Assessment of Appearance and Behaviors (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:01 Let's talk about appearances.

    00:03 We're going to be assessing the appearance of the person in front of us.

    00:07 Now, we assess appearances all the time.

    00:11 We are looking at people and judging their appearance, when we are in a store, when we go into a restaurant, when we're sitting on a subway or a bus.

    00:25 It is a natural thing because our brain will say to us, are we safe or are we not safe? That's not the same assessment that we're doing, when we look at a patient who's being admitted, in a psychiatric unit.

    00:43 We are looking at this patient to see if there is a difference in their gait.

    00:50 How are they walking? Are they unsteady when they're walking? Is there a little bounce? Does it look like they're shuffling their feet? What about their posture? Are we looking at that person and seeing them standing up like this? Are we seeing a person who's very collapsed? Are we seeing a person who's kind of standing like this? I often look to see if they're shifted to the right, shifted to the left.

    01:24 Do we find there are some people that you will look at, and you'll see that one shoulder is up and one shoulders down, and their posture is really moved over? We want to look at people's clothing.

    01:36 How are they clothed? Do their clothes fit? Are their clothes dirty? Are their clothes appropriate? How about their hair? How about their nails? Their hands? Are they clean? Is their hair clean? Have they been brushing their teeth? Sometimes, with some of my patients, the first indication I get that they're beginning to what we call decompensate, which means fall back into their mental illness is they'll come in with dirty teeth.

    02:09 And I will say to them, "I noticed you weren't brushing your teeth this morning.

    02:13 I usually keep toothbrushes in my office." I'll say, "Would you like to use a toothbrush? I have some extra ones and some toothpaste." And I watched to see what they say to me.

    02:26 I had one patient who as he was becoming sicker and sicker, he was in the middle of the summer, his clothing started to change.

    02:35 And one day when he came in to speak with me, he was wearing a winter coat.

    02:40 It was 80 degrees out. He was sweating.

    02:44 And I said, "Are you comfortable in that coat?" He said, yes.

    02:48 I said, "Do you know what month it is?" He said, "Yes, It's December." It was August.

    02:54 Being able to observe changes is going to let us know what's happening in our minds.

    03:00 Even for yourself.

    03:02 Think about days that you just don't feel up to getting dressed.

    03:07 And you go out. People look at you and say, "Are you okay?" They're assessing your appearance.

    03:14 When we are looking at our patients, we have to take that critical assessment up three notches.

    03:21 We want to look at their behaviors.

    03:25 I find that a person who has PTSD is usually frozen.

    03:30 And what do I mean by that? They have no gestures.

    03:34 They'll sit there and they'll tell me their story.

    03:37 And then I watched and the train came, and my mother was trying desperately to get out of the car.

    03:43 And cannot get out of the car.

    03:45 And then there was no car.

    03:47 And there's no movement. There's no facial expression.

    03:51 There's no arm movement.

    03:53 Or someone saying, "I don't know. I don't know.

    03:57 I don't know how to get this done. It's like..." And I will say to them, "Wow, your arms are really excited." How are they gesturing? Are they using gestures? What kind of mannerisms that you're seeing? Are they clicking their tongue.

    04:16 There are some medications that will give us some extra pyramidal symptoms, which might be tremors, or they might have automatic behaviors or mannerisms like...

    04:33 poking their tongue into the side of their cheeks that comes from medication.

    04:37 Or maybe tongue thrust, they'll be talking to you.

    04:41 And then all of a sudden their tongue comes out.

    04:45 You want to make sure that if you see anything like this, that you are writing it down, and you're going back, and checking their medications to see if in fact they're starting to have extra pyramidal symptoms from their psychiatric meds.

    05:00 We want to look at their expressions?** Why do you think expression might be really important? We're looking for that congruence.

    05:08 The congruence between their mood and their affect.

    05:11 We want to find out, if they're smiling at you, and they're talking to you, and they're telling you about the time they lost a baby.

    05:21 And they seem to be really happy about it.

    05:25 But, you know, this is really terrible, because what they're telling you is not going with the way they're looking.

    05:32 So look at the expressions that they're making.

    05:36 See if they're making expressions.

    05:39 Look to see, if they're having eye contact with you, or if they're looking away, or are incapable of holding eye contact.

    05:48 When you ask them to do things, are they able to follow your commands? Please have a seat.

    05:55 They sit down.

    05:57 If you say to them, "I'd like you to put your hands on your lap." Put your hands on your shoulders, and then using your right finger.

    06:05 Just tap your nose." And they look at you.

    06:10 Put the hands on their lap, their chin, scratched their head.

    06:17 Can they follow commands? One command, two commands, three commands.

    06:22 A command like, put your right hand to your nose, also checks, do they know their right from their left? Are they able to follow those commands? What kind of activity are we seeing in their body? Are they very rapid movements, when they walk in? Are they jittery? Are they moving around? Or when they come in, are they coming in with this very slow laboris movements? Are they going to sit down... and sitting down slowly? This is their psychomotor activity.

    07:03 We want to know is it active or is it a retarded psychomotor activity? Are there some compulsive movements? Is the person every few minutes...

    07:20 seven little taps on their hands? Or pulling on their face, Are their compulsive moments that you are noticing? All of these behaviors present simultaneously.

    07:39 And so the skill of assessing them of being able to look at each one of these different categories is really important because it comes at you all at once.

    About the Lecture

    The lecture Assessment of Appearance and Behaviors (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Psychiatric Assessment (Nursing).

    Included Quiz Questions

    1. Posture
    2. Hair
    3. Grooming
    4. Mood
    5. Facial expressions
    1. The fit of the clothing
    2. If the clothing is dirty
    3. If the clothing is appropriate to the weather
    4. The style of the clothing
    5. The price of the clothing
    1. Gestures
    2. Facial expressions
    3. Mannerisms
    4. Clothing
    5. Hygiene
    1. Crying while discussing a deceased relative
    2. Smiling while talking about a recent accomplishment
    3. Laughing while telling the nurse a joke
    4. Crying while discussing how much the client enjoyed today’s group
    5. Laughing while talking about an anxious feeling

    Author of lecture Assessment of Appearance and Behaviors (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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