suicide threats or attempts seriously.
■ Observe Pt closely.
■ Encourage expression of feelings.
■ Assign tasks to increase feelings of usefulness.
■ Provide full schedule of activities.
■ Show acceptance, respect, and appreciation.
■ Do not argue with Pt.
■ Remind Pt that there are alternatives to suicide.

Groups at Increased Risk for Suicide
■ Adolescent and young adult Pts (ages 15–24).
■ Elderly Pts.
■ Terminally ill Pts.
■ Patients who have experienced stress or loss.
■ Survivors of persons who have committed suicide.
■ Individuals with bipolar disorder or schizophrenia.
■ Pts coming out of depression.
■ People who abuse alcohol or other drugs.
■ Patients who have previously attempted suicide.
■ More women attempt suicide; however, more men actually complete suicide.

Lethality Assessment
■ Intention: Ask Pt if he or she thinks about and/or intends to harm self.
■ Plan: Ask Pt if he or she has formulated a plan. What are the details; where, when, and how will the plan be carried out?
■ Means: Check availability of method to commit suicide. Does Pt have access to gun, knife, pills, etc?
■ Lethality of Means: Pills vs. gun; jumping vs. slitting wrist.
■ Rescue: Possibility of rescue.
■ Support or lack of support.
■ Availability of alcohol or drugs.
■ Anxiety level.
■ Hostility.
■ Disorganized thinking.
■ Preoccupation with thought of suicide plan.
■ Prior suicide attempts.
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Common Psychiatric Disorders

Psychotic (Schizophrenia)
■ Characteristics: Delusions, hallucinations, impaired reality, disordered thinking, ambivalence, autistic thinking, disorganized verbalizations, flat or blunted affect.
■ Subdivided into: Paranoid, catatonic, undifferentiated, and disorganized.
■ Common Treatments and Medications: Chlorpromazine (Thorazine), haloperidol (Haldol), risperidone (Risperdal).

Mood (Mania/Depression)
■ Characteristics: Manic Phase: Hyperactivity, euphoria, flamboyance, flight of ideas, sexual acting out, dehydration, delusions of grandeur, hostility and aggression; Depressive Phase: Loss of ambition, lack of interest, low self-esteem, boredom, sadness, high suicide risk.
■ Common Treatments: Mania: Lithium (Lithotabs; toxic: 1.5 mEq/L);
Depression: Amitriptyline (Elavil, doxepin (Sinequan), sertraline (Zoloft), imipramine (Tofranil), fluoxetine (Prozac), phenelzine (Nardil).

Anxiety: Obsessive-Compulsive Disorder (OCD)
■ Characteristics: Uncontrolled, recurrent thoughts; ritualistic behavior that serves to reduce tension from obsessive thoughts.
■ Common Treatments: Clomipramine (Anafranil).

Personality (Borderline Personality)
■ Characteristics: Impulsivity, unpredictability, behavior problems, difficulty interacting, marked mood shifts, predisposition to self-harm, uncertainty about self-image, gender identity, values, splitting.
■ Common Treatments: Protect from self-mutilation and suicidal gestures, set limits, use calm approach, teach relaxation techniques and cognitivebehavioral therapy.

Somatoform (Hypochondriasis)
■ Characteristics: Unrealistic belief of having a serious illness regardless of medical reassurance; preoccupation with bodily functions that are misinterpreted; history of seeing many doctors with numerous diagnostic tests; dependent behavior; focus is anxiety, not perceived symptom.
■ Common Treatments: Use diversionary activities, limit interactions, provide correct information about etiology of perceived symptoms and cognitive-behavioral therapy.
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Psychiatric/Mental Health Assessment

General Safety Guidelines
■ Safety:Your safety ALWAYS comes first!
■ Awareness:Watch for nonverbal indicators of aggression or violence: clenched fists, pacing, raised tone of voice, increased respirations, profanity, verbal threats, weapons, wide-eyed stare.
■ Exit: Always position yourself between Pt and an exit. Never allow Pt to block your means of escape.
■ Be Assertive: Make your boundaries known, set limits, and stick to them. Avoid arguing or bargaining with Pts.

Psychiatric Mental Status Assessment
Appearance
■ Grooming, hygiene, posture, eye contact, correlation between appearance and developmental stage and age.

Motor Activity
■ Tremors, tics, mannerisms, gestures, gait, hyperactivity, restlessness, agitation, echopraxia, rigidity, aggressiveness.

Speech Pattern
■ Aphasia, volume, impairments, stutter.

General Attitude
■ Cooperative, uncooperative, friendly, hostile, defensive, guarded, apathetic.

Mood
■ Depressed, sad, anxious, fearful, labile, irritable, elated, euphoric, guilty, despairing.

Affect
■ Congruent with mood, flat, inappropriate.

Thought Process
■ Form of Thought:Tangentiality, word salads, neologisms, echolalia, attention span
■ Content of Thought: Delusional, suicidal, homicidal, obsession, paranoid, suspicious, religiosity-based, phobic,  magical.

Sensory/Perceptual Disturbances
■ Hallucinations (auditory, visual, tactile, olfactory, gustatory), illusions (depersonalization, derealization).

Cognitive
■ Alertness, orientation, memory, abstract thinking.

Impulse Control
■ Aggression, fear, guilt, affection, sexual.

Judgment/Insight
■ Decision making, problem solving, coping.
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Dermatomes

Dermatomes
Each dermatome represents an area supplied with afferent or sensory nerve fibers from an individual nerve root from the spinal cord; cervical, C1–8; thoracic, T1–12; lumbar, L1–5; sacral, S1–5. Dermatomes are used to assess sensation when trying to locate source of lesion or spinal cord injury.

Assessment
■ Test sensation to pinprick in all dermatomes.
■ If Pt is found to have no sensation below level of nipples, then lesion or injury is likely to be at level of T4.

Document
■ Record most caudal (lowest) dermatome that feels pinprick (e.g., “No sensation at or below level T4”).

Dermatomes
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Levels of Consciousness

Levels of Consciousness

■ Alert: Awake, alert, and oriented and responds appropriately.
■ Lethargic: Oriented to person, time, and place; sluggish speech; sleepy; awakens and remains awake with sufficient stimulation.
■ Confused: Disoriented to person, time, and place. Memory deficits, difficulty following commands, restless, agitated.
■ Obtunded: Extreme drowsiness, responds with one–two words, follows simple commands, but requires vigorous stimulation.
■ Stuporous: Minimal movement, responds unintelligibly, and awakensbriefly only to repeated vigorous stimulation.
■ Coma: Unresponsive to verbal stimuli. May have appropriate motor response (withdraws from pain) or nonpurposeful or no response.
AVPU Scale
A
Alert
Pt is alert and requires no stimulation.
V
Verbal
Pt responds only to verbal stimulation.
P
Painful
Pt responds only to painful stimulation.
U
Unresponsive
Pt is unresponsive to any stimulation.
Possible Causes of Altered LOC
Cause
Remarks
A
Alcohol
Protect airway, anticipate emesis.
E
Epilepsy
Protect Pt from injury, do not insert object into
Pt’s mouth, assess seizure med levels.
Electrolyte
Monitor and treat serial serum electrolytes.
I
Insulin
Protect airway, obtain stat blood glucose level
and treat accordingly (dextrose for
hypoglycemia or insulin for hyperglycemia).
O
Overdose
Protect airway, take precautions to protect self if
Pt is aggressive, give reversal agents.
U
Uremia
Assess for overuse of NSAIDs, especially with
elderly; Pts will require dialysis.
T
Trauma
Protect airway, immobilize cervical spine, assess
pupils, assess for neurologic deficits.
Temp
Obtain core (preferred) body temperature,
administer prescribed antipyretics, use cooling
blanket, lukewarm sponge bath as ordered.
I
Infection
Protect airway, obtain blood cultures, and
administer antibiotics as ordered.
P
Psychiatric
Protect self, do not confront Pt, get help.
S
Stroke (neuro)
Protect airway, position Pt onto affected side,
assess pupils, assess for neurologic deficits.
Shock
Establish ABCs; immobilize c-spine as indicated.

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Deep Tendon Reflex Grading Scale

Deep Tendon Reflex Grading Scale

0 . . . . . . . Absent
1+ . . . . . Diminished
2+ . . . . . Normal
3+ . . . . . Hyperactive without clonus
4+ . . . . . Hyperactive with clonus
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Muscle Strength Grading Scale

Muscle Strength Grading Scale

0 . . . . . . . No muscle movement
1 . . . . . . . Visible muscle movement, but no joint movement
2 . . . . . . . Joint movement, but not against gravity
3 . . . . . . . Movement against gravity, but not against added resistance
4 . . . . . . . Movement against resistance, but less than normal
5 . . . . . . . Normal strength
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Glasgow Coma Score

Glasgow Coma Score
Eyes Open
■ Spontaneously . . . . . . 4
■ To command . . . . . . . 3
■ To pain . . . . . . . . . . . . 2
■ Unresponsive . . . . . . . 1
Findings
Best Verbal Response
■ Oriented . . . . . . . . . . . 5
■ Confused . . . . . . . . . . 4
■ Inappropriate . . . . . . . 3
■ Incomprehensible . . . 2
■ Unresponsive . . . . . . . 1
Findings
Best Motor Response
■ Obeys commands . . . . . . . . 6
■ Localizes pain . . . . . . . . . . . . 5
■ Withdraws from pain . . . . . . 4
■ Abnormal flexion . . . . . . . . . 3
■ Abnormal extension . . . . . . 2
■ Unresponsive . . . . . . . . . . . . 1
Findings
Total....................
Note: The total GCS score should be broken down into its relative components (e.g., a GCS of 11 could be stated as E3V3M5). A GCS of 13–14 may indicate a mild brain injury; 9–12, moderate brain injury; 3–8, severe brain injury.
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Brief Neurologic Exam

Brief Neurologic Exam

Mental Status
■ Impression: Observe affect, mood, appearance, behavior, cognition, and grooming.
■ Speech: Assess for clarity and coherence.
■ LOC: Is Pt alert, lethargic, stuporous, or obtunded?
■ Orientation: Person, place, time, and/or situation.

Motor
■ Inspect: Involuntary movements, muscle symmetry, atrophy.
■ Muscle Tone: Flex and extend wrists, elbows, ankles, and knees; slight, continuous resistance to passive movement is normal. Note any decreased (flaccid) or increased (rigid or spastic) muscle tone.
■ Motor Strength: Have Pt move against your resistance and score accordingly.

Reflexes
■ Tendon Reflexes.
■ Babinski (Plantar Reflex): Stroke lateral aspect of sole of each foot with reflex hammer. Normal response is flexion (withdrawal) of toes. Positive Babinski is characterized by extension of big toe with fanning of other toes (abnormal).
■ Clonus: With knee supported in partially flexed position, quickly dorsiflex foot. Rhythmic oscillations: positive clonus.

Gait/Balance
■ Observe gait while Pt walks across room and comes back.
■ Have Pt walk heel-to-toe or on heels in a straight line.
■ Have Pt hop in place on each foot.
■ Have Pt stand from sitting position or do shallow knee bend.

Coordination
■ Rapid Alternating Movements: Instruct Pt to tap tip of thumb with tip of index finger as fast as possible.
■ Point-to Point Movements: Instruct Pt to touch his or her nose and your index finger alternately several times. Continually change the position of your finger during test.
■ Romberg Test: Be prepared to catch Pt! Request that Pt stand with feet together, eyes closed for 10 seconds. If Pt becomes unstable, test is positive, indicating proprioceptive or vestibular problem.
■ Proprioception: While standing, instruct Pt to close eyes and alternate touching his or her index fingers to nose.

Sensory
■ Using your finger and a toothpick, instruct Pt to distinguish between sharp and dull sensations. Compare left to right, with Pt’s eyes closed.
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Genitourinary Reproductive Assessment

Genitourinary Reproductive Assessment

■ Pain: Female Pts: Assess for dysmenorrhea (abnormally severe cramping or pain in lower abdomen during menstruation); Male Pts: Assess for pain in penis, testes, scrotum, and groin area. Is there any history of painful or burning urination?

■ Lesions: Inspect perineum for blisters, ulcers, sores, warts, or rashes.

■ Breast: Inspect for asymmetry. Inspect skin for dimpling or edema. Inspect nipples for color, discharge, or inversion. Palpate in concentric circles, outward from nipple, including axillae, for lumps or tenderness and presence of implants. Does Pt perform regular breast self-examinations?

■ Testicles: Palpate scrotum and groin area for lumps, masses, or swelling. Does Pt perform testicular self-examinations?

■ Discharge: Female Pts: Assess for vaginal discharge and note color, odor, amount, and any associated symptoms; Male Pts: Inspect meatus for discharge and note color, amount, and any associated symptoms.

■ Menstruation: Describe last menstrual period including date. Do periods occur regularly? Have Pt describe her “normal flow.” Bleeding other than normal menstrual period should be further assessed including frequency, quantity, and associated symptoms.

■ Genitourinary Symptoms: Kidney stones, blood in urine, dysuria, change in voiding pattern (frequency), itching, or erectile dysfunction in males.

■ Sexual History: Is Pt sexually active? Does he or she use protection against infection? Method of birth control? Multiple or same-sex partners? Any concern with or history of STD?

■ Document: Assessment, interventions, and outcomes.
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Skin: Integumentary

Skin: Integumentary
Assess
Document: Assessment, Interventions, Outcomes
Color
Cyanosis, redness, pallor, or jaundice.
Temp
Coolness or warmth.
Moisture
Diaphoresis or excessive dryness.
Turgor
The time it takes the skin to flatten out after pinching section over forehead or sternum (do not use hand or arm; these are unreliable areas); poor skin turgor may indicate dehydration (may be normal in elderly).
Edema
Extremities, sacrum, dependent side (if debilitated, bedfast, or chairfast), facial/sclera, bilateral vs. unilateral.
Lesions
Presence and type of skin lesions.


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Extremities

Extremities
Grips
Equality and strength: Have Pt squeeze your fingers with
his or her hands and assess push-pull strength of feet.
CSM
Distal pulses, capillary refill, sensation, and motor
movement.
Nails
Cyanosis, angle of attachment, clubbing.
ROM
Limitations and pain during movement.
Edema
Localized vs. diffuse, dependent vs. nondependent.
DVT
Homans’ sign (calf pain on dorsiflexion of foot) especially with postsurgical and debilitated Pts (NEVER massage affected extremities!). Signs/symptoms include pain, venous distention, localized tenderness.


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Assessment of Abdomen

Abdomen
Skill
Document: Assessment, Interventions, Outcomes
Inspect
Skin, distention, scars, obesity, herniations, bruising, pulsations.
Auscultate (before palpate)
Bowel tones: Hypoactive, every minute; normal, every 15–20 seconds; hyperactive, every 3 seconds.
Percussion
Dullness: Solid organ such as the liver.
Tympany: Hollow organs such as bowels.
Resonance: Air-filled organs such as lungs.
Flatness: Dense tissue such as muscle and bone.
Palpate (last)
Pulsations, masses, tenderness, rigidity.
■ Work from area of least pain toward area of most pain.
■ Assess each abdominal quadrant (RUQ, LUQ, RLQ, LLQ).
■ When documenting assessment findings, always refer to specific abdominal quadrant related to finding.


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Order of Auscultating Lung Sounds

Order of Auscultating Lung Sounds
Circulation and Pulses
Assess
Document: Assessment, interventions, outcomes.
Pulses
Equality and character of pulses, comparing right and left.
6 Ps
Pain, pallor, pulselessness, polar, paresthesia, paralysis.
S/S
Swelling, limb pain, change in sensation, fatigue.
Skin
Color, temperature, moisture, hair growth.
Edema
Extremities and dependent areas for edema, varicosities.
Nails
Capillary refill, cyanosis, angle of attachment, clubbing.
History
PVD, DM, HTN, CHF, DVT, surgical procedures, lymphedema, meds.


Capillary Refill
Normal . . . . . . . . . . . . . . . <3 seconds
Delayed . . . . . . . . . . . . . . . >3 seconds

Pulse Strength
>0 . . . . . . . . . . . . . Absent
1 . . . . . . . . . . . . .Weak
2 . . . . . . . . . . . . . Normal
3 . . . . . . . . . . . . . Full
4 . . . . . . . . . . . . . Bounding
Right arm:
Left arm:
Right leg:
Left leg:

Edema Scale
+1 . . . Slight pitting with 2 mm of depression that disappears rapidly. No visible distortion of extremity.
+2 . . . Deeper pitting with 4 mm of depression that disappears in ~10–15 seconds. No visible distortion of extremity.
+3 . . . Depression of 6 mm that lasts >1 minute. Dependent extremity appears swollen.
+4 . . . Very deep pitting with 8 mm of depression that lasts 2–3 minutes. Dependent extremity is grossly edematous.

Common Pulse Points
Temporal . . . . . . . . Just anterior to upper third of ear
Carotid . . . . . . . . . Below angle of jaw on either side of trachea
Apical . . . . . . . . . . Left side of chest at the 5th ICS, midclavicular line
Brachial . . . . . . . . . Medial antecubital fossa
Radial . . . . . . . . . . Medial-ventral wrist below base of thumb
Femoral . . . . . . . . . Crease of groin between pubis and hip bone
Popliteal . . . . . . . . Popliteal fossa behind knee
Dorsal pedis . . . . . . Medial dorsum of foot
Posterior tibial . . . . Slightly below the posterior malleolus of the foot
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Cardiac Auscultation Sites

Cardiac Auscultation Sites

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Lung Sounds Differential Diagnosis

Lung Sounds: Differential Diagnosis

Rales (Crackles)
■ Simulated by rolling hair near ear between two fingers.
■ Best heard on inspiration in lower bases.
■ Unrelieved by coughing.
■ Associated with bronchitis, CHF, and pneumonia.

Wheezes
■ High-pitched, squeaky sound.
■ Best heard on expiration over all lung fields.
■ Unrelieved by coughing.
■ Associated with asthma, bronchitis, CHF, and emphysema.

Rhonchi
■ Coarse, harsh, loud gurgling.
■ Best heard on expiration over bronchi and trachea.
■ Often relieved by coughing.
■ Associated with bronchitis and pneumonia.

Stridor
■ Harsh, high-pitched, audible sound.
■ Easily heard without stethoscope during inspiration and expiration.
■ Indicates progressive narrowing of upper airway and can be lifethreatening, requiring immediate attention.
■ Associated with partial airway obstruction, croup (inspiratory), and epiglottitis (severe, audible).

Unilaterally Absent or Diminished
■ Inability to hear equal, bilateral breath sounds.
■ Associated with pneumothorax, tension pneumothorax, hemothorax, or history of pneumectomy.

Documentation of Lung Sounds
■ Rate, rhythm, depth, effort, sounds (indicate if sound is inspiratory and/or expiratory phase), and fields of auscultation.
■ Interventions (if any implemented) and outcomes.
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Assessment of Respiratory System

■ Inspect: Respirations for rate, depth, effort, pattern, and presence of cough (productive or nonproductive); note signs of distress such as nasal flaring or sternal retractions. Inspect size and shape of chest, symmetry of chest wall movement, and use of accessory muscles. Inspect extremities for cyanosis and fingers for clubbing indicating chronic hypoxia. Inspect trachea for scars, stomas, or deviation from midline.

■ Palpate: Anterior and posterior thorax for subcutaneous emphysema, crepitus, and tenderness. Assess tactile fremitus by palpating the chest as the Pt says “99.”

■ Percuss: Anterior and posterior thorax for tympany (hollow organs), resonance (air-filled organs), dullness (solid organs), or flatness (muscle or bone).

■ Auscultate: Using stethoscope, auscultate all anterior and posterior lung fields, noting normal, abnormal, or absence of lung sounds.

Respiratory Patterns
Normal (eupnea)
Regular and comfortable at 12–20 breaths/minute.
Tachypnea
>20 breaths/minute.
Bradypnea
<12 breaths/minute.
Hyperventilation
Rapid, deep respiration >20 breaths/minute.
Apneustic
Neurologic: sustained inspiratory effort.
Cheyne-Stokes
Neurologic: alternating patterns of depth separated by brief periods of apnea.
Kussmaul
Rapid, deep, and labored: common in DKA.
Air trapping
Difficulty during expiration: emphysema.
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Assessment of Cardiovascular System

Assessment of Cardiovascular System

■ Inspect: Overall condition and appearance. Inspect skin, nail beds, and extremities for flushing, pallor, cyanosis, bruising, and edema. Observe chest for scars, symmetry, movement, and deformity. Inspect neck for JVD and inspect PMI for any remarkable pulsations. Analyze ECG recording if available.

■ Palpate: Skin temperature and moisture. Palpate PMI for any lifts, heaves, thrills, or vibrations. Palpate and grade radial, dorsalis pedis, and posterior tibial pulses; note rate and rhythm. Palpate and grade edema if present.

■ Percuss: Starting at the midaxillary line, percuss toward the left cardiac border along the fifth ICS. Sound should change from resonance to dullness at midclavicular line.

■ Auscultate: Using stethoscope, auscultate apical pulse and compare it with radial pulse. Auscultate heart valves for normal S1 (lub) and S2 (dub) heart sounds. Abnormal sounds include extra beats (S3 and S4), bruits, valvular murmurs, pericarditic rubs, and artificial valve clicks.
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Head and Neck Assessment

Appearance: Inspect Pt’s overall appearance.
■ Hygiene, state of well-being, nutrition status.
■ Level of consciousness, emotional status, speech patterns, affect, posture, gait, coordination, and balance.
■ Any gross deformities.

Skin: Inspect and palpate exposed skin.
■ Warmth, moisture, color, texture, lesions.
■ Scars, body piercings, tattoos.

Hair and Nails: Inspect hair, hands, and nails.
■ Hair color, fullness, and distribution, noting any signs of malnutrition (thinning).
■ Infestation or disease.
■ Clubbing of nails, deformity, abnormalities of hands.

Head: Inspect and palpate face and scalp.
■ Facial symmetry.
■ Scalp tenderness, lesions, or masses.

Eyes: Inspect sclera, conjunctiva, and pupils.
■ Color and hydration of conjunctiva and sclera.
■ PERRLA: Pupils equal, round, reactive to light and accommodation.

Ears: Inspect.
■ Hearing impairment.
■ Use of hearing aids.
■ Pain, inflammation, and drainage.

Nose: Inspect.
■ Congestion, drainage, and sense of smell.
■ Patency/equality of nostrils, nasal flaring.
■ Septal deviation.

Throat and Mouth: Inspect teeth, gums, tongue, mucous membranes, and oropharynx.
■ Color and hydration of mucous membranes.
■ Gingival bleeding or inflammation.
■ Condition of teeth (any missing, severe decay), dentures.
■ Difficult or painful swallowing.
■ Presence or absence of tonsils.
■ Oral hygiene and the presence of odor.

Neck: Inspect and palpate neck. Test ROM.
■ Jugular vein distention (JVD), tracheal alignment (deviation), and retractions.
■ Swollen lymph nodes or enlarged thyroid.........
■ Decreased ROM, stiffness, or pain.
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